I spoke to a class of graduate nursing students yesterday in the city of Worcester. The topic was on cultural competency and health care — a topic I’ve spoken on for many years. They were an amazing group of students; smart, engaged, thoughtful, and diverse.

When I began to do this work around 13 years ago I knew it all. I spoke with confidence and flair, I had all the ‘best’ examples and brought people into the conversation in a new way. But this work is like living cross-culturally; the more you learn, the more you realize you don’t know. The more you experience, the less you are sure of any absolutes. So now, I’m much less sure of outcomes, yet much more committed to the process.

If you define cultural competency at its most basic level, it is about learning to communicate and function effectively across cultural barriers, cultural differences. So no matter where you live in the world, it is something that is useful to learn. In our increasingly diverse societies, it is indeed a critical life skill. The difference however when it comes to cultural competency and health care is that the stakes are higher. Cultural competency, knowing how to function in the midst of cultural differences, can change an outcome, can be the difference between life and death, or life and permanent, irreversible damage and I am not being dramatic when I say that.

• There is the 71-million dollar word resulting in an 18 year-old becoming a quadriplegic.
• There is the story of Lia Lee; a Hmong child who ended up having severe brain damage, largely because the arrogance of western biomedicine and the ignorance of healthcare providers who did not take into account the family’s belief system.
• There is the story of a Japanese mom who ‘didn’t sound worried’ over the phone so was not given an appointment for her small child. By the time she did get the appointment, it was too late and the child died.

There is an argument in the field of cultural competency on the word ‘competency’. I would argue that in every field there are certain competencies that need to be met. As a nurse, I was not allowed to do certain things until I had reached a certain level of competency. It didn’t mean I knew everything, it meant that I was at a point where I could function well and not be a danger to patients. The same is true for cultural competency – I believe that people can reach a level of competency and have tools to use when it comes to communicating effectively across cultural boundaries.

But critical to this field of study, to this skill set is the idea of cultural humility. This term was developed in 1998 by two physicians: Dr. Melanie Tervalon and Dr. Jann Murray-Garcia. They proposed that this was what the goal should be when it comes to looking at outcomes. They say this: “Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non paternalistic clinical and advocacy partnership with communities on behalf of individuals and defined populations.”

How does that work out in practice?

It means being a student of the patient, person, or the community — not an expert.

It means not equating limited language ability with limited intellectual ability.

It means admitting what you don’t know, and seeking to learn what you need to.

It means seeking out those who can function as cultural brokers, as cultural informants and asking them questions, learning from them.

It means knowing the importance of culture for all who we encounter.

It means being capable of complexity. 

It means learning the fine art of negotiation, and the finer art of putting what we think is best in the background, focusing instead on what the person or community thinks is best .

Most of all, it means knowing who you are, what your cultural beliefs and values are, and how they may come into conflict with those you are wanting to serve. We wear our culture like skin. we’re so used to it we don’t even think that what we do, how we think, how we govern, how our schools are set up, our infrastructure, our medical system, is all based on cultural beliefs and values. Until we recognize both the complexity and the pervasiveness of our cultural beliefs we cannot move forward in communicating effectively across cultural boundaries. Then, and only then can we move forward on this path.

I left the students yesterday with this quote: 

Most things that don’t make sense from the outside usually do make sense if understood from the inside…

It’s a life long journey, but so worth pursuing. 

Blogger’s Note: One book I would recommend that looks at cultural competency in the context of western medicine is The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures by Anne Fadiman. It is a profound look at culture, healthcare, and what can go wrong.

Related articles

• Critical Cultural Competence (ansjournalblog.com)
• Cultural Competency Faculty Course (adrseattle.wordpress.com)
• Health Literacy and Cultural Competency (saraemcd.wordpress.com)
• Goodbye Lia Lee