CULTURAL COMPETENCE
IN HEALTH CARE
DIVERSITY HEALTH INSTITUTE
POSITION PAPER
AUGUST 2006
Sarah Stewart
Coordinator, Workforce Development Education & Training
Diversity Health Institute
Sydney West Area Health Service
Ph: 9840 3764
Fax: 9840 3755
Email: [email protected]
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
1
INTRODUCTION
The term ‘cultural competence’ is steadily gaining currency in Australia, but
has not yet been embraced to the extent that it has been in other countries.
One of the objectives of the Diversity Health Institute (DHI) is to provide a
forum for the exchange and cross-fertilisation of knowledge and skills of those
working in the field of diversity health. This position paper is offered as a
contribution towards this objective. Specifically, the paper will address the
following:
•
What is cultural competence?
•
Why is cultural competence important in the context of health
care?
•
How is cultural competence developed?
•
How can cultural competence be measured?
•
What needs to happen to progress the cultural competence
agenda in health?
WHAT IS ‘CULTURAL COMPETENCE’?
History of the term
The term ‘cultural competence’ first emerged in the1980s in the USA in
response to the need for human services providers across a range of
disciplines (education, social work, health and welfare) to better meet the
needs of an increasingly multicultural population. In the context of healthcare
provision, there was growing evidence that people from non-dominant cultural
groups (ethnic and racial minorities) continued to experience significantly
poorer health outcomes than people from the majority/dominant culture
(Betancourt et al 2003; Brach & Fraser 2002). The concept of ‘cultural
competence’ has since been taken up in a number of other English-speaking
countries, particularly those with significant immigrant and indigenous
populations. A vast amount of literature about cultural competence has been
generated, most of it emanating from the USA and Canada, with a substantial
amount being generated in the UK, Europe and also in New Zealand1. There
is now also a growing body of work being produced to respond to Australasian
contexts, some of it addressing the relationship between ‘cultural respect’ and
working with Aboriginal peoples.
1
In Aeotearoa New Zealand, the term ‘cultural safety’ is often used in preference to ‘cultural
competence’. Many Maori commentators vigorously reinforce this distinction based on the fact
that the term ‘cultural safety’ has its origins in the colonial context of NZ and was instigated by
Maori nurses. Its introduction into nursing education has, however, not been without
controversy, For discussion of the NZ experience, see Papps & Ramsden (1996).
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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Many definitions
A review of the literature indicates that while there is no one universallyaccepted definition of ‘cultural competence’, many definitions share key
elements. These elements include: valuing diversity, having the capacity for
cultural self-assessment, being conscious of the dynamics inherent in crosscultural interactions, institutionalising the importance of cultural knowledge
and making adaptations to service delivery that reflect cultural understanding
(Goode 1995). In addition, cultural competence may be viewed as both a way
to improve access and equity and a business strategy to enhance costeffectiveness.
The following definition by Cross et al (1989) remains one of the most
frequently cited and succinct definitions:
Cultural competence is a set of congruent behaviours, attitudes and policies
that come together in a system, agency or among professionals and enable
that system, agency or those professionals to work effectively in cross-cultural
situations (Cross et al 1989).
Different levels
As the above definition indicates, cultural competence has a number of
components and ideally operates concurrently on different levels.
At the systems, organizational or program level, a coordinated and
comprehensive plan needs to be in place to support the efforts of individuals.
Such a plan includes strategies to address policy making, infrastructure
building, workforce development, program administration and evaluation and
service delivery.
Cultural competence is much more than awareness of cultural differences, as
it focuses on the capacity of the health system to improve health and
wellbeing by integrating culture into the delivery of health services (NHMRC
2005)
At the individual level, cultural competence may be regarded as:
The ability to identify and challenge one’s cultural assumptions, one’s values
and beliefs. It is about developing empathy and connected knowledge, the
ability to see the world through another’s eyes, or, at the very least, to
recognize that others may view the world through different cultural lenses
(Fitzgerald 2000).
Distinction between ‘competence’ and ‘competency’
There is a tendency in the literature to use the terms ‘competence’ and
‘competency’ interchangeably. However, it is important not to conflate their
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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meanings as the political and educational differences are profound (Smith
2005).
‘Competence’ refers to a broad global capacity; it is an outcome that
describes what someone can do (Tight 1996). ‘Competency’ is a much more
narrow concept that is used to label specific skills and abilities that are
observable and assessable (Smith 2005).
Currently in Australia, Competency-Based Training (CBT) is very popular in
the Vocational Education & Training (VET) arena and continues to enjoy
strong support at a national level from both industry and government. This has
led some in the ‘cultural competence movement’ to align themselves with
CBT. Some argue that this is a useful strategy to gain ‘legitimacy’ and help
put diversity issues on the training agenda. Others, however, warn that there
are risks in uncritical acceptance of CBT as this can lead to reducing human
attributes to discrete activities that can be objectively and (some would say)
mechanistically measured. While it may be that some aspects of cultural
competence can be broken down into such discrete and observable skills
(and there may be value in assessing these), many would argue that it is
highly debatable that values and attitudes may be so measured2. Proponents
of CBT, however, might argue that, as behaviour tends to reflect attitudes,
and behaviour can be observed, then it is possible to infer attitude change
from behaviour change.
Nevertheless, given the unresolved nature of such debates, it may be prudent
to adopt the more global term ‘competence’ when referring to the attributes
required to deliver services that are respectful and responsive to the beliefs
and practices of culturally and linguistically diverse (CALD) client populations.
Difference between ‘competence’ and ‘awareness’
Is ‘cultural competence’ just a newer version of ‘cultural awareness’ or
‘cultural sensitivity’? How is it different? It is argued that ‘competence’ implies
both action and accountability and in this sense potentially takes the notion
of cultural responsiveness further along the continuum of change. It is
possible to be aware of and even sensitive to cultural difference without
necessarily doing anything about this, that is without changing practice. The
practice aspect of cultural competence adds an important skills component to
the domains of knowledge and awareness. A third important aspect of cultural
competence is the notion of reciprocity. This emphasises that the
development of cultural competence involves a two-way learning process
between health service provider and consumer.
2
In 1992, a set of seven generic skills (that became known as the Mayer Key Competencies)
was identified as the basic transferable competencies required for employability and
participation in community activities. Despite considerable lobbying to include ‘cultural
understandings’ as the Eighth Key Competency, the Mayer Committee argued that this was
inappropriate as it involves values and attitudes, which were considered outside the domain
of key competencies.
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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WHY IS CULTURAL COMPETENCE IMPORTANT IN THE
HEALTH CARE CONTEXT?
Changing demographics, increasing workforce diversity and
disparities in health access and outcomes
Australia’s population comprises people with over 200 different ancestries.
Over 200 languages are spoken and over 100 religions are observed. Almost
one quarter of the population (22%) were born overseas and approximately
15% speak a language other than English at home (ABS 2001). In addition to
this diversity is the diversity within Australia’s Indigenous population who at
the last census made up 2.4% of Australia’s population (ABS 2001). As one of
the most culturally diverse societies in the world, it is therefore incumbent on
Australian health care systems and providers to respond in ways that ensure
that this diversity is effectively accommodated in order to promote and sustain
the health of Australian society now and into the future (Johnstone & Kanitsaki
2005). Moreover, the increasing diversity that is reflected both internally in the
health workforce and externally in health consumer populations has clear
implications for effective ‘diversity management’3. A health care organization
that is ‘culturally competent’ is able to provide culturally responsive services
and at the same time reap the benefits of ‘productive diversity’.4 Indeed, the
development of cultural competence has been identified as an effective
access and equity strategy as well as a quality improvement process that is
linked to improved health consumer outcomes (Betancourt et al 2003; Brach
& Fraser 2002; DHFS & AIHW 1998).
Benefits of cultural competence in healthcare
Specifically, the benefits of delivering culturally competent health care include:
• Improved access and equity for all groups in the population
• Improved consumer ‘health literacy’ and reduced delays in seeking
health care and treatment
• Improved communication and understanding of meanings between
health consumers and providers, resulting in
o better compliance with recommended treatment
o clearer expectations
o reduced medication errors and adverse events
o improved attendance at ‘follow-up’ appointments
o reduced preventable hospitalization rates
o improved consumer satisfaction
• Improved patient safety and quality assurance
• Improved ‘public image’ of a health service
3
‘Diversity management’ is essentially a way of managing that develops an organisation’s
ability to build an inclusive environment that gets the best from a diverse workforce, minimises
workplace challenges and provides the best possible service to its customers (Gardenswartz
& Rowe, 1994)
4
‘Productive diversity’ is a public policy that promotes and supports utilising Australia’s
language and cultural diversity for the economic and social benefits of all Australians (DIMIA
2003)
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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•
Good business practice and better use of resources.
Conversely, it follows that there are substantial risks that are likely to incur
costs if healthcare provision is culturally incompetent.
The influence of ‘culture’
It is well-established that cultural beliefs shape understandings of and
responses to health and illness (Kleinman et al 1978; Angel & Thoits 1987;
Kirmayer & Young 1998; Fadiman 1997). It is important that health care
providers remember that culture also shapes the clinical encounter and that
health care services in Australia are generally provided according to a
‘Western’5 bio-medical paradigm. For many client groups, this approach does
not fit with their belief systems. When there is a ‘mismatch’ between belief
systems, health outcomes are likely to be poorer. The tendency of the health
system (or more specifically medicine) to represent itself as a ‘culture of no
culture’ thus results in a culture-blind and ethnocentric approach. This
effectively creates an exclusionary system (Kagawa-Singer & Kassim-Lakha
2003).
The impacts of colonisation, migration and refugee
experiences
The impacts on individuals of the legacies of colonisation, experiences of
migration and refugee resettlement vary depending on a range of social,
economic and environmental determinants. The resulting diversity of
intersecting needs challenges the health system to be truly responsive to the
heterogeneity in our population. Failure to meet the challenges has significant
negative health outcomes for some groups of people.
Aboriginal & Torres Strait Islander people
It is well-documented that the health status of Aboriginal and Torres Strait
Islander people is substantially poorer than that of non-Indigenous
Australians. Disadvantage across a range of socio-economic factors impacts
negatively on the health of Aboriginal and Torres Strait Islander people.
Both morbidity and mortality rates are higher, with Indigenous people more
likely to experience disability and reduced quality of life due to ill-health. Life
expectancy of Indigenous Australians is estimated to be approximately twenty
years lower than for other Australians (ABS & AIHW 2003). In applying the
principles of cultural competence to working with Indigenous people, their
unique historical context must be taken into account and interventions tailored
accordingly. In recognition of this, the Australian Health Ministers’ Advisory
Council (AHMAC) commissioned its Standing Committee on Aboriginal and
Torres Strait Islander Health (SCATSIH) to develop the Cultural Respect
Framework for Aboriginal and Torres Strait Islander Health (AHMAC 2004).
5
While the descriptor ‘Western’ is commonly used in Australia, it probably more accurately
refers to a North West European and North American perspective.
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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Immigrants
Health requirements for immigration ensure that people immigrating to
Australia generally enjoy good health on arrival. However, despite an initial
‘healthy migrant effect’, this relative advantage tends to decrease, as length of
residence increases (AIHW 2002; Young 1992). Some evidence suggests that
mortality and morbidity rates from certain diseases are increasing for some
migrant groups. For example, cervical cancer mortality rates among women
born in Asia are higher than among Australian-born women generally,
possibly partly due to lower participation rates in pap smear screening (AIHW
2004). Proportionately, more overseas-born people than Australian-born also
report having diabetes, with mortality rates also being higher for those born in
some parts of Europe and Asia (AIHW 2004). Hospitalisation rates for
tuberculosis, cataract removal, gastritis, duodenitis, kidney and ureter calculus
are also higher among people born is some parts of Europe and in Asia
(AIHW 2004). Moreover, some groups continue to experience problems in
dealing with the Australian health care system and, as a result, many health
services may still under-utilised by CALD groups. This leads some
commentators to the conclusion that “there is mounting evidence that the
‘positive’ health inequalities in migrant groups…are now converting (or have
already converted) to ‘negative’ health inequalities” (Johnstone & Kanitsaki
2005:25).6 However, given the heterogeneity both within and between
groups, it is difficult and inadvisable to draw conclusions about the health of
immigrants in general.
Refugees and asylum-seekers
While most refugees are healthy on arrival into Australia (like other migrants,
having undergone screening for serious conditions), many new arrivals are at
heightened risk for a number of health conditions that are reflective of their
experiences and sometimes of their region of origin. These health issues
include poor dental health, undetected or poorly managed chronic diseases,
infectious diseases, malnutrition, under-immunisation, physical and
psychological consequences of torture (including sexual violence) and armed
conflict (Smith 2003). Evidence also suggests that newly arrived refugees are
also more likely to rate their own health as either ‘fair’ or ‘poor’ (NSW Health
2004). While refugees and other humanitarian entrants who are permanent
residents are eligible for Medicare7, they face a number of barriers in
accessing healthcare. These include language barriers, financial constraints,
limited trust of health service providers, lack of familiarity with the Australian
healthcare system and culturally incongruent service delivery.
6
Johnstone & Kanitsaki (2005) take this argument further contending that “without
comparative cross-cultural research investigating the relationship between morbidity and
mortality, the assumptions underpinning the ‘healthy migrant’ effect cannot be sustained”(p24)
and so the conclusion that low hospitalisation rates reflect ‘good health’ is highly
questionable.
7
Temporary Protection Visa holders are ineligible for certain Commonwealth funded health
services and some asylum-seekers are ineligible for Medicare.
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Legislative and policy context
Legislative frameworks operate at both federal and state levels to regulate
multicultural and human rights in Australian jurisdictions.8
In addition, public policy at the national level affirms access and equity
principles in The Charter of Public Service in a Culturally Diverse Society
(DIMA 1998), by emphasizing that cultural diversity considerations should be
incorporated into the strategic planning, policy development, budgeting and
reporting processes of service delivery. The key statement of Australia’s
multicultural policy, Multicultural Australia: United in Diversity (May 2003),
similarly promotes acceptance and respect for our cultural diversity and
supports the rights of all Australians to maintain and celebrate, within the law,
their culture, language and religion. Four principles underpin multicultural
policy.
These are:
• Responsibilities of all – to support Australia’s basic democratic
structures
• Respect for each person – to express their own culture and beliefs,
subject to the law
• Fairness for each person – in relation to equality of treatment and
opportunity
• Benefits for all – in terms of ‘productive diversity’, that is, the cultural,
social and economic dividends arising from the diversity of our
population.
At the state level, in NSW, the Charter of Principles for a Culturally Diverse
Society (1993) reiterates the obligations to improve service delivery to a
culturally diverse society. These responsibilities are articulated in the NSW
Community Relations and Principles of Multiculturalism Act 2000 which
outlines a number of principles that public sector agencies are required to
observe. These principles echo those at the federal level and constitute the
policy of the state of NSW in relation to cultural diversity9.
In the context of NSW Health, the most current key policy documents at the
time of writing are Strategic Directions for Health 2000-2005 and NSW Health
and Equity Statement: In All Fairness (2004). In the former document, “Fairer
Access” is noted as one of the key goals and in the latter, “Cultural Diversity”
is named as one of the key underpinning principles. A recently-released
consultation document, Fit for the Future, outlines NSW Health’s broad
directions for the next two decades. ”Respect for individuals and communities”
8
Five federal laws cover discrimination and breaches of human rights. These are Racial
Discrimination Act 1975, Sex Discrimination Act 1984, Disability Discrimination Act 1992,
Human Rights and Equal Opportunity Commission Act 1986, Age Discrimination Act 2004. All
Australian States and Territories also have their own anti-discrimination legislation.
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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and “access and equity” are two of the core values espoused in the document
(NSW Health 2006).
It is beyond the scope of this paper to comprehensively detail the evolution of
multicultural and human rights public policy and legislation and its effects on
health care in Australia. However, evidence suggests that, despite over thirty
years of multicultural policies and programs and notwithstanding policy and
legislative frameworks, Australia’s health care system is still not as responsive
as it needs to be to the cultural diversity of the populations that it purports to
serve (Johnstone & Kanitsaki 2005).
HOW CAN CULTURAL COMPETENCE BE DEVELOPED IN
HEALTH SERVICES?
As noted, the concept of cultural competence is gaining popularity in
Australia. However, a focus on conceptualising at the expense of
operationalising, has resulted in some confusion regarding how the notion
translates from theory into practice.
Support from the top vital
In the absence of a clear framework for implementation and endorsed
standards for practice, policy statements are likely to remain in the realm of
rhetoric. Therefore, first and foremost, a commitment to operationalise cultural
competence must be evident in the leadership of an organization and
embedded in key performance indicators. Such commitment must not only
take the form of unambiguous statements that ‘good practice’ is ‘culturally
competent practice’ and ‘quality health care’ is ‘culturally competent health
care’, but such statements must be backed with allocation of resources to
implement and evaluate initiatives. Without ‘diversity champions’ at the most
senior levels, efforts at the individual level are unlikely to create or sustain
substantial systemic change (Cope & Kalantzis 1997; Gardenswartz & Rowe
2002; Dowd 2002).
Combination of strategies at different levels
The process of becoming culturally competent in healthcare requires multilevel strategies and involves both ‘top-down’ and ‘bottom-up’ change
management strategies. Reciprocal learning between health service providers
and culturally and linguistically diverse consumers is also integral to fostering
a culturally competent health system (NHMRC 2005; Procter 2003).
At the organizational and systemic levels, this occurs in relation to the
development of policy and guidelines, implementation frameworks and
guidelines and workforce development plans. It may require re-examination of
mission statements, protocols and procedures, data collection, administrative
practices, staff recruitment and retention, staff orientation and professional
development opportunities, interpreting and translating processes, research
tools, community partnerships, health promotion activities, complaints
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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mechanisms, client satisfaction surveys, capacity building and participatory
action research involving consumer consultants (Goode 1995; Betancourt et
al 2003). Valuing workforce diversity and fostering culturally inclusive
workplaces are fundamental to organizational cultural competence strategies.
At the individual / clinical level, health professionals and clinicians need to
be aware of their own attitudes, values, biases and preferences, as well as be
prepared to acquire new skills and knowledge. The process of individual
cultural competence development may be facilitated by organizational
education and training initiatives. It should be noted, however, that ‘training’
ought not to be viewed as the only avenue for individual learning. Other
opportunities to develop cultural competence include working with cultural
brokers/mediators/consultants and mentoring programs.
Education & training: what works?
Despite its limitations, staff training and professional development remain a
popular cultural competence intervention and so it is worthwhile examining the
options that are available.
Integrated’ or ‘modular’ training?
Very often, such training is provided in the form of ‘stand-alone’
modules/workshops/seminars variously called ‘Working with Diversity’,
‘Cultural awareness’ or ‘Cross-cultural Communication’. The time allocated to
such sessions varies enormously, as does the content, format and quality.
While the intention of this sort of training may be to enhance practice, the
context in which it is delivered may well limit its effectiveness. If it is offered as
optional, the audience is invariably ‘the converted’. If it is mandatory (as is
frequently the case after a ‘critical incident’ occurs), then participants are often
unreceptive and it is perceived as punitive. Neither scenario augurs well for
organizational change.
Another option in relation to cultural competence training is integrating
diversity issues into ‘mainstream’ courses for health workers, at the
undergraduate (preservice) level as well as in the context of continuing
professional development. Many commentators voice a strong preference for
the ‘integrated’ approach over the ‘modular’ approach. However, few specify
how to ensure that this occurs. While such an enterprise may well yield more
far-reaching and sustainable results than ‘add-on’ courses, the lack of a
coherent educational framework and rigorous evaluation processes severely
hampers efforts (Beach et al, 2005; Anderson et al, 2003). Furthermore, there
are varying interpretations of ‘integration’. In some contexts, it implies a
longitudinal threading of diversity issues throughout the entire curriculum,
while in others, a ‘session’ inserted into a longer program is deemed
‘integrated’. Moreover, a truly integrated approach to curriculum development
poses a long-term challenge and is therefore often less appealing to those
who would prefer to opt for the apparently quick-fix solution of mandating all
staff members to attend ‘diversity training’ (also known as ‘the sheep-dip
approach’).
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Key features /elements of effective training
Much is still contested in the field of cultural competence learning and
teaching. However, despite the absence of a solid evidence base in relation to
what training approaches are most effective, there is emerging from the
literature a picture of what might constitute ‘good practice’.
•
Trainers - the training must be delivered by trainers who demonstrate a
level of cultural competence themselves. This may seem self-evident, but
it is worth articulating what this might mean. In addition to a good
knowledge of diversity issues, a number of other criteria have been
proposed for selecting suitable trainers. These include demonstrating
important personal attributes such as self-awareness and psychological
adaptability, empathy and responsiveness, freedom from ethnocentricity
and an ability to act as an agent of change. In addition, the literature
frequently notes such important trainer characteristics as commitment to
the principles of adult education, good process competence, familiarity
with the routines and procedures of the health facility in which the
participants work (vital for credibility) and strong facilitation skills to
manage diverse opinions and sometimes emotionally volatile situations
(Anand 1999; Gilbert 2003). Some commentators note that a mixed
ethnicity and mixed gender training team has benefits, but also potential
drawbacks (Anand 1999).
•
Content – A broad, inclusive understanding of ‘culture’ as complex,
dynamic and fluid is necessary to underpin the content. Such an
understanding encompasses the range of dimensions of human diversity
and look beyond narrow definitions of ‘culture’ that relate only to
birthplace, language and ethnicity. Connected to this idea is that cultural
competence is not about knowing everything there is to know about this or
that particular cultural / linguistic group. Indeed the pursuit of such an
unrealistic goal invariably leads to stereotyping.
The three inter-related learning domains of awareness, knowledge and
skills are frequently proposed as the basis for an appropriate framework for
cultural competence training (Gunn 1995).
•
Awareness - The starting point for effective cultural competence training
must be self-examination, rather than a focus on ‘the other’, as this can
only perpetuate an ‘us and them’ way of thinking which is precisely what is
to be avoided. This includes encouraging participants to become aware of
their own internalized beliefs and biases (including those deriving from
their organizational and professional culture) and how these might impact
on interactions with client/patients.
•
Knowledge – In terms of equipping learners with the necessary
knowledge-base, trainers need to contextualize their training within the
relevant policy and legislative frameworks. Training frequently risks
becoming merely information provision, as participants often request
guidance on how to work with specific ethno-cultural groups and the
temptation is to offer up lists of cultural traits or masses of culturally
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
11
specific information. However, the most effective training will resist taking
this route of least resistance10. While this may result in some disgruntled
participants who feel as if their needs are not being met, it is important to
remember that it is often in this space of discomfort and confusion that
important self-reflection takes place and ‘transformative’ adult learning
results (Mezirow 1995; Merriam & Caffarella 1999).
•
Skills – skills development in the areas of cross-cultural communication,
including, but not limited to, knowing when and how to work with
professional interpreters, conflict resolution, negotiation of explanatory
models and critical thinking are typically cited in the literature as integral to
effective cultural competence training (Carillo et al, 1999).
•
Format / techniques – Consistent with adult education theory, good
cultural competence training will involve a range of techniques to
accommodate the diversity of adult learning styles, acknowledge prior
learning experiences (good and bad) and be tailored to meet the specific
needs of the participants. The approach taken and the balance of activities
addressing each of the learning domains (affective, cognitive,
psychomotor) will obviously vary depending on a number of factors,
including the time available. However, evidence suggests that practical
and experiential activities yield the best results when facilitated skilfully11.
•
Context - the most effective training programs are embedded in an overall
organizational plan to develop cultural competence. It is important to
remember that, despite its popularity as a potential panacea for all that is
lacking in health service provision, training is not the answer to the
problems. Well-targeted and effectively facilitated, it can be a valuable
strategy to assist in the process of long-term organisational change. Most
importantly, developing cultural competence should be seen as an
ongoing and incremental lifelong process, and not a one-off event.
Therefore, learning opportunities should be regularly scheduled and any
one session/workshop/course/seminar on its own should be seen as
simply a step in the process of developing what some prefer to call
‘cultural humility’ (Tervalon & Murray-Garcia 1998).
10
This is not to say that in some situations culturally-specific information is not useful.
Indeed, Fitzgerald’s (2000) take on cultural competence is that it involves three distinct
perspectives that are equally valid – ‘culture specific competence’, ‘intercultural competence’
and ‘culture general competence’.
11
Experiential learning can take various forms including discussion of case studies and
scenarios drawn from participants’ everyday work contexts, role playing interview techniques,
simulation activities and introspective/reflective exercises.
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
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HOW CAN CULTURAL COMPETENCE BE MEASURED?
No explicit criteria for cultural competence assessment and
lack of evaluation
Despite its widespread popularity as a goal to strive towards, no explicit
criteria have yet been established to assess the achievement of cultural
competence. Agreement across the different health care professions in
relation to the measurement of cultural competence is conspicuously lacking
(Johnstone & Kanitsaki 2005). The difficulties inherent in conducting cultural
competence evaluation (because of the lack of appropriate tools and
resources) are compounded by reluctance on the part of many health service
providers to participate in meaningful evaluation and data collection activities
(Diversity Rx 2002 cited in Johnstone & Kanitsaki 2005).
Perhaps another reason for the scarcity of rigorous evaluation studies may be
the lack of agreement as to the meaning of the term ‘culture’ (Hunt 2001). If
we understand ‘culture’ in its broadest possible sense, as suggested, it is
dynamic and complex, encompassing the full range of dimensions of human
diversity (eg gender, sexual preference, age, (dis)ability, socio-economic
status etc.) The term ‘competence’, however, has been well-defined by
educators (particularly in the VET sector, as previously noted) and so,
perhaps in an effort to ‘pin down’ the slippery and elusive concept of ‘culture’
and attach some ‘measurables’, it has been linked, by some, to the
Competency Based Training (CBT) movement. However, the end result may
well be a ‘dangerous liaison’ that tends towards representing culture as a
decontextualised set of traits or cultural characteristics that can be ‘known’.
This approach runs the grave risk of promoting stereotyping and runs counter
to notions of individual client/patient centred intervention.
Clearly the challenge in cultural competence evaluation lies in finding the right
balance between maintaining the fluidity of the core concepts and meeting the
demands for ‘hard’ measurement of effectiveness. Importantly, research is
needed that explores the impact of cultural competence interventions on the
‘end-users’; we need to know more about what strategies have the most
beneficial impacts on health consumer outcomes.
Various tools / instruments to assess competence at the
individual level
One approach to assessment has been the development of a number of tools
or instruments for individual practitioners/clinicians to assess their own
cultural competence. For this to be most effective, scrupulous honesty on the
part of the individual is called for. To encourage such honesty, the results of
such self-assessments are often not collated or fed into ‘the system’, but are
intended to encourage self-reflection and to give the individual some ‘baseline
data’ about their own cultural competence. However, it is worth noting that the
collation and analysis of a critical mass of such individual self-assessments
may well provide a ‘barometer reading’ of the cultural competence of an
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
13
organization. Embedded in such tools is the notion that there are a number of
personal characteristics or attributes that a culturally competent individual
demonstrates and which, presumably those who are not yet competent, can
develop12. Other possible ways of measuring individual cultural competence
include clinical case file audits and the incorporation of cultural competence
into staff orientation and performance management processes. However, in
the absence of agreed practice standards, the value of such assessment tools
is questionable.
In addition to individual checklists, there are a number of models (mainly
developed in the USA) that provide useful practical frameworks for
implementing and assessing cultural competence at both the individual and
the organisational level. Most of these are based on a developmental
continuum approach13.
Standards to assess competence at the organisational level
Perhaps the most useful way of assessing organisational cultural competence
is by measuring performance against a set of agreed standards. This
approach was formally adopted in 2001 in the US through the publication of
National Standards for Culturally and Linguistically Appropriate Services in
Health Care issued by the Office of Minority Health, US Department of Health
& Human Services. The fourteen standards are grouped according to three
themes. These are ‘Culturally Competent Care’ (Standards 1-3), ‘Language
Access Services’ (Standards 4-7) and ‘Organisational Supports for Cultural
Competence’ (Standards 8-14). Within this framework, the standards vary in
terms of their stringency and enforceability. Only the four standards that relate
to Language Access Services are mandated for services receiving Federal
funds. The remaining standards are either recommended guidelines or
recommendations for voluntary adoption by health care organisations.
In Australia, there is currently no equivalent standards framework for health
services at the National level. 14At the State level, in NSW, the Ethnic Affairs
Priority Statement (EAPS) Standards framework arguably goes some way
towards encouraging systemic cultural competence. A project to embed
cultural diversity into the health services accreditation system is currently
being undertaken by the Australian Council on Healthcare Standards (ACHS)
and Quality Management Services (QMS), in partnership with South Eastern
Sydney & Illawarra Area Health Service and NSW Health. Some
organisations have developed their own cultural competence standards15 and
some professional groups have developed competence standards that
12
For example see: Cultural Competence Health Practitioner Assessment (CCHPA)
developed by the National Center for Cultural Competence, Georgetown University Center for
Child & Human Development http://gucchd.georgetown.edu/nccc/selfassessment.html
13
For example, see Cross et al’s (1989) six level Cultural Competence Continuum from
‘cultural destructiveness’ through to beyond ‘competence’ to ‘cultural proficiency’.
14
However, it must be noted that considerable progress has been made in this respect in the
area of mental health – see the National Mental Health Strategy’s Framework for the
Implementation of the National Mental Health Plan 2003-2008 in Multicultural Australia
15
See for example the Multicultural Disability Advocacy Association of NSW’s ‘Cultural
Competence Standards’ www.mdaa.org.au/publications/faqs/standards.html
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
14
incorporate cultural issues16. There are, however, persistent gaps in the
system and a lack of consistency across the range of health care service
providers.
WHAT NEEDS TO HAPPEN TO PROGRESS THE CULTURAL
COMPETENCE AGENDA IN HEALTH?
To date, efforts to advance the cultural competence agenda in Australian
health care have been piecemeal and have suffered from a lack of
coordination. However, change in this respect may be on the horizon.
The National Health & Medical Research Council (NHMRC) has recently
released a document titled Cultural Competency in Health – a guide for policy,
partnerships and participation. This is a comprehensive document, aimed at
high-level policy makers, that describes a model with national application.
Such a document has the potential to lead the way forward for the
development of cultural competence in Australian health care - if it can
galvanise action to make cultural issues “core business at every level of the
health system” (NHMRC 2005:1).
Identified areas for action include:
• National collaboration on a framework for culturally competent health
practice
• Addressing gaps in research to strengthen the evidence base in
relation to what interventions are most effective
• Development of accountability mechanisms and performance
indicators
• Identification of core competencies and processes for addressing these
in education and training
• Improved data collection, reporting and sharing
• Development of a range of ‘hands-on’ resources and toolkits.
CONCLUSION
The DHI urges all those involved in the provision of health care –
governments, funding bodies, policy makers, managers, researchers and
practitioners - to engage in ongoing discussions, with each other and with
health consumers from diverse communities, to contribute to coordinated
action for change. The development of a truly culturally competent health care
system is a long-term goal that involves a multifaceted, multilevel approach.
The sustained commitment of all stakeholders in this process is needed if this
goal is to be realized for the benefit of all Australians.
16
See for example Australian Nursing Council 2001 and National Standards for Mental Health
Services 1997.
Cultural Competence in Health Care - Sarah Stewart, DHI, August 2006
15
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