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National Review of Nursing Education

Multicultural Nursing Education 

5. Australian nursing education today

5.1 Current models of multicultural education

A number of theoretical models of multiculturalism and nurse education exist and are used in the process of developing nursing curricula.

The Leininger model

Why transcultural nursing?

The notion of transcultural nursing originated in the United States, which, despite a long history of immigration, had held an ethnocentric viewpoint based on the Christian values of the dominant culture. This viewpoint, also shared by the United Kingdom, has largely shaped nursing education in relation to multicultural health (Price & Cortis 2000). Transcultural nursing was created largely through the work of Madeleine Leininger in Seattle (Washington), Salt Lake City (Utah), Detroit (Michigan), Troy (Alabama), and Omaha (Nebraska) over the past five decades.

Leininger (1998) defined transcultural nursing as:

an essential area of study and practice focused on the cultural care beliefs, values, and lifeways of people to help them maintain and/or regain their health, or to face death in meaningful ways. Essentially, transcultural nursing has focused on understanding cultures and their specific care needs and how to provide care that fits their lifeways rather than assuming professional nurses always know what is best for them. Transcultural nurses have taken the early lead among health professionals to discover and provide care in specific ways for Mexican, Vietnamese, Japanese, African, Anglo, and other cultures and subcultures. Providing culturally congruent care is the goal of transcultural nursing. As the largest health care providers, nurses can make a significant difference in providing culturally congruent and beneficial care for the well, sick, disabled, or dying client with transcultural nursing knowledge and competencies.

Leininger’s theory was the first nursing theory to focus on the role of culture in nurse/patient dynamics. Her approach borrowed from anthropology to pioneer the development of a ‘Culture Care Theory of Diversity and Universality’ (Leininger 1996a; Leininger 1991; Leininger 1996b; Leininger 1988). This transcultural perspective aimed to identify both diverse and universal cultural variables found among human social groups and was developed to help nurses improve the care of patients from different cultural backgrounds by providing formal educational programs. Leininger started her mission ahead of her time, as transcultural nursing took twenty or thirty years to gain a toe-hold in nursing education in countries like the United Kingdom. However, the Leininger model eventually came to influence nursing education in developed countries around the world (Lazure et al. 1997), including Australia. (Omeri 1996). The Royal College of Nursing in Australia presented Dr Leininger with its first International Nursing Achievement Award.

Leininger, like Giger and Davidhizar (Giger & Davidhizar 1991), was one of several nurses who supported a sort of cultural relativism, a principle which, according to Baker (Baker 1997) ‘is an implicit principle underlying the conceptual approaches developed by nurses to guide cross-cultural caregiving. Borrowed from anthropology, cultural relativism refers to the perspective that the behaviors of individuals should be judged only from the context of their own cultural system’. The limitations recognised in such relativist thinking spurred the development of the diversity model.

Leininger semi-retired from Wayne State University, College of Nursing and the Department of Anthropology in 1995.

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The diversity model

Beyond culture ­ race and inequity

By the 1980s, nursing education had become alert to the importance of racial and structural issues. Despite efforts to identify diverse and universal cultural variables, the Leininger model was criticised as being too focused on the culture of the ‘other’: presenting cultures as static and deterministic (Price & Cortis 2000). It ignored huge differences within as well as between ethnic groups due to social stratification, as well as the social changes that affect individuals at different stages of the life cycle. It did not reckon for the influence of population movements, socialisation, acculturation, and other dimensions of diversity. And it did not consider the impacts of dominant or majority groups or the relationships between dominant and minority groups. Critics such as Lister even argued that it fed into oppressive aspects of racism. Indeed, by seeing inequalities as the result of failure by the majority group to demonstrate familiarity with the cultural practices of minority groups, it reinforced the ‘New Racism’ (Lister 1999). Whatever the truth of these criticisms, Leininger was ahead of her time and set the scene for the current developments. Her work is as valid today as it ever was.

Approaches which focus on the culture of the ‘other’ or the ‘out-group’ may be criticised on a number of grounds. These include failing to refer to the ‘in’ or majority social group; focusing on the cultural differences without checking the acceptance of their validity by nursing students; analysing functional problems along cultural lines to the exclusion of other main lines of division in society; remaining static and overlooking the effects of acculturation and culture shock (Cortis 2000). According to Cortis, the multicultural approach to nursing education does not address the real issue which explains inequalities, which he identifies as racism.

A similar critique of multiculturalism in nursing is made by Lorraine Culley, of De Montfort University, Leicester, who comments on the British experience. She notes that while the ‘multicultural’ debate has gone forward in the social sciences to consider ‘race’ and education and ‘race’ and social work, the same has not been true in health care, particularly nursing. Here a cultural essentialism continues to dominate the debate, in which health educators use ‘culture’ to maintain a separation between ethnic minority patients and those of the dominant white group (Culley 1996). Similarly, The King’s Fund’s study of racial equality and the nursing profession indicated that British nursing education placed too much emphasis on culture and language and not enough on equal opportunity and anti-racism. Price and Cortis of the University of Leeds warn that cultural competence in nurse education needs to challenge rather than propagate stereotypes, voicing the concerns of a growing number of nurse educators. (Price & Cortis 2000). In short, the transcultural model will not necessarily lead to culturally competent practice.

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Learning about diversity and race

The cultural perspective has been criticised for failing to address issues of discrimination, oppression and racism. On the other hand, as pointed out by Susan Stanford Friedman, simply making a feature of race and discrimination can lead to a ‘difference impasse’ in which ‘White’ and ‘colour’ are seen as binary with no common ground (Friedman 1998). Binary narratives do explain domination, but do not capture the changing and shifting subject positions.

Mary Abrums and Carol Leppa ( 2001) thoughtfully describe a program in which Stanford Friedman’s theory of ‘relational positionality’ into practice: using it as a guide for teaching, rather than as a theory to teach. In this model, narrative scripts of relational possibility are proposed as a means for students to examine oppression. It is proposed that rather than building bridges between cultures, students begin to identify commonalities that cement them, without ignoring or devaluing one another’s identities.

In their ‘Nursing Care and Cultural Variation’ course for RNB students at the University of Washington, Abrums and Leppa have broadened the definition of cultural competence. They ‘identified two course goals based on the theory of relational positionality for teaching this content: (a) increase student self-awareness in relation to issues of discrimination and oppression in health care; (b) create a safe classroom space to decrease ‘Us-Them’ polarization and/or the silencing of individuals’. They begin the course by focusing on shared cultural experiences and the least threatening topic, ‘The Culture of Nursing’. Students explore concepts of culture, subculture, acculturation, intra- and inter-group variations, and Western medical ethnocentrism, in reference to their experience as nurses. Exploring shared experiences provides a non-threatening introduction to the topics of oppression and oppressed group behaviour.

The second cultural experience examined is the content of American culture ­ with focus on the culture of the dominant White group of students. The theory of relational positionality is introduced as students begin to recognise and own their own social perspectives while acknowledging the different perspectives of their classmates in these relatively unthreatening areas.

The course moves on, with care to avoid slipping into the ‘culture as other’ mentality countered by continued emphasis on the benefits and limitations of the Western health care ethnocentrism. Students are required to analyse the power structures that identify some health beliefs as legitimate as they work through the issues of communication, and the use of interpreters by conducting explanatory model interviews.

At this point in the course, Abrums and Leppa shift the focus to social identity and bring in the experiences of race, class, gender, sexual orientation, and disability in combination with a cultural identity. Students learn that multiple contradictory relations can exist between individuals at any one time (Stanford Friedman’s theory of relational positionality). Students learn that it is difficult to comprehend these varying perspectives because each individual sees every encounter and every other person or group through their own lens. The students have had experience in exploring various individual perspectives and now they must identify societal perspectives of which they were previously unaware, or they must recognise perspectives they hold, and explore how these are perceived by others. Next the students focus on the nursing care of disenfranchised or forgotten groups. The focus here is on discrimination.

Finally, the students synthesise the matrix of oppression and evaluate the influence of their personal and social geography on their professional care-giving role. In their final writing assignment, they discuss their personal experiences related to race or class by writing a social, geographical or personal analysis ­ the makeup of their neighbourhoods when children; their first awareness of racial or class differences; how their religious backgrounds contributed to racial beliefs or class beliefs ­ and they include any important experiences which may have influenced their development on these issues (Frankenberg 1998). Abrums and Leppa’s cultural training course moves the focus of reflection from the very personal to the broadly social. Its approach is highly relevant to Australia’s learning environment.

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Cultural competence

Definitions

The idea of 'cultural competence' implies a responsibility at both the organisational and individual level. That is, providing quality care to a diverse population requires both systemic responses (policy, procedures etc.) and the delivery of care by skilled and sensitive providers. This is defined by Terry Cross et al ( 1989). in a broad sense:

Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enable effective interactions in a cross-cultural framework.

In another definition of Seattle King County Dept of Public Health, 1994

Cultural competency is the ability of individuals and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic backgrounds and religions in a manner that recognizes, affirms, and values the cultural differences and similarities and the worth of individuals, families, and communities and protects and preserves the dignity of each. 

Again, in a definition provided by the Cross Cultural Health Care Program, Seattle (Cross-Cultural Health Care Program 1999), as:

Cultural competence involves recognition and respect for differences among patients in terms of their values, expectations, and experiences with health care, while at the same time recognizing the culture-based practices and dictates of organized medicine, and the values, expectations, and experiences of the providers who practice it. Culturally competent care becomes possible only with the skillful management of the interplay between these elements which make up a medical encounter, and determine the points of access or barrier at the institutional level.

Cultural competence has also been defined by Maureen Fitzgerald at University of Sydney as

the ability to identify and challenge one’s cultural assumptions … the ability to see the world through different cultural lenses … to analyse and respond to the ‘cultural scenes’ and ‘social dramas’ in ways that are culturally and psychologically meaningful … for client and professional alike … and the ability to turn such thinking into praxis … providing meaningful, satisfying and competent care. (Fitzgerald 1999)

Many contemporary writers now view cultural competence as the desired outcome of cultural learning. For example, Philip Lister at University College of Worcester sets cultural competence at the pinnacle of his proposed experiential taxonomy of cultural awareness, cultural knowledge, cultural understanding, cultural sensitivity and cultural competence (Lister 1999).

In addition, Smith, at the State University of West Georgia, has also provided a useful concept analysis of cultural competence designed to clearly separate cultural competence from its measurement and clarify and differentiate the term as it is used in health care and nursing literature. . Smith compares the definitions based on review of sources such as archaeology, anthropology, history, psychology, policy, criminal justice, occupational therapy, medicine, nursing, and education (Smith 1998a; Smith 1998b).

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Cultural competence in nursing education

Since the 1980s, nursing education courses leading to registration in the United Kingdom have been required to address multicultural issues in their curricula. In the context of nursing education in the United Kingdom, Lister at University College of Worcester (1999) has identified a taxonomy for developing cultural competence, to guide curriculum development. The taxonomy comprises five stages. Firstly, the student begins by developing cultural awareness. Once aware, the student can describe how beliefs, values and personal or political power are shaped by culture; Secondly, the student develops cultural knowledge, beginning to show familiarity with the broad differences, similarities, and inequalities in experience and practice among various societal groupings. Then comes cultural understanding, where the student recognises the problems and issues faced by individuals and groups when their values, beliefs and practices are compromised by a dominant culture. Fourthly, the student develops cultural sensitivity, showing regard of the individual client’s beliefs, values and practices within a cultural context, and showing awareness of how their own cultural background may be influencing professional practice. Finally, the student develops cultural competence, providing or facilitating care which respects the values, beliefs and practices of the client, and which addresses disadvantages arising from the client’s position in existing power structures.

This taxonomy goes beyond essentialist notions of ethnicity and follows a similar cognitive, affective and behavioural sequence to taxonomies of experiential learning (Steinaker & Bell 1979). The cultural competence model maps onto the experiential taxonomy and is integrated where the curriculum is planned on this basis. An example of this learning model in nursing might be :

    • Awareness/exposure: An early session with nursing students might involve them sharing something of their backgrounds in small groups.
    • Knowledge/participation: An early assignment involves students researching a neighbourhood profile including its ethnic composition, and evaluation of the degree to which local health-care services meet the needs of minority groups. This is supported by sessions on inequalities in health in relation to class, gender, ethnicity and age.
    • Understanding/identification: At the next level in the taxonomy, an assignment requires the student, using a case study from practice, to compare and contrast lay and professional views and experiences of illness and the caring relationship.
    • Sensitivity/internalisation: The student is given an assignment to evaluate the effectiveness of their own area of service provision in meeting needs.
    • Competence/dissemination: Processes such as clinical supervision, mentorship, and professional profiling would facilitate development at this level of the taxonomy.

Another example of a pragmatic teaching model which guides cultural competence comes from Juliene Lipson at University of California San Francisco. In her model, cultural perspective includes three interacting elements: cultural assessment as the core of client and community characteristics that influence health and illness; a subject component on nurses as self-aware cultural beings; and the socioeconomic and political context that influences a cross-cultural encounter (Lipson 1999).

Taxonomies of cultural competence, focusing on the practice rather than teaching of nursing (by which authors seem to mean hierarchies rather than taxonomies) abound. Most share in common the progression from knowledge and awareness to competence. Willis ( 1999) at San Diego State University proposes a step-wise framework:

    • Step 1: Knowledge of one’s own cultural affiliation and lifeways
    • Step 2: Knowledge of others’ cultural beliefs, values and lifeways
    • Step 3: Non-threatening/non-fear provoking situations
    • Step 4: Tolerance
    • Step 5: Inclusion
    • Step 6: Appreciation/acceptance
    • Step 7: Competence

In Australia, cultural competence for allied health professions has been the subject of research and training through the Intercultural Interaction Project, with the School of Occupational Therapy at the University of Sydney (Fitzgerald et al, 1997). Its aim has been to explore culture and communication issues in OT practice and to provide students with an opportunity to use the research process to develop cultural knowledge and communication skills to inform their practice. It has also been argued that cultural competence in research ­ which involves collaboration and consensus with the target population as well as knowledge and sensitivity ­ is more powerful than the generally prescribed practice of simply matching the cultural attributes of researcher and participant (Sawyer et al. 1995). In the USA, Meadows (1991), as Director of Minority Affairs in the American Physical Therapy Association called for ‘multicultural communication’ from health care practitioners to improve client’s health, health care seeking and compliance with treatments.

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Defining cultural competence in nursing practice

Despite efforts to publish toolkits for culturally competent services, there is no clear definition of cultural competence in nursing practice, a shortcoming which Afaf Meleis at University of California San Francisco highlights as reflecting gaps in nursing knowledge and research (Meleis 1996). Meleis depicts an urgency to the development of culturally competent care because of increasing diversity, increasing disclosure of identities, increasing inequity in access to health care and care delivery moving to homes..

Kim-Godwin and colleagues at North Carolina and Idaho carried out a concept analysis, from which they clustered definitions of cultural competence into those which define it as a process, and those that view it in terms of ‘end abilities’. Both definitions include caring, cultural sensitivity, cultural knowledge and cultural skills (Kim-Godwin, Clarke, & Barton 2001). According to Kim-Godwin et al.., there is a focus on the relationship between cultural competence and health outcomes for diverse populations. In 1992, the American Academy of Nursing (AAN) Expert Panel on Culturally Competent Nursing Care described culturally competent care as:

care that is sensitive to issues related to culture, race and gender and sexual orientation. This care is provided by nurses who use cross cultural nursing theory ,models and research principles in identifying health needs and in providing and evaluating the care provided. It is also care that is provided within the cultural context of the client (The AAN Expert Panel on Culturally Competent Nursing Care 1992).

The focus of the report is on minority populations which in the United States are African Americans, Hispanics, Asian/Pacific Islanders, and Native Americans.

Others, such as Leininger ( 1995), view cultural competence as a distinct concept of transcultural nursing care, which incorporates a variety of abilities and cultural skills. Purnell and Paulanka ( 1998) at University of Delaware propose that a culturally competent approach involves developing an awareness of one’s own existence, thoughts and environment without letting it have an undue influence on those from other backgrounds; demonstrating knowledge and understanding of the client’s culture; accepting and respecting cultural differences; and adapting care to be congruent with the client’s culture.

Campinha-Bacote ( 1994) defines the attainment of cultural competence as:

a process, not an endpoint, in which the nurse continuously strives to achieve the ability to work within the cultural context of an individual, family or community (who come) from a diverse cultural/ethnic background (pp.59-60).

In the culturally competent care model developed by Campinha-Bacote at Ohio State University and the University of Cincinnati, the development of cultural competence is seen as a process rather than an end-point. Competence involves cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. Writing in the context of cultural competence in nursing research Labun ( 2001) at University of North Dakota College of Nursing describes one attractive learning objective in terms of a ‘cultural discovery’. Exposure to, and working with patients of diverse backgrounds, does not in itself lead to this cultural discovery.

Definitions of cultural competence have been adapted for a variety of specialty areas of nursing such as psychiatric and mental health nursing (Warren 2000). In promoting best practice, Warren believes that the cultural competence process may be easier for psychiatric and mental health nurses to develop and incorporate into their nursing education than some other specialties.

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Measuring cultural competence in nursing

In a South-Eastern area of the US, Smith ( 1998b) has analysed the relationship between scores and sub-scores on scales measuring concepts of cultural competence among nurses. The number of scales included in the analysis conveys some impression of the diversity of concepts being targeted by the measures. These include the Giger and Davidhizar Transcultural Assessment Model, the Theory and Cultural Self-Efficacy Scale (CSES) and the Cultural Attitude Scale developed by Bonaparte ( 1979).

Although the nursing education literature has come to celebrate ‘cultural competence’, it seems there is no rigour to what is really meant by it. In addition, the term has conjured a tendency towards the development of check-lists or tool-kits to measure it. Taxonomies of cultural competence in nursing (by which authors seem to mean hierarchies rather than taxonomies) abound. Most share in common the progression from knowledge and awareness to competence. However, Clare Carberry ( 1998) at La Trobe University raises a legitimate concern in that the competency framework may be nothing other than ‘another manifestation of the economic rationalist/business methods currently dominant’ and that ‘in this environment the product of worker activity or, alternatively worker performance itself, [cultural competence] is disproportionately paramount’. Carberry warns that a competency framework does not allow for uncertainty, which is a vital part of cultural competence.

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Some limitations

Despite its substantial theoretical advance over the old ‘cultural sensitivity’ or ‘cultural relevance’, one gets the feeling that the term cultural competence is sometimes bandied about as jargon. There are some noteworthy critics. Clare Carberry at La Trobe University questions the adequacy of the competency approach when applied to nursing. Carberry take a leaf from the criticism by Clark ( 1995) on the introduction of a competency approach to social work. Carberry and Clark are in accord that the competency approach focuses too much on performance and not enough on the person (Carberry 1998).

The development and assessment of cultural competence focuses on outcome, but the client is notably absent from the list of experts available to assess health professionals’ knowledge. Carberry advocates that clients should be involved in the formulation and evaluation of cultural competence. Wells, in Georgia, warns that cultural competence has not gone far enough along the road from cultural awareness and cultural sensitivity and that the next step after competence is cultural proficiency, which extends into nursing practice, administration, education, and research (Wells 2000). Walker, at University of Tasmania, has undertaken ‘a "radical hermeneutic" interrogation of the cultural text of clinical practice’ and ‘a poststructuralist interpretation of the literal text of the Australian competency project’, to expose ‘the problems posed by an uncritical appropriation of competency based training and assessment in nursing education’ (Walker 1995).

Finally, as an antidote to cultural competence being simply a shallow mastery through checklists, there is a voice in medical education for ‘cultural humility’ which, according to Melanie Tervalon at University of California San Francisco, ‘incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the dynamic between the health care provider and the patient, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations’ (Tervalon & Murray-Garcia 1998).

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Applications of cultural competence theory in nursing

It is in nursing that cultural competence has spawned, influencing broad areas of nursing practice. Theories of cultural competence have been applied to:

    • Nursing education and research: Faculty infrastructure for cultural competence education (Chrisman 1998); education (Campinha-Bacote, Yahle, & Langenkamp 1996); a multicultural care plan for nursing education (Bucher, Klemm, & Adepoju 1996); cultural competence in oncology nurse education (Taoka 1997); (Stewart 1998), scholarship and research (Alpers & Zoucha 1996; Campinha-Bacote 1995; Campinha-Bacote & Padgett 1995; Meleis 1996; Sawyer, Regev, Proctor, Nelson, Messias, Barnes, & Meleis 1995) and other areas areas 
      (Lester 1998a; Lester 1998b);
    • Care delivery: (Felder 1996); Using local knowledge to increase cultural competence in primary care nursing (Holland & Courtney 1998); General ­ enhancing cultural competence (Grossman 1994); The ethics of culturally competent nurse education and research (Silva 1994); Culturally competent teaching strategies for Asian nursing students for whom English is a second language language (Kataoka-Yahiro & Abriam-Yago 1997) and cultural competence for working with specific ethnic populations such as the Latino (Peragallo 1999) and Japanese clients in the United States (Sharts-Hopko 1996) and with Lakato Native Americans (Kavanagh et al. 1999); nursing in non-Western settings such as in Saudi Arabia (Crane 1994) (Luna 1998).
    • (Kavanagh et al. 1999; Lester 1998b; Lester 1998a)
    • Care within clinical specialties: perioperative (Giordano 1996), and dermatology nursing (Chussil 1998); HIV/AIDS care nursing (O'Connor 1996); and psychiatric nursing (Campinha-Bacote 1994a); Psychiatric nursing care for clients with a history of sexual abuse (Austin et al. 1999); domestic violence in the context of nursing (Campbell & Campbell 1996); cultural competence of measurement scales of menopausal symptoms (Im, Meleis, & Lee 1999) and ethnopharmacology (Campinha-Bacote 1994b);
    • Obstetric and gynaecological care: a culturally competent model of perinatal risk reduction (Gonzalez-Calvo et al. 1997); culturally competence nursing care during the perinatal period (Willis 1999); care in nurse-midwifery for immigrant and refugee women (Downs 1977); maternal patient education (Freda 1997); nursing and child health policy (Campinha-Bacote 1997); Rori ( 1996) el al. at Boston University have described the role nurse-midwifes can take in promoting cultural competence in primary care services for women
    • Health promotion and community care: Community based experiences in nursing (Baldwin 1999); Transcultural perspectives in nurse administration (Andrews 1988); The role of health promoters in cultural competence (Poss 1999); Competency-based nursing practice models of staff development in a multicultural setting setting (Marrone 1999; Stewart 1991); Bilingualism among health staff including nurses (Elderkin-Thompson, Silver, & Waitzkin 2001);
    • Measurement of Cultural Competence: Efforts have been made to measure cultural competence in nursing. Campinha-Bacote ( 1999) proposes an instrument, the Inventory to Assess the Process of Cultural Competence Among Healthcare Professionals (IAPCC), a 20-item instrument that measures the constructs of cultural awareness, cultural knowledge, cultural skill, and cultural encounters. According to Campinha-Bacote, the instrument has construct validity because of its linkage with a theoretical model and the use of the known-groups technique. One catch The IAPCC is self-administered. Rosemary Taylor in Miami ( 1998) outlines strategies for nurse managers to check their cultural competence. Salimbene ( 1999) at Interface International, Rockford, Illinois, lists ten elements in measuring culturally competent nursing care. Kim-Godwin et al. at University of North Carolina School of Nursing developed the Cultural Competence Scale (CCS) (Kim-Godwin, Clarke, & Barton 2001; Salimbene 1999; Taylor 1998).

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The explosion of cultural competence theory in health

We see cultural competence applied to health care in many areas of medicine and health sciences ­

    • Clinical areas such as diabetes education (Brown & Hanis 1999); critical care (Hadwiger 1999); and transplantation (Washington 1993);
    • Developmental and life-cycle areas such as the physician-patient relationship in paediatrics (Flores 2000); adolescent health (Martinez 1998); working with young children and families (Lynch & Hanson 1992); the meaning of filial piety in parent child relationships (Tsai 1999); and care of the elderly (Bakalchuk et al. 1991);
    • Antisocial behaviour (Coatsworth et al. 1997); treatment programs for partner abuse (Williams & Becker 1994); treatment programs for drug abusing (Hewitt 1993) people including adolescents (Kurtines & Szapocznik 1995),
    • Behavioural areas such as research ethics in psychology (Gil & Bob 1999); occupational therapy and mental health (Dillard et al. 1992); increasing the therapeutic alliance and patient compliance (Langer 1999); child and adolescent psychiatric residency training (Kim 1995); and the ethnic and cognitive match between therapist and patient in psychotherapy and counselling (Sue 1998);
    • Building cultural competence into health consumer satisfaction (Bushy 1995); resources for building cultural competence (Lu 1996; May 1992); health services management (Jones, Bond, & Cason 1998); managed care ( 1999), measurement of quality of managed care organisations (Lavizzo-Mourey & MacKenzie 1995), managed care (Lavizzo-Mourey & Mackenzie 1996; Rogers, Spencer, & Uyangoda 1998) (Campinha-Bacote & Campinha-Bacote 1999; Like 1999);
    • A range of other areas including medical ethics (Richardson 1999); family practice healthcare (Setness 1998); refugee health (Gervais 1996); primary care for women (Rorie, Paine, & Barger 1996); public health (Hanley 1999; Jones, Bond, & Mancini 1998);and lesbian and gay health (McGarry, Clarke, & Cyr 2000);

Cultural competence is also establishing a toe-hold in various health care professions, including dentistry (Lund 1999) (Mercado Galvis 1995). It also would seem to underpin workforce diversity management (Shaw-Taylor & Benesch 1998). For example, George Simmons International has produced HealthCare DIVERSOPHY, a cultural competence training tool for nurse executives (George Simons International 2001; Salimbene 1998).

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Cultural safety

Why cultural safety?­ The bicultural context of New Zealand

Cultural safety is a concept that has been developed by a group of Maori nurses in New Zealand in order to reflect on nursing practice from their point of view as the indigenous minority. Culturally unsafe practice is defined as:

‘any actions which diminish, demean or disempower the cultural identity and well-being of an individual.’ Culturally safe nursing practice includes ‘actions which recognize, respect and nurture the unique cultural identity of the Tengata Whenua [‘people of the land’], and safely meet their needs, expectations and rights’ (Wood & Schwass 1993).

It is also defined as

‘the effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on his/her own cultural identity and recognises the impact of the nurse’s culture on his/her own nursing practice’ [Nursing Council of New Zealand 1996 in (Spence 2001b) .

Cultural safety was brought to the national media's attention by Irihapeti Ramsden (Ramsden 1990) and, in the spirit of the Maori renaissance in New Zealand, adopted by the Nursing Council of New Zealand as part of the basic curriculum for nursing training. Catherine Cooney of the Whangarei Area Health Service notes that cultural safety and transcultural nursing share in common an emphasis on nursing education; the importance of nursing understanding the concept of culture; nurses understanding their own cultural values; and difficulty for nurses who are not members of the dominant culture. The differences between the two approaches are 'perspective' versus 'reality'; 'unicultural orientation' versus 'institutional racism'; and 'theory' versus 'conceptual framework' (Cooney 1994). Cultural safety is not cultural sensitivity, and seeks to replace that idea. 'Cultural safety is not about cultural practices as such but seeks to recognise the position of certain groups in society, and how they are treated rather than how they are different. It is not based on multiculturalism, but on biculturalism, and focuses on the power and racism of the dominant over the native inhabitants. Biculturalism asserts the primacy of the Tengata Whenua or Maori, the original inhabitants of the land. Within this model, structural inequalities within a society need to be addressed (Papps & Ramsden 1996; Polaschek 1998) [but see Leininger's responses to Cooney (Leininger 1996c; Leininger 1997)].

Work on cultural safety in New Zealand concentrated on the attitudes which individual nurses bring to their practice, attempting to change the effects of their social conditioning on their approach to nursing (Polaschek 1998). It is embedded in the thinking of New Zealand nursing education (Ramsden 2000; Sherrard 1991; Wright 1995). It is noteworthy that cultural safety was adopted by the Nursing Council of New Zealand as part of the basic curriculum for nursing training, and Kearns at University of Auckland suggests that cultural safety has a place beyond nursing education (Kearns 1997). The notion of cultural safety is also being taken seriously in Australia. For example, a team of Queensland Aboriginal community organisations, the Council of Remote Area Nurses of Australia (CRANA) and University of New England, noting the depth of cultural danger perceived by Aboriginal clients, has applied cultural safety to community development and health (Dowd & Eckermann 1992).

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The New Zealand strategic review of nursing education

It is appropriate in this consideration of cultural safety to draw lessons from the New Zealand Strategic Review of Undergraduate Nursing Education (KPMG Consulting 2001). The review’s overall objective of was to provide recommendations to the Council on the preparation of nurses to meet health sector requirements in the year 2010. Consultation with Maori was a core component of the review and extensive input was sought. Key elements of the consultation process included the establishment of a national Maori reference group (separate from the general reference group of the review), drawing members from Maori nursing groups, Maori nursing council representatives, Maori educators, Maori policy makers and funders, Maori consumers, and Maori health providers; and formal consultation with key Maori groups and individuals, including the conduct of four hui nationwide.

Consultation with Pacific peoples was important, including formal consultation with groups and individuals, and the conduct of two fono to enable key issues to be identified and discussed.

Specific issues were identified for Maori.

Nurses will need to understand why the Treaty of Waitangi is often used by Maori as the framework for which to express their values, developmental aspirations and service expectations. The Treaty, as a starting point, will ensure that the nurse of the future understands the loss and deprivation of culture that Maori experience; hence the future nurse will understand and empathise with different value systems.

The second major issue … is continuing health disparities …The nurse of the future will have to be flexible and adaptable to meet the wider socio-economic realities of Maori, including poverty, rurality, and communication barriers. An understanding… of public health principles, within a Maori context, will be important in understanding health care needs and how to respond to them at an individual and community level.

Appreciation of tikanga and te reo can only nurture the working relationship between the nurse and the Maori whanau. The nurse will have to be more mobile to increase Maori access to services, and as a "broker" to other non-medical services.

…It will be an expectation that the nurse of the future understands the Maori holistic views of health, such as whare tapa wha, and accordingly assesses and services whanau with this prerequisite in mind.

The report also identifies specific issues for Pacific peoples.

The teams that work in the communities will have (as a minimum) Pacific nurses. These nurses will have a confident understanding of their own culture and language and will be able to nurse with Pacific communities in a way that enables the well being of patients and clients. According to a forum of Pacific nurses, the current cultural safety programme does not properly prepare nurses to work with Pacific peoples.

The Pacific nurse of the future will be a role model for upcoming undergraduate nurses, …(and) will also be participating actively with non-Pacific colleagues at every level of the health sector.

One might reflect upon the capacity of broad, generally focused education in multicultural health to bring about a change in practices based on cultural biases - focusing instead on the need for a cultural mix in the nursing profession that matches the local cultural diversity (for example, will have as a minimum a complement Pacific Nurses). This is an issue for student recruitment.

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Some limitations

The concept of cultural safety has come under criticism, mainly in the local media. Cultural risk is not specifically about being indigenous, but being a minority, no matter what their origins, oppressed by the dominant culture. Second, the definition of culturally unsafe practices refers to individual experience, so nurses naturally are encouraged to learn to be culturally safe in their clinical interactions with individuals. At the same time, the definition of cultural safety has to do with Maori as a collective , but the relation between the individual and group levels is not well understood. These criticisms reflect the political rather than academic origins of cultural safety (Polaschek 1998).

Spence notes that the implementation of cultural safety in nursing education has created tension within the profession and between nursing and the wider community. Spence carried out a hermeneutic study that explored the experience of nursing people from cultures other than one’s own. As nurses negotiate the conflicts, the play of prejudice, paradox and possibility is evident at intrapersonal and interpersonal levels as well as in relation to professional and other discourses. Nurses are challenged to continue their efforts to understand and move beyond the prejudices that otherwise block the exploration of new possibilities (Spence 2001a; Spence 2001b). The point about cultural safety is that, unlike other neo-colonial academic studies of culture and health, there has to be genuine sharing of power rather than appropriation of cultural knowledge by the experts.

One final point here concerns the political and social context of the various approaches to nursing education described above. Forwell and colleagues at University of British Columbia compared the reflections of occupational therapy students in Canada and New Zealand to illuminate the lived experiences of the students as they learned about cultural issues issues (Forwell, Whiteford, & Dyck 2001).However, New Zealand is a bicultural society and countries such as Canada and Australia are multicultural. Attempting a comparison between such diverse contexts in the teaching of cultural competence in nursing education may, in fact, be an attempt to compare apples with oranges.

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A key example of cultural safety in Australia ­ Indigenous nursing education at Flinders University

Flinders University has gone further than most in articulating cultural safety and embedding it in its undergraduate nursing program. The following is extracted from the new curriculum of the Bachelor of Health Science/Bachelor of Nursing, and accredited by the Nurses Board of South Australia.

The School of Nursing & Midwifery acknowledges the unique nature of Aboriginal and Torres Strait Islander peoples’ culture and traditions. Further, the School has prioritised cultural safety as a specific factor to be monitored within the ongoing development of the Bachelor of Nursing. Whereas cultural awareness and cultural sensitivity are processes, cultural safety in education and practice refers to an outcome that can be measured by people receiving the service. Cultural safety is defined as:

The effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on their own cultural identity and recognises the impact of the nurse’s culture on (their) own nursing practice. Unsafe cultural practice is any action which diminishes or disempowers the cultural identity and well being of an individual (Nursing Council of New Zealand 1995; endorsed by the Congress of Aboriginal and Torres Islander Nurses, 1997/8).

The School has chosen to:

      • Mainstream education in Aboriginal Health issues rather than provide specific topics (so that Aboriginal Health issues are a specific part of every course/topic and cannot be marginalised by students (or staff);
      • Provide a specific indigenous health option topic in both second and third year and compulsory for those students undertaking a rural/remote placement
      • Work collaboratively with Northern Territory University and Territory Health Services to provide clinical placements for FUSA students in Central Australia in acute, remote and community settings;
      • Plan with THS and NTU and Batchelor College to articulate Aboriginal Health Worker education with undergraduate programs in Nursing and Health Science;
      • Ensure that Aboriginal and Torres Strait Island students are supported during their education in various ways; and
      • Ensure that Aboriginal and Torres Strait Island staff is attracted to the School through evidence of culturally safe practice.

The School of Nursing & Midwifery has been proactive in ensuring that staff are provided with the opportunity to undertake staff development programs that will further develop their understanding of indigenous culture and the impact this has on the Australian health system.

In recognising the need to ensure that cultural safety is a priority issue addressed in program development, a Cultural Safety Working Group was formed in the School of Nursing & Midwifery in 1997. Issues of racism, effects of colonisation on the health of indigenous peoples, sociopolitical issues such as poverty, lack of clean water, adequate housing, access to affordable food and so on and specific health issues affecting the lives of indigenous people, are addressed. An elective topic is available in both second and third year addressing specific indigenous health issues.

The School of Nursing & Midwifery has an established pattern of collaboration and consultation with identified experts in program development, research and education with a number of Aboriginal organisations. There are only 27 identified Registered Nurses who are Aboriginal in Australia and Commonwealth resources are required to support their work as consultants and advisers and to recruit students into educational opportunities.

The specific objectives for each of the three years of the Bachelor or Nursing and Bachelor or Health Science/Bachelor or Nursing degrees at Flinders University include the following year-by-year outcomes regarding cultural safety

At the end of year one, students will be able to:

      • Describe their personal insights into what is nursing and its cultural contexts
      • Demonstrate understanding of the principles of cultural safety in their classrooms, practice settings and assessments.
      • Explain a range of different cultural concepts of health, wellness, illness and disease
      • Describe their personal insights into the range of cultural narratives about indigenous history and health
      • Articulate the tensions between cultural explanations and economic, educational and social implications at a beginning level
      • Practice with cultural awareness

At the end of year two students will demonstrate in their practice, classroom and assessment:

      • Evidence of their ability to reflect critically on cultural implications and imperatives of health care in a range of settings
      • Question and critique texts that are monocultural in intent
      • Reflect and consider the attitudes and behaviours of self and others in cultural safety terms
      • Continued development and analysis of theories of difference including the ways in which categories such as race; ethnicity; gender; age; ability are constructed and maintained in a multi-cultural and global context
      • Demonstrate in their practice an ability to discern culturally appropriate nursing care
      • Understand the ethical implications of nursing care in culturally diverse situations.

At the end of year three Cultural Safety will be the outcome of nursing care provided by all third students. They will:

      • Integrate cultural safety within all aspects of their nursing
      • Demonstrate that they can deliver culturally competent care
      • Appreciate and articulate the particular ethical implications of research practices for nurses working with Aboriginal communities and peoples from other marginalised groups in society.

The course outline above values cultural safety as a core goal of its nursing education practise. It demonstrates that cultural safety skills are for everyone in nursing education, not just specialists.

 

 

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