In May I wrote about the Case for Diversity and Cultural Competence. After participating in a meeting sponsored by the California Endowment on “Nursing and Cultural Competence” I would like to offer additional insight to this essential topic. As I reviewed the papers developed for the meeting and listened to the discussion it struck me that the discipline has not established a commonly understood framework and that more discussions like this one would help refine and advance the knowledge and awareness of this complex field.
My best characterization of the discussion is that how we define cultural competence today embodies a tension between a series of perspectives. There is no particular right or wrong with where and how these tensions come about, but dissecting the dichotomies may lead to deeper understanding of why we desire cultural competence, clarified meaning of our definition and improved approaches to the realization of the desired goals.
Particularistic ----- Relationship
The first paired tension is between a particularistic approach to cultural competence and one which is more relationship based. The particularistic views cultural competence as a knowledge or task based undertaking that involves skills, understanding and appreciation of particular cultures and the capacity to translate the existing health care system into a context that appreciates and communicates with that cultural perspective. The particularistic approach values the collection of new knowledge about unique cultures and how they understand health and accommodate disease. It is respectful of these cultures but seeks to understand and unlock them so as to align them with the goals of the dominant health care system.
The other side of this tension is a relationship based perspective that values the distinctiveness of each individual, but seeks to balance this in a quality of relationship between patient and provider or provider and provider. Here the core value is on that interaction between two individuals and assumes that some qualities of human interaction transcend cultural distinctions. Key to this approach is a foundation of cultural humility which approaches the “other” with a mind open to discovery and a willingness to reveal parts of oneself in the process, including uncertainty.
My general sense of this tension is that most of the traditions of health care and professionalism in the US will reside more comfortably on the particularistic side of the equation. Neither side, to the exclusion of the other, offers what is needed in building the internalized cultural competence in individuals and throughout the organizations that provide care. Both individuals and systems will work best as they seek to understand and balance these two approaches to improve the outcomes of the system.
Conceptual ----- Experiential
This little essay is of course on the conceptual side of this tension and efforts to provide frameworks, vocabulary, analysis, and links to other literature will only help strengthen the understanding and appreciation of cultural competence as a construct and a reality. Important work is being done in groundbreaking fashion in an effort to strengthen our grasp of these phenomena. But for every step into the conceptual realm it is vital to remember that knowing cultural issues inside and out will be only part of effective practice. The other piece can only come with an experiential immersion into the discomfort of interactions, uncertainties, and resolutions that occur when one takes the chance to embrace those individuals and patterns that live outside of where we comfortably reside. This is accomplished by action; the firsthand experience of seeing how a new pattern of interaction impacts oneself and others and how mutual interest and effort can resolve the impasses which may arise when two cultures collide.
Transactions ----- Transformations
If cultural competence is only seen as a transaction, one that can be improved with particular knowledge, then the meaningfulness of the exchange will be improved but will not transform the essence of the exchange between patient and provider or health system. This difference may come to be seen as very important because if we are trying to change the character of the health system through cultural competence, it will mean more than just giving instructions in Spanish, as important as that is as a first step. Such efforts will improve the transactions, but not reach the level of a transformation. For such a change to occur, the attention to cultural competence will need to be engaged in a way that is both particular and focused on the relationship and allows for both conceptual and experiential understanding. In this way the dominant culture of medicine and its orientation toward healing sickness can truly be transformed to encourage health through aligned and intact cultures. Balancing cure with well-being is the ultimate challenge and the health care system is more likely to succeed in this endeavor with a deeper understanding and clearer definition of cultural competence.