Irena Papadopoulos PhD, MA (Ed), BA, DipN Ed, DipN, NDN Cert, RN, RM
Professor of Transcultural Health and Nursing
Research Centre for Transcultural Studies in Health
London N19 5LW
Mary Tilki MSc, PhD, BA, DipN Ed, RN
School of Health and Social Care
Queensway EN3 4SF
Shelley Lees MRes, BSc, RN
Health Policy Officer, Public Health Southwark PCT
358 Waterloo Road,
London SE1 8RG
There is an urgent need to develop cultural competence among nurses and other care workers if they are to meet the needs of the diverse populations they serve, yet there is limited clarity about what this means, or how it can be measured. To date few attempts have been made to measure the effectiveness of education and training programmes which are designed to promote cultural competence. A research project commissioned by mental health service providers was undertaken to deal with the increasing need for cultural competence in a number of mental health care settings. It involved the delivery of a training intervention with an assessment of cultural competence before and after the intervention. The training intervention was negotiated with the participating teams and was based on the Papadopoulos, Tilki & Taylor model (1998). The project included the design and development of a tool for assessing cultural competence (CCATool). The paper discusses the challenges faced by the trainers during this intervention and proposes a set of principles for the development of effective cultural competence programmes.
Cultural competence, awareness, sensitivity, knowledge, cultural competence assessment tool, intervention
What is already known on this topic in the UK?
Despite increasing reference to the term cultural competence in Department of Health (DoH) and National Health Service (NHS) documents in recent years, there is limited attention to what this actually means for patients or staff and as such it is difficult to establish how it might be measured.
There is significant investment in study days, short courses and more substantive programmes by NHS Trusts and public services providers. These initiatives are diverse in content, duration, mode of delivery and of the skills of those who facilitate them. However, these have not been evaluated to measure their impact on practice.
The Race Relations (Amendment) Act 2000 places a duty on all public authorities to tackle racism in service delivery, so the onus is on authorities to bridge their knowledge gap, challenge prejudices and stereotypes and respect the needs of citizens from all cultures.
There are vast differences as to what is the state of knowledge in the USA, Australia or other parts of the world.
What this study adds?
Provides details of how the Papadopoulos, Tilki and Taylor model was used to develop the cultural competence of mental health practitioners.
Provides details of the development and use of a Cultural Competence Assessment Tool.
Proposes levels of cultural competence to facilitate the measurement of it.
Provides a set of principles for effective cultural competence training.
Promoting cultural competence in health care through a research based intervention
The body of work in the field of transcultural theory has increased since Madeleine Leininger first began her work in the 1950s, and in recent years there has been an expansion in the number of transcultural models on offer to inform nursing practice. They have mirrored social and political shifts in attitude towards and concern for Black, immigrant and aboriginal communities in the USA, Australia and New Zealand. With a few exceptions, the National Health Service (NHS) and British nursing were somewhat late in seriously addressing transcultural issues (Holland & Hogg, 2001). However, in the late 1990s and early 2000s a raft of cultural diversity policies emerged, recognising the changed demography of Britain and the need to address cultural issues in the wake of the Macpherson Report (1999) of the Stephen Lawrence Enquiry (see box 1) and in an NHS undergoing modernisation.
Box 1:The Macpherson Inquiry This article describes a research based training intervention which included the development and use of a cultural competence assessment tool. It discusses the challenges of teaching cultural competence and reflects on factors which enhance or impair the success of training interventions.
Despite increasing reference to the term cultural competence in Department of Health (DoH) and National Health Service (NHS) documents in recent years, there is limited attention to what this actually means for patients or staff and as such it is difficult to establish how it might be measured. This reflects the wider literature where there is limited consensus around an exact definition of what constitutes cultural competence and a particular absence of what it means for the client. In the UK, health and social care literature and policy documents are unclear and appear to use the terms cultural sensitivity and cultural awareness (and others) synonymously with that of cultural competence. However, there is little doubt about its desirability for nursing clients from all cultures in all care settings (Holland & Hogg, 2001). If cultural competence is to be operationalised and its use and effectiveness measured, it is important to have a clear definition of what it is. It is particularly salient that such a definition is not an abstract statement but is meaningful and applicable for health and social care practitioners, providers of services and those charged with the development of cultural competence training programmes.
There is significant investment in study days, short courses and more substantive programmes by NHS Trusts and public services providers. However, a trawl of UK websites using the terms such as cultural competence, sensitivity or awareness training show that these initiatives are diverse in content, duration, mode of delivery and of the skills of those who facilitate them. More surprisingly the authors of this article have been unsuccessful in their attempts to find studies which attempt to measure the impact of educational initiatives on practice or in terms of patient satisfaction.
Cultural competence is variously defined in terms of the outcomes for individual clients and groups or as the attitudes, and behaviours of practitioners and organisations or a combination of both. While there is never likely to be a single definition which is wholly acceptable to all, the following typifies the definitions found in the literature. It highlights the aims of cultural competence and the attitudes and skills which are essential for its development.
“… the ability to maximise sensitivity and minimize insensitivity in the service of culturally diverse communities. This requires knowledge, values and skills but most of these are the basic knowledge and skills which underpin any competency training in numerous care professions. Their successful application in work with diverse people and communities will depend a great deal upon cultural awareness, attitudes and approach. The workers need not be as is often assumed highly knowledgeable about the cultures of the people they work with, but must approach culturally different people with openness and respect – a willingness to learn. Self awareness if the most important component in the knowledge base of culturally competent practice.” (O’ Hagan, 2001, p. 235)
The importance of cultural competence
As the diversity of populations continues to grow in most parts of the world, the importance of cultural competence in the caring professions has never been more acute. Health services designed to cater for relatively mono-cultural populations are increasingly required to review their ability to meet the needs of different ethnic groups. Government directives, legislation, health and social care policies, health improvement targets, consumerism, shrinking resources, economic rationalisation, and a host of other initiatives demand cultural competence by organisations and practitioners. Increasingly there is a danger, that organisational or government targets which rely on uptake of services or particular service outcomes will not be achieved without culturally competent provision, particularly in areas of high population diversity (Acheson, 1998).
Lack of evidenced based transcultural nursing and research knowledge about cultural differences makes it difficult for providers to deliver and for clients to experience quality, cost effective care. While there are many similarities between people from all parts of the world, there are also differences which arise from culture, religion, family background and individual or group ‘influencing care’ experiences. These differences not only impact on the values, beliefs and behaviours of clients, they underpin ideas around the provision of care and influence the expectations that clients and practitioners have of each other.
Although there is evidence of racism in the NHS, it is less a product of the malicious intentions of individual staff or service providers, but reflects what the Macpherson report (1999) refers to as institutional racism (Box 2). Failure to recognise cultural differences, a feeling that these differences are not significant or that attention to individualised care will transcend them, can result in discrimination which may be either intentional or unintended. Health and social care staff are constantly under pressure of time which they argue, prevents them from looking in depth at the cultural needs of their clients. However, while this is not denied, it is also possible that they are unwilling or fearful of the unknown, reluctant to admit lack of knowledge or understanding health beliefs and practices which do not fit their own world view. Similarly partial knowledge or inadequate understanding can lead to assumptions or adherence to stereotypes which categorise cultural groups without attention to the diversity within them. This leads to assumptions that all members of a group hold the same beliefs and think and behave in the same way, denying the differences which reflect gender, class, age and experience.
Box 2:Macpherson's definition of institutional racism
While the Macpherson definition of racism is useful in highlighting the subtle institutional factors which impact on clients, institutional racism is no less damaging than more overt forms of racism, so there is no reason to be complacent. The Race Relations (Amendment) Act 2000 places a duty on all public authorities to tackle racism in service delivery so the onus is on authorities to bridge their knowledge gap, challenge prejudices and stereotypes and respect the needs of citizens from all cultures.
Models for developing cultural competence
Whilst it is acknowledged that the dominant theory of transcultural nursing is that based on the pioneering work of Madeleine Leininger (1969), there now exist a number of other transcultural models providing systematic approaches to nursing practice (Campinha-Bacote 1991, Geiger and Davidhizar 1995, Purnell and Paulanska 2003, Papadopoulos et al 1998).
Transcultural models, like generic nursing models, can be used in their own right to guide nursing assessment and care but in recent years are more likely to be incorporated into the interdisciplinary documentation developed for Integrated Care Pathways to patient care (Stead & Huckle, 1997). Nursing models such as Leininger’s Sunrise Model (1995), Purnell’s Cultural Competency Model (2003), and the Papadopoulos et al’s (Papadopoulos, Tilki & Taylor, 1998) model for developing cultural competencies, provide detailed frameworks for the development of culturally competent nursing. The training intervention for this study was based on the latter model.
Papadopoulos (2003) defines cultural competence as:
“…the capacity to provide effective healthcare taking into consideration people's cultural beliefs, behaviours and needs…cultural competence is the synthesis of a lot of knowledge and skills which we acquire during our personal and professional lives and to which we are constantly adding…transcultural health is the study of cultural diversities and similarities in health and illness as well as their underpinning societal and organisational structures, in order to understand current health care practice and to contribute to its future development in a culturally responsive way” . (p. 5)
To provide this knowledge and skills with structure and to facilitate learning, the following stages were proposed (see Figure 1)
Figure 1: The Papadopoulos, Tilki and Taylor Model for Developing Cultural Competence
A conceptual map is provided for each stage as a guideline only and can be modified to suit the type and level of students. The first stage in the model is cultural awareness which begins with an examination of one’s personal value base and beliefs. This raising of self awareness crucially contributes towards one’s understanding of the nature and construction of their cultural identity. At the same time a person becomes more aware that his/her cultural background is a major factor in shaping one’s values and beliefs which in turn influences one’s health beliefs and practices. Therefore the ‘cultural awareness’ stage constitutes an essential first stage in the process of achieving cultural competence; unless one goes through this stage, it is unlikely that s/he can become culturally sensitive and ultimately competent.
The second stage is cultural knowledge which can be gained in a number of ways. Meaningful contact with people from different ethnic groups can enhance knowledge about health beliefs and behaviours and raise understanding of the problems they face. This knowledge is required in order to understand the similarities and differences of cultural groups as well as the inequalities in health within and between groups, which may be the result of structural forces in society, such as the power of health care professionals, and the role of medicine in social control. Sociological study encourages the students to consider such issues and to make links between personal position and structural inequalities. However, cultural knowledge can be gained from all disciplines normally used to underpin nursing curricula, such as psychology, biology, pathology and so on. Of particular relevance are anthropological studies, whilst historical understanding is increasingly being emphasised. Most importantly, evidence based transcultural nursing knowledge is expanding through research studies conducted by nurses across the world. However, it has to be acknowledged that large components of nursing knowledge, as indeed is the case for other professions, remains non-research evidence based (Smith 1991).
An important element in achieving cultural sensitivity - the third stage - is how professionals view people in their care. Considering research participants as true partners, is an essential component of cultural sensitivity and a crucial element in anti-oppressive practice (Dalrymple & Burke 1995). Partnership demands that power relationships are challenged and that real choices are offered. These outcomes involve a process of facilitation, advocacy and negotiation that can only be achieved on a foundation of trust, respect and empathy. The importance of cross-cultural interpersonal communication cannot be underestimated. Ting-Toomey (1991) warns us that most of the interpersonal communication theory originates largely from individualistic, Western cultures, thus it is inevitable that terms that are widely used reflect a Western-based ideology. Therefore, although the concepts proposed under the cultural sensitivity map should be part of nursing curricula, there is no guarantee that these are taught from a transcultural perspective.
The achievement of the fourth stage, that of cultural competence requires the synthesis and application of previously gained awareness, knowledge and sensitivity. Further, focus is given to practical skills such as assessment of need, clinical diagnosis and other caring skills. A most important component of this stage of development, is the ability to recognise and challenge racism and other forms of discrimination and oppressive practice.
Throughout professional life, a set of culturally generic competencies that are applicable across cultural groups are developed and used (Gerrish & Papadopoulos, 1999). These culture-generic competencies, such as the appreciation of how cultural identity mediates health, or a deeper understanding of the underpinning societal and organisational structures which promote or hinder culturally competent care, help the acquisition of culture-specific competencies, which are particular to specific cultural groups. It is impossible for any health worker to know all about the numerous cultural groups in the UK. However, using culture-generic competencies it is possible to gather the relevant culture-specific information needed to care for the patient. Figure 2 depicts the dynamic relationship between culture-generic and culture-specific competencies (Papadopoulos & Lees, 2002).
Figure 2: The culture-generic and culture-specific model The Cultural Competence in Action Project (CCAP)
The aim of the project was to deliver a team based, practice focused model of education and training to promote cultural competence in a small number of multi-disciplinary mental health teams.
CCAP Project Design
The project began with an assessment of cultural competence at micro-organisational level, using a tool designed by the authors who led the research project. This was followed by service users’ focus groups which highlighted issues important to clients and their families. These parts of the project will not be discussed in this paper. The participants of the project undertook an assessment of their cultural competence prior to the educational intervention using a tool (CCATool) designed by the authors. The educational intervention was planned to capture the existing strengths of participants and to remedy deficiencies. Priorities were negotiated and agreed with the participants, resources identified and appropriate learning activities decided. The agreed educational programme was facilitated in the workplace by two of the authors who are experienced trainers over a four month period. It was followed by a post intervention assessment of their cultural competence using the same tool. A conventional evaluation of the training intervention was conducted which will not be reported on in the paper.
The Cultural Competence Assessment Tool (CCATool)
The self assessment CCATool is based on the Papadopoulos, Tilki & Taylor (1998) model and was developed drawing on the ethnic health and transcultural literature and reflecting the authors’ experience as nurses, researchers and educationalists. It consists of four sections (awareness, knowledge, sensitivity and competent practice) with an equal number of statements in each section to which the participant can either agree or disagree with. In addition, visual analogue scales (VAS) are included which allow the participants to self-rate their cultural awareness, knowledge, sensitivity and practice (see Figure 3 for section one of the tool.).
Figure 3 Section One of CCATool
Validity and Reliability of CCATool
In order to establish the validity of the statements, comments were invited from a panel of experts in the field of mental health, ethnicity and culture. The tool was revised in the light of comments from the expert panel and a version with twelve statements per section was piloted with mental health professionals and students to test reliability and internal consistency. The statistical test for this revealed that in each of the four sections answers to 10 of the 12 statements were highly correlated (Chronbach’s alpha score > 7). These forty statements formed the final tool. Statements included generic cultural items relevant to any area of health care practice as well as statements specific to mental health care.
Cultural Competence Levels
The agree/disagree responses to statements were marked by the authors and a level of cultural competence was assigned depending on which statements were correct. The levels which they could achieve were cultural incompetence, cultural awareness, cultural safety, or cultural competence. As they were unable to determine their own level of cultural competence on completion of the tool the Visual Analogue Scale (VAS) provided them with an opportunity to self-assess their competency and provided the researchers the opportunity to compare personal perceptions of cultural competence with the objective scoring. It was anticipated that the participants would achieve a higher level of cultural competence as a result of the intervention.
Although the CCAP project was initiated by NHS mental health Trust managers the content of the programme was negotiated with the care staff who would be participating. Specific content was negotiated with them but the intervention was also tailored to address the underlying philosophies and constructs of the model. Thirty five members of staff participated in the project, attending eight sessions, arranged in their workplace, over a four month period. Two sessions were planned for each stage of the model but adapted to meet the requirements of the different participating teams.
Cultural Awareness Sessions
The aim of the cultural awareness sessions were to assist participants in recognising the need to examine their own cultural values, beliefs and practices in order to reduce the risk of cultural bias, cultural clashes and the imposition of inappropriate or unethical care through ethnocentric assessments. A cultural introduction exercise focussed on the culture of the participants, exploring the impact of gender, age and socio-economic and other differences and socialisation in different communities and societies. It highlighted the culture of all peoples including those of English, Irish and other White groups, their regional identities, and the way in which individuals adhered to different aspects of their culture contextually. This was followed by a values clarification exercise emphasising the values which exist across cultures but which are shaped by time and society. Another session focussed on values, beliefs and behaviours exploring the concept of ethnocentricity, examining ways in which they inform perceptions of people and events and particularly how they impact on health care practice.
Cultural Knowledge Sessions
The cultural knowledge sessions did not aim to provide detailed information about cultures but to highlight the potential for misunderstanding due to ethnocentricity, stereotyping and the impact of the unequal distribution of power. However, one staff team requested information about the local Turkish population and therefore they were provided with information about the differing ethnohistories and experiences of the three Turkish speaking communities in the locality and their impact on mental health and attitudes to health services. One session was provided on health beliefs and behaviours and the cultural meanings of mental illness in different minority ethnic groups, and their impact on health and healthcare were examined and one session was devoted to the origin of common stereotypes, examining myths and realities about particular ethnic groups and the impact on mental health and access to healthcare.
Cultural Sensitivity Sessions
The cultural sensitivity sessions focussed on ways of avoiding insensitivity and establishing trust and rapport in order to facilitate accurate assessment, diagnosis and the delivery of holistic culturally appropriate care. One session dealt with interpersonal relationships with clients whose first language was not English and explored differences in verbal and non-verbal communication which impact on the therapeutic relationship. This session included attention to the differing ways in which distress is expressed across cultures and religious groups. The second session focussed on family responsibility and role in relation to caring in different cultures, highlighting differences in family structure, function and roles which influence mental health and health care.
Cultural Competence in Practice Sessions
As cultural competence is comprised of cultural awareness, knowledge and sensitivity, the focus in these sessions was on mental health practice. One session explored the principles of anti-oppressive practice in relation to black and minority ethnic clients and families, exploring their strengths and challenging racist attitudes and practices which tended to problematise them. The other session explored ways of helping clients overcome fear and mistrust, assessing mental state and working with clients’ explanatory models and coping strategies. As in all the sessions, participants shared examples of good and bad practice, and drew upon their own cultural knowledge, professional practice, and perspectives from differing professional disciplines. Where possible research based evidence was utilised but much was learned from the cultural knowledge and experience of participants.
The Results of the Assessment
Thirty five (35) members of staff completed a pre-training assessment of cultural competence tool. Twenty four (24) were found to be culturally aware, 10 were culturally safe and one member of staff was culturally competent. On completion of the training 18 staff completed the assessment tool, the majority remained culturally aware, 4 moved up to culturally safe. Two members of staff moved down a level to culturally aware. Statistical tests revealed no relationship between the assessment according to the statements and the self-rated VAS.
As only half of the participants completed the post intervention assessment it is difficult to draw strong conclusions. Most of the participants stayed at the same level and it is of note that two of them moved down a level. This would suggest that the education intervention had not been very successful. However, the authors postulate that this may be because the impact of such training has a longer term effect, and it may be more useful to re-assess cultural competence a number of months after an intervention and when the participants have had the time to reflect on what they have learnt and put it into practice.
While there was much support for the project at managerial level and several individual practitioners welcomed it, the trainers faced many challenges at all stages of the project. The teams selected for the education intervention were suspicious as to why they rather than other groups had been chosen to participate. Attendance varied among teams and varied according to the topic which was on the agenda. Some participants who appeared under pressure to attend, engaged reluctantly believing they did not need training because they were a senior practitioner, had lived and worked with people from different cultures, or were a member of a minority ethnic group and knew the needs or problems they faced. There was also a feeling that since they practiced ‘individualised care’ they were by implication culturally competent. Staff in one of the participating organisations questioned the credibility of the White trainer believing that only a Black person could understand the experience of discrimination. They also queried the extent to which somebody who was not a mental health practitioner could understand issues for people with mental health problems.
At a practical level it was challenging to reach consensus about what to cover in the limited time available and to obtain the commitment of professionals who perceived they had undergone a similar programme of training in the recent past. There was greater willingness to identify knowledge deficits about particular cultural groups rather than examine beliefs, attitudes towards clients or to reflect on professional practice. The workload of participants influenced their ability or willingness to attend regularly and fully participate and this impacted on group dynamics. It required considerable skill to enable participants to express honest views and attitudes in the presence of, seniors and professionals from other disciplines. There were a number of conflicting views between trainer and trainees and between trainees and at times it was difficult to handle the prejudice, generalizations, stereotypes and thinly veiled racism that emerged in the sessions.
Conclusions and recommendations
The training intervention has highlighted a number of problems with cultural competence training and has consolidated the authors’ belief that there are a number of principles for effective cultural competence training.
Principles for effective cultural competence training
i) Compulsory mandates to attend cultural competence training programmes can lead to resistance or at best superficial participation, invoking sensitivities by suggesting that their performance is less than satisfactory. Therefore, it is more effective to adopt a whole organisational approach involving participants in decisions about the training programme, emphasising the benefits for all the patients/clients as well as the whole organisation (Kandola & Fullerton, 1998). ii) Focusing only on developing the cultural competence of individual care givers will not necessarily result in a culturally competent organisation. To achieve this, the whole organisation needs to be committed and have in place the necessary structures and policies. iii) It is necessary to allow adequate time out for staff to disengage from the intensity of their everyday work and to engage in cultural competence learning. iv) Those involved in delivering training around cultural competence should have time to establish trust and rapport and to be aware of wider organisational factors which impact on the training or caring processes. v) It is important to have a clear framework for the delivery of cultural competence training and to recognise that while educational content is essential, the process of learning is equally significant. vi) Although factual knowledge about groups, habits and customs may be more acceptable to participants, training should be moved beyond the delivery of facts to challenging ethnocentric beliefs, practices and unwitting prejudice among staff. vii) Commencing training with cultural self-awareness is non-threatening, as it highlights the cultural nature of all human beings and helps to establish rapport. viii) It is necessary to include culture-generic and culture-specific input. ix) It is desirable to involve service users in the planning and delivery of the training. x) The learning methods should be responsive to the different cultural backgrounds and diverse learning styles of the participants. xi) The skin colour or ethnicity of the trainer is less important than his or her knowledge and skills in this area. xii) It is essential that the training offers a safe environment to challenge individual racist behaviour whilst not attacking the individual per se. xiii) Cultural competence training invokes strong feelings and even with skilled facilitation may leave well-meaning people feeling guilty about their ethnocentricity or unwitting prejudice. There should be sufficient time for debriefing in order to allow the participants to identify how past weaknesses may become strengths. xiv) Pre and post training assessment of cultural competence is highly desirable for three reasons; to provide information about their existing levels of cultural competence, to give an indication of the effectiveness of the training to the trainers, and to provide the participants with a measure of their progress. xv) Training programmes should be evaluated and lessons learned, and if possible shared with others.
The application of these principles will lead to effective cultural competence training which will result in better patient care for all.
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Box 1: The Macpherson Inquiry The Macpherson Inquiry was a government inquiry into the way in which the Metropolitan Police dealt with the death of the Black youth Stephen Lawrence in London in the late 1990s. The Inquiry headed by Sir William Macpherson of Cluny demonstrated a catalogue of negligence and poor policing which led to the failure to follow up leads and gather sufficient evidence to convict the killers of the young man. The inquiry found that the Metropolitan Police failed to take seriously the racialised nature of the fatal assault against Stephen. While there was evidence of overt racism in the police force, attitudes, organisational systems and policing practices were more a reflection of the stereotypes, ignorance and unchallenged prejudices held at all levels.
Macpherson W. (Chair) (1999) The Stephen Lawrence Inquiry. Report of an inquiry by Sir William Macpherson of Cluny. The Stationery Office, London.
Box 2:Macpherson's definition of institutional racism “Institutional racism consists of the collective failure of an organisation to provide an appropriate and professional service to people because of the colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviours which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic clients” (Macpherson. 1999, p. 18)
Figure 1: The Papadopoulos, Tilki and Taylor Model for Developing Cultural Competence
Challenging and addressing prejudice, discrimination and inequalities