‘Culture’ refers to integrated patterns of human behaviour that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups. ‘Competence’ implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities.
‘Cultural competence’ refers to the relationship between the helper and the person being helped, in a cross-cultural context. While cultural safety centres on the experiences of the patient, cultural competence focuses on the capacity of the health worker to improve health status by integrating culture into the clinical context. This last point is important, and demonstrates the importance of moving beyond cultural awareness. Recognition of culture is not by itself sufficient rationale for requiring cultural competence; instead the point of the exercise is to maximise gains from a health intervention where the parties are from different cultures.
Cultural competence is defined as a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations. Operationally defined, cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of health services; thereby producing better health outcomes. Cultural competence is an important vehicle to increase access to quality care for all patient populations, by tailoring delivery to meet patients’ social, cultural, and linguistic needs.
Therefore, those who practice Medicine and those who impart medical education must develop cultural literacy and cultural tolerance to provide holistic patient care.
“The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in healthcare delivery, while considering first the health of the patient.”
Cultural dictatorship, which enforces a particular practice or prevents other forms of practice, will result dysfunctional medical practice. Dysfunctional medical practices may precipitate glaring deficiencies, poor conflict management and ineffective communication between physician and patient. Unmotivated employees and frustrated patients are the result of such practices. In the worst situations, the health of both groups can be at risk.
Therefore, medicine and medical education stand for providing best care to the patient.
Such a patient-centred care is the truth that needs to be stressed upon without being influenced by nationality, culture, age, gender or religious beliefs. Such a care needs to be nurtured by training the physician to have knowledge about cultural differences. This is essential in the patient-physician relationship dynamics.
The concept of cultural safety is used as an analytical tool to understand everyday interaction between the caregiver and caretaker. Cultural safety is based on the experience of the recipient of care, rather than from the perspective of the medical practitioner. It involves the effective care of a person or family from another culture by a medical practitioner who has undertaken a process of reflection on their own cultural identity and recognises the impact their culture has on their own medical practice.
Cultural safety aims to enhance the delivery of health services by identifying the power relationship between the medical practitioner and the patient, and empowering the patient to take full advantage of the healthcare service offered.
Unsafe cultural practice is any action that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual. Patients who feel unsafe and who are unable to express degrees of felt risk may subsequently require expensive and often dramatic medical treatment.
Cultural safety gives people the power to comment on the care provided, leading to reinforcement of positive experiences. It also enables them to be involved in changes in any service experienced as negative.
Cultural safety recognises that inequalities within healthcare interactions represent in microcosm the inequalities in health that have prevailed through history and within nations more generally. It accepts the legitimacy of difference and diversity in human behaviour and social structure. It recognises that the attitudes and beliefs, policies and practices of medical practitioners can act as barriers to service access, and is concerned with quality improvement in service delivery and consumer rights.
The concept of cultural safety is predicated on the understanding that a caregiver’s own culture, and assumptions that follow, impact the manner in which a clinical encounter is played out and therefore impacts the patient’s care. The burden of cultural adaptation that results when intercultural interactions occur, should be relieved from the patient whenever possible.
A true understanding of the imbalances in a caregiver-patient dynamic requires that the caregiver engages in a process of self-reflection in which one’s own culture and assumptions are recognized. This attitude of “cultural humility” entails an enduring commitment to self-evaluation and self-critique. A culturally safe environment develops from an individual and institutional philosophy of empowerment, individuality and choice.
Patient empowerment arises from practices that increase access to information and increase individuals’ decision making power. The term “health literacy” refers to an individual’s ability to use the healthcare system appropriately and maintain a healthy lifestyle, which is connected to health outcomes.
The barriers that one needs to be aware in achieving a culturally safe care can be:
• Linguistic barriers: the potential for misunderstanding descriptions of presenting symptoms and history of the client and/or the prescribed course of diagnostic or therapeutic intervention. E.g., a traditional language may have no contemporary vocabulary, hence no word or phrase that can be used to communicate an essential idea.
• Cultural barriers: the potential for misunderstanding the cultural context of the presenting pathology and/or the ability to successfully implement a prescribed course of action in the face of contradictory world views, perspectives, value sets, norms and mores. E.g., even if the words are understood, compliance may not occur because of differences in custom with the mainstream, or provider population.
• Practice barriers: conventional services or practices contrasted with traditional practices specific to the culture(s) in question. E.g., contraindications in the use of manufactured pharmaceuticals concurrent with traditional medicines.
• Context or structural barriers: the potential for misunderstanding or mishap due to cultural habitats and (lack of) knowledge associated with them. E.g., the differences in community infrastructure and differences in accessing services and support in urban, rural or remote settings.
• Systemic barriers: disconnects between mainstream systems and specific population providers including territoriality, overlaps, gaps, policy differences, differing approaches, health status, etc. Examples often relate to access and availability.
• Genetics: failure to know of or take into account inherent issues in a population. E.g., genetic predisposition to diabetes.
• Racism/Discrimination: manifestations of bigotry, prejudice or intolerance that result in the differential provision of services or care.
• Power, history and politicization of health: spotlights individual issues which risk disrupting energy and resources from other priorities, often associated with ties to treat rights to health, or racial discrimination as an underlying issue – relates to historical issues and grievances, failure to consult and/or power/control issues.
These issues must be addressed in order to creating a cultural safety and, better healthcare in a multi-ethnic or cross-cultural setting like ours.
by Dr D S Sheriff