2.2: Cultural Competence, Humility, and Safety

Culture

Leininger defines culture as the learned, shared, and transmitted values, beliefs, norms, and lifeways to a specific individual or group that guide their thinking, decisions, actions, and patterned ways of living and is passed from generation to generation (Leininger, 2002, p. 47). Hall (1975) paralleled culture to an iceberg. He proposed that, like an iceberg, only 10% is visible on the surface and that 90% of culture is not readily seen or identified. The 10% that can be seen is described as surface culture and include behaviors, traditions, and customs that are easily observable with touch, taste, smell, and sound. The 90% of the iceberg that is not seen or easily identified is described as deep culture. Deep culture is an individual or group’s worldview that includes core values, beliefs, attitudes, assumptions, and perceptions. Gaining an understanding of deep culture broadens the interpretation of culture beyond race and ethnicity and expands the understanding of views such as religious beliefs, interpretation of body language, notions of self, beauty, friendship, modesty, and cleanliness, views on marriage, raising children, gender roles, etiquette, attitudes towards social status and age, and the importance of time and space. Employing cultural aptitude aids us in learning more about the deep culture that makes up their worldview and influences decision-making. When individuals from different cultures meet, they are often unfamiliar with the 90% of culture that exists below the surface. If deep culture is not explored, it can contribute to assumptions, stereotypes, and biases.

Cultural Competence

Cultural competence refers to a set of culturally congruent practices, behaviors, and policies that allow nursing professionals to deliver high-quality services in a variety of cross-cultural scenarios. Cultural competence is an essential requirement in nursing (Albougami, 2016). Cultural competence is having the knowledge, understanding, and skills to respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, ages, abilities, spiritual traditions, immigration status, sexual identity, and other factors in a manner that recognizes, affirms, values, and preserves dignity (Danso, 2018; Loftin et al., 2013). Culturally competent providers value diversity and respect individual differences; however, cultural humility must be incorporated to interact effectively with culturally diverse populations. A critique of employing cultural competence alone is that it suggests there is a categorical knowledge that can lead to bias and discrimination and that it donates an endpoint to becoming fully culturally competent (Khan, 2021).

Cultural Humility

Cultural humility involves understanding the complexity of identities, that even in sameness, there is a difference, and that one will never be fully competent about the evolving and dynamic nature of an individual’s experiences (Khan, 2021). Therefore, cultural humility is a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture but starts with an examination of our own beliefs and cultural identities (Yeager, 2013). Cultural humility does not focus on competence or confidence and recognizes the more an individual is exposed to cultures different than their own, they often realize how much they do not know about other cultures (Yeager, 2013).

Campinha-Bacote (2018) coined the term 'cultural competemility' to describe this synergistic relationship between cultural competence and cultural humility. The origin of cultural competemility is the deliberate blending of the terms cultural competence (compete) and cultural humility (mility). Campinha-Bacote asserts cultural competemility requires healthcare providers to maintain both an attitude and a lens of cultural competence and cultural humility as they engage in cultural encounters, obtain cultural knowledge, demonstrate the cultural skill of conducting a culturally sensitive cultural assessment, and become culturally aware of both their own biases and the presence of “isms” (e.g., racism, sexism, ableism, classism, ageism, anti-Semitism, heterosexism, colorism, ethnocentrism).

Cultural competence and cultural humility: apposition rather than opposition. Both process (cultural humility) and product (cultural competence) are needed to interact effectively with culturally diverse populations. When cultural competence and cultural humility are authentically exercised, cultural safety occurs in healthcare delivery, decreasing health disparities and improving health outcomes.

Cultural Safety

A social justice framework underpins cultural safety and requires individuals to undertake a process of personal reflection. Cultural safety is a holistic and shared approach and creates an environment that is safe for people where there is no assault, challenge, or denial of their identity, who they are, and what they need. It is about shared respect, shared meaning, shared knowledge, and experience of learning, living, and working together with dignity and purposeful listening (Williams, 1999).

Cultural safety advocates that professionals and institutions work to establish a safe place for clients that is sensitive and responsive to their social, political, linguistic, economic, and spiritual concerns. Cultural safety is more than an understanding of a client’s ethnic background; it requires healthcare providers to examine themselves and the potential impact of their own culture on clinical interactions.

Culture Care

Culture care incorporates cultural aptitude and emphasizes considerations of a client's beliefs and heritage when developing a healthcare plan. Culture care requires healthcare providers to acknowledge that individuals belong to different cultures, therefore, necessitate treatments that respect the uniqueness of each individual.

Culture care emphasizes consideration of a client’s worldview when developing a healthcare plan that respects the uniqueness of each individual and their culture. Culture care recognizes when an individual meets another person(s) from a different culture, assumptions are made literally from the tip of the iceberg (surface culture). To ensure clients adhere to their healthcare plan, the healthcare provider must apply cultural aptitude to understand deep culture and provide culturally congruent care. Table 2.1 outlines definitions and characteristics of cultural competence, cultural humility, and cultural safety.

TABLE 2.1 What’s The Difference?

	Definitions	Characteristics
Cultural Competence	Having the knowledge, understanding, and skills to respond respectfully and effectively to all people in a manner that recognizes, affirms, values, and preserves dignity.	Recognizes commonalities and embraces differences. Requires cultural humility and cultural safety.
Cultural Humility	A lifelong process of self-reflection and selfcritique whereby the individual not only learns about another’s culture but starts with an examination of their own beliefs and cultural identities.	Requires examination of one’s own beliefs, cultural identities, and conscious evaluation of one’s own assumptions, biases, and values.
Cultural Safety	Ongoing self-reflection and self-awareness and holding themselves accountable for providing culturally safe care, as defined by the client/individual and their communities. Is measured through progress towards achieving health equity.	Provides a focus for the delivery of quality care through changes in thinking about power relationships and client’s rights.