Beyond cultural competence: tips for teaching about diversity
I have to be honest: I struggle with the term “cultural competence.” Nursing has taught this concept for over 30 years, aiming to improve health services for our increasingly diverse society and to address health inequities1. I have seen cultural competence taught in nursing education in a similar way described by Tervalon & Murray-Garcia2 in medical education: as “an easily demonstrable mastery of a finite body of knowledge” (118). To be sure, in this era of continued racial/ethnic health inequities3, entrenched racial segregation in our communities4, and increases in hate crimes towards racial, religious, and sexual minorities5, nurse educators have a critical responsibility to prepare America’s future registered nurses to understand the sociopolitical and cultural factors that influence the health of diverse populations. It is time to stop approaching nursing education in ways that assume that cultural competence as a discreet endpoint that, once reached, will assure optimal care for diverse populations.
On that note, and with full awareness of the irony of distilling tips for preparing nurses to work with diverse patients into a reference list, here are my tips for teaching “cultural competence” to nursing students:
- Don’t teach cultural competence: teach cultural humility.
Tervalon & Murray-Garcia2 argue that we should be teaching and practicing cultural humility rather than cultural competence. Cultural humility requires that nurses engage in a lifelong process of learning, self-evaluation and self-critique as they interact with diverse patients. By using patient-focused interviewing and care strategies, cultural humility helps to redress power imbalances in provider-patient relationships and releases nurses from having to memorize everything about every culture before ever asking patients about their culture. Instead, patients are the experts on their own cultural context, creating a more equal partnership where each party contributes expertise towards the goal of improved health.
- Encourage written reflection rather than emphasizing memorization of cultural traits.
In shifting towards cultural humility, educators should emphasize class assignments and activities that promote critical reflection as opposed to rote memorization of cultural characteristics. Certainly, students should have opportunities to read about different cultures and educate themselves about general practices, beliefs, history, and values prior to interacting with members from that group. But rather than using this information to make assumptions about specific patients and unilateral plans of care, such knowledge should help guide interactions with patients by helping to form relevant questions for patients while reflecting on any historical context that each party may bring to the interaction. For example, our public health nursing students learn about historically disenfranchised cultural groups through community assessment activities and written reflections that prompt them to incorporate the historical and social-ecological context of their identified group, evidence about population-level health outcomes, and self-reflection about their reactions to the activities and implications for their nursing practice.
- Teach about white cultures using a critical social theory lens
“Cultural competence,” often narrows who “has” culture to racial/ethnic minorities, which is problematic1; it renders nonminority cultures—and the power and influence they have had to shape institutions that reflect their values, beliefs, and practices—invisible. In the case of race/ethnicity in the United States, while we educate students and celebrate certain aspects about white culture (e.g., music, art, literature), rarely do we educate about aspects that contribute to population-level racial/ethnic inequities and interpersonal-level discrimination, prejudice, microaggressions, and implicit bias. In order to understand how these cultural power dynamics still operate today, students should be exposed to critical social theory throughout the curriculum and explore concepts such as institutionalized racism6, white supremacy, and white fragility7,8. This is particularly important for nurses to reflect on, given that our profession remains predominantly white.
- Teach yourself, not just your students, and model vulnerability
Cultural humility is all about a commitment to lifelong learning and self-examination. Therefore, nursing faculty must model these practices and be willing to show vulnerability in order to help others learn and grow. There are many opportunities for self-reflection, both personally (e.g., reading, journaling) and professionally (e.g., joining or creating faculty/staff book clubs, movie nights, diversity & inclusion committees, community events and groups dedicated to addressing inequities).
- Set ground rules
Conversations about diversity can be enlightening and exciting. When issues such as discrimination, privilege, and power are included, they can also become uncomfortable and volatile—particularly without ground rules. Work with your group to set agreeable ground rules and return to them frequently. For example, show grace to others by assuming ignorance rather than ill intent when an offensive comment is made. Yet regardless of intent, we must still address the impact of those words or actions. At some point, we all experience being the offender or the recipient of well-intended comments that hurt. Therefore, we must respectfully challenge each other to grow and humble ourselves to receive feedback as we work toward a truly equitable and representative healthcare system.
References & Additional Resources:
- Drevdahl, D. J., Canales, M. K., & Dorcy, K. S. (2008). Of goldfish tanks and moonlight tricks: Can cultural competency ameliorate health disparities? Advances in Nursing Science, 31(1), 13-27.
- Tervalon, M. & Murray-Garcia (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.
- Williams, D.R., & Mohammed, S.A. (2009). Discrimination and racial disparities in health: evidence and needed research. Journal of Behavioral Medicine, 32, 20-47. doi: 10.1007/s10865-008-9185-0
- University of Virginia Demographics Research Group. (2017). The racial dot map. Retrieved from https://demographics.coopercenter.org/racial-dot-map
- Levin, B., & Reitzel, J. D. (2018). Report to the nation: hate crimes rise in US cities and counties in time of division and foreign interference. Retrieved from https://ncvc.dspacedirect.org/handle/20.500.11990/975
- Jones, C.P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212-1215.
- DiAngelo, R. (2018). White fragility: Why it's so hard for white people to talk about racism. Beacon Press.
- DiAngelo, R. (2019). Critical racial and social justice education. Retrieved from https://robindiangelo.com/