Cultural Competency for Health Professionals in Canada

Defining and Classifying Cultural Competency

This paper discusses cultural competency for health professionals in Canada. Defining cultural competence in healthcare as a respectful awareness of cultural differences, the paper explores the importance of this perspective across several dimensions — from the purview of the healthcare insurance industry to the perspective of the Canadian Nurses Association. Rani Srivastava's Guide to Clinical Cultural Competence is used to guide the discussion alongside articles from scholarly journals.

According to the United States National Institutes of Health (NIH, 2015), cultural competency, as applied to healthcare, "enables providers to deliver services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients." In another formulation, it is defined as "a set of congruent behaviors, attitudes and policies that come together to enable a system, organization or professionals to work effectively in cross-cultural situations" (Srivastava, 2007). Using a question-and-answer format, the NIH guide explains that cultural competency is required for appropriate delivery of health care, and that "cultural competence is also critical for achieving accuracy in medical research" (NIH, 2015).

The classic cautionary example used to illustrate the importance of cultural competence concerns patients' use of traditional and herbal medications and teas that may directly counteract or interfere with physician-prescribed treatments. The healthcare practitioner needs to be sensitive to, and aware of, cultural differences that might impact the patient's well-being and that form an important part of the patient-and-family dynamic that must be considered.

Another significant perspective on cultural competence is found in The Healthcare Professional's Guide to Clinical Cultural Competence by Rani Srivastava (2007), one of the leading works dealing with the development of cultural competence in a healthcare setting. Focusing on client-centered healthcare, the book offers an introduction to cultural competence development. It begins by defining the concept, then moves into deeper practical and theoretical aspects, with illustrations of how these concepts apply to clinical settings and different populations (Srivastava, 2007).

It is worth noting that Canadian and British authors in the relevant literature tend to use the word "competence" where American authors would say "competency." The two terms are used interchangeably throughout this paper.

The Growth of Cultural Competency in Canadian Healthcare

Srivastava defines cultural competency as "the application of knowledge, attitudes, and skills that enhance cross-cultural communication and foster meaningful, respectful interactions with others" (Srivastava, 2009, p. 25). Cultural competency is an important strategy for improving quality and eliminating ethnic and racial disparities in healthcare, and this concept has increasingly garnered attention. In 2002, interviews were conducted with cultural competence experts from government, academia, and managed care in Canada and globally in order to understand their perspectives on the field. Research findings were presented and current cultural competence trends were identified, with a focus on healthcare practice, policy, and education. The analysis shows that several stakeholders in healthcare are involved in developing cultural competence initiatives (Betancourt et al., 2005), though motivations for advancing cultural competence — as well as the approaches adopted — differ based on goals, mission, and spheres of influence.

Cultural competence has caught the attention of policymakers, healthcare providers, educators, and insurers as a strategy for improving quality and eliminating ethnic and racial healthcare disparities. Its goal is to create a healthcare workforce and system capable of delivering high-quality care to all patients regardless of culture, ethnicity, race, or language proficiency. Achieving this requires action across different healthcare sectors, each with different approaches, leverage points, and motivations (Betancourt et al., 2005).

According to Srivastava, cultural competence is guided by "the shared and transmitted knowledge of values, beliefs, norms and life ways of a particular group of people that guides an individual or group in their thinking, decisions, and actions in patterned ways" (as cited in Srivastava, 2007, p. 14). Three practical reasons explain the emergence of cultural competence as a significant issue. First, as countries become more culturally diverse, healthcare practitioners will increasingly encounter patients with a wide range of perspectives on health, typically shaped by their cultural or social backgrounds. Patients may describe their symptoms in ways that differ substantially from clinical conventions, may have limited English proficiency, or may hold different healthcare-seeking thresholds and expectations. Unfamiliar cultural perspectives may also influence whether they follow providers' recommendations. Second, research has shown that provider-patient communication is associated with patient satisfaction, adherence to medical advice, and health outcomes (Betancourt et al., 2005). When socio-cultural differences between providers and patients are not reconciled in clinical encounters, poorer health outcomes may result. A landmark report from the Institute of Medicine — Crossing the Quality Chasm — emphasizes the significance of cultural competence and patient-centered care in quality improvement and the elimination of ethnic and racial disparities in healthcare (IOM, 2001).

Current trends in the healthcare field confirm these perspectives. Health insurers such as Aetna, Blue Cross and Blue Shield of Florida, and Kaiser Permanente have established cultural competence initiatives. Kaiser Permanente has pursued long-standing efforts, ranging from educational articles to complete "Centers of Excellence in Cultural Competence" targeting specific population segments (Betancourt et al., 2005). Aetna began collecting data on ethnicity and race from its members and developed culturally competent disease management programs, while also mandating cultural competence training for its in-house medical directors, case managers, and nurses. Blue Cross and Blue Shield of Florida similarly adopted cultural competence initiatives, including in-house diversity training and education for healthcare providers (Betancourt et al., 2005).

Healthcare purchasing coalitions such as the National Business Group on Health have also actively informed their members about ethnic and racial healthcare disparities and cultural competence. Accreditation agencies, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA), have been exploring ways to incorporate measures for tracking cultural competence and disparities (Betancourt et al., 2005). Despite these major developments, strong resistance to investment in cultural competence still exists because financing entities seek evidence of cost savings and quality improvement. Organizations that have invested in cultural competence tend to view themselves as committed to equity, quality, and diversity, and accept the potential for increased market share by marketing these efforts.

Effect of Cultural Competency on Health Professionals in Canada

The patient population in Canada is diverse and increasingly so, requiring health professionals to be more alert to racial equality and cultural ethos, and to discharge their duties with sensitivity to ethnic concerns. In most documented cases of improper treatment, there is little evidence of deliberate racial discrimination or bias. Disparities often arise from common professional causes related to time pressures. Such constraints can cause stereotyped, reflexive responses, and a lack of concentration can produce what might be called an "application error" — that is, failure to apply specific epidemiological data to the individual patient due to the pressures of multitasking. These lapses are not expressions of directed cultural bias but rather a common occurrence in a demanding profession where the physician or healthcare worker loses focus on the patient's cultural context (Geiger, 2001).

Health care quality suffers and disparities arise from racial diversity — a well-documented fact. The solution is to improve the cultural competency of both professionals and organizations in the field. Cultural competence, understood as the ability to discharge duties equitably across cultural communities, requires sensitization to cultural attributes, understanding of how such influences shape interpersonal interaction, and the development of practical strategies to address them.

Scholarly studies have also highlighted that children are among the worst affected by discrimination in healthcare services. Minority and disadvantaged children carry early childhood experiences into adulthood, and these experiences are reflected in their cognitive and educational outcomes. The same dynamics that apply to low-income and less-privileged populations also apply to racial and cultural discrimination, contributing to an overall decline in quality of life (Grant, Parry, & Guerin, 2013).

Defining "culture" properly is important here, as a clear understanding leads to a better grasp of the skills needed to counter discrimination in healthcare practice. Lack of consistency in the use of the term "culture" creates confusion and inconsistency in practice. According to one definition, culture is an integration of characteristics of an individual or group influenced by language, practices, values, beliefs, rituals, customs, and expectations grounded in political, social, professional, racial, religious, and ethnic group membership. Policymakers need to incorporate this understanding into frameworks for building cultural competency. Minority groups — including those from different ethnic and cultural backgrounds, those with disabilities, those with same-sex identities, and those from refugee backgrounds — should be encompassed within a broad policy framework for marginalized and disadvantaged groups (Rowan et al., 2013). Marginalized people should receive care informed by their history and background, with support from clearly stated policies and legal frameworks, particularly given that their children are often exposed to distressing conditions (Rowan et al., 2013).

A study by Hammerich (2014) noted a general lack of policy structure and curriculum framework that would allow healthcare students to pursue cultural competency as a distinct or standalone subject. As a result, healthcare professionals are often ill-equipped to treat and interact with ethnically and culturally diverse patient populations. The recommendation is that students should be given the opportunity to explore these concerns during their formative training years, and that faculty should be trained under continuing education frameworks to teach and deliver care effectively to ethnically diverse populations, with an emphasis on cultural competency (Hammerich, 2014). Cultural competence and safety should be made integral parts of the core skills taught to students at the institutional level in Canada (Rowan et al., 2013).

A commonly expressed concern is the lack of adequate funding to support training in cultural safety and cultural competency. One positive development has been the targeted attention given to Aboriginal culture, language, and practices (Rowan et al., 2013). However, there is also a shortage of knowledgeable faculty and senior practitioners who could guide students through the complexities of cultural considerations affecting marginalized populations and visible minorities (Rowan et al., 2013).

To address these gaps, the Office of Minority Health has established standards for cultural competency, and corresponding training schedules have been developed. The Accreditation Council for Graduate Medical Education (ACGME) requires trainee medical professionals to be alert to cultural disparities and to practice sensitivity when treating patients during their training period.

In a controlled study conducted in Canada, four mental healthcare professionals were trained in cultural competency. They were subsequently rated highly for empathy, professional skill, trustworthiness, and equitable treatment when presented with cases from low-income African American patients. This intervention lasted four hours of counseling. In another experiment, professionals were taught Spanish over twenty hours, and patients reported similarly positive evaluations after the intervention. In a separate three-day, state-sponsored initiative aimed at improving social equity and cultural competency among support staff at healthcare facilities, the emphasis was placed on clinical issues, team training, cultural competency, and recovery principles for service recipients. Patients who received care under this initiative reported that the staff was humane and sensitive to their concerns. Across all trials, it became evident that cultural competence puts patients at ease and fosters a sense of being well cared for, even though similarly explicit positive feedback about clinical outcomes was not consistently documented (Beach et al., 2011).

The quality of healthcare service provided by an organization or clinic is influenced by the cultural competency of its interacting team members and their interactions with patients. Team members need to be aware of the social, cultural, economic, and political influences that each colleague carries by virtue of their nationality and ethnicity. Recognition and appreciation of these defining characteristics play an important part in providing adequate and safe care, in much the same way that the quality of the patient-caregiver relationship does. Attention should also be given to power differentials between different professional categories — for example, physician and nurse, nurse and physiotherapist, physiotherapist and physician — as these dynamics also shape care quality and equity (Oelke, Thurston, & Arthur, 2013).

Cultural competency should be introduced at both the organizational level (hospitals and clinics) and the institutional level. Organizations should pursue an ethos of cultural tolerance and respect as a matter of corporate policy, embedded deeply through training, seminars, and workshops. Such initiatives benefit well-managed healthcare organizations. The values that need to be cultivated at both levels include respect for cultural diversity and practices, genuine consideration for patient care, and appreciation of the socio-cultural and political backgrounds of colleagues and patients alike.

Although due attention is being given to improving the cultural competency of physicians, nurses, and physiotherapists directly involved in clinical services, little attention has been paid to others, such as receptionists, managers, and administrators. Growing evidence indicates that the overall cultural competency of an organization reflects the contributions of all its members, and that higher organizational cultural competency leads to improved healthcare quality and greater patient satisfaction (Oelke et al., 2013).

Conclusion

It can be stated unequivocally that cultural competence is an important issue in healthcare at all levels. This is being recognized nationally, at the provincial level, and at local community levels as well. Cultural competence has become embedded in the healthcare industry, from insurance providers to hospitals, and from nurses to physicians. In part, this area is still in its relative infancy, as much ground remains to be covered given the immense diversity of global populations and their increasing intermingling. A large city hospital could easily encounter individuals from five or more national and ethnic groups in a single day. It is not always possible to have the exact and appropriate language interpreter present, nor is it always possible to have a cultural representative available. However, if awareness of cultural diversity is inculcated into the mindset of healthcare professionals, it can bridge many of these gaps. Simply being aware that a different culture may carry a different understanding of healthcare issues — such as medication adherence, diet, dietary changes, and familial involvement in healthcare decisions — can go a long way toward more effective and equitable care.

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