Our Take

The Case for Cultural Humility

20 Minute Read

    To better serve an increasingly diverse patient population and reduce existing health disparities, many organizations have implemented cultural competency models. However, the current model many provider organizations have embraced is insufficient, and arguably outdated. This approach can create a false sense of understanding an identity group, perpetuate biases, and promote stereotypes.

    Rather than striving for cultural competence, organizations should aspire to cultural humility. A cultural humility model—adopted at the institution and clinician level—better positions organizations to have a significant impact on building trust, supporting patients’ engagement in their care, and improving outcomes. Learn the four steps organizations can take to make the shift, in mindset and action, from cultural competence to cultural humility.

     

    The conventional wisdom

    As populations have become more diverse across the last several decades, researchers have increasingly examined the health disparities across specific groups to uncover the root causes of these disparities. One major contributing factor to disparate outcomes is inequity at the point of care—when care teams don’t adequately meet the needs of historically marginalized or vulnerable patient groups. Inequity at the point of care can range from an insufficient understanding of patient needs to bias (implicit or explicit) and discrimination, which can lead to miscommunication, patient distrust, and worse clinical outcomes for at-risk groups. 

    To address the needs of changing communities and bolster health equity efforts, provider organizations began to strive for cultural competency—also known as cultural congruency, cultural proficiency, or culturally responsive health care. This refers to a clinician’s ability to deliver health care tailored to a patient’s cultural and social context. The concept, which first appeared in the academic literature in 1989, has gained attention and been adopted by health care organizations in the years since then. Traditional models of culturally competent care tend to have two components:

    • Language services: In-person, telephonic, and virtual interpretation for patients who are hard of hearing or have limited English proficiency (LEP).
    • Cultural competency education: Training and tools (such as checklists or reference guides) about different racial, ethnic, religious, or cultural groups that are prevalent in the health system’s community, with information on how their values or traditions may impact care preferences and behaviors (e.g., religious dietary restrictions). 

    These models have shown some success. While connecting patients to language services has improved quality outcomes, the evidence is both mixed and incomplete when it comes to cultural education for staff.

     

    Our take

    Given the mixed evidence demonstrating the effectiveness of cultural competency education on patient outcomes, along with persistent trends in disparate treatment at the point of care, leaders must rethink how, and even if, cultural competency fits within their organization’s broader health equity strategy. Moreover, organizations looking to achieve elusive and illusory “competency” run the risk of causing harm by perpetuating stereotypes about specific identity groups.

    Rather than striving in vain for clinicians to achieve “competency,” provider institutions should aspire to cultural humility at the organizational level. In contrast to traditional competency-based frameworks, cultural humility has no end state. It requires ongoing learning, self-reflection, and skill-building for how to understand a person's cultural context through that person’s own lens. The goal is a true shift in mindset. The focus shifts from interacting with people who are "different" from a perceived norm (reinforcing their “otherness”) to appreciating the inherent value of others’ perspectives and cultures. Cultural humility embraces the notion that it's simply not possible to become truly competent, let alone an expert in a culture or lived experience that is not one’s own. Instead, cultural humility mean that institutions and individuals are humble—that they don’t consider their norms better than any other. They listen to listen to and learn from people's lived experiences. Practitioners of cultural humility routinely interrogate their own identity and lived experiences, and reflect on how they influence their interactions with others.

    Cultural humility is a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities.

    - Katherine A. Yeager and Susan Bauer-Wu, Applied Nursing Research

    Yeager and Bauer-Wu’s comparison of cultural competence and cultural humility models

    cultural competency and humility comparison

     

    A cultural humility framework can strengthen legacy approaches in two ways:

    1. Reinforcing patients’ humanity, rather than “otherness” by practicing true person-centered care

    No one’s identity is generalizable, and groups aren’t monolithic. Each person’s identity is uniquely formed at the intersection of one’s gender, sexual orientation, physical and cognitive abilities, age, race, ethnicity, nationality, immigration status, family, community, social needs, passions, and more. It’s not possible to become “competent” in another culture with a brief overview, much less fully understand the nuances of another person’s lived experiences without deeply knowing them.

    Cultural humility, therefore, focuses on delivering true person-centered care in a manner that honors a patient’s identities. This includes things like:

    • Asking what name and pronouns every patient uses, documenting that information in the EHR, and using it in communications with patients and family members and during key care protocols, like patient identification and handoffs.
    • Employing techniques such as motivational interviewing to find out what patients value most—in their care, and in life—to craft an effective care plan that meets each patient’s unique definitions of success.
    • Screening all patients for limited English proficiency and offering access to comprehensive language services.

    2. Illuminating that we all play a role in delivering equitable care to patients– as individuals and, more importantly, as institutions 

    Traditional approaches based on cultural competency focus too narrowly on adjusting the interpersonal behaviors of frontline staff. While important, this strategy doesn’t acknowledge that staff operate within the larger organization’s cultural ecosystem. Leaders who don’t address the institutional drivers of biased or inequitable care, or who fail to build an organizational culture committed to advancing equity, will struggle to make long-term change. 

    This begins with realizing that the health care institution itself—not just individual caregivers—plays a role in providing culturally sensitive care. To begin to understand the communities they serve, provider organizations must study troubling histories of social injustice that impact their patient populations. Education must include the legacies of structural inequities on a macro-level (e.g., national policies, cultural norms) and a local level (e.g., the provider organization’s role in furthering inequities, social determinants of health). 

    In addition, care teams using a cultural humility framework must understand uncomfortable truths about themselves. This includes acknowledging one’s own biased thoughts and behaviors as well as inequitable power dynamics between the patient and the provider that impact care delivery (e.g., paternalism).

    Acknowledging these injustices helps care teams understand the root causes of poor health outcomes, which can occur because of both systemic and individual failings. In turn, provider organizations and care teams are better able to extend empathy to patients during discrete interactions with the health system and more motivated to drive enduring systemic change at the institution or system level.

     

    A four-step approach to engendering cultural humility at the institution level 

    Cultural humility is chiefly discussed as a requirement for patient-clinician interactions. And this is for good reason—the model can make a significant impact on building trust, supporting patients’ engagement in their care, and improving outcomes. However, provider organizations must pair this interpersonal focus with an infrastructure of institutional support to create an enduring cultural shift. There are four steps to engendering cultural humility.

    • Step

      Instill institutional accountability for culturally sensitive, equitable care

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      Help staff feel confident in investing the time for person-centered care

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    • Step

      Teach staff what's required for ongoing learning and introspection

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      Elevate underrepresented voices in strategic decision-making

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    Parting thoughts

    Engendering cultural humility across an organization, the workforce, and within each staff member can be a complex and sometimes overwhelming process. Setbacks and missteps are natural, so champions of equity must regularly evaluate progress, reflect, gather more input, learn from missteps and failures, and make necessary changes over time.

    As one progresses on what is a lifelong journey of cultural humility, consider the two next-level approaches detailed below.

    • Expand the mandate for cultural humility across the industry.
      Hold other stakeholders beyond hospital and health systems (e.g., health plans, life sciences organizations) accountable for adopting the cultural humility framework. As your organization forms partnerships with other organizations, ensure they are an appropriate fit from a cultural and values standpoint, and help them instill similar accountability for equity at their organization.
    • Advocate for structural change.
      Now that you understand the root causes of inequities, determine how you as an individual and how your organization can address them and advocate for your community. Some hospitals and health systems develop a department for policy advocacy to lobby for community health priorities on a local, state, and federal level. Others embrace their role as an anchor institution in the community and take strategic steps to uplift the socioeconomic outcomes of their communities.
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