Cultural competence is loosely defined as the ability to engage knowledgeably with people across cultures. It's a product of the 1960s and 1970s, grounded in the sociopolitical climate of the civil rights movements. The term hence became ubiquitous in healthcare, with an assumption that the more knowledge we have about another culture, the greater the competence in practice. However, “cultural competence” also bears two main problems: It suggests that there is categorical knowledge a person could attain about a group of people, which leads to stereotyping and bias, and it denotes that there is an endpoint to becoming fully culturally competent.
This has led to the shift from cultural competence frameworks to that of cultural humility and sensitivity.
The term "cultural humility" was introduced in 1998 as a dynamic and lifelong process focusing on self-reflection and personal critique, acknowledging one’s own biases. It recognizes the shifting nature of intersecting identities and encourages ongoing curiosity rather than an endpoint. Cultural humility involves understanding the complexity of identities — that even in sameness there is difference — and that a clinician will never be fully competent about the evolving and dynamic nature of a patient's experiences.
Cultural humility involves understanding the complexity of identities — that even in sameness there is difference — and that a clinician will never be fully competent about the evolving and dynamic nature of a patient's experiences.
How to develop cultural humility
At its base, cultural humility means opening up a conversation in a way that genuinely attempts to understand a person’s identities related to race and ethnicity, gender, sexual orientation, socioeconomic status, education, social needs, and others. An awareness of the self is central to the notion of cultural humility — who a person is informs how they see another. Awareness may stem from self-reflective questions such as:
- Which parts of my identity am I aware of? Which are most salient?
- Which parts of my identity are privileged and/or marginalized?
- How does my sense of identity shift based on context and settings?
- What are the parts onto which people project? And which parts are received well, by whom?
- What might be my own blind spots and biases?
With this awareness, a provider can ask questions about how they receive the patient: Who is this person, and how do I make sense of them? What knowledge and awareness do I have about their culture? What thoughts and feelings emerge from me about them?
Cultural competence and cultural humility together
A "culturally competent" provider needs to have knowledge and awareness of:
- health-related beliefs, practices, and cultural values of diverse populations;
- illness and diagnostic incidence and prevalence among culturally and ethnically diverse populations;
- treatment efficacy data (if any) of culturally and ethnically diverse populations.
A provider operating with cultural humility must listen with interest and curiosity, have an awareness of their own possible biases and attempt a non-judgmental stance about what they hear, and recognize their inherent status of privilege as a provider and be willing to be taught by their patients.
Utilizing one of these frameworks without the other misses the mark, and effective interventions would uphold both. However, intertwining cultural humility and competence into healthcare, ideally, would go beyond individual providers and their patients.
Healthcare institutions from a cultural humility and cultural competence lens
Racism, sexism, ableism — all of these 'isms and others — are embedded in the world at large and trickle down to national levels, state levels, institutions, and systems of care and how policies and procedures are established. It is imperative that healthcare providers are aware of and troubled by these severe inequalities and inequities.
A crucial way to build cultural humility into a healthcare system is with representation. A diverse workforce is essential, but it doesn’t stop there.
Truly multiculturally attuned providers upholding values of cultural humility and cultural competence, promoting health equity, and improving access to care necessitates that clinicians understand how these 'isms are operational within the systems in which they provide services. For this, cultural competence and humility and sensitivity trainings are essential.
One challenge is that healthcare executives, providers, and others working in the system aren’t having honest, authentic conversations about systemic or individual biases because it makes them uncomfortable. Everyone has biases. Avoiding or concealing them only escalates the problem. Instead, healthcare institutions and providers need to raise them to the surface and become more comfortable with having uncomfortable conversations to effect change.
It's imperative to reckon with the complexity of these cultural terms and not shift to either-or binaries amid already problematic and polarized us-them dichotomies at the core of these challenges.