by Diana Taibi Buchanan, PhD, RN
Culture is a broad and pervasive concept. It gives motivation and meaning to our actions and shapes our interactions. Culture can bring richness and diversity, or conflict and misunderstanding. Although culture saturates all human behavior, the impact of culture within the health care team is rarely given due attention. It is well-accepted that healthy functioning of interprofessional health care teams improves patient outcomes and is crucial for patient safety. New initiatives teach health care providers strategies to work as a team. However, these strategies do not attend to the variety of cultural backgrounds represented by each team member. Individuals’ use of strategies, such as those provided by TeamSTEPPS, occurs in the context of rich personal and cultural histories of the persons giving and receiving the communication. Research to date on interprofessional education (IPE) suggests that IPE may not be effectively translated to ultimate goal of collaborative practice. Training health care team members in cultural competence may be a way to bridge that gap by preparing persons who are self-aware of their own cultures and know how to be curious about and respectful of others’ cultures.
What is culture?
The National Institutes of Health explains that culture is “the combination of a body of knowledge, a body of belief and a body of behavior. It involves a number of elements, including personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups.” (NIH, 2014).
In health care, team members bring both professional and personal cultural backgrounds that impact their views of care issues and their relational styles. Below are some examples of culture at the personal level that might impact care. Several of these cultures may influence a person’s motivations and behaviors at any given time and to varying degrees.
- Ethnic (e.g., African American, Italian American, Creole)
- Religious/faith (e.g., atheist, Buddhist, Christian)
- Geographic/regional (e.g., Southern U.S., Midwest)
- Social (e.g., Republican, pacifist, Mountaineer)
Health care team members also bring the culture of their professional backgrounds. Health professionals may not consider that their professional group has a culture, but based on the definition of culture representing knowledge, belief, and behavior, health professions are indeed cultures. Professions clearly have different bodies of knowledge, but they are also socialized to different behavioral norms, and may arrive at different beliefs about what is best in patient care.
Interprofessional Education for Cultural Competence
For teams to be effective, members must learn to navigate culture. IPE is used with this intent, but IPE activities are often oriented toward group functioning rather than mutual understanding. IPE is defined as “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 7). However, students may not learn about each other effectively without being given a framework for understanding. Cultural competence is an important framework for such understanding. Accordingly, principles of cultural competence within the health care team are explicitly listed in the values/ethics domain of the Core Competencies for Interprofessional Collaborative Practice:
- "VE3. Embrace cultural diversity and individual differences characterizing patients, populations, and health care teams.
- VE4. Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions.” (Interprofessional Educaton Collaborative Expert Panel, 2011, p. 19).
The National Center for Cultural Competence (NCCC) defines cultural competence as values and principles for working cross-culturally, as demonstrated through behaviors and attitudes (NCCC, nd). The NCCC also states that cultural competence is a developmental process that occurs over time. Therefore, principles of cultural competence should be taught early in pre-licensure education and applied throughout professional training.
Another helpful concept in developing cultural competence within the health care team is learning in a community of practice. Communities of practice are when “people engage in a process of collective learning in a shared domain” (Wenger, 2011, p. 1). This is the concept underlying IPE. The health care team is a community of practice; therefore, health sciences students are best taught how to work as a team by being placed within that team/community. The same could be said of cultural competence in team communication. Interprofessional students will best learn to apply the principles of cultural competence by learning about it together.
Several frameworks for cultural competence are available. The NCCC adopted the approach published by Cross, Bazron, Dennis, & Isaacs (1989). Some approaches that these authors recommend for individual development of cultural competence include the following. Although Cross and colleagues stated these points at the provider-patient level, I have expanded the statements to also encompass provider-provider interactions.
- Acknowledge cultural differences and be aware of how these impact care.
- Recognize how one’s own culture impacts one’s thoughts and actions.
- Understand cultural differences at the practice level, when patients and providers bring unique histories.
- Make a conscious effort to understand the meaning of the other’s behavior within the context of his or her culture.
- Health care providers should gain information as they can, but comprehensive knowledge is not attainable. Providers should how obtain information needed in the moment to reach a patient care goal.
(Cross et al., 1989, pp. 32-35)
Each of these principles can be used to plan interprofessional activities to understand culture in the context of the health care team. As an early learning exercise, students might complete a group activity to understand culture. They might take a few moments to write about aspects of their own professional culture and what they view as the culture of other profession. Then they could share these and discuss how self-identified culture is similar or different to the other’s expectations of that culture. The discussion should conclude with reflection on how understanding of culture could impact the functioning of the health care team. A higher level exercise could be a simulated clinical case with a scripted cultural conflict. For instance, two team members (acting from a script) engage in conflict over a misunderstanding based in cultural differences. The other team members are students who must navigate this conflict to achieve the goals of patient care. Debriefing would focus on understanding how culture contributed to the conflict, how individuals’ responses were impacted by their own culture, and what strategies could be effective or ineffective in navigating the conflict.
“Team” as a Culture
It is important to recognize that creating a professional identity of “team” also creates a new culture with group norms for values and behavior. The cultural values could be said to be those stated in the Core Principles & Values of Effective Team-Based Health Care (Mitchell, et al., 2012): shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes (p. 6). Another core value of this new culture is full inclusion of patients as team members (Mitchell, Hall, & Gaines, 2012). Cultural competence training should encompass interactions with the patient in the context of the team, rather than individual interactions as is often the focus. Such training could begin in a simulated setting with a standardized patient, but could also be accomplished in student experiences in the clinical setting in learning activities with objectives clearly focused on cultural competence.
To conclude, cultural competence is a core competency for effective health care team functioning. Training health care professionals in this area involves teaching them to recognize culture as an influence on team interactions, respect diversity, and problem-solve difference from a shared approach.
Cross, T. L., Bazron, B. J., Dennis, K. W., Isaacs, M. R. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, D. C.: National Institute of Mental Health, Child and Adolescent Service System Program.
Interprofessional Education Collaborative Expert Panel. (2011) Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
Mitchell, P., Hall, L., & Gaines, M. (2012). A social compact for advancing team-based high-value health care. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2012/05/04/a-social-compact-for-advancing-team-based-high-value-health-care/
Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, E.,… Von Kohorn, I. (2012). Core principles & values of effective team-based health care. Washington, D. C.: Institute of Medicine.
National Center for Cultural Competence. (nd). Conceptual frameworks/models, guiding values and principles. Retrieved from http://nccc.georgetown.edu/foundations/frameworks.html#ccdefinition
National Institutes of Health. (June 3, 2014). Cultural competency. Retrieved from http://www.nih.gov/clearcommunication/culturalcompetency.htm
Wenger, E. (2011). Communities of practice: a brief introduction. Retrieved from https://scholarsbank.uoregon.edu/xmlui/handle/1794/11736
World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. Geneva, Switzerland: World Health Organization.