Guided Reading Activity 6.3 Cultures and Lifestyles Answers

Appl Nurs Res. Author manuscript; available in PMC 2014 Nov 1.

Published in final edited form as:

PMCID: PMC3834043

NIHMSID: NIHMS510949

Cultural humility: Essential foundation for clinical researchers

Katherine A. Yeager

^aNell Hodgson Woodruff School of Nursing, Emory Academy, Atlanta, GA 30322, United states of america

Susan Bauer-Wu

^bTussi and John Kluge Professor in Contemplative End-of-Life Care, University of Virginia School of Nursing, Charlottesville, VA 22908-0826, USA

Abstract

Cultural humility is a process of cocky-reflection and discovery in order to build honest and trustworthy relationships. Information technology offers promise for researchers to understand and eliminate health disparities, a continual and disturbing problem necessitating attention and action on many levels. This paper presents a discussion of the procedure of cultural humility and its important office in research to improve understand the perspectives and context of the researcher and the enquiry participant. We discern cultural humility from similar concepts, specifically cultural competence and reflexivity. We will also explore ways to cultivate cultural humility in the context of human subjects inquiry. Mindfulness is ane approach that tin be helpful in enhancing awareness of self and others in this procedure. With a foundation in cultural humility, nurse researchers and other investigators can implement meaningful and ethical projects to ameliorate address health disparities.

Keywords: Nursing, Enquiry, Culture

1. Introduction

Understanding and eliminating health disparities requires a close examination of our past work and hereafter focus in wellness care research beyond settings. How we approach the many factors that contribute to health disparities and social inequities requires an exam of the environment, context, and civilization of those experiencing these disparities. Attending has been given to role of culture in the health intendance field recently. As the dissimilar parts of the world become increasingly diverse and multicultural, wellness intendance providers take been encouraged to become aware of cultural differences and their touch on on health. Much focus has been given to exist preparing health care providers, such every bit nurses and physicians, to requite culturally competent intendance at the bedside (Waite & Calamaro, 2010). Withal, minimal attention has been on researchers to conduct culturally competent enquiry. Nurse researchers are trained to view health and affliction from a holistic arroyo and therefore should lead the way in this expanse to address the role of culture in the behave of research. Papadopoulos and Lees (2002) acknowledge the need for culturally competent researchers in order to produce valid inquiry and improve practice; they also note that for also long, research has been unicultural although generalized to a multicultural world.

Initially discussed in the context of clinical practice, cultural humility is a process of self-reflection and discovery to understand oneself then others in order to build honest and trustworthy relationships (Tervalon & Murray-Garcia, 1998). It is a promising approach with utility for researchers every bit well and can play a part in addressing health disparities in research. The purpose of this article is to provide a thoughtful exam of cultural humility with practical relevance for investigators involved in human subjects research. The concepts discussed are applicative to whatever clinical researcher who is studying someone different from her/himself—different in race, ethnicity, gender, faith, sexual preference, socioeconomic status, and geographic location—in any cultural context and in any part of the world.

2. Cultural humility - what it is and what information technology's non

As we learn to appreciate the value of cultural humility in research, it'southward important to explore the foundations of this concept and to conspicuously draw information technology. There are also related concepts (i.e., cultural competence and reflexivity) that may be inappropriately used interchangeably, then it's important to sympathize the subtle differences among them.

3. What it is

Cultural humility, originally described equally a tool to educate physicians to work with the increasing cultural, racial and ethnic multifariousness in the United States, is useful for all researchers involved in man subjects research. Cultural humility is a lifelong process of self-reflection and self-critique whereby the private not but learns well-nigh another's culture, but one starts with an examination of her/his own beliefs and cultural identities (Tervalon & Murray-Garcia, 1998). This critical consciousness is more than than but cocky-awareness, but requires 1 to step back to understand i's own assumptions, biases and values (Kumagai & Lypson, 2009). Individuals must look at ane's own background and social surroundings and how it has shaped experience. Cultural humility cannot be collapsed into a form or pedagogy offering; rather it's viewed every bit an ongoing process. Tervalon and Murray-Garcia (1998) state that cultural humility is "best defined not as a discrete finish signal but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing ground with patients, communities, colleagues, and with themselves" (p. 118). This procedure recognizes the dynamic nature of culture since cultural influences change over time and vary depending on location. Throughout the mean solar day, many of u.s. move between several cultures, often without thinking about it. For example, our home/ family unit civilisation oft differs from our workplace culture, school culture, social group culture, or religious arrangement civilization. The overall purpose of the process is to be aware of our own values and beliefs that come from a combination of cultures in lodge to increase understanding of others. 1 cannot understand the makeup and context of others' lives without existence aware and cogitating of his/her ain groundwork and state of affairs.

iv. What it's non—related concepts

iv.1. Cultural competence

In cultural competence training programs, the focus is to learn and examine the patient or research participant'southward conventionalities organization. Many institutions take made cultural competency training required for clinicians to sensitize them to the special needs and vulnerabilities of dissimilar populations. The programs often focus on caring for racial and indigenous minorities and on traits and practices of these groups, with the goal to break downwardly cultural barriers to quality health intendance. Unfortunately the traditional approaches of cultural cross-training have been criticized for potentially promoting stereotyping (Kumagai & Lypson, 2009). Also despite the emphasis on cultural competence in health care, a national survey of over 3,000 physicians constitute that 1 in five felt unprepared to deal with socio-cultural bug—such as patients with religious beliefs that impact handling decisions, patients that mistrust the health care organisation, new immigrants, and patients with wellness beliefs at odds with conventional medicine (Weissman et al., 2005).

Despite many resources devoted to cultural competence education, shortcomings have been identified. Kumas-Tan, Beagan, Loppie, MacLeod, and Frank (2007) systematically reviewed the virtually oft used cultural competence measures and identified assumptions embedded in these measures: civilization is usually equivalent to ethnicity and race, and niggling attention is given to other components of civilization such as gender, class, geographic location, country of origin, or sexual preference. These instruments assume that civilisation is possessed by the patient or client or the 'other'. In many of the measures, for example, whiteness is understood and represented as the norm. Cultural incompetence is due to a lack of knowledge about the 'other' and perhaps related to the provider'due south discriminatory attitudes toward the 'other'. Didactics about the 'other' is the key to developing cultural competence. Therefore, cultural competence does not incorporate cocky-awareness since the goal is to learn about the other person'due south civilisation rather than reflection on the provider's groundwork. Finally cultural competence is about the provider being confident and comfortable when interacting with the 'other'. The authors conclude that the assumptions taken together create a worldview that civilisation is a misreckoning variable that white providers must control when they care for people of different races than themselves (Kumas-Tan et al., 2007). The goal of cultural competence is to produce confident, competent health care providers with a specialized noesis and skills that can then serve the communities of ethnic or racial minority groups. Other terms such equally cultural awareness, cultural knowledge, and cultural sensitivity often are supported by these same assumptions of cultural competence (Tabular array 1).

Tabular array 1

Departure between cultural competence and cultural humility.

Attributes	Cultural Competence	Cultural Humility
View of culture	•Group traits	•Unique to individuals
	•Group label associates group with a list of traditional traits and practices	•Originates from multiple contributions from dissimilar sources.
	•De-contextualized	•Tin can be fluid and change based on context
Culture definition	•Minorities of ethnic and racial groups	•Dissimilar combinations of ethnicity, race, historic period, income, education, sexual orientation, class, abilities, faith and more
Traditions	•Immigrants and minorities follow traditions	•Everyone follows traditions
Context	•Majority is the normal; other cultures are the dissimilar ones	•Power differences exist and must exist recognized and minimized
Results	•Promotion of stereotyping	•Promotion of respect
Focus	•Differences based on group identity and group boundaries	•Private focus of not just of the other but also of the self
Process	•A defined course or curriculum to highlight differences	•An ongoing life process
		•Making bias explicit
Endpoint	•Competence/expertise	•Flexibility/humility

4.ii. Reflexivity

Reflexivity, a technique used in qualitative research, calls on the researcher to explore personal beliefs in lodge to be more aware of potential judgments that tin can occur during data collection and analysis (Jootun, McGhee, & Marland, 2009). Existence reflexive often requires an sensation and reflection of what is happening while being present to i's perceptions and internal experience in the moment. Reflexivity by the researcher is done by placing her/himself within the experience and meaning of the written report participant and then examining the participant-researcher human relationship (Hofman, 2004). In the absenteeism of such contextual information, researchers and written report participants are engaged in an impersonal and, oftentimes, hierarchical relationships. Reflexivity is oft used with qualitative studies where sample sizes are modest and the researcher and the research participant interaction is ofttimes somewhat intimate, however this process can be beneficial in all types of studies, including big quantitative trials, whenever researchers report groups different from themselves.

v. Cultivating cultural humility in research

Cultural humility is a process of reflection to gain a deeper understanding of cultural differences in order to improve the way vulnerable groups are treated and researched. Cultural humility does not focus on competence or confidence and recognizes that the more you are exposed to cultures different from your own, you often realize how much y'all don't know about others. That is where humility comes in. Ideas of ethnocentrism and racism, where the underlying idea implies that the problem is due to the difference, are abandoned. Humility requires backbone and flexibility. Strengths and challenges of individuals and groups are explored as well as the advantages and privileges of sure grouping membership.

When used past the researcher, this procedure of reflection includes the unpeeling of the layers that make up a person and incorporates an examination of personal, professional person, and research values that may guide the researcher's actions. In order to continue the process of cultural humility, this personal review is followed by an inspection of the research participant's perspective.

half-dozen. Inventory of values

6.1. Reflection of person

In the procedure of cultural humility, personal values, behavior, and biases that are derived from your own civilization must be examined. Behavior about race, ethnicity, form, faith, immigration condition, gender roles, age, linguistic capability, and sexual orientation are explored. Family experiences and values, peer influences, relationships with different types of people are also reviewed. Where you live or grew up matters (i.due east., rural, urban, suburban, affluent, or impoverished) and shapes your views of others. What neighborhood you alive and piece of work in influences who you deal with on a day-to-day basis and how you lot define community. Everyday activities such as where you shop, how you lot travel to work, and what you lot consume tell something almost your values. Political views and the way you limited them are important. All of these attributes and the value given to them are of import to examine.

Examining and defining ane'south civilisation is a complex process particularly since today virtually individuals in the United States and other countries are a combination of more than than ane culture with many different variations and mixtures. Group identities oft define our cultural perspective simply these groups, whether based on religion, race, or ethnic classification, are broad categories. Minority groups such every bit American Indians, Alaska Natives, African Americans, Hispanics, Asians, or Pacific Islanders are often given certain cultural characteristics, just those descriptions can miss the mark. Within each grouping, many subpopulations exist with very unlike cultures, historical experiences, and views on health and illness. An individual's civilization is non a single identity; rather it's a rich mixture of many influences and values. Thus agreement oneself and others is a circuitous and lifelong process.

half dozen.2. Reflection of profession

Professional person identity of the clinical researcher is also an important expanse to reflect on. Specifically nurse researchers first must place that their own values, perspectives, and biases are derived non only from their own cultural origin, but also from the biomedical world view of their professional person training. Health care itself is a cultural organisation with its ain specific linguistic communication, values, and practices that must be translated, interpreted, and negotiated with patients and family members. Training in Western medicine using a bio-medical framework ofttimes influences how one sees the earth. This perspective often defines 'normal' as the modern Western civilisation. In the stereotypical perspective, difference is more often than not divers as anyone who is non-white, non-Western, not-heterosexual, not-English speaking, and non-Judeo-Christian. Often the values of medical grooming, and to some degree nursing preparation, reflect a potent inclination toward medications, procedures, and cure, and less focus on psychosocial and spiritual influences. In add-on, health care providers and clinical researchers must consider the privilege and ability of their profession and its effect on do and research.

6.3. Reflections of researcher

An boosted set of values worthy of exam are the values embedded in research often guided by upstanding principles. Autonomy, beneficence, and justice are the basic ethical principles that should underlie the conduct of biomedical and behavioral research (The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979). Every clinical researcher must have at least basic training in these values and Institutional Review Boards (IRBs) ensure that researchers incorporate these values in their studies. Researchers demand to keep these principles in mind when they select participants, obtain consent, and conduct research.

How researchers ascertain and operationalize these upstanding principles in their enquiry is important since inquiry values may be conceptualized differently from person to person. At each pace of the research process, thoughtful consideration of these values and principles is needed. For instance, during informed consent, how does a researcher proceed when a patient is capable of making decisions for her/himself yet instead prefers that the family decides? For some, value is given to family-centered decision making instead of individual autonomy. In add-on, the very definition of family is variable and evolving, sometimes including self-selected family members rather than the traditional family. The standard consent class that an individual reads and signs is just one part of the process and should take decision-making into account, which varies between cultures. The timing and catamenia of the research process may need to be adapted to allow for discussions of the risks and benefits based on a study participant'due south personal values. The scientific values that the researcher brings to the potential participant may non be appreciated by others whose values are grounded in other areas such as religious teachings. Research procedures involving informed consent, confidentiality, and patient safety may look differently when dealing with different groups. A researcher must consider how a participant'south cultural values align with the values of research and to be wary not to brand assumptions nigh the values of others.

In wellness research, cultural stereotypes and assumptions derived from notions of divergence observe their way into explanations of study findings (Hunt, 2005). Researchers often explicate their findings and base of operations their conclusions past making assumptions nigh cultural groups. It is problematic when researchers use cultural and racial stereotypes based on someone's indigenous identity or national origin to explain study findings. For example, researchers have explained their study findings by saying that the reason strange-built-in Mexican Americans had less mental affliction compared to U.S. built-in Mexican Americans was due to (the researcher's belief that) Mexican families being close knit; no measure of family unit construction or quality was included in the study measures (Grant et al., 2004; Chase, 2005). Using cultural stereotypes in this way disregards the heterogeneity of groups and wrongly assumes that cultural beliefs and behaviors always proceed with ethnic identity. In some other case, a report about amniocentesis decision-making, clinicians described Latinos equally part of large extended families, beingness especially family-oriented, and highly influenced past opinions of family members (Chase & de Voogd, 2005). In contrast, the sample of Latino women in this study did non behave equally expected. The women made independent decisions almost the testing and the clinicians seemed to steer the patients in sure direction due to the assumptions made about the patients' cultural values. Therefore, when research results are reported, the bias of the researcher must be acknowledged.

Research values also come from the larger research customs, which has traditionally taken a paternalistic approach and sometimes denied participants the opportunity to evaluate the cost and benefits of research participation in light of their own goals and values. As well, unfortunately researchable questions go unanswered because researchers shy away from doing research with vulnerable groups because of bureaucratic complexities, such as IRB policies created to protect vulnerable individuals. Regrettably, such well-intentioned protections may have compounded the issue. After some groups had experienced coercion, deception and boldness, policy makers institute it was easier to exclude or limit inquiry participation of entire groups in gild to preclude any further violations against them (List, 2005). These policies tin can be problematic considering they exclude groups from participating in inquiry and therefore as well exclude groups from reaping the benefits of research. For example, many take voiced business concern about conducting research with individuals at the end of life (Gysels, Shipman, & Higginson, 2008). Despite these concerns, a study of patients at the cease of life showed that the bulk reported no burden associated with participation in enquiry and noted benefits of participating including social interaction, sense of contributing to society, and opportunity to talk over their experiences (Pessin et al., 2008). End-of-life enquiry certainly has some limitations and necessary precautions, yet it is a high priority topic (National Found of Nursing Research, 2011), particularly with our current crumbling population. These examples highlight the importance of examining the values of the larger research customs.

7. Mindfulness as a tool to raise awareness and insight

Mindfulness is both a mental practice and a trait that involves paying attending to present-moment experience with an mental attitude of receptivity and acceptance (Bauer-Wu, 2011; Kabat-Zinn, 1990). Shapiro and Carlson (2009) define it every bit "the awareness that arises through intentionally attending in an open, caring, and nonjudgmental manner" (p. iv). Through mindfulness practices one can cultivate self-sensation through noticing bodily cues, thoughts, and emotions, and sensation and sensitivity to others, to context and circumstances, and to the environment. Mindfulness is essentially seeing and experiencing things more than accurately (as they are)—without mental filters, self-narratives and judgments—in society to run across conspicuously and respond thoughtfully. In this process, such mental processes are not pushed away or ignored. Rather, they are recognized equally opportunities to learn about oneself and one'southward biases. Information technology is in this way that mindfulness has a role with developing cultural humility.

Typically, busy researchers and clinicians go almost their days on autopilot, going from one task to another, with little if any acknowledgement of their attitudes, assumptions, and biases or how their words and actions are affecting others. More ofttimes than not, these individuals are overextended and running short on fourth dimension, so they may chop-chop proceed with their activities with little awareness of what they are doing or because another'south perspective and how their actions (or lack of) have consequences on others. Mindfulness interrupts "automatic airplane pilot" and allows for more than thoughtful consideration leading to wise action (Bauer-Wu, 2011; Kabat-Zinn, 1990).

Evidence is burgeoning on the effects of mindfulness training in areas such every bit:

• encephalon role, including perceptual acuity (MacLean, Ferrer, Aichele, Bridwell, & Saron, 2010), working retentiveness and attending (Jha, Krompinger, & Baime, 2007; Lutz et al., 2009;

• self-regulation of emotions (Wadlinger & Isaacowitz, 2011);

• interpersonal attributes of empathy (Krasner et al., 2009);

• recognizing others' emotions (Kemeny et al., 2012).

It has been shown to exist helpful to clinicians and can lead to being more mindful in the clinical setting and other aspects of everyday life (Krasner et al., 2009; Galantino, Baime, Maguire, Szapary, & Farrar, 2005. While no studies take specifically explored if clinical researchers can benefit from mindfulness practices, one can extrapolate such a role based on the evidence to engagement coupled with the theoretical underpinnings (Brown, Ryan, & Creswell, 2007) (Fig. one).

Example of mindfulness as a tool for cultural humility in clinical research.

8. Building relationships with research participants

Afterwards the researcher has an opportunity to explore his/her own issues related to civilisation, she/he side by side considers the culture of the research participant. Who is the person, who has a life and story of her own, on the other side of the consent form or the survey or lab specimen? Consider the dynamics at play during a dialogue between a person of privilege (i.e., an educated, middle course, healthy clinical researcher) and the vulnerable research participant who may be living in poverty with avant-garde affliction and multiple co-morbidities. The ability imbalance betwixt the researcher and participant must be recognized and minimized in the research process (Kvale & Brinkmann, 2009). Cultural humility calls on individuals to exist flexible and humble enough to let get of the false sense of security that stereotyping brings and to explore the cultural dimensions of the experiences of each person. Humility is needed to check the power imbalances that exist in the dynamics of researcher-participant communication. In order to build productive relationships with the participant, the researcher must explore the values, behavior, and biases of the inquiry participant specific to health care and research participation.

9. Understanding the past and nowadays

In club to understand how research participants may view research, one must be enlightened of history. Historically some groups have already been deprived of quality health care and take a long history of not existence treated fairly and deservedly (Smedley, Stith, & Nelson, 2003), and have experienced corruption and disrespect, as is the case with African Americans (Bakery, Brawley, & Marks, 2005). The Public Health Service's Syphilis Experiment at Tuskegee is an unfortunate landmark instance that illustrates the worst of research with vulnerable groups. For forty years, the U.S. Public Health Service conducted an experiment on blackness men in the tardily stages of syphilis who were never told what disease they were suffering from or of its seriousness (Jones, 1993).

This history of mistrust by vulnerable populations has led to skepticism well-nigh the purpose and outcomes of research thereby necessitating conscientious effort to build trust (Douglas et al., 2009). In order to build trust, the reasons for mistrust must exist uncovered. Some signal out that the focus should not be on the participants' mistrust, rather the focus should be on the trustworthiness of the system (Corbie-Smith & Ford, 2006). The lack of trustworthiness in the system is rooted in history equally well as the current state of wellness disparities. The history of slavery, racism, and segregation, and the standing shortage of minority providers and researchers contribute to mistrust. In addition, poor patient-provider communication and a lack of true cultural understanding past health care providers and researchers influence level of trust (List, 2005). Wellness disparities and lack of admission to quality wellness care can add to mistrust. How practise you answer a potential written report participant when he says, "yous want me to help you with this research study but I cannot get health intendance coverage that I can beget."

Equally important to the recognition of historical influences is the need to understand the heterogeneity of groups. All racial and ethnic groups are heterogeneous and may have different histories and follow different lifestyles. Education, religion, sociocultural factors, geographic location, gender, sexual orientation, and age affect attitudes toward research equally much as historical events. As well values, beliefs and attitudes may differ based on age and generational factors, need to besides be considered (van Ryn & Burke, 2000).

x. Breaking downward stereotypes

Relationships betwixt the study team and study participants must be thoughtfully and courageously examined forth with barriers imposed by the use of stereotypes to classify individuals. For example, many stereotypes exist about the poor and are often communicated with lilliputian hesitancy or shame (Lott, 2002). Common descriptors used to describe the poor include: uneducated, lazy, dirty, stupid, immoral, criminal, calumniating, and tearing (Cozzarelli, Wilkinson, & Tagler, 2001, Kemeny et al., 2012). Health care providers may also concord these stereotypes. For example they may perceive patients with lower socioeconomic status every bit having more negative personality characteristics, lower level of intelligence, less probable to be adherent, and less likely to want active lifestyle even when decision-making for other demographic factors (van Ryn & Burke, 2000). Clinical researchers must be cautious to avoid stereotyping groups and must consider the individual who may exist distinctly different than others in a similar group. Beyond beingness a study "subject", the research participant is a partner who is an expert in her/his own experience. Paternalistic behaviors and gate keeping activities specifically in research recruitment demand to be replaced with honest communication and respect.

11. Conclusion and recommendations

Cultural humility, a procedure of reflection and lifelong enquiry, involves self-awareness of personal and cultural biases likewise as awareness and sensitivity to significant cultural issues of others. Core to the process of cultural humility is the researcher'southward deliberate reflection of her/his values and biases. Looking toward the future, cultural humility and practices that cultivate it, similar mindfulness, ought to be an essential component of the training of clinical researchers. Given that nursing naturally espouses a holistic perspective, it is logical that nurse researchers have a lead in this area. With a foundation in cultural humility, nurse researchers and other investigators tin implement meaningful and upstanding projects to better accost and minimize wellness disparities.

Acknowledgments

Funding argument: Dr. Yeager was a recipient of the Doctoral Scholarship in Cancer Nursing from the American Cancer Club and likewise supported past training award, F31NR011383, from the National Constitute of Nursing Research during the time that this piece of work developed. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institute of Health.

Footnotes

Disharmonize of involvement statement: No conflict of interest has been alleged by the authors.

Dr. Bauer-Wu was a Georgia Cancer Coalition Distinguished Cancer Scholar during the period of development of this manuscript.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834043/

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