Supporting work across cultures

[Introduction] 

This is a Research in Practice podcast, supporting evidence informed practice with children and families, young people, and adults. 

Dyfrig: Hello and welcome to the Research in Practice Podcast, I'm Dyfrig Williams, Head of Learning at Research in Practice. In this podcast, we're going to be looking at supporting work across cultures and what effective practice might look like. Today, I'm talking with Luciann Blake, who's a Research and Development Officer at Research in Practice. Luciann, can you introduce yourself?

Luciann: Hi, I'm Luciann and I'm a Research and Development Officer at Research in Practice, and I work across children and families and adults.

Dyfrig: Brilliant, cheers Luciann. So, in today's podcast, we're going to look at what cultural competence is, applying it in practice and relevant research around cultural competence and some of the resources that we have here at Research in Practice. So before we start, Luciann, you examined cultural competence in your undergraduate degree. Can you tell us why you started researching this topic?

Luciann: Yes, absolutely, so I have two degrees in social anthropology, and social anthropology basically looks at societies and cultures and the way people live their lives using ethnographic research, which is, kind of, qualitative observational research. So I was really interested in how cultural competence is being taught within the NHS, especially through nursing training, because I think there's a big contrast there with how anthropologists understand culture. So I'll, kind of, get into this larger discussion of cultural competency in a little bit, but I just think it's worth mentioning that there's a really strong critique of cultural competence from the social sciences, which says that it's really important that we talk about culture in a way that reflects the way people actually live their lives and actually experience their own cultures. So while cultural competence can often describe other cultures as quite monolithic, that means, you know, giving the impression that all people from the social group live lives in the same way. Or that, you know, that culture's been static across time, we know from social anthropology and other social sciences that, actually, members of the same social group often have very different relationships to their own cultural heritage.

So yes, we'll get into, kind of, what culture is and what it does, in this conversation, I suppose, but yes, that tension was what I found interesting. And that's why I've, kind of, taken this on at Research in Practice, it was one of the first projects that I was given when I started here last year and I was quite happy that it fell into my lap because I actually... they didn't know that I had that expertise but I did. So I was really happy to take on the challenge and, kind of, really thinking about going beyond cultural competence, actually, to think about things like cultural humility or cultural safety and thinking about a wider set of resources that we might use that we might have at our disposal to think about diversity, think about what's important to people and think about how we can safely deliver effective care and support for all the people that, kind of, come to our services.

[What is the relevance of culture to social care?] 

Dyfrig: How have we got to the point where cultural competence has become such a focal point in our work?

Luciann: Yes, so basically it's, kind of, the result of a few decades of research and practice development in a couple of different, sort of, academic schools of thought, I suppose. So on the one hand, we've got in the, kind of, social sciences and public health sciences, a lot of research on differential outcomes between different social groups when it comes to health and social care. So that means, kind of, observing from data that there are these significant differences, so people might be familiar with concepts like the social determinants of health, for instance, which suggests that there are a vast range of non-medical factors which are playing into people's experience of health and social care and their, kind of, need for these services. So for instance, that might be things like diet or housing or access to green spaces, and so observing that these factors are unequally distributed across society. So yes, so there's this, kind of, yes, observation of different outcomes for different social groups and this prompts a question of how are we going to address this, obviously there's a socioeconomic aspect to this, there's a racial aspect to this, there's often also a gendered aspect to this. And at the same time, we have work within the social sciences thinking about culture when it comes to medicine and social care, so there's the observation in medical anthropology that people's understanding of things like medicine or people's understanding of their own health and wellbeing has a really deeply cultural aspect.

So there might be something like stigma around certain illnesses or needs. So yes, it may be different meanings that we assign to experiences of illness or mental health, for instance. So there's, you know, there's a deeply cultural aspect to how people experience their health and wellbeing and there's also, importantly, a cultural aspect to health and social care, so we can say that institutions and organisations have their own professional cultures that relate to, kind of, how people follow certain rules or exhibit certain behaviours within the workplace. And how there can often be a disconnect between the very medical world of... that can, kind of, be in healthcare, especially, and coming into aspects of social care. And also the way that people, you know, what's actually important for people in the way they live their lives and, yes, that very experiential dimension of the way people are understanding their own experiences.

So it might be useful just as that point to, kind of, define culture as, like, it's always a thought for me as an anthropologist to think about how to define this. Because if you've got ten anthropologists in a room, you probably have eleven definitions of culture. So when I'm talking about culture, I'm talking about the beliefs, practices and traditions that one acquires while you're growing up as part of a social group. So there may be lots of factors that feed into this, your cultural identity might be strongly affiliated with your religious identity, for instance, or your national identity. But there's also going to be different things impacting that like maybe your disability or your socioeconomic status or your sexuality and gender, for instance. And it may also be something that changes across your life, you may, kind of, identify with different parts of your cultural heritage at different points of our life. So yes, so there's this, kind of, complex interplay of factors there that I'm starting to identify and there are lots of different people theorising on these things, kind of, across these different disciplines.

So cultural competence arises in this space, in these debates that people are having. Thinking about, you know, how we can understand these complicated social factors and how those are having an impact on people's experiences of accessing care and support. So the person who actually conceptualised cultural competence the first time, this was towards the end of the 1980s, I can't remember the year off the top of my head. It was Terry Cross, who was a Native American social worker and some of his colleagues in his organisation, they first conceptualised cultural competence as a framework for care because they were observing the unmet need of children from marginalised ethnic and cultural groups with the US, especially Native American children. So, since that was theorised, that's become far and away the most widely-used framework for delivering culturally appropriate care. So cultural competence in their, kind of, framework is both the spectrum of proficiency that goes from cultural destructiveness at one end, which basically means that the policies of the, sort of, health and social care institution are actively destructive to cultural difference and are highly disrespectful of diversity, to cultural competence and cultural proficiency at the other end, which means that those differences are celebrated and are given the due respect within that organisation. So it's, kind of, it's a spectrum for professionals and organisations to reflect upon and say, 'What do our policies contribute to along the spectrum and how do we move towards the proficient and competent end of that spectrum?'

[Issues with how cultural competence is applied in practice] 

Dyfrig: That's really helpful, that's more complex... I already knew it was quite a difficult thing for people to get their heads around, and speaking about myself as somebody with all the privilege, I definitely like I've got a lot to get my head around here as a straight white man, but I suppose what do you see is the main issues with cultural competence as it's then applied in practice?

Luciann: I'm very happy to divulge that, that's one of my favourite topics, is the issues of cultural competence. Because I think that talking about these issues is a really good way of learning about that really complicated, kind of, massive debate that I've just been identifying there, which you absolutely do not need to have a good handle on in order to have a good handle on delivering culturally appropriate care. I would just say that... so, actually, I'd like to go straight in with what you were just saying about, kind of, of a feeling of relative privilege, because I think that something that isn't always talked about in cultural competency models is the way that culture and cultural difference is deeply inflected with power dynamics where certain groups have privilege over others. So it's very much identifying that cultural difference is just one aspect of these deep inequalities that we're seeing, kind of, across the world and across in the country in people's care experiences, experiences of care and support, rather. So I think it's important to say that we're, like, we live in the UK, this is a country with a long history of empire. So the diversity that we have in the country at the moment is deeply linked to the fact that, you know, white British people in the last few hundred years have colonised other countries and lay the foundations of immigration and economic systems which deeply shape the way that our country looks today.

So what that means for us is that the norm is very much white British and the norm is quite middle-class, it's quite heteronormative, as you also identify. So there's a certain privilege, there are a number of privileges that combine to make that experience, or the closer you are to that normative experience, easier for most people to navigate, sort of, public services, for instance, or life in general, as well. Everything that we're doing in this space of thinking about cultural diversity, there's an important power dynamic there that we've got to be cognisant of. So yes, so that, kind of, leads on to the second point that I want to make about cultural competence, which is that, often in the way that it's spoken about, implies that the practitioner belongs to the mainstream social group, the mainstream culture, the dominant social group, I should also say. And that cultural competence, so developing cultural competence is about developing confidence in working with other people who have different culture to your own.

That can give the wrong impression, that culture is something that other people have, that people who are of the, you know, global majority, non-white population is something that “other,” in quotation marks, people have. And that's not true, every single person in the world has culture, that's part of the human experience. That you grow up, you socialise with a group, the people around you and you develop those, yes, those traditions, those values, those behaviours, that you accumulate as part of growing up. So yes, so it's really important to, in this process, be thinking, yes, about that privilege but also about what cultural heritage, what the cultural heritage that you have and is... what impact that is having on the way you're seeing the world, the way you're understanding that encounter with people you're working with. And of course, with your colleagues as well and the white community. And then, I suppose, the third thing that I wanted just to say about cultural competence is that it can often give the impression in the way that it's taught that culture is a static and monolithic, sort of, block of things that people do. And that's absolutely not true. You know, there are so many different factors that are going to impact on how somebody relates to their cultural heritage. In my undergraduate degree, when I was writing my dissertation, I was looking at nursing manuals and they often would say things like, 'People from this country express pain very strongly,' you know, implying that they might not be believed if they were to express strongly that they were in pain. And that is just, you know, a fallacy to think that, that you should disregard the feelings of the person in front of you because of a paragraph that you read in a textbook a few years ago.

So, making sure that you are, kind of, thinking about the person before the culture, their cultural heritage is just one part of who they are and making sure that you are understanding context, understanding the person holistically, understanding what has brought them to this encounter that you're having with them. It's so much more important than a kind of... static and un-nuanced idea of somebody else's culture or even your own. You might also think that you have a lot in common with this person because you share a cultural background, but that may not always be true. You may be making assumptions. So, yes, being open and respectful and engaged with the person you're working with is always going to be more important than static ideas of what a member of a certain cultural group should be doing.

So, yes, in responding to the really diverse cultural needs of our communities, it can be really helpful to think about the different kinds of approaches that are needed. So when I was researching this topic for the briefing I wrote, I read a few different review papers looking at and comparing the evaluative outcomes of cultural competence initiatives round the world. So one of the interesting things that came up a couple of times was thinking about a distinction between, sort of, surface level approaches versus deep structure changes within an organisation. So, surface level culturally responsive care provision might be things like making sure people have food that's familiar to them or celebrating a range of religious holidays in a domiciliary care environment, for instance. So these kind of things are great and they're really welcomed by people. They're really great for making people feel at home and there are definitely positive outcomes for reported experience of services. However, they don't really get to the bottom of, they don't really address those deeper disparities in care, like, between communities on a more demographic level. So, deep structure changes might be things like community outreach and consultation, or it might be co-designing services. And it's also going to be things like ensuring high quality interpretation or translation for people who don't have English as their first language. Or it might also be something like developing an anti-racist policy charter. There's an aspect there of, sort of, power sharing, which is a far more radical idea than enacting cultural competence in the workplace. So it's asking, kind of, what can you do to make your organisation more directly meet the needs of the people they're serving.

So, to get to this, I prefer, above cultural competence, I really prefer concepts like cultural humility and cultural safety. So these are alternate approaches to delivering culturally responsive care. So, cultural humility was developed by, I believe, two American physicians, Doctors Tervalon and Murray-Garcia in a response to cultural competence. And cultural safety was developed by Dr Irhapeti Ramsden and her Maori nurse colleagues in Aotearoa/New Zealand. Both of these in the '90s. So, both of these concepts involve a far deeper level of power sharing with the people who are accessing services. Really thinking about what can we do as an organisation to really, just, flip that power dynamic and say, 'What we're doing is for you. What can we do that lives up to your expectations and your needs?' So that really means the practitioner giving that power to the person they're working with within that relationship, to decide whether the care and support they're receiving is working for them and working for their needs. And it also devolves that responsibility of thinking, 'What are the cultural needs of this person from X heritage?' It speaks to that idea of the person accessing services being the expert in their own life. That they're the person that's got the knowledge of how these factors are interacting to, you know, impact on their current experience and need for care and support. So, yes, I think those approaches are really powerful and I think that, in general, they, kind of, fit better with what we're trying to do in social care. I mean, if I may say so myself.

[Implications for the workforce] 

Dyfrig: So in thinking about culture, what does that mean within the workforce?

Luciann: So, there's a really important dynamic here of making sure that the workforce is really representative of the local community, in terms of ethnicity and cultural background and so on. So, on the one hand, we know from research that, especially at higher levels of seniority, we have a much lower level of diversity within our organisations than at the front line, and also within the communities served by our organisations. So that's a really important issue to be addressing. But we've also got to be careful, on the other hand, that we're not, sort of, pigeon-holing practitioners and saying, you know, 'Your background is from this country and this family are from the same region, therefore you must be able to instantaneously connect with them, or instantaneously know exactly what's going on with them,' because that's not always going to be the case. So, research shows that ethnic matching can be perceived as a positive by people accessing services, but often it's more about the relationship and about the bond of trust that is forged between the person and the professional that they're working with. So it's much more, kind of, nuanced things than just matching based on ethnicity and cultural background.

So, yes, I think that it can be a really positive thing for those we work with, to be able to share insights into different cultural backgrounds and different, kind of, aspects of identity with one another. So forging that kind of relationship where you can draw on the expertise of your colleagues and vice versa is a really positive and powerful thing. But, yes, of course, that still leaves open that question of how are we going to make sure that those levels of diversity are improved across the board. And for anybody thinking about that, I would absolutely recommend our Practice Supervisor Development Programme resources on that topic. Like I say, a really important challenge. But yes, for both of those questions, it's going to involve doing some deep thinking about that professional culture and thinking about what kind of behaviours, values and traditions, in that definition of culture, are being supported or discouraged by the structure of the organisation and of the relationships within it.

[Relevant research]

Dyfrig: Are there any interesting bits of research on this topic that you think are particularly relevant to practitioners?

Luciann: Yes, absolutely. I did loads of really interesting reading when I was writing this frontline briefing for Research in Practice, which should be published by the end of the summer. So, yes, I think there's a lot of, kind of, research about the sector that's ongoing that highlights the need for achieving equality, diversity and inclusivity across the sector and, like we were just talking about, culturally appropriate care being part of that. So, despite the fact that we're a really multicultural country, there's still a lot of work to be done there. Because we can see from research, such as Michael Preston-Shoot's SARs analysis from the last couple of years, which keeps identifying missed opportunities to think about ethnic and cultural factors in adults' cases.

So, yes, I think one of the interesting things that comes out in the research is the complexity that it takes to understand the multifaceted roots of behaviour and beliefs. So, for instance, we can attribute some actions or values to culture that, actually, might spring from other sources. It may often spring from histories of oppression and discrimination within that public service that somebody's trying to access. For instance, I read a really interesting paper by Gob Krishnan (ph 22.49), which was talking about how stigma in certain communities around accessing mental health services is often assumed to be a cultural trait, that certain cultural groups may feel that mental health is, you know, a taboo subject. But actually, it's often linked to negative past experiences around accessing services. So it's a really interesting interplay there between cultural heritage and the actual experience of accessing services. So we want to keep an open mind about those causes of behaviour, trying to understand why somebody may feel a certain way, or have a hesitancy towards engaging with services. So, yes, just keeping an open mind, that's the most important thing.

One other thing that really stood out to me in researching the topic is that there can be really big differences in outcomes for services depending on whether you're addressing, sort of, surface level cultural preferences versus deeper structural issues with access and engagement. For instance, things like knowing what meals somebody may prefer will often improve satisfaction scores, if you're collecting that sort of data. And people will appreciate that, that's a nice gesture to be able to make for somebody and to, kind of, have that little bit of cultural knowledge around the way they would like to spend their days. But it isn't going to make a big difference necessarily on engagement rates across a community. So, to, kind of, tackle that latter objective, you're going to have to be thinking about things like high quality translation and interpretation for people who don't have English as their first language, for instance. Or it might be things like outreach and consultation with communities to see what unmet need there is in your local area. And things like developing tiered care in community options, it's going to have a much more significant impact on how people are, on a wider level, accessing services. Rather than just thinking about those very welcome but more surface level interventions.

And, of course, there's this really important dynamic here of making sure that the workforce within social care is representative of the local community and of the country in general, that is, in terms of ethnicity and cultural background and so on. So, there's a lot of research that I'm sure people will be aware of showing that at the high levels of seniority in an organisation, we have a much lower level of diversity than at the front line. So it's really important on this, kind of, journey, to be thinking about how the organisation can develop a really positive working culture that is culturally inclusive on all levels, not just to the people we serve but also between colleagues and within the organisation and being responsive to needs of staff and responding to complaints well and being inclusive wherever the opportunity presents itself. We've got some great resources on the Practice Supervisor Development Programme which relate to that especially.

[Outro] 

Dyfrig: Brilliant, thanks Luciann. So, we'll share all the resources that you've mentioned today in the show notes on the website. It was great to talk to you and to delve a little bit further into cultural competence. I know I've got a bit of a better understanding now than I did before we started talking, so just to say thank you very much.

Luciann: Thank you Dyfrig, it's always a pleasure to share what I know.