Practising cultural humility to promote person and family-centred care
Intended for healthcare professionals
CPD    

Practising cultural humility to promote person and family-centred care

Lucille Kelsall-Knight Lecturer in children’s nursing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, England

Why you should read this article:
  • To understand the concept of cultural humility

  • To develop your awareness of conscious and unconscious personal and cultural bias

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

The concept of cultural humility in nursing involves an awareness of diversity and how an individual’s culture can affect their health behaviours. Nurses can use this awareness to develop sensitive, tailored and person-centred approaches to patient care, which ultimately contribute to a positive healthcare experience. This article examines the concept of cultural humility with reference to person and family-centred care. It also explores how individuals and organisations can challenge discriminatory attitudes and behaviours in the workplace.

Nursing Standard. doi: 10.7748/ns.2022.e11880

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@LKelsallKnight

Correspondence

L.M.Kelsall-Knight@bham.ac.uk

Conflict of interest

None declared

Kelsall-Knight L (2022) Practising cultural humility to promote person and family-centred care. Nursing Standard. doi: 10.7748/ns.2022.e11880

Published online: 17 January 2022

Aims and intended learning outcomes

The aim of this article is to assist nurses to consider cultural humility in relation to person and family-centred care. After reading this article and completing the time out activities you should be able to:

  • Understand what is meant by cultural humility, person-centred care and family-centred care.

  • Identify patient groups in which nurses may be required to pay particular attention to cultural humility.

  • Work in partnership with patients and their families to ensure that their cultural needs are recognised.

  • Support other members of staff in recognising the importance of cultural humility and its effect on patients and their families.

Key points

  • Patient populations are becoming increasingly diverse, which means that patients may exhibit a range of health behaviours influenced by their cultural backgrounds

  • Cultural humility involves ‘a process of being aware of how people’s culture can impact their health behaviours and, in turn, using this awareness to cultivate sensitive approaches in treating patients’

  • To challenge discriminatory practice and promote cultural humility it is imperative that healthcare leaders set an example by reflecting on their own bias and attempting to develop open and honest healthcare environments

  • A commitment to cultural humility can contribute to the elimination of disparities in healthcare and support nurses to provide optimum person and family-centred care

Introduction

In the UK, patient populations are becoming increasingly diverse, which means that patients may exhibit a range of health behaviours influenced by their cultural backgrounds (Prasad et al 2016). Examples of health behaviours that could be influenced by a person’s background might include a reluctance to give up smoking despite the health benefits or decisions regarding vaccinations (Short and Mollborn 2015).

Healthcare professionals may face challenges related to language and/or cultural issues, which in turn could be deemed as a threat to patients’ safety (Kaihlanen et al 2019) and affect their experience of healthcare services negatively. NHS England (2021) describes patient safety as ‘the avoidance of unintended or unexpected physical or emotional harm during the provision of healthcare’, which infers that there may be times when patients feel their safety has been compromised due to a lack of understanding of factors such as religious custom, or assumptions about gender or sexuality.

In the UK, The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018) is structured around four domains – prioritise people; practise effectively; preserve safety; and promote professionalism and trust. These four domains encapsulate concepts such as professional values; communication and interpersonal skills; nursing practice and decision-making; and leadership, management and team working, all of which contribute to the standard of care expected by the NMC, the nursing profession and the public (NMC 2018). The Code (NMC 2018) is not a static document and is reviewed periodically through consultation with the nursing profession and the public, and as such is designed to reflect society’s expectations of standards of nursing care.

In recent years, issues such as nurses’ interactions with social media – such as avoiding unacceptable behaviour or making inappropriate comments about patients (NMC 2019) – a focus on person-centred care, and working in partnership with patients, has reflected greater expectations of equality and diversity in society. Adherence to the Code (NMC 2018) aims to ensure that nurses treat people fairly and with respect. This is endorsed by the NMC’s (2020a) equality, diversity and inclusion strategic framework, which states that the NMC aims to contribute to a society in which people are treated fairly and are valued for their diversity. Stenhouse (2021) supports this, commenting that nurses must treat people as individuals, avoid making assumptions, recognise diversity and individual choice, and respect and uphold people’s dignity and human rights.

Equality in healthcare involves ensuring that everyone has equal opportunities and fair access to inclusive services regardless of their abilities, background or lifestyle (Salway et al 2016). Equity in healthcare may be regarded as the provision of varying levels of support depending on people’s needs or abilities, while recognising the impact of privilege, inequality and discrimination (Bhugra 2016).

Incorporating cultural humility in everyday practice can assist nurses to ensure equality, equity and inclusion for their patients; therefore, it is important that they understand this concept and its implications.

TIME OUT 1

Consider the patients you have cared for recently. Did you attempt to ensure that they had equal opportunities in terms of access to healthcare? How did you achieve this and were there any challenges?

Cultural humility

The concept of cultural humility involves ‘a process of being aware of how people’s culture can impact their health behaviours and, in turn, using this awareness to cultivate sensitive approaches in treating patients’ (Miller 2009). As a concept, cultural humility stems from the theory of cultural competence, which assumes that healthcare professionals can learn a set of attitudinal and communication-based skills, which will enable them to work effectively while considering the various cultures represented by their patients (Prasad et al 2016). For example, an attitudinal skill might include a nurse reflecting on their cultural understanding and assumptions through reflective writing or participating in group discussions with their peers. Cultural competency is a broad term with a defined end point, in that nurses can demonstrate cultural competence, for example by completing a proficiency assessment. Conversely, cultural humility is a continuous process which enables nurses to be self-reflective in their everyday practice. Cultural humility is strongly linked with reflexivity, the process of being self-aware of factors such as feelings, motives or reactions. This is because practising cultural humility requires the nurse to be aware of and reflect upon events at any given moment, at the same time as ‘being present’ or fully aware of their perceptions, internal experiences, and any conscious or unconscious bias (Yeager and Bauer-Wu 2013).

Power imbalances

Cultural humility enables nurses to consider potential power imbalances in their relationships with patients, and potentially other members of staff, which could affect patient outcomes and experiences (Corless et al 2016). These power imbalances may occur as a result of professional status and knowledge, which can place nurses in a position of power, for example, compared with their patients (Corless et al 2016). Some nurses, for example, may believe that they ‘know best’ and regard patients as lacking medical knowledge (Henderson 2003). Power imbalances can also arise, for example, if English is not a patient’s first language, or if they are unaware of how the UK healthcare system works. Similarly, power imbalances can occur as a result of assumed privilege due to characteristics such as race, age, gender and sexuality (Burr 2003, Stemple and Meyer 2014).

Whether consciously or unconsciously, nurses occupy a position of power in relation to patients; however, they have a responsibility to alleviate or reduce the effects of any power imbalance in accordance with the Code (NMC 2018). Nurses can do this by incorporating cultural humanity into their everyday practice, by seeking to understand patients’ cultural differences or similarities, and by treating them with dignity and respect.

TIME OUT 2

Reflect on the patients you have cared for recently. Was English their first language? Did any of them experience cognitive impairment? Were they anxious, possibly due to previous negative healthcare experiences? What was your approach to care provision for these patients and what attempts did you make to understand their perspectives? Consider how you could reduce the power imbalance between yourself and your patients, and thereby display cultural humility. For example, you might consider involving patients’ family members or friends in their care, or contacting an advocate from a patient’s community

Intersectionality and microaggressions

Intersectionality is linked to power balance and describes a ‘lens’ through which diversities such as race or gender can be seen to intersect and overlap (Crenshaw 1989). The theory of intersectionality states that identity markers such as class, race, gender, sexual orientation and religion can lead to oppression and disadvantage (Kelsall-Knight 2021). It is common for people to have multiple intersections, all of which contribute to their identity, and which may increase the likelihood of them experiencing microaggressions (McCann and Monaghan 2020).

Microaggressions are defined as small acts or remarks that result in someone feeling insulted or badly treated because of, for example, their race, sex, gender or sexuality – even though the insult or treatment may not have been intended – and which can combine with further microaggressions over time resulting in emotional harm (Cambridge English Dictionary 2021). Examples of unconscious microaggressions may include comments about someone’s career, such as ‘you’re too clever to be a nurse’; judgments about a colleague or patient’s body; or remarks about someone’s accent.

Microaggressions emerge from prejudice and discrimination and may result in hostile or derogatory behaviour and comments, which may be consciously or unconsciously directed at members of minority social groups such as those from the lesbian, gay, bisexual, transgender and others (LGBTQ+) community, those of differing skin colour and women (Sue 2010). One result of microaggressions is ‘minority stress’ (Meyer 2003), which may be felt by members of a minority group due to the relationship between their own and a dominant group’s values, which may create conflict within a particular environment. One example of this is when same-sex parents are challenged about their family constellation by a healthcare professional (Kelsall-Knight 2021).

The theory of microaggression was introduced in the 1970s and at the time was related to race, but has since expanded to include other marginalised groups. It has been found to be causally related to mental health issues due to the cumulative effects of subtle prejudice (Farr et al 2015, Nadal et al 2016). It is important to note that microaggressions exist in a broad context; for example, microaggression can include bullying and harassment between people of an identical or low-to-high power group, such as the bullying of a manager by their staff (Björklund et al 2019).

Person-centred care

Person-centred care involves healthcare professionals viewing each patient as unique and doing all they can to put the patient’s needs first (NMC 2020b). In practice, this means that nurses should assess individuals holistically, including their physical, psychological, spiritual and social requirements. This enables nurses to identify patients’ concerns and needs, develop a personalised care plan, share the appropriate information at the appropriate time, and signpost them to relevant services and support (Mills 2017). It supports partnership working between patients and healthcare professionals, and ensures that patients can make informed decisions about their care and treatment (Gray 2020, Health Education England (HEE) 2021).

A person’s identity is comprised of various intersections and by acknowledging the effect of these on their patients, nurses can deliver optimum care tailored to individuals’ needs (Ruiz et al 2021). When delivering person-centred care, nurses should place the individual at the centre of any clinical decisions and ensure that their preferences, needs and values are considered so that any subsequent care is respectful, responsive and delivered without prejudice (Mills 2017, HEE 2021). Clinical decision-making between the patient and the healthcare professional enhances patient outcomes as well as providing cost-effective healthcare (HEE 2021).

To improve the quality of healthcare, it is important for nurses to provide person-centred care and cultural humility in tandem. To deliver person-centred care nurses must consider peoples’ diversities and perspectives to enable joint decision-making. Thus, practising cultural humility has the potential to improve the quality of person-centred care, which in turn increases the likelihood of improved patient outcomes.

Family-centred care

Family-centred care is a UK government initiative (Department of Health (DH) 2004) originally based in children’s healthcare services, and which focuses on collaborative planning, delivery and evaluation of healthcare between healthcare professionals, patients and their families. Family-centred care is widely practised in the UK and provides an exemplar for healthcare professionals (DH 2004). To deliver family-centred and culturally appropriate care, nurses must be able to work effectively within patients’ and families’ cultural context; that is, they must be sensitive to families’ values and customs and provide the specific information that patients require (Campinha-Bacote 2009).

Definitions of ‘family’ vary and may include a group with two parents of any gender mix and their children, or single parents of any gender and a child and/or children, or the offspring of a common ancestor, or a group of people who are related to each other (Gil de Lamadrid 2013). As societal norms and laws have diversified, so too has the concept of the family. As such, the concept of family is fluid and non-binary (Bauman 1991) and may include close friends or people regarded as significant, faith communities, or communities in which English is a second language who may not be related but regard themselves as a ‘family’. It is also vital to consider how inclusionary the concept of family is in the documentation used by healthcare organisations in everyday practice; for example, whether these depict two parents or one, or heterosexual or same-sex parents.

A family-centred approach to children’s healthcare should consider the emotional and developmental needs of the child, and the overall well-being of the family. This is most effective when the healthcare system supports the family to meet the child’s needs by involving the family members in the plan of care (Shields et al 2012). The principle of family-centred care is a partnership between patients, family members and healthcare professionals. This is demonstrated by mutual respect and dignity, information sharing, and the involvement of patients and their families in decisions about treatment options (Ramezani et al 2014). In addition, active parental participation in care planning and treatment has been shown to increase parents’ satisfaction with and confidence in their children’s care (Bastani et al 2015). Family-centred care places the child or young person in the centre of any decisions and ensures the needs of the family are recognised (Shields 2015).

Although family-centred care is often considered in the context of children’s health services, it can be expanded to all areas of nursing and should be considered within the context of cultural humility. To practise effective family-centred care, nurses should also be sensitive to family members’ values and customs, and work with them to plan and deliver care that meets the physical, emotional and cultural needs of the patient.

TIME OUT 3

In terms of family-centred care, what does the concept of ‘family’ mean to you? How will you ensure that you prioritise the patient and their family members in your care, as well as practising cultural humility with regard to their cultural differences and needs?

Equality Act 2010

The Equality Act 2010 applies in England, Scotland and Wales and protects people from discrimination on the basis of what are referred to as the ‘nine protected characteristics’ – age, gender reassignment, sex, race, religion or belief, pregnancy and maternity, marriage and civil partnership, sexual orientation, and disability (Royal College of Nursing 2021). Discrimination associated with one or more of these characteristics is unlawful under the Act. The Act protects people from discrimination by employers, businesses and organisations that provide goods or services including transport, as well as public bodies such as government departments and local authorities, including those concerned with health and education.

The Act replaced nine major acts of parliament and almost 100 sets of regulations that had been introduced over several decades and provides a single, consolidated source of discrimination law covering all types of unlawful discrimination. It simplified the law by removing anomalies and inconsistencies that had developed over time and extends protection against discrimination to areas such as workplaces, public services and shops (Department for Education 2014). In terms of healthcare, the Act stipulates that all healthcare workers and patients must acknowledge that prejudiced and discriminatory practice will not be tolerated. Therefore, the nine protected characteristics detailed by the Act protect those that provide and receive healthcare from being treated unfairly. Although people from the groups identified as having protected characteristics are more likely to encounter discrimination (McCann and Monaghan 2020), it is vital that the cultural diversity of all patients is recognised and that they can expect any care to be provided according to the principles of cultural humility.

Challenging discriminatory attitudes and practising cultural humility

The ‘prioritise people’ domain of the Code (NMC 2018) states that nurses must put the interests of patients first and that patients’ care and safety should be nurses’ main concern. Regardless of whether a person has protected characteristics under the Equality Act 2010 or not, it is important that their dignity is preserved, that their needs are recognised, assessed and responded to, and that no assumptions about them are made. Patients and their families or significant others must receive respectful care, and any discriminatory attitudes and behaviours must be challenged.

It is vital for nurses to consider the diversity ‘landscape’ within their organisations when seeking to exercise cultural humility. For example, many NHS trusts in England have adopted the rainbow badge project in which badges are worn by staff who have pledged to provide support and signposting to people from the LGBTQ+ community. However, such initiatives alone do not create an inclusive environment because they do not alter the attitudes of all healthcare professionals. In addition, institutional homophobia and discrimination or ‘being treated differently’ are still factors in some healthcare settings, as evidenced by the use of documents and forms in some children’s services that assume that parents will be part of an opposite-gendered pairing (Kelsall-Knight 2021).

To challenge discriminatory practice and promote cultural humility it is imperative that healthcare leaders set an example by reflecting on their own bias and attempting to develop open and honest healthcare environments. By role modelling authentic, respectful and inclusive leadership styles, nurse leaders, for example, can develop a sense of inclusion and belonging within healthcare settings (Adams et al 2020). Examples of such role modelling include showing empathy and actively listening to staff, patients and family members, as well as recognising the effects of factors such as English not being an individual’s first language, religious customs or diverse family structures (Sprik and Gentile 2019). As well as being practised by healthcare leaders, these are principles that can be adopted by all team members.

In addition to promoting inclusive leadership, incorporating emotional intelligence into daily life can encourage inclusive and welcoming environments. In a nursing context, emotional intelligence is the nurse’s ability to self-monitor their emotions as well as recognise how emotions can affect their relationships with others. By working towards a goal such as inclusive practice, and by recognising their own feelings and those of others, nurses will be well-placed to demonstrate cultural humility (Carragher and Gormley 2017).

In healthcare settings, microaggressions must be recognised and acted on by challenging the perpetrator in a professional manner, ideally at the time of the incident. While it is not possible to control or predict what someone else says, it is important to respond to microaggressions in a sincere and direct manner and to address the microaggression, not the micro-aggressor. One way of doing this is for the nurse to explain that they have an issue with what was said or done, not with the person themselves. It is also important in this type of situation to practise inclusive leadership by showing empathy to the perpetrator and the person affected, as people may be unaware that their comments are inappropriate.

TIME OUT 4

Reflect on your own prejudices and consider your thoughts about people with different characteristics and identities to yourself. Have you encountered microaggressions, whether intentional or not? Now that you are aware of microaggressions, how would you respond if you encountered them? Are there times when you might find it difficult to challenge them? Consult your organisation’s equality and diversity policy and familiarise yourself with the process for escalating concerns

Supporting others to practise cultural humility

It is important to support patients and families, as well as other healthcare professionals, to practise cultural humility and develop inclusive environments. Patients, their significant others, nurses and other healthcare professionals can all benefit from cultural humility because, power relationships aside, everyone has diversities that must be acknowledged and supported. To practise cultural humility in healthcare settings, it is vital that healthcare professionals treat patients and their families as partners by incorporating shared decision-making into treatment and care planning (Mills 2017). Nurses must be sensitive to patients’ and their families’ values and customs, which they can demonstrate by employing active listening and asking open questions to enable exploration of patients’ specific needs, and acting on the responses. Patients must also be provided with the information they require to make informed decisions about their care, and everyone – regardless of whether they are patients or staff – should be treated with respect and dignity and must have their voices heard. If necessary, these voices should be amplified by nurses who should act as advocates for their patients or colleagues (NMC 2018).

When seeking to align their care to the Code (NMC 2018), it is imperative that nurses recognise and understand diversity, and work in partnership with patients, families and other healthcare staff. To develop open and inclusive environments it is vital that nurses interact directly with patients and their family members who may be of a diverse ethnicity, sexual orientation, family unit or gender, or who may have disabilities. This will expand nurses’ understanding of diversity and increase their communication skills as they develop ‘mindful intercultural communication’ – an awareness of differing values and customs through talking to people from diverse groups (Campinha-Bacote 2009). In addition, acting as role models and advocates for people from minority groups will enable nurses to develop their cultural humility.

TIME OUT 5

Access the Point of Care Foundation Patient and Family-Centred Care toolkit at: pointofcarefoundation.org.uk/resource/patient-family-centred-care-toolkit and the e-learning for healthcare cultural competence programme at: e-lfh.org.uk/programmes/cultural-competence and explore, reflect on and review your understanding of patient and family-centred care and cultural competence

Conclusion

Cultural humility is an ongoing process of self-reflection in which nurses review their understanding of diversity and power imbalances, as well as learning about concepts such as intersectionality and microaggression. Cultural humility requires the nurse to develop self-awareness of conscious or unconscious personal and cultural bias, as well as acknowledgement of the cultural diversity of others. A commitment to cultural humility can contribute to the elimination of disparities in healthcare and support nurses to provide optimum person and family-centred care.

TIME OUT 6

Consider how cultural humility relates to the Code (NMC 2018) or, for non-UK readers, the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article you may want to complete the multiple-choice quiz and write a reflective account. To find out more go to rcni.com/reflective-account

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