Critical Cultural Competence for Culturally Diverse Workforces:

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Advances in Nursing Science Vol. 36, No. 3, pp. 200–212 Copyright c© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Critical Cultural Competence for Culturally Diverse Workforces Toward Equitable and Peaceful Health Care

Adel F. Almutairi, Doctor of Health Science, MSN, RN; Patricia Rondney, PhD, MSN, RN

In this article, we argue that attaining equity, and therefore peace in health care delivery, necessitates that nursing and other health care professions more carefully attend to the sociocultural context in which health care is delivered. That sociocultural context includes culturally diverse patients, families, and communities, as well as health care providers who are themselves culturally diverse. We draw on findings from Almutairi’s doctoral research with health care providers in Saudi Arabia to argue for what he has identified as critical cultural competence for health care providers. In so doing, we explicate the complexity of cultural and linguistic issues and power relations induced by race, class, and gender that can contribute to vulnerabilities for health care providers and recipients alike. Key words: cultural competence, cultural safety, culture, equity, peace, postcolonial

I N THIS ARTICLE, we argue that theconcepts of peace and health are highly associated with one another, where the absence of one can lead to the absence of the other at the individual, family, and community levels. Peace and health have been discussed extensively in the literature—frequently during and after war, and particularly in

Author Affiliations: School of Nursing, University of British Columbia Vancouver, British Columbia, Canada (Drs Almutairi and Rondney); and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia (Dr Almutairi).

The authors express their appreciation and sincere grat- itude to Dr Joan Anderson, Professor Emeritus at the School of Nursing, University of British Columbia, for her critical review and feedback on this article.

The authors have disclosed that they have no signif- icant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Adel F. Almutairi, Doctor of Health Science, MSN, RN, School of Nursing, University of British Columbia, T201-2211, Wesbrook Mall, Vancou- ver, BC V6T 2B5, Canada (Adel.Almutairi@nursing. ubc.ca or almutairiAd1@ngha.med.sa).

DOI: 10.1097/ANS.0b013e31829edd51

relation to how war can affect the social, cultural, and economic factors that, in turn, result in the poor health status of and disparities among people.1,2 It is important to note that the definition of peace varies across cultures; some cultures conceptualize it as the absence of negative conditions such as war or violence, and others tend to emphasize the presence of positive char- acteristics such as harmony, balance, and equality.3 Peace is seen largely as a political responsibility of the state,4 but we see peace as relevant in all human encounters. Thus, in addition to the political meaning of peace, establishing a sociocultural understanding of peace is important to more fully understand its application to health and health care. To understand peace as a sociocultural concept as well as a political concept, we find the following quotation from political theorist Amy Gutmann to be compelling:

The demand for recognition, animated by the ideal of human dignity, points in at least two directions, both to the protection of the basic rights of individ- uals as human beings and to the acknowledgement

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of the particular needs of individuals as members of specific cultural groups.5 (p 8 )

As Gutmann points out in the aforemen- tioned quotation, “attending to human rights is prerequisite to attaining peace, and meet- ing human needs is inherent in attending to rights.” In health care delivery, we see equity as foundational to both processes.6 By equity we mean treating all persons with respect for their inherent dignity while also attending to their unique needs and sociocultural contexts that may be enabling or constraining. In this article, we argue that attaining equity—and ultimately peace—in health care delivery necessitates that nursing and other health care professions more carefully attend to the sociocultural context in which health care is delivered. That sociocultural context includes culturally diverse patients, families, and com- munities, as well as health care providers who are themselves culturally diverse. We draw on findings from Almutairi’s7 research with health care providers in Saudi Arabia to argue for what he has articulated as critical cultural competence for health care providers. In so doing, we explicate the complexity of the cultural and linguistic issues and power inherent in race, class, and gender relations by using the lens of postcolonial theories and cultural safety. Such sociocultural complexity can contribute to vulnerabilities for health care providers and recipients alike, which, in turn, can influence equity and peace in the health care context. As we close, we articu- late some implications for nursing actions in practice, policy, and leadership to promote equity in health care delivery. We see equity and peace as outcomes of such actions.

CULTURAL DIVERSITY IN HEALTH CARE DELIVERY

The global migration of peoples, coloniza- tion of indigenous peoples, and mobility of health care workforces have contributed sig- nificantly to the creation of culturally diverse environments for health care delivery within

and across nations.8 Those culturally diverse environments are characterized by several cultures with different norms, beliefs, and practices operating in one shared space. In health care settings in many countries around the globe, health care providers are either themselves from diverse cultural backgrounds or encountering and providing care to popula- tions from cultural and linguistic backgrounds different from themselves.8 While we see cul- tural diversity as a precious resource, cultur- ally diverse encounters can have significant and profound consequences for providers, pa- tients, and their families. Indeed, the conse- quences can jeopardize peace and health. Cul- tural diversity can produce a highly charged context for addressing human needs due to the different cultural norms, beliefs, and prac- tices that cause conflicts and tension and that also provide a platform for discrimination and racism. As we have argued throughout this article, such cultural tension can negatively affect the sociocultural context and subse- quently jeopardize the fulfillment of human rights and human needs, which are key com- ponents for a sense of peace.

More specifically, culturally diverse health care environments can lead to assumptions about the marginalized “other,” with negative consequences for equity and health9,10 and hence peace. Culture tends to be conflated with ethnicity, yet “definitions and meanings of ethnicity and race are social constructions that shift constantly, reflecting the changing dynamics of gender, race/ethnic, and class relations over time.”11(p227) Ethnicity is a social identity, which refers to an affiliation to a group of people who share common characteristics, such as racial traits, religious beliefs, or a common origin. In this under- standing, ethnicity and nationality differ fundamentally from and are not synonymous with the word culture in that a collection of cultures may exist in one nation and specific ethnic groups.12 We see culture as including individualized as well as shared values and beliefs and meaning systems that are fundamental to individuals’ under- standings of their selfhood.13 Indeed, “the

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transmission and creation of both illness and health care are also cultural processes”12(p84)

and the dominant cultural model of Western medicine is its own culture.14,15 This means that when countries such as Saudi Arabia import Western medicine, they are also importing Western views about how health care providers such as nurses should be prepared, organized, and regulated.

Furthermore, as several scholars point out that it is not just differences in culture that shape how people deal with health, illness, and suffering. The material circumstances of people’s lives such as poverty and geographic location, as well as intersecting social factors such as gender, racialization, and ageism, are profound influences.10,16,17 Thus, for exam- ple, when nurses from other countries such as the Philippines migrate to countries such as Saudi Arabia to engage in health care de- livery, they bring not just the cultural values and beliefs that they hold but also the mate- rial circumstances such as family poverty that have caused them to migrate.18 Overall, cul- ture permeates all levels of health care—from individual values, beliefs, and meanings to group norms and practices, to organizational patterns and societal ideologies.15 Improving the sociocultural context in which health care is delivered requires that we understand such complexities. To illustrate, we turn to find- ings from Almutairi’s7 research with health care providers in Saudi Arabia in terms of their experience of cultural competence.

RESEARCH ON CULTURAL CONFLICT IN A SAUDI HEALTH CARE CONTEXT

Historical background of cultural competence

The significance of cultural competence has been recognized in the United States since the late 1980s19 because of the increas- ing number of immigrants there and has been recognized in numerous other countries since. This concept was originally attributed to Madeleine Leininger,20 as the first scholar

who embraced the concept of cultural com- petence in nursing.21,22 The overall goal of cultural competence is to create and maintain health care systems and a workforce that has the ability to provide optimal, equitable, individualized, and safe health care for the patient, family, and community irrespective of cultural and linguistic differences.23 There is a lack of universal definition for the concept of cultural competence, which means that all the existing definitions and explanations are to some extent different from each other and are formulated in ways that reflect the discipline in which the concept is applied, such as in medicine, psychology, education, and social work.24 A comprehensive defini- tion of cultural competence was articulated by mental health care researchers more than 2 decades ago as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations.”25(p13) In the nursing context, cultural competence is commonly defined as an “ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community).”26(p181)

In response to the increasing demographic changes in many countries, several cultural competence frameworks and models have been developed—primarily Western in origin—to effectively overcome the issue of culture diversity and provide culturally sensitive care. These frameworks, with their similarities and differences, are particularly in- fluenced by their contexts and tend to address the unique sociopolitical, cultural, and his- torical aspects relevant to those contexts.27

Many authors of the concept of cultural competence over time in the literature have considered cultural awareness, cultural knowledge, and cultural skill as requirements for cultural competence.19-22,24,26 Campinha- Bacote has been a significant scholar in the field of cultural competence.

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Almutairi’s doctoral research project

The theoretical underpinnings of the ap- proach to critical cultural competence that we articulate in this article is an extension of the findings from Almutairi’s doctoral re- search project, which was a qualitative explo- ration of the cultural competence of a multi- cultural nursing workforce in a tertiary hos- pital in Saudi Arabia.7 The nursing workforce in that Saudi tertiary hospital includes nurses from more than 25 nationalities from different parts of the world who provide care to the indigenous people of Saudi Arabia. The find- ings in Almutairi’s doctoral research project explicated the complex nature of cultural and linguistic diversity during clinical encounters. He found that this diversity poses threats to the physical, psychological, emotional, spir- itual, and cultural safety of nurses, patients, families, and their communities. Such threats are caused by the increased potential for cul- tural clashes, negative attitude, and misunder- standings related to both communication and behavior.

In his doctoral dissertation research project, Almutairi used Campinha-Bacote’s26

cultural competence model as a conceptual framework to guide data collection and anal- ysis. This was the first time that Campinha- Bacote’s model had been implemented to examine a culturally diverse context where the nursing workforce was not only culturally and linguistically different from each other but also culturally different from their pa- tients and those patients’ families. Almutairi’s doctoral research project addressed the strengths and the shortcomings of Caminha- Bacote’s model of cultural competence. Given the complexity of the interactions that occur in the particular context of Almutairi’s research, Caminha-Bacote’s model of cul- tural competence provided useful insights; however, it did not explain all the nurses’ ex- periences that occurred in the study setting, which resulted in a large, unexplained set of data. Almutairi subsequently undertook an inductive analysis that yielded essential con- cepts that went beyond the individual nurse’s agency to the process of cultural competence

and to the mediating contexts such as disempowerment.

The multicultural nursing workforce mani- fested their disempowerment as a lack of con- fidence, which was related to intimidation by hospital management as well as the indige- nous Saudi people who were sociopolitically dominant.7,28 The nurses he interviewed de- scribed their inability to advocate for their patients’ safety and uncovered related patient safety challenges. Pondering such complex- ity raised 2 critical questions for Almutairi: (1) Were cultural and linguistic diversities the only features that complicated the interaction in this clinical context? and (2) What other possible factors could implicitly or explicitly operate in such a context? Such questions led Almutairi to a postcolonial view of cul- tural competence in his postdoctoral work, which we explicate in this article. In the fol- lowing section, we commence by illustrating the complexity of language barriers in health care encounters, barriers that expose patients to risks and subsequently affect the equity and peace in health care.

Communication challenges

Communications challenges were perva- sive throughout Almutairi’s7 research in Saudi Arabia. The following interview segment illus- trates such challenges:

I think the unit assistants [interpreters] do speak English and Arabic and they speak them both quite well, but their interpretive skills are lacking. I don’t think they’re trained well and I think especially when you are trying to educate patients about their disease or . . . how to give themselves injections or something like that. And you’re telling the unit assistants to tell the patient he needs to take off the cap off the needle for example. The unit assistant will go on for half an hour, then the patient will talk to the unit assistant, then the unit assistant will talk to the patient, and this will happen for a few minutes. And then the unit assistant will say, “Yes it’s okay, he knows how to do it.” And I don’t know what the unit assistant has said to the patient, and I don’t know what the patient said back to the unit assistant, I don’t know if the patient has any questions. (Nurse research participant)

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From this interview segment, it can be seen that while the unit assistants provided a valuable role in the translation of languages, they were not necessarily trained as profes- sional interpreters who could help nurses, patients, and family members negotiate mean- ings across diverse cultural contexts. It is im- portant to note that this is not just a problem in Saudi Arabia. A growing body of research has made it clear that using untrained (ad hoc) interpreters such as visitors, students, other patients, friends, or family members, while convenient, is a notable barrier to the inter- action process, with profound consequences for the quality of care and patient safety.29,30

Ad hoc interpreters may not necessarily be knowledgeable about the medical terminol- ogy often used in health care situations, with the added risk of committing errors, making omissions, and introducing opinions, which can result in inaccurate assessment data that may threaten patient safety.7,29

In many culturally diverse environments, the majority of health care providers are either from minority groups and do not speak their patients’ native languages, such as in Saudi Arabia, or encounter patients from minority groups who do not speak the common me- diating language in the particular health care context, which often happens in Canada, the United States, and other westernized coun- tries. In both cases, effective communication is essential to a safe and successful interac- tion, which is expressed in language that pre- cisely conveys the intended meaning.26 Many studies in the literature illuminate the con- sequences of language barriers during health care encounters, which contribute to health care inequities and expose both patients and nurses to risks.30-32 Therefore, from a cultural competence perspective, an assessment of the linguistic needs of patients and their fami- lies during nurse-patient encounters is crucial. When language barriers exist, access to well- trained interpreters is essential due to their ca- pacity to interpret communications more ac- curately, to increase patient satisfaction, and to protect patient safety.29,30

Power imbalances Underlying many of the communication

challenges in Almutairi’s research from Saudi Arabia and others’ research from various countries are power imbalances—the critical perspective in critical cultural competence. The sociocultural context in which health care is delivered is affected by power dynam- ics that often operate in subtle ways in health care encounters and result in a profound im- pact on health care and equity. Postcolonial theory can facilitate the examination and, ulti- mately amelioration, of such power dynamics. Postcolonial scholars take a view of culture beyond the set of beliefs, norms, and values that members of a particular group share to a recognition that culture is created within a particular context through the process of negotiation of cultural meanings where both health care providers and patients are in- volved. One of the significant goals of post- colonial theory is explicating how the con- cepts of race, ethnicity, and culture have been socially and historically constructed and used as categorization means to place those who are viewed as different as “essentialized, in- ferior, subordinate.”33,34 Postcolonial theory also provides a lens through which to un- derstand the complexities of intersectionali- ties of race, gender, class, power imbalance, and culture during interactions in clinical settings.35-37 Thus, the strength of postcolo- nial theory stems from its ability to address a specific individual experience based on the unique individual as that individual intersects with particular sociocultural contexts.

In the aforementioned interview transcript excerpt, for instance, the nurse was from an- other country and was facing economic con- straints such that she did not feel free to challenge the way that unit assistants oper- ated and possibly jeopardize her employment. Similar power dynamics are present in most countries.8 For example, in Canada, nurses who have immigrated from the Philippines and are supporting their family members at home may be reluctant to speak out about their conditions of work.18 Furthermore,

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nurses in Canada and other Western countries are struggling to provide care in a system that too often emphasizes short-term efficiencies over the quality of patient care and nurse well- being.38,39 What this means is that the struc- tural problem nurses face in health care deliv- ery in all countries can make it more difficult for them to support those whom they serve. Nursing serves unique individuals intersect- ing with particular sociocultural contexts— contexts that are too often disempowering for individuals, families, and communities.

Postcolonial theorizing is also important because of how it helps us better understand power dynamics related to “race.” From a crit- ical perspective, we conceptualize race as a category that is usually used to classify peo- ple in terms of neutral and natural superiority over others and to subordinate those who are different; racialization is the process of doing so. As several scholars point out,40-42 the con- struct of race is not a neutral one; it shapes our assumptions about those who are considered different and might operate unwittingly in our interactions with one another, including the interactions between health care providers and patients, whether white or people of color.43 An example drawn from Almutairi’s7

study explains how one nurse of color was faced with derogatory and racialized com- ments by the local dominant people in Saudi Arabia:

Oh my God, for me as a South African . . . I don’t know if they [Saudi people] seen somebody who is black like me. I’m not even that black because like . . . they [are] staring at you, they don’t see this woman who is not covering her hair and face they are looking at you like . . . “is she a human being” . . . or “where is she coming from” . . . whereas they have Sudanese, they have Nigerian, they have Kenyan, who are almost the same . . . and with the same hair style . . . they are passing remarks on you, anyway you don’t even understand what they are saying because they are speaking in Arabic . . . . (Nurse research participant)

Another example indicates how some nurses were placed in an inferior category by their patients in comparison with their col- leagues from different countries. A nurse from

a Western country expressed her sentiments about this issue:

I find out that sometimes they (patients) might think that especially if you are from America they treat you different [in a] really different way . . . than if you are compared to an Asian nurse, I can say a big difference . . . sometimes I feel bad be- cause of the other nurses, that I am treated like sometimes better and we [are] still doing the same job . . . and even they speak Arabic better . . . . (Nurse research participant)

Postcolonial theories can help us better understand the background behind the ac- counts from nurses in Almurairi’s research. Al- though postcolonial theories in the literature emerged from countries that experienced col- onization, the ultimate goal of these theories is to elucidate and analyze the legacy of the colonial past and the postcolonial present in terms of power relations and cultural domina- tion. Since the 1960s, this topic has been an area of interest by many distinguished schol- ars from different disciplines, such as Frantz Fanon,44 Edward Said,45 Gayatri Spivak,46 and Homi Bhabha.47 Regardless of their different disciplinary perspectives, postcolonial theo- ries have recently been taken up in a nurs- ing discourse to address the issues of unequal power relation, equity, and social justice.48

Therefore, the precepts of these theories are applicable and transferable to diverse sociocultural contexts. This is because neo- colonialism and racialization practices, which nourish inequities and social injustices, are ubiquitous. As Anderson explains, “postcolo- nial theories are relevant to all; there are no spaces that are not colonized; the racial- izing gaze is fixed upon all of us.”40(p239)

Anderson also claims that “suffering, health and well-being are woven into the fabric of the socio-historical-political context.”40(p239)

For this reason, postcolonial theory provides a powerful lens through which to critique and analyze complex social issues within their mediating cultural, political, and histori- cal circumstances. It illuminates global issues such as oppression, power differences, dias- poras, and globalization,48 which are associ- ated with social injustice and inequities with

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detrimental impacts on health and well- being.6,8,17 As we explain in the next section of our article, postcolonial theory can also help us cultivate critical cultural competence to promote equity and peace in health care delivery.

TOWARD CRITICAL CULTURAL COMPETENCE

Cultural competence through a postcolonial lens

Proponents of postcolonial theory warn against the danger of having a static view of culture,37,49 as this will lead to misunderstand- ing and stereotyping of people based on their culture and could lead to discrimination.50

Furthermore, such a static view can influence the thoughts of policy makers, which results in the design and creation of policies based on constant and generalized, yet narrowed, views of people. This has also been a ma- jor criticism arising in literature critiquing the concept of cultural competence. For instance, the fundamental problem frequently raised (particularly emerging from an anthropolog- ical perspective) is the tendency of many of the existing cultural competence models to reduce and oversimplify the complex nature and fluidity of culture to a set of requirements and measurable variables that have a con- stant and predictable outcome.51 Anthropol- ogists argue that such conceptualizations of culture run counter to the dominant theory of culture in anthropology that conceptual- izes culture as being a dynamic and ongoing process that is socially constructed as a result of human interaction.51

Indeed, such a static view of culture is con- gruent with the epistemological perspectives of Western biomedicine, which, as we indi- cated at the outset of this article, is considered as a culture itself that is based on “science” and “facts.” Hence, a static view of culture tends to view people from “other” cultures as having fixed belief systems, values, and be- haviors, as well as having certain expectations and, for example, food preferences that can

be catalogued and acted upon.40,49 Adopting a homogenous approach to culture when inter- acting with patients is therefore risky and can influence the patients’ and nurses’ psycho- logical, spiritual, emotional, physical, and cul- tural safety and health care outcome7 as well as the general sense of peace. In the examples from Almutairi’s research we have cited ear- lier, for instance, the nurses see how they are being categorized and “othered” according to their country of origin and the color of their skin.

From a critical cultural competence per- spective informed by postcolonial theory, in a culturally diverse environment, we see that the individual is shaped by his or her partic- ular cultural heritage, which is constructed within unique sociopolitical, historical, and economical contexts. A person’s culturally mediated values, beliefs, and practices deter- mine the way he or she interprets the situa- tions around himself or herself and attaches meaning to things, as well as how he or she deals with other people.52,53 This understand- ing leads to the critical concept of ethnocen- trism, which was defined early on by Sumner as “the view of things in which one’s group is the centre of everything, and others are scaled and rated with reference to it.”54(p119)

Ethnocentric people are seen to use their cul- tural values and belief systems as the template to evaluate and judge the behavior and cul- ture of other people. Moreover, ethnocentric people often believe that their cultural val- ues and norms are superior to those of other cultures.55 Taking people’s norms and beliefs this way as the right and natural ones that are valid and applicable in all situations compli- cates interactions, because “the other’s” be- liefs and practices are considered and inter- preted as inferior or strange and wrong.28

The complexity of cultural diversity lies in the fact that one’s culture becomes one’s norm; therefore, people may fail to conceive that there is another way of viewing social life and that, although other cultural perspec- tives are different, they are equally valid.56 In contrast, postcolonial theory emphasizes the creation of a climate where health care

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providers question their assumptions about their culturally diverse patients35,40 and go through the process of self-reflection with subsequent consciousness of personal biases, prejudices, and stereotypes so that such at- titudes do not adversely impact their in- teractions with people from other cultures. Several scholars also emphasized such self- reflection process.26,27 This process of rec- ognizing one’s own attitudes can go a long way in helping health care providers avoid the cultural impositions and ethnocentric viewpoints that cause harm to patients and their families.57 For example, a few nurses in Almutairi’s7 doctoral research project spoke of the importance of self-reflection and what it can bring to their interactions with their patients. This nurse stated:

It’s really different people, different culture, it is totally different, but it’s quite challenging really, because you have to assess your own personality and how will you cope with this new environment. (Nurse research participant)

We are deploying the term “critical cul- tural competence” to link the benefits of prior scholarship on cultural competence to the crucial insights into power dynamics offered by postcolonial theory. Critical cultural com- petence entails the recognition that one’s be- liefs, values, norms, and patterns of behav- ior are socially constructed and culturally rel- ative to a particular context. Therefore, what appears appropriate and acceptable for per- sons in one culture is not necessarily the same in another culture and is also dependant on each individual’s unique sociocultural loca- tion. Furthermore, people in a particular cul- ture are understood on the basis of the values and norms of their cultural context, not those of other cultures.58 The following description of a Western nurse participant in Almutairi’s7

doctoral research project articulates how the nurse used her cultural lens improperly to evaluate the cultural norms of Saudi people in terms of the importance of the family in health care.

The visitors: They drive me crazy! They seem not to realize that nurses have a job to do and that

me doing my job is possibly more important than getting coffee for their family member. Or, they are having the curtains closed because they want to . . . I hate that . . . but at [my] home if there’s visitors and the nurse comes in, usually they’ll get up and leave because the nurse needs to do something . . . . (Nurse research participant)

What this nurse expressed was a lack of critical cultural competence that left her frus- trated and in conflict with the family, who themselves might also be frustrated with her. In this situation, the nurse and the family likely did not feel safe or at peace. If the nurse had been educated, oriented, and supported from a critical competence perspective, she would have been able to better reflect on her own ethnocentric biases, appreciate the families’ beliefs about their roles, and negotiate mutu- ally beneficial plans of care.

In summary, postcolonial theory leads us to a critical approach to cultural competence because it points out the danger of relying on unexamined assumptions that people make about those who are constructed as different and how that can contribute to inequalities, vulnerability, and disempowerment.33,35,40

Such understanding is not only about those who have been disfranchised and oppressed by history and colonization but also about everyone, including patients, their families, and health care providers, regardless of eth- nic background or other attributes, who have experienced racism, inequalities, and the like.

Cultural safety

Operationalizing critical cultural compe- tence can be facilitated by the related action- based concept of cultural safety. Cultural safety was first articulated within a nursing education context that can be traced back to the late 1980s in New Zealand. It was originally coined by Maori nurses as a re- sult of the disparities and inequities in health care services and the poor health status of the indigenous Maori people.59 Although this concept was originally developed in a bicul- tural context, its tenets are highly relevant and applicable to culturally diverse contexts and

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have informed our analysis throughout this article. The concept of cultural safety specif- ically addresses issues of individual and insti- tutional racism and the oppressive attitudes held toward indigenous minority people by the colonizing majority.60 It also points to challenges in power relationships in health care and how such relationships can compro- mise patients’ rights to receive care that rec- ognizes, respects, and accommodates cultural differences.

The concept of cultural safety was devel- oped to redistribute power relationships in favor of those who are oppressed and disem- powered in their societies and during health care encounters, with the aim that patients and their families would receive culturally competent and safe care60 that maintains their rights and recognizes and respects their cul- tural identity.61 Operating within this con- cept, health care providers must be aware that patients who feel unsafe will not access the benefits of health care and that serious conse- quences might arise due to their avoidance of culturally unsafe services.62 Accordingly, “any action which diminishes, demeans or disem- powers the cultural identity and wellbeing of an individual” is attributable to unsafe cultural practice.63(p4) Proponents of cultural safety have written this concept in a way—relevant to its original context—that goes beyond the usual notions of cultural sensitivity and cul- tural knowledge toward action to address sys- temic inequities. Cultural safety would mean, for example, that health care agencies in Saudi Arabia and other countries would en- sure the presence of trained interpreters and promote policies around respectful and eq- uitable treatment of patients and their fam- ilies as well nurses and other health care providers.

In summary, we see critical cultural com- petence as an important vehicle for attend- ing to the complex sociocultural contexts in which health care is delivered to bring about and promote equity and peace in culturally di- verse health care environments. The related concept of cultural safety points us toward

actions to address power differences and in- equity related to cultural diversity.60

MOVING TOWARD EQUITY AND PEACE IN HEALTH CARE DELIVERY

As we have indicated earlier, actions to ameliorate power differentials and inequities must address all who are involved in health care delivery—patients, their families, com- munities, and health care providers, espe- cially nurses. The situation of nurses glob- ally has worsened with recent economic turmoil,8 and even in westernized (and pur- portedly well-resourced) countries such as Canada, nurses face excessive workloads, di- minished leadership roles, and a host of re- lated challenges that can mitigate against crit- ical cultural competence.16,38,39,64 Research conducted in Western countries indicates that patients and their families may be “othered” because of attributes, such as lack of language fluency, Aboriginal heritage, or a history of substance use, and hence may receive sub- standard care.9,50

There are many implications for nursing ac- tions in practice, policy, and leadership to promote equity in health care delivery. For nurses to engage in culturally safe care that promotes equity and peace with all those whom they serve, they must be supported to enact their agency through supportive health care organizational structures and processes. For example, when they arrive in a new coun- try to work, they ought to be well oriented when they arrive, have access to trained inter- preters, and be provided with enough social and financial stability to feel safe questioning those practices about which they are unsure. As a profession, nursing ability to contribute to equitable and peaceful health care is also predicated on a culturally safe approach by every nurse, which requires that all engage in thoughtful self-reflection and share a commit- ment to equity as well as social justice.16,43

As we have indicated throughout this article, social justice means treating all persons with

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Critical Cultural Competence for Culturally Diverse Workforces 209

respect for their inherent dignity while also attending to their unique needs and sociocul- tural contexts. Thus, we see critical cultural competence as an approach that is able to ad- dress the difficulties arising from cultural and linguistic differences, as well as other con- textual power relations determinants, such as race, class, gender, poverty, and the like, that are often present in a culturally diverse con- text. Managing such complexity can promote individuals’ sense of peace, which can be re- stored by feeling secure, respecting and ap- preciating other cultural identities, maintain- ing individuals’ rights, and meeting human and cultural needs.

Therefore, moving toward an action- focused approach necessitates an explicit conceptual framing for the constituents of the critical cultural competence, which targets health care providers and nurses in particu- lar. Pulling together the threads that were dis- cussed throughout this article, critical cultural competence can comprise 4 areas. The first is critical awareness, which implies the recog- nition of cultural differences and what that can bring to a given situation, the recognition of ethnocentric views, personal biases, preju- dices, and stereotypes, as well as the aware- ness of power relation determinants. The second is critical knowledge, which means having knowledge about the conceptualiza- tion of culture as discussed in this article, the danger of relying on a static view of culture, and communication challenges. The third concerns critical skills, which is the ability to create a negotiation space for cul- tural meaning and ethical decisions during clinical encounters, as well as the ability to meet the cultural needs of patients and their families. The fourth area encompasses the health care providers’ empowerment in terms of their racialization, or their disempower- ment due to their gender, economic situa- tion, culture, geographic location, or insti- tutional or individual racism. While some of these aspects might be the result of individ- ual nurse’s agency, the organization clearly

plays a large role in this process. Achieving a positive climate requires adequate organiza- tional support through policy that addresses the sociocultural determinants of health. The role of the organization also entails the pro- vision of required resources and continuous professional development and training pro- grams to enhance individual’s conceptualiza- tion of critical cultural competence.

How to move forward to achieve such ends is not yet clear, but is, fortunately, the fo- cus of a growing body of nursing scholar- ship. It is becoming increasingly clear that we must move forward as a collective to better influence research, policy, and prac- tice in health care delivery.8,16,65,66 This will require that we act as a nursing profession within and between countries and that we act with other health care professions within and across those same borders to promote equity and peace in health care delivery. In a fore- word to the philosopher Iris Marion Young’s posthumous publication, Responsibility for Justice, Young’s colleague Martha Nussbaum explains:

Young argues that the most helpful concept with which to approach structural injustice is that of shared responsibility. We turn away from the past and toward the future, accepting, collectively, the fact that as citizens we bear responsibility for monitoring political institutions and ensuring that . . . structural injustices do not arise within them, or, if they are already there, that they are ameliorated.67 (pxvi)

In this article, we have argued that be- cause of its foundations in postcolonial theory and cultural safety—as well as its operationalization through critical aware- ness, critical knowledge, critical skills, and empowerment—critical cultural competence offers an action orientation from which to enact our shared responsibility and address structural injustices. It is our conviction that as a nursing profession we are well positioned to look toward the future and share responsi- bility locally, nationally, and globally to foster equitable and peaceful heath care.

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