Cultural Humility In Advanced Nursing Practice

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Introduction

Concepts are a way to classify information; they are essential components from which theory is built. Theory usually explains some aspect of nursing and enables us to make predictions about behavior. The concept analysis process contributes to the development of theory by dissecting the concept and simplifying it in order to bring clarity and understanding. McEwen & Willis, (2014) say that when a concept or term is questionable or needs further clarification in nursing, then a concept analysis is indicated. This helps to clarify ambiguous concepts in theory and to produce scientific, valid, evidence-based results, which are unbiased, and objective. I will analyze cultural humility as it applies to the Nurse Practitioner role. The Campinha-Bacote’s & Fitzgerald approach to cultural humility will be explained. The definition of what cultural humility means to healthcare as well as a literature review will be presented. The defining attributes of cultural humility including the antecedents and consequences will be discussed. No study is truly valid until validity studies are done; the empirical referents will be explained. Application to life of cultural humility will be presented in the form of construct cases, where a model case, a borderline case and a contrary case will be presented. The theoretical application of cultural humility using the latest Campinha-Bacote’s & Fitzgerald approach will be explained. I hope that by the time that I conclude this paper you will be challenged to not just strive for cultural humility, but cultural excellence

Definition

A group of somber looking men, one holding a little green branch of a tree, walk into the intensive care unit. They come up to you and ask you to tell them where the room is where their family member died. They explain to you that this is a ritual they do, to fetch the spirit of their loved one and take it home to rest. Your attitude is humble and respectful, you see that the room is empty, and you allow them to do what they need to do, for closure. You learned something new today, your mind cannot fathom how a spirit can attach itself to a tree branch. As you reflect on this, you tell yourself that you must find out more about this practice. Your behavior fulfilled the definition of cultural humility. Adelstein, (2015) says that cultural humility is a skill every nurse should have. She defines cultural humility as “a lifelong process of self-reflection and self-critique” that permits one to assess what is the same or different from their own beliefs and values. This allows the healthcare professional to recognize their own biases. It helps them to understand the patient’s perspective and health care goals. As a nurse practitioner working with a diverse population one must have cultural humility. In order to better serve the population and achieve the HealthyPeople2020/2030 goals for equitable care for ALL, a nurse practitioner must develop this skill. (healthypeople.gov)

Defining Attributes

The three attributes of cultural humility are: self-awareness, humility and self-reflection. Self-awareness is the ability to understand yourself and why you act and behave the way you do. You must have a good grasp of your own character, what drives you? what motivates you? your passions as well as your flaws. Rasheed, Younas & Sundus (2018) say that when a nurse is self-aware, she is able to develop a “therapeutic nurse-patient relationship”. Self-awareness improves perception, self-regulation, prevents burn out and results in positive outcomes. Methods to improve self-awareness are mentoring, group therapy, performance appraisal and role playing.

The Johari Window is a theoretical model that is used to evaluate self-awareness using four aspects of self: open, blind, hidden and unknown. (Rasheed, 2015).

Humility is not a weakness but a virtue that shows strength in character. The opposite of humility is pride. Clinical humility is when you understand the limits of your own abilities. As nurse practitioners we must be careful not to fall into the trap of “I know it all.” Sometimes being highly educated can cause you to have a prideful attitude, believing that you are better than everyone else. When we practice with humility, it will keep our patient care inspired, realizing that we are just part of the great scheme of life.

Self-reflection is a process of thinking back about what we might have done differently in a nursing situation or what we might have done well. When we examine our own actions, we can see our knowledge gaps. Once you see your own limitations, this inspires you to seek more knowledge on your own, promoting life-long learning. Drick, (2014) calls self-reflection contemplation. She describes this as a process of looking inward to assess your inner wisdom, thoughts, behaviors, experience and values. She comes up with a few practical suggestions of how to self-reflect. She suggests journaling, sitting and gazing, keeping an intuitive log, reflecting on your body and self-care. This is something I plan to implement whilst I am a student, so that once I become a nurse practitioner, self-reflection will be an established practice.

Antecedent and Consequence

Power imbalance is an antecedent in cultural humility. Power imbalance comes in many forms e.g. gender, social, relationship or bullying power imbalance. One of our attributes as nurses is that we do hold a position of power in relation to our patients. This would include one’s professional status as a nurse practitioner with a Master or Doctoral education. The patient on the other end is sick or in pain, lying in bed, fearful and in a position of powerlessness. This feeling of powerlessness is compounded if the patient is a minority, speaks a different language or is an immigrant. Our power as nurses might come from the fact that we have access to private information about a patient and this can cause a power imbalance. Negative implications of power imbalance are helplessness, disinterest in participation for health goals, distrust and communication breakdown.

A consequence of cultural humility would be mutual empowerment. We saw how the nurse-patient relationship is destroyed and there is no trust when there is an imbalance of power. This can be turned around by mutual empowerment. Mutual empowerment is a social process of collaboration between nurses and patients, that allows the patient to have control, act or take part in the decision -making processes of care. Piper, (2014) implies that mutual empowerment is the rebalancing of power in the nurse patient relationship. In order to rebalance power a relationship of trust must be built which will promote a therapeutic nurse-patient relationship. When one communicates respectfully and listens actively with empathy, helps build trust. Self-awareness, by acknowledging your own emotional responses and being unbiased improves cultural humility. When there is mutual empowerment there is a balance of power and the patient becomes more responsible, accountable, determined and is inspired to participate in health goals.

Empirical Referents

The Inventory for Assessing the process of Cultural Competency (IAPCC) and the Cultural Competence Assessment instrument (CCA) are the two empirical referents for cultural humility. Campinha-Bacote’s, (1998) developed The IAPCC it is an instrument that consists of 20 items that measure the constructs of cultural awareness, cultural skill, cultural knowledge and cultural encounters. There are five questions addressing each of the constructs. It is a self-administered test and uses a four-point Likert scale. Completion time is about fifteen minutes. Scores range from 20-80 and indicate the results of the four constructs. This is a validity test, which is an important step in research, because reliable and true results are necessary for evidence-based practice.

The CCA tool was developed by Schim and colleagues. It measures cultural diversity, awareness, sensitivity and competence behaviors among healthcare providers. (Schim, Doorenbos, Miller, & Benkert, 2003.)

Construct Cases: The construct cases that I will describe have to fulfill the constructs of the theory. I am using the Campinha-Bacote’s & Fitzgerald theory of Competermility which revolves around five constructs: cultural awareness, cultural skills, cultural knowledge, cultural encounters and cultural desires.
Model case: A model case is like the one I described under the definition. The nurse was culturally aware, she used her cultural skill and knowledge by being respectful, checking to see if it was possible for them to enter the room and then allowing them to do what they needed to do. This cultural encounter was new to her and she desired to know more about this ritual in the context of that culture.
Borderline Case: A borderline case would be if she used most of the five constructs but omitted one or two. For instance, she would receive the somber men respectfully acknowledging their culture. Allowing them in to do what they need to do, but once they left, she would make a joke about this. This is too strange for her; she is not interested in finding out more about their practice in the context of their culture to get better clarification. She has missed the construct of cultural encounters and cultural desires.
Contrary Case: In a contrary case most or all the constructs of the theory are missed. The nurse receives the men. She asks them what they need, they explain this to her. She tells them that this has never been done before and, in any case,, it’s been a while since their family member passed and several more people have passed in that room. She is reluctant to let them in the room even though the room is empty. She calls the nursing supervisor in front of the men and tells the supervisor, starting with: “You won’t believe what these people standing in front of me want to do,” The men stand there looking embarrassed but determined. The supervisor chided her and told her to be respectful and let them do what they need to do. She is irritated that the supervisor did not back her, she rudely shows them into the room and tells them to hurry because she is expecting an admission into that room. This example shows that she did not fulfill any of the five constructs for cultural Competermility.

Theoretical Application of the Concept

Campinha-Bacote’s & Fitzgerald (2019) developed a new approach to cultural humility. They have combined cultural competence and cultural humility to one word ‘Competermility.’ This intersectional approach is a conceptual framework derived from Campinha-Bacote’s models of cultural competence. (Campinha-Bacote’s, 2011, 2013) This approach is about healthcare professionals and healthcare organizations continuously working together within the cultural context of a client, family, individual or community. (Campinha-Bacote’s, 2019). In this approach cultural humility guides each of the five constructs of cultural competence from both organizational and individual perspectives. Acronym is ASKED – awareness, skill, knowledge, encounter and desire.

Conclusion

My concept analysis was on cultural humility, I described what a concept was, and I defined the term cultural humility. I did a literature review of six scholarly articles explaining why I used these sources and how they strengthened and supported my discussion. I named and discussed three attributes of cultural humility. I explained an antecedent and a consequence in great detail. Two main validity tools for cultural humility were introduced. I gave examples of cultural humility in practice by sharing a model case, a borderline case and a contrary case. Campinha-Bacote’s & Fitzgerald cultural Competermility theory was applied to the concept of cultural humility. Writing about this concept of cultural humility has challenged me not to just have cultural humility but to have cultural excellence!

“Excellence is never an accident; it is the result of high intention, sincere effort, intelligent direction, skillful execution, and the vision to see obstacles as opportunities “ – Anonymous

References

Adelstein, J. (2015). Cultural humility: A lifelong process for professional nurses. Retrieved from digitalcommons.uri.edu: Https://digitalcommons.uri.edu/srhonorsprog/426/
Campinha-Bacote’s, J. &. (2019). An intersectionality approach to the process of cultural Competermility- Part II. The Online Journal of Issues in Nursing, 24(2). doi:10.3912/OJIN
Campinha-Bacote’s, J. (1998a). The process of cultural competence in the delivery of healthcare services. (Available from Josepha Campinha-Bacote’s PhD, RN, CS, CTN, FAAN, President, Transcultural C.A.R.E.)
Drick, C. (2014). Nurturing yourself to enhance your practice. International Journal of Childbirth Education, 29(1), 46-51. Retrieved from https://search-ebscohost.com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&AN=awh&AN=9397348&site=eds-live&scope=site (Links to an external site.)
Piper, S. (2013). How to empower patients and involve the public. Nursing Standard Journal, 29(4), 37-41. doi:10.7748/ns.29.4.37. e8685
Rasheed, S. (2015). Review paper: self-awareness as a therapeutic tool for nurse/client relationships. International Journal of Caring Sciences, 8(1), 211-216.

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