1 Strategies and Challenges to Integrate Cultural Competence for Providers and Organisations – The British Case Carol Baxter Head of Equality & Diversity

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Strategies and Challenges to Integrate Cultural Competence for Providers and Organisations –

The British Case

Carol Baxter

Head of Equality & DiversityNHS Employers, UK

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Contents

• An historical perspective

• From the margins to the mainstream

• The emergence of a policy agenda

• A paradigm shift from goodwill to competence

• Joining up the agenda

• Close

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An Historical Perspective

• Response rate: 76%

• Number of schools: 176

_____________________________________

• Pre-dominance of a cultural model

• Theory / Practice dichotomy

• Teacher preparation

• The role and position of BME staff

Survey of Schools of Nursing, 1993

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Survey of Schools of Nursing, 1993RESPONSES NO. OF

INSTITUTIONS%

Culture and health 87 93.3

Specific client groups 64 61.5

Racism and discrimination 30 28.8

Communication skills 24 23.0

Racial inequalities in health 22 21.1

Practical hospital care 15 14.4

Demography / Migration 14 13.5

Care in the Community 12 11.5

Patterns of illness 8 7.7

No. of institutions replying to this question 104

Table 1. Subject areas reported by nurse teachers to be covered in teaching on race equality

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Survey of Schools of Nursing, 1993WORDS WHICH TOGETHER REFLECT A CULTURAL PERSPECTIVE

TOTAL FOR ALL DOCUMENTS

WORDS WHICH TOGETHER REFLECT AN ANTI-RACIST PERSPECTIVE

TOTAL FOR ALL DOCUMENTS

Culture / Cultural 91 Racism 12

Special needs 88 Prejudice 10

Ethnic 50 Multiracial 8

Customs 16 Black 4

Spiritual / Religious 16 Racial 4

Multicultural 13 Discrimination 4

Immigrants 12 Stereotypes 3

Habits / Practices 10 Inequalities 3

Taboos 5 Colour 2

Rituals 4 White 1

TOTAL 305 TOTAL 51

Table 2. Content analysis: Implied meaning in documents – word frequency

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Challenging racism and racial stereotypes - when using material which gives cultural information the following questions should first be asked:

• Who has been involved in compiling the information? Is it written by someone from the community being addressed?• Is the material dealing with the culture of:

− an entire society?− a particular social class or group?− a particular area of the country?− a small localised group?

• Is it clear what sections of the population the information refers to?• Does the material simply describe patterns of behaviour?

− are the patterns described in a way that makes them seem absurd or bizarre?

adapted from Mares, Henley & Baxter (1985)

Guidelines for Evaluating Information on Cultural Norms

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− does it suggest possible explanations? − does it discuss the underlying reasons for unfamiliar patterns of

behaviour?− is it clear whether the patterns described are ideal or actual norms?

• Does the author make value judgements about the cultural patterns described? eg: does the author’s attitude strike you as positive, neutral or negative?• Is culture seen as a fixed state or a dynamic phenomenon? Is this aspect discussed or ignored?• Does the information analyse the situation of minority cultural groups in Britain purely in terms of culture and cultural differences? Does it make any reference to important economic and social factors (eg: unemployment and racial discrimination)?• What specific new insight have you gained from the information? Has it increased your understanding of the culture described, or created further questions in your mind about aspects you were not previously aware of?

Guidelines for Evaluating Information on Cultural Norms

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which generates misinformation and

ignorance about these groups of

people

which become socially sanctioned attitudes, beliefs,

feelings and assumptions

which become the justification for

further mistreatment

Systematic mistreatment of

people of colour and third world people

Racism is one consequence of a self-perpetuating imbalance in economic, political and social power

Racism hurts all of us, whether or not we are members of the targeted group

Adapted from Ricky Sherouer-Marcuse, Unlearning Racism Workshops, 6501 Dana, Oakland CA 94609, USA

Racism

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• Racism is part of the culture within British society and individuals within it have been socialised from childhood into this• Racism encompasses not only our prejudice but also the power held by white society to translate its prejudices into practices that initiate and perpetuate injustice• Both black and white people are hurt by racism but in different ways. In the process of becoming aware of our own racism the pain of that hurt must be made conscious• Racism Awareness training is concerned with enabling individuals to explore how racism is part of themselves, the organisations in which they work and in society as a whole• Individuals are required by the teacher to take responsibility for their own learning. • The teacher thus acts primarily as a facilitator who helps to build a group sense of trust; has an understanding that guilt can block change; and is willing to confront racism and help individuals to make choices about future assumptions and behaviours.

Basic Premise and Principles of Racism Awareness Training

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• The teacher therefore requires a deep knowledge and understanding of how racism operates, as well as skills as a groups facilitator and sensitivity to group process and individual emotions• Racism Awareness does not take place in one-off short workshops. It is part of a broader programme of organisational development towards equality of opportunities in which the overall aim is to confront and change institutional structures and procedures• The ultimate value of Racism Awareness training lies in its generation of both individual and group commitment to action for changing racist practices and achieving justice. This is achieved by overcoming emotional blocks that can undermine other initiatives such as Equal Opportunity Programmes or antiracist confrontations

Basic Premise and Principles of Racism Awareness Training

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EXAMPLE: MULTIRACIAL MULTICULTURALCAUSES OF INEQUALITIES

Largely due to racism Largely due to cultural differences

FOCUS OF TRAINING AND DEVELOPMENT

• Specific issues arising from black / white relations• Perception of BME cultures contributing to inequality and disadvantage

Lifestyle of various cultural groups

2 PERSPECTIVES:

“Multiracial” vs “Multicultural”?

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From Margins to MainstreamLANGUAGE OF OPPRESSION RESPONSES

• Discrimination• Prejudice• Exclusion• Power• Marginalisation

• Anti-oppressive practices• Anti-racism• Anti-sexism• Anti…

LANGUAGE OF INCLUSION RESPONSES

• Engagement• Consultation• Involvement

• Rights and responsibilities• Genuine choices• Valuing diversity

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Competency:

“The behaviours that employees must have, or must acquire, to input into a situation in order to achieve high levels of performance”

- CIPD

Building Cultural Competence Within the Organisation

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“Cultural Competence”:

Cultural Awareness:

Cultural Knowledge:

Cultural Sensitivity:

Recognition that others might be different from you

Understanding of specific cultural needs

Knowing that cultural differences as well as similarities, exist, without assigning values eg. better or worse, right or wrong etc

Understanding Organisational Competence

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• There is such an entity as cultural competence – which can be acquired

• It is possible to describe and to provide training to improve the cultural competence of healthcare professionals which will improve the competence of the organisation

• The employment of ethnic minority healthcare staff (particularly nurses) will improve organisational competence

Cultural Competence - Assumptions

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Attitudes / Values:

• Stereotypes

• Prejudice

• Personal racism

• Institutional racism

Knowledge:

• Demographic and population issues

• Inequalities in health

• Specific illnesses

• Concepts of health and illness

Race Equality in Healthcare and Education, Baxter, 1997


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Skills:• Communication across cultural and language barriers

• Practical hospital care – physical and spiritual

• Care in the community

• Specific client groups

Approaches:

• Change management

• Policies and strategies

• Building networks

• Sharing experiences, good practice and ideas


Race Equality in Healthcare and Education, Baxter, 1997

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• Sex

• Ethnicity

• Disability

• Age

• Sexual Orientation

• Religion and Belief

• Human Rights

The Emergence of a Policy Agenda

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Sex / Gender

Race / Ethnicity

Disability

Age

Sexual Orientation

Religion and Belief

Human Rights

1970s 1980s 1990s 2000s

employment

goods, facilities, servicesboth

EPA SDA

RRA RR(A)A

EA

DDA DDA

EE(A)R

EE(SO)R

EE(RB)R

HRA

EA(SO)R

EA(RB)R

GRA

Equality Legislation: Quickening Pace

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Gender

Race

Disability

Age

Sexual Orientation

Religion and Belief

Human Rights

EMPL SERV GENERAL DUTY: SPECIFIC DUTIES:

Equality Impact Assmts etc

Gender Equality Duty

Race Equality Duty

Disability Equality Duty

Race Equality Scheme

Disability Equality Scheme

Gender Equality Scheme

Equality Impact Assmts etcEquality Impact Assmts etc

√√ √√√√

√√

√√√√

√√

√√

√√

√√

√√

√√

√√

2009?

Equality Legislation: Equality Duties

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From Goodwill to Competence

Promote equality and value diversity

Act in ways that support equality and value diversity

Develop a culture that promotes equality & diversity

Support equality and value diversity

NHS KNOWLEDGE AND SKILLS FRAMEWORK CORE DIMENSION 6 Equality & Diversity

Core

2

3

4

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= This is a key aspect of all jobs that everyone does. It underpins all dimensions in the NHS KSF

LEVELS:

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Act in ways that support equality and value diversity

KSF CORE DIMENSION 6 Equality & Diversity

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Indicators:The worker: a) acts in accordance with legislation, policies, procedures and good practiceb) treats everyone with whom s/he comes into contact with dignity and respectc) acknowledges others’ different perspectivesd) recognises that people are different and makes sure they do not discriminate against other peoplee) recognises and reports behaviour that undermines equality and diversity

Examples of application: a) around: age, racial group, disability , gender, human rights, mental health etc

b) – e) may include:• what they do or say• what they do not do or say• when interacting with colleagues• when interacting with service users• when working with the public• when working with visitors to the organisation

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2

Indicators:The worker: a) recognises the importance of people’s rights and acts in accordance with legislation, policies and proceduresb) Acts in ways that:• acknowledge and recognise people’s expressed beliefs, preferences and choices• respect diversity• value people as individualsc) takes account of own behaviour and its effect on othersd) identifies and takes action when our own or others’ behaviour undermines equality and diversity

Examples of application:a) around: age, racial group, disability, gender, human rights, mental health etcb) might relate to:• food and drink• how they like to be addressed and spoken to• personal care• privacy and dignity• the information they are given• the support they would like• their faith or beliefd) would include:• recognising when equality and diversity is not being promoted and doing something about it• recognising when someone is being discriminated against and doing something about it

Support equality and value diversity

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3

Indicators:The worker: a) interprets equality, diversity and rights in accordance with legislation, policies and procedures and relevant standardsb) evaluates the extent to which legislation is applied in the culture and environment of own sphere of activityc) identifies patterns of discrimination and takes action to overcome discrimination and promote diversity and equality of opportunityd) enables others to promote equality and diversity and a non-discriminatory culturee) supports people who need assistance in exercising their rights

Examples of application:a) around: age, racial group, disability, gender, human rights, mental health etcb) might relate to:• communication with different people• health, safety and security / risk management• quality systems standards and guidelines• the allocation of resources• the availability of services• the development of services c) might relate to:• the learning and development offered to different people• the recruitment, selection and promotion of staff


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3

Indicators:The worker: d) enables others to promote equality and diversity and a non-discriminatory culturee) supports people who need assistance in exercising their rights

Examples of application:d) might include:• acting as a role model• being aware of the wellbeing of all members of the work team and supporting them appropriately• enabling others to reflect on their behaviour• identifying training and development needse) might relate to:• advocacy• enabling people to make the best use of their abilities• intervening when someone else is discriminating against someone on a one-off basis or routinely• making arrangements for support • representing people’s views


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4

Indicators:The worker: a) interprets legislation to inform individuals’ rights and responsibilitiesb) actively promotes equality and diversityc) identifies and highlights methods and processes to resolve complaints as a consequence of unfair and discriminatory practiced) supports those whose rights have been compromised consistent with legislation policies and procedures and good and best practice

Examples of application:a) and d) around: age, racial group, disability, gender, human rights, mental health etcb) would include:• acting as a mentor to people from diverse groups• acting as a role model• actively working in partnership with diverse groups• developing and supporting own team in relation to equality and diversity• ensuring that development opportunities are available to all staff• ensuring the fair recruitment and selection of staff

Develop a culture that promotes equality and diversity

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4

Indicators:The worker: e) actively challenges individual and organisational discriminationf) evaluates the effectiveness of equality and diversity policies and procedures within the service / agency and contributes to the development of good and best practice

Examples of application:b) would include:• focusing resources to deliver equitable outcomes• involving the local population in the development of services• listening to the experiences and views of different groups and acting on them• modelling good practice• promoting an open and fair culture throughout the organisation• promoting equality and diversity during partnership working

Develop a culture that promotes equality and diversity

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NHS Leadership Qualities Framework

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Joining up the Agenda

“An environment where all staff feel valued and enjoy a fair and equitable quality of working life, and where different backgrounds, perspectives, knowledge and experiences are welcomed and the benefits that this diversity can bring are actively sought and embraced.”

“A service which continuously seeks to improve the quality of healthcare provided to an increasing diversity of patients and clients, through nurturing, supporting and developing its staff.”

Vision for the NHS

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Cultural Awareness

Policies

Procedures

Standards

Behaviours

BY / OF INDIVIDUALS SYSTEMATIZED WITHIN AN ORGANISATION

QualityOf

Service

CULTURE

STRATEGY

POLICIES & PROCEDURES

CLIMATE SYSTEMS

STRUCTURECultural Sensitivity

Cultural Knowledge

Making cultural competence effective

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LINK TO HUMAN RIGHTS

DOMAIN AND STANDARD HOW TO MEASURE

eg:

THE RIGHT NOT TO BE DISCRIMINATED AGAINST IN RELATION TO ANY OF THE RIGHTS

Leadership and Governance Healthcare organisationdemonstrates culturallyCompetent leadership andgovernance

Leadership • Being representative of its community • Individual and collective knowledge • Non-discriminatory decision-making and attention to vulnerable groups • Individual and collective responsibility for the organisation’s performance in meeting the needs of minority and vulnerable groups

RIGHT TO LIFE Commissioning and ProcurementHealth care organisations will applyHuman Rights principles in procuringgoods and services

Commissioning• Involvement and participation of minority and vulnerable groups in the commissioning process • The use of up-to-date and reliable population data in the commissioning process

The Regulators: UK NHS Healthcare Commission –Draft Strategic Cultural Competence Framework

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CLOSE

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GlossaryEA - Equality Act, 2006EA(RB)R - Equality Act (Religion or Belief) Regulations, 2007EA(SO)R - Equality Act (Sexual Orientation) Regulations, 2007 DDA - Disability Discrimination Act, 1995

- Disability Discrimination Act, 2005DED - Disability Equality DutyDES - Disability Equality SchemeEE(A)R - Equality in Employment (Age) Regulations, 2006EE(RB)R - Equality in Employment (Religion and Belief) Regulations, 2003EE(SO)R - Equality in Employment (Sexual Orientation) Regulations, 2003EPA - Equal Pay Act, 1970GED - Gender Equality DutyGES - Gender Equality SchemeGRA - Gender Recognition Act, 2004HRA - Human Rights Act, 1998RED - Race Equality DutyRES - Race Equality SchemeRRA - Race Relations Act, 1976RR(A)A - Race Relations (Amendment) Act, 2000SDA - Sex Discrimination Act, 1975SES - Single Equality Scheme

Documents

1 Strategies and Challenges to Integrate Cultural Competence for Providers and Organisations – The British Case Carol Baxter Head of Equality & Diversity