Physiotherapy October 2002/vol 88/no 10

620

IntroductionIncreased movement and the reset-tlement of peoples generally across theglobe have created major changes in the mix of cultures in some countries and the major cities of the world. As aconsequence, the systems of healthcarethat serve these communities will need torecognise the different attitudes of peopletowards health and adopt care systemswhich are effective in meeting theirneeds. In order to make this approach areality, education of healthcare under-graduates in management of diversity iscrucial.

Within the United Kingdom, healthcareeducation lies on the interface of two ofthe main public sector services: educationand health. Whereas the education sectorhas long recognised its responsibility forequipping pupils to live in a multi-culturalenvironment, especially at primary schoollevel, within healthcare the picture hasbeen somewhat different. It has takenmany years for the service to recognisenot only that there are inequalities in healthcare but also that racism within the National Health Service affectsboth staff and students (Baxter, 1997b).More recently a deficiency in existingpolicies to deal with racism has becomeevident.

Thus it is imperative that in the devel-

opment of systems of care, diversity isrecognised in its broadest sense, ie thecontinuum from being treated withrespect as an individual to the con-sideration of group similarities in apositive light without stereotyping, andthat policies are developed which makeovert the expectations of the institution in ensuring that these systems workeffectively. Likewise, different culturalgroups and cultural traditions need to beincorporated into the development of aframework from which the subsequentcare package will emerge.

NHS InitiativesThe introduction of clinical governanceand a rise in litigation has alertedclinicians including those with aresponsibility for education of under-graduate healthcare students to the needto demonstrate evidence of the quality ofservice they provide to all their clients.For this reason among others, nursing,medicine, dentistry and the allied healthprofessions are being persuaded toinvestigate the levels of culturalcompetence in their undergraduateprogrammes.

Clinical Governance: Quality in the newNHS (DoH, NHSE, 1999) highlightsclinical governance as a ‘frameworkwithin which local organisations can workto improve and assure the quality ofclinical services’ and provide ‘mechanismsfor ensuring local delivery of high qualityservices … reinforced by a new statutoryduty of quality and supported byprogrammes of lifelong learning and localdelivery of professional regulation’.

Likewise the strategy Working Together:Securing a quality workforce for the NHS(DoH, 1998a) highlights the aim ofequality in the workplace, and A First Class Service: Quality in the NHS (DoH,1998b) states that all patients in the

Cultural Competence inUndergraduate HealthcareEducation Review of the issues

Summary People who are clinically competent are alsooften assumed to be culturally competent. Whereas clinicalcompetence is increasingly judged on the outcome measuresand standards issued by the professional organisations andgovernment, similar guidelines for the assessment of culturalcompetence are lacking. This paper suggests that thecomponents of cultural competence may be derived fromprevious research and appropriate literature, and discussesways in which these components could make a contributionto developing cultural competence in healthcareundergraduates.

Key WordsCulture, competence, cultural competence.

by Mel Stewart

Stewart, M (2002).‘Cultural competencein undergraduatehealthcare education:Review of the issues’,Physiotherapy, 88, 10,620-629.

620-629Stewart 19/9/02 7:19 am Page 620

Physiotherapy October 2002/vol 88/no 10

621Scholarly paper

Author and Addressfor Correspondence

Mel Stewart MEdMCSP DipTP is alecturer inphysiotherapy in theSchool of HealthSciences, University ofBirmingham, MorrisHouse, Edgbaston,Birmingham B15 2TT.

This article wasreceived on May 31,2001, and acceptedon May 5, 2002.

National Health Service are entitled tohigh quality care.

More recently, the launch of The VitalConnection: An equalities framework for theNHS working together for quality and equality(DoH, 2000a) provides a framework foraction on equal opportunities, andhighlights specific priorities and actionsto be taken by all sections of the NHS withregard to delivering high quality service in order to meet the diverse needs of the population. The ‘Tackling RacialHarassment in the NHS’ campaignlaunched by the NHS Executive in 2001sets out clearly that not only should chiefexecutives of health authorities, trusts andprimary care groups ensure that theirpolicies and practices are reviewed in thelight of good practice, and progressmeasured against a national standard, but that a local plan of action should be drawn up with the involvement of staff (DoH, 1998a).

In view of the wide-ranging governmentplans, the policies identified above, andthe strategies that are under developmentto tackle the existing inequalities inhealthcare, it seems that the assumptionmade in the past that all clinically com-petent practitioners are also culturallycompetent may not be accurate. Theneed for training required for qualifiedstaff and healthcare students to tackleinequalities in healthcare has beenrecognised and some governmentinitiatives have already been set intoplace, for example those on the recentlyestablished website on ‘Race Equality inthe Department of Health’ (www.DoH.gov.uk/race).

The challenge to the developers ofundergraduate healthcare curricula lies inseeking out effective strategies that willaddress inequalities in health andhealthcare to help students in developingprofessional competence.

Defining Cultural CompetenceIt is not immediately obvious from theliterature or from current usage what ismeant by the term ‘cultural competence’.Independent definitions of the two wordsfrom which the term has been derived --‘culture’ and ‘competence’ – haveprovoked lengthy analyses by socialscientists, educators and professionals,without an agreed consensus on eitherterm. As a consequence, the definition ofcultural competence remains locked into

individual perceptions and contexts.There is also little indication that it hasbeen investigated in a comprehensivemanner in healthcare. Indeed, the maj-ority of the evidence points toward a lackof expertise in dealing with the topic.

CultureDefinitions of culture are said to ‘denotea way of life’ and to be people’s ‘sharedexperiences and the schema they acquireon the basis of those experiences’ (Straussand Quinn, 1997). Fernando (1991)assumes that it is characterised byattitudes and behaviour, determined by upbringing and choice, and ischangeable. Hall (1984) proposes threelevels of culture: the explicit manifestculture (‘tertiary level culture’), which isvisible to the outsider and known only tothe members of the cultural groupthemselves such as cuisine, festivals anddress. A second level is the public ‘facadepresented to the world at large’, egbeliefs, rules. The third and deepest level,he describes as ‘secondary level culture’where rules and assumptions are implicitto the group but are rarely shared withoutsiders. This latter level is the mostresistant to change and the least open to manipulation. However, one shouldguard against the inclination to makegeneralisations based on this categ-orisation since differences between indiv-iduals may be just as marked as thedifferences between cultural groups.Within cultures there are likely to befurther categorisations based on class,age, physical ability and other factors.

These interpretations and categories ofculture are often fluid, complex andtrans-national; therefore it is importantthat the context of culture is interpretedaccurately. Additionally, the existence ofsubcultures such as nursing, student, andsports, are often superimposed on themain cultural classification. For example,it is recognised that students will undergosome form of enculturisation as theyprogress through the education processwhere they slowly acquire some of thecharacteristics of the professionals withwhom they are engaged.

Competence As in attempting to define culture,definitions of competence are context-bound. A more useful definition may begained if the term ‘competence in…’ is

620-629Stewart 19/9/02 7:19 am Page 621

Physiotherapy October 2002/vol 88/no 10

622

defined instead of mere competence.Many writers have attempted to clarify the meaning of competence in highereducation with varying degrees of success.Stengelhofen (1993) describes a model of professional competence thatencompasses knowledge, skills andattitudes at different levels. The lowesttier of the hierarchy are observableactivities and professional relationships, a second level involves reflection on knowledge which becomes moresystematic, until finally the the moreelusive attributes are reached whichencompass values and attitudes and aremore difficult to measure.

The current picture of culturalcompetence depicts a move from itspreviously itemised constituents -- areductionist and mainly behaviouristapproach to an account that incorporatesnot only per formance/practicerequirements but also intellectual andprofessional challenges (Edwards andKnight, 1995). The overall belief appearsto be that, by whatever meanscompetence is assessed, if it can beassessed, it is an outward and visibleinterpretation of the activity or activitiesrequired in a particular context.

Gosling (1999) in contrastingcompetence with continuing professionaldevelopment in a physiotherapy context,suggests that it is ... ‘more reductionist,task-based, focused on individuals’maintenance of a minimum level of safetyto practise and driven by organisationalneeds’. However she acknowledges thatcharacteristics of competence can be‘multi-faceted and multi-levelled’,‘fulfilling individual professionalresponsibility’, ‘recognising ... individuals’scope of practice’ and ‘an organisation’sfulfilment of its responsibility’. Thus itmay be broadened to have ethical andemotional dimensions. However, therequirement to ensure a minimumstandard, recognise the ability of in-dividuals, address poor/under-per f-ormance, and deal with unsafe practice,suggests that there may be a potential bias towards a prescriptive approach in healthcare education generally.

Therefore, in seeking a definition ofcultural competence, the individualdefinitions of the two terms bring theirown complexities, in which values,attitudes, ethics and emotion are viewedas important dimensions. In addition, the

dynamic nature of cultural competence,ie the interaction between the activities ofindividuals and the context in which theyoperate, is made explicit.

Cultural Competence A definition of cultural competence maybe derived from the literature byinvestigating the ways in which peoplehave tried to develop competence inothers. Ways of developing culturalcompetence have been suggested(Chandra, 1996; Nooderhaven, 1999;Lister, 1999) but the practical means bywhich it may be achieved withinundergraduate healthcare programmeshas rarely been addressed. Noorderhaven(1999) in writing about cultural differ-ences in physical therapy highlights theimportance of learning about culturaldifferences, specific cultures and the needto remain alert to subtle communicationcues, but he offers little guidance on howthis may be done in a practical way.

One of the few writers who haveattempted to do this is Lister (1999) whoproposes a taxonomy to develop culturallycompetent practitioners. He suggests that the topic could be addressed in‘increasingly sophisticated and increas-ingly praxis-orientated ways’ where issuesof power and the construction ofmeanings and identities go beyondessentialist notions of ethnicity. He pointsthe way forward by drawing on the ‘socialrealist’ approach of Fernando (1995) thatmakes central the individual’s relat-ionships, values, beliefs and practices inthe context of social structures such asmedicine and education. He also drawsdirectly on Papadopolous et al (1995) inLister (1999) and proposes a new model.

This new model is said to view culture asa fluid process, and a set of practices to dowith the construction of meaning andidentity. He therefore demarcates it fromessentialist and racist definitions in whichhe suggests that culture is fixed in a set oftraditional practices. Lister’s frameworkencompasses knowledge, understanding,sensitivity, and competence. ThoughLister’s taxonomy recognises the com-petencies associated with race, colour and ethnicity, he requires individualresearchers to extricate these from theframework he offers. He states thatundergraduates in healthcare require abroad framework perspective on culturerather than a concentration on the

620-629Stewart 19/9/02 7:19 am Page 622

Physiotherapy October 2002/vol 88/no 10

623Scholarly paper

‘essentialist notions of ethnicity’ in orderto inform their practice.

An alternative view by Baxter (1997a)supports the case for specifically spellingout certain issues like race and racismwithin the curriculum of healthcarestudents. Unlike Lister, she provides somepractical measures by which these subjectsmay be approached, for example methodsof amending the teaching of racial issuesin the undergraduate curriculum.

Thus two questions arise: if students arerequired to practise in settings where theissues of race, colour and ethnicity havebeen shown to have a major impact onthe healthcare of the population theyserve, should these issues assume agreater priority than Lister’s frameworkaffords? And how appropriate is ageneralist approach in developingcultural competence in some settings ifthe ‘essentialist notions of ethnicity’ aregiven only cursory attention?

The concern to develop culturalcompetence is also on the government’sagenda in the USA where the US Healthand Human Services, Office of MinorityHealth has begun to look at nationalstandards for cultural and linguisticallyappropriate services (USDoHHS, 2000).Here, a culturally competent programmeis referred to as ‘one that demonstratessensitivity and understanding of culturaldifferences in programme design,implementation and evaluation’, andcultural competence as ‘a set ofcongruent behaviours, attitudes andpolicies that come together in a systemagency or among professionals thatenables effective work in cross-culturalsituations’.

Concern about developing culturalawareness in healthcare students has alsobeen recognised by the American MedicalAssociation which has recently issued areport encouraging medical schools ‘tooffer electives in culturally competenthealthcare with the goal of increasingawareness and acceptance of culturaldifferences between patient and provider’(AMA, 2000).

Chandra (1996) in Facing up toDifference: A toolkit for creating culturallycompetent health services for black andminority communities decided to coin theterm ‘cultural competence’ to ‘denoteservices perceived by black and minorityethnic users as being in harmony withtheir cultural and religious beliefs and not

just provided by people who are, or areassumed to be “culturally sensitive”’.

Meleis (1996) recognised that theknowledge base for cultural competenceis underdeveloped and urged researchers,theoreticians and reviewers to addresseight criteria to ensure rigour and cred-ibility in its development: contextual-ity, relevance, communication styles,awareness of identity and power diff-erentials, disclosure, reciprocation,empowerment and time.

In a different field of work, Manoleas(1994) outlines a model for assessing thecultural competence of graduate studentsin social work. The objectives given fordeveloping cultural competence incorp-orate a study of human development, lifeevent, caregiving patterns, nature, time,spirituality and group versus individualfocus, skill objectives related to diagnosis,interviewing techniques, psychosocialassessment and self-assessment, culturaland professional values.

It becomes apparent that culturalcompetence has been investigated frommulti-cultural, anti-racist and social realistapproaches with the majority of viewscentred around a broad sociologicalperspective but that there is a dearth ofresearch regarding the theory that hasguided its development in healthcare.

The term ‘cultural competence’ isconsistently applied in the context of thedevelopment of services for disadvantagedgroups. Hence the assessment of power differentials between minoritygroups and the majority populationcannot be excluded in efforts made todevelop it.

Power-distance is the ‘degree to which different cultures encourage ormaintain power and status differencesbetween interactants’ (Robinson, 1998b).Although the power-distance relationshipis often applied to cultures on a nationalbasis it may also be applied at a more locallevel. It is clear that an individual’s desireto bring about a change in power-distancewill be influenced by threats and/oradvantages to be gained to self and to the self-defined cultural group to whichthat individual belongs. The influence of the law, an individual’s moral code,professional codes of conduct, andreligion are all pertinent factors that mayinfluence this desire. Thus in developingcultural competence, power-distance may be one of the complexities to be

620-629Stewart 19/9/02 7:19 am Page 623

Physiotherapy October 2002/vol 88/no 10

624

explored not only between cultures at a national level but at the inter facebetween healthcare practitioners andtheir clients.

Contributing Factors The general lack of pertinent theoreticalmodels from which to derive a practicalapproach to developing culturalcompetence suggests that an alternativemay be exploring some of the factorshighlighted in the literature to inform thedevelopers of undergraduate healthcarecurricula (see panel).

� Awareness Reactions to cultural differences vary.They range from valuing thecontributions that one culture mightmake to another to open hostility. Inrecognition of cultural diversity,practitioners need to become increasinglyaware of the social context of their clientsand offer appropriate opportunities toempower them in a context that ismeaningful to them. Currently thisstrategy is under-used. For example, in aparticular cultural group if the focus ofcare for an individual is regarded as theresponsibility of the whole family and not just the individual, then this degree of family involvement needs to beunderstood and not interpreted as thefailure or the lack of will of individuals to become independent.

� Gaining Knowledge about CultureKnowledge may be viewed as the lowestcognitive level within the process oflearning, but since all the other levels oflearning are assumed to be subsequent to it, it forms a vital foundation in the development of education. It isincumbent on health professionals todevelop a wide knowledge base abouttheir clients, without which anyassessment of the quality of the careadministered may be called in toquestion.

An investigation of cultural competenceshould examine the eurocentric approachwhich sometimes assumes that Europeansystems are always the most approp-riate methods for the delivery of care(Robinson, 1998a). A eurocentricapproach is also highly suspicious ofcertain values and attitudes towardshealthcare as they exist in other cultures.Cultural competence requires pract-itioners to investigate the differences andsimilarities in different groups and to usethe findings to structure a delivery of carewhich achieves maximum involvement ofclients. It recognises that the impositionof a particular or a traditional approachto practice may not be applicable orappropriate for some users of the service.Indeed these practices may breach rulesof professional conduct, prove unaccep-table to clients, and at worse prove to bedetrimental to health.

Acquiring basic knowledge about dailyreligious practices, holy days, dress codeand so on, ie learning about ‘tertiary levelculture’ and the public façade thatdifferent cultures present to the world asoutlined by Hall (1984) may be one of theearly steps in the process of developingcultural competence.

� Self-knowledge An individual’s cultural values andidentity develop out of exposure todifferent social environments, religion,family values, education, and geneticdifferences. The impact of individualsquestioning their identity, and the factorsthat contribute to the values they hold areareas that often cause great emotionaldisturbance, especially when they areshown to be in conflict with those ofothers within the immediate environ-ment, for example in one’s place of work.However, disturbing as it may be, withoutpractitioners examining their own identity

Factors contributing to development ofcultural competence in undergraduatehealthcare curricula

� Awareness and acceptance of thewide range of cultural diversity (in developing systems of care).

� Acquisition of knowledge of culturaldifferences and similarities andknowledge of clients’ culture.

� Knowledge of one’s own culturalvalues and identity.

� Ability to communicate effectivelyacross cultural groups.

� Use of knowledge to adapt servicesand skills.

� Development of lifelong learning andreflection that includes examinationof attitudes and values of culturalgroups.

620-629Stewart 19/9/02 7:19 am Page 624

Physiotherapy October 2002/vol 88/no 10

625Scholarly paper

and the cultural values they hold and thefactors contributing to them, it may bedifficult to understand the culture ofother groups without stereotyping(Robinson, 1998b).

The history of migrant groups to Britainas in many other countries is complex and often the assumptions and theconclusions reached are indifferent or atworse negative and discriminatory inrelation to the majority cultural group. InBritain, the impact of the slave trade, theholocaust, past colonialism and themovement of refugees are but four of thehistorical events that have had a profoundimpact on the cultural identities of someof the minority groups in receipt anddelivery of healthcare. The extent towhich the majority population under-stands this is unknown but professionalshave a duty of care both to understandthe attitudes and values of their clientsand to examine their own attitude tothem.

� CommunicationAbility to communicate is an importantaspect of survival. Whether verbal or non-verbal, practitioners’ ability to maintaineffective lines of communication betweenthemselves and their clients is crucial in the care process. Yet on numerousoccasions it has been demonstrated thatcommunication in healthcare may bepoor or even non-existent for a variety ofreasons. Perhaps the most obvious cause isthat people do not always speak the samelanguage.

This problem has been remedied inpart by NHS trusts which have employedthe use of translators and interpreters.Unfortunately the differences betweenthem are not often considered, andconsequently the results are oftenunsatisfactory. An interpreter may give asubjective and value-laden interpretationof a situation. Alternatively, a translatordelivers a word-for-word translationwithout the advantages of acting as anadvocate for the client. Minors are alsooften called upon to act as interpretersfor their parents or relatives in situationswhere the ethical, legal and moralconnotations have not been addressed.Where examples of ‘good culturallysensitive practice’ have been developedthe use of minors has been deemedunacceptable.

A preliminary study carried out by

Clifford et al (1999) suggests that the mostimportant factor affecting the ability ofundergraduate healthcare students andstaff to deliver culturally sensitive care iscommunication, usually when clientsspeak little or no English. Verbal and non-verbal cues used by different culturalgroups in establishing and maintainingcommunication are often missed ormisunderstood by practitioners. Bothparties may also misinterpret interactionbetween practitioners and clients, forexample in the use of eye contact, ahandshake, other physical gestures, andin the use of physical distance anddifferent postures.

Methods for developing effective linesof communication should not assume thatall members of a cultural group areliterate. Translating information leafletsinto different languages has been shownto be useful but its value is limited if someclients cannot read at all.

Care schemes that incorporate the useof ‘advocates’ for clients are becomingincreasingly popular and their con-tribution in bridging the cultural gap inhealthcare has been shown to be effectivein some areas (DoH, 2000a). Advocatesare normally from a culture similar to thatof the clients or people who havesignificant insight into healthcare, andare trained in the art of communication.They may be among the few people withan overview of the total healthcarepackage of their clients; therefore one oftheir additional contributions may be inhelping to co-ordinate care services.

In recognition of the importance ofcommunication in healthcare thegovernment has issued in item 9.18 TheNHS Plan: A plan for investment, A plan toreform, the following directive: ‘It will be apre-condition of qualification to deliverpatient care in the National HealthService that an individual has demon-strated competence in communicationwith patients’ (DoH, 2000b). In order to demonstrate effective communi-cation, it is necessary to have a clearmessage and to establish that under-standing has taken place and that theresponses are regarded as appropriateand meaningful to all concerned. Abreakdown in communication may occurbetween any of these three areas, throughomission or inaccurate assumptions.

620-629Stewart 19/9/02 7:19 am Page 625

Physiotherapy October 2002/vol 88/no 10

626

AdaptationThe development of cultural competenceassumes that there is the desire to dojustice coupled with the desire to change.If the latter is absent, attempts to developcultural competence will soon bedefeated. It is suggested that it is onlywhen an individual or an institutionrecognises, from the evidence thatdiversity exists in system, that the system isoperating unjustly and that it is withintheir power to make a change, that thedevelopment of cultural competence canbegin. The adaptation of services andskills using the appropriate knowledgeand existing evidence may then be usedto benefit clients.

The requirement for all healthcarepractitioners to demonstrate continuingprofessional development links thedevelopment of practitioner skills toclinical effectiveness. In measuringclinical effectiveness it is argued that thecompetence of the practitioners is underscrutiny and that clinical effectivenessincludes a measure of their culturalcompetence. Systems of care andpractitioners’ skills require continuousadaptation in order to take into accountthe different cultural issues that affecthealthcare.

� Attitudes and Values Without an investigation of the attitudesthat exist within different cultural groupsand the factors that affect attitudinalchange, it is difficult to conceive howpractitioners can understand the be-haviours of different groups, and moreimportantly, develop the skills to managebehavioural changes. It is known that thehealth beliefs of individuals play asignificant part in the effectiveness oftheir healthcare (Helman, 2000). Thenature of caring within a cultural groupwill need to be understood in order totailor care to individual needs.

Education is viewed as life-long process.It may be assumed also that the study ofthe attitudes and the values of people indifferent cultures is dynamic andtherefore cannot be limited to a momentin time. Similarly, the view of education as a process by which an individual ischanged makes the approach to devel-oping cultural competence a lifelongventure. The requirement to evaluate andre-evaluate administration of the careprocesses suggests that the maintenance

of cultural competence is also a lifelongprocess requiring continuous learningand adaptation.

In summary the development ofcultural competence begins with arecognition of the growing culturaldiversity within the population throughthe increasing knowledge of cultural differences and similarities and the examination of one’s own culture andvalues.

As a consequence, development ofcertain practitioner skills including thoseof inter-cultural communication is viewedas an important requirement for implem-entation and effective adaptation ofservices. The views of clients are seen ascentral to the process and acted uponappropriately. Evaluation of developingcultural competence including exam-ination of the attitudes and values ofthose involved should be viewed as acontinuing process.

Guide to Setting Standards A standard is considered to be ‘a prof-essionally agreed level of performanceappropriate to the population addressed,which reflects what is achievable,observable, desirable and measurable’(Kendall and Kitsell, 1986).

Several frameworks have had aninfluence on the implementation ofquality initiatives in healthcare based onthe use of three criteria as suggested byDonabedian (1966): structure, processand outcomes of care. It is not theintention here to write definitive stan-dards since they are specified levels ofcare against which actual performance is compared in a specific context. Butstemming from the literature, the sug-gestion is that consideration should begiven to the factors listed in the panel, thedesire of individuals and institutions tochange, and the management of blamewhen standards of cultural competenceare being addressed.

Desire to ChangeThe argument has been presented thatthe basis for developing culturalcompetency lies in the recognition ofdiversity and the readiness of anindividual and/or an institution toaddress injustice, and willingness tochange, in order to optimise care for all.These desires may be strongly influencedby the types of evidence that address

620-629Stewart 19/9/02 7:19 am Page 626

Physiotherapy October 2002/vol 88/no 10

627Scholarly paper

health and care needs, and the motivationof individuals to seek it out where it may be less obvious. Additionally, anindividual’s moral code, religiouspersuasion, prejudices, and community,peer and family pressures are amongother influential factors. Attempts tomeasure cultural competence will requirean explicit assessment of these complexfactors.

It may be partly due to the recognitionof this difficulty and the motivationrequired to carry out this exercise that theCommission for Racial Equality hasdeveloped ‘The Leadership Challenge’.This scheme identifies and givespublished recognition of institutions thathave identified the desire to improveinequalities based on race. It is aninvitation to all institutions to takeresponsibility for monitoring andbringing about attitudinal change withrespect to racism (CRE, 1999). Althoughthis approach does not provide acomplete answer for the setting ofstandards in cultural competence, itattempts to deal with racism which isviewed as one of the important factors to be assessed.

Management of BlameThe arguments surrounding theMcPherson Report (1999) have high-lighted the problems that can ensue whencultural competence is viewed as both aninstitutional and an individual state. If theinstitution receives a negative label, forexample ‘racist’, then it is likely that theindividuals within it could take the viewthat they cannot be held primarilyresponsible for its cultural incompetence.Likewise, if the finger of blame is pointedtowards an individual working within aninstitution, the case may also be madeagainst the institution rather than theindividual for lack of clear policies andguidelines to deal with the problems. The complexity of unravelling some ofthe problems associated with ‘blame’ inthis scenario is self-evident, but it is also a problem to be addressed in thedevelopment of cultural competence. Afurther consideration in developingcultural competence is the concept ofcultural relativism, where one cultureassumes superiority in judging thecultural practices of another group(Cook, 1999). Unfortunately, the moraland ethical implications of this view

cannot be explored within this shortpaper.

In summary, the extent to which cult-ural competence may be assessed as out-lined in this paper lies in:

� Desire of individuals and institutions to change

� Acquisition of knowledge andunderstanding of the concepts ofcultures, race and ethnicity.

� Examining one’s own attitudes andvalues towards culture, race andethnicity.

� Management of blame. � Developing abilities that promote

culturally sensitive practice. � Increasing awareness of identity, power

differentials, and communicationstyles.

� Examining and adaptingadministrative policies to promotecultural competence.

� Facilitating the active participation ofmembers of minority communities toinform practice.

� Demonstrating on-going reflectivepractices and evaluation that examineprejudice, stereotyping anddiscrimination, and the measurestaken to address them.

ConclusionIn light of the measures being taken bygovernment at a national level to addressinequalities in health and healthcare, it isincumbent on all those with theresponsibility for delivering undergrad-uate healthcare education to recognisetheir professional obligation in meetingthe needs of individuals in a society that isbecoming increasingly diverse, and todevelop the skills in order to do so. Todate, the literature gives little indicationof the practical ways by which to developcultural competence in undergraduatehealthcare students or how effectively theprocesses outlined above contribute to itsdevelopment.

Healthcare practitioners of the futurewill need to respond with added insightinto the cultural background of theirclients as they attempt to demonstrateclinical governance and professionaldevel-opment. The literature is clearlylimited but it gives some help indeveloping guidelines to inform practice.

620-629Stewart 19/9/02 7:19 am Page 627

Physiotherapy October 2002/vol 88/no 10

628

Further investigations into this latter areaare urgently required to identify effectivestrategies that might be incorporated

into the undergraduate curriculum ofhealthcare students to facilitate thedevelopment of cultural competence.

References

American Medical Association (1999). Reportof the Council on Medical Education. PolicyH-295-905.

Baxter, B (1997a). Race Equality in Healthcareand Education, Balliere Tindall, London.

Baxter, B (1997b). Op cit, pages 3-4.

Chandra, J (1996). Facing up to Difference: A toolkit for creating culturally competent healthservices for black and minority ethnic communities,King’s Fund, London.

Chartered Society of Physiotherapy (2000).Core Standards, CSP, London.

Chartered Society of Physiotherapy, Councilfor Professions Supplementary to Medicine(1996). The Curriculum Framework, CSP, London.

Clifford, C, Stewart, M and Sweeney, A (1999).‘Developing and evaluating educational andtraining programmes to increase the culturalsensitivity of healthcare professionals topromote positive health outcomes: Interimreport’, School of Health Sciences, Universityof Birmingham (by permission from the NexusProject team).

Cook, J W (1999). Morality and CulturalDifferences, Oxford University Press, page 3.

Commission for Racial Equality (1999). TheLeadership Challenge for the Health Sector, CRE,London.

Department of Health (1998a). WorkingTogether: Securing a quality workforce for the NHS,HMSO.

Department of Health (1998b). A First ClassService: Quality in the NHS, HMSO.

Department of Health (1998c). Tackling RacialHarassment in the NHS: A plan for action, HMSO.

Department of Health, NHS Executive (1999).Clinical Governance: Quality in the new NHS,Stationery Office.

Department of Health (2000a). The VitalConnection: An equalities framework for the NHSworking together for quality and equality,Stationery Office.

Department of Health (2000b). The NHS Plan:A plan for investment, a plan to reform, cm 4818-1,Stationery Office.

Department of Health (2000c). Op cit (2000a)page 9.

Donabedian, A (1966). ‘Evaluating the qualityof medical care’, Millbank Memorial FundQuarterly, 44 , 2, 166-206.

Edwards, A and Knight, P (1995). AssessingCompetence in Higher Education, Kogan Page,London.

Fernando, S (1991). Mental Health, Race andCulture, Macmillan, London.

Fernando, S (1995). Mental Health in Multi-ethnic Society: A multi-disciplinary handbook,Routledge, London.

Gosling, S (1999). ‘CPD and competence:Related but different -- An initial consider-ation of concepts’, Physiotherapy, 85, 10, 536-540.

Hall, E T (1984). Cited in: Helman, C G(2000) op cit, pages 2-4.

Helman, C G (2000). Culture, Health and Illness,Butterworth Heinemann, Oxford, 4th edn, pages 29-31.

Kendall, H and Kitsell, A (1986). Standards ofCare: A framework for quality, Royal College ofNursing, London, pages 29-31.

Lister, P (1999). ‘A taxonomy for developingcultural competence’, Nurse Education Today,19, 8, 313-318.

Macpherson, W (1999). The Stephen LawrenceInquiry, Home Office, London.

Manoleas, P (1994). ‘An outcome approach toassessing the cultural competence of MSWstudents’, Journal of Multi-cultural Social Work, 3,1, 43-57.

Meleis, A I (1996). ‘Culturally competentscholarship: Substance and rigor -- based on a keynote speech given at the eleventhresearch conference “Toward CulturallyCompetent Healthcare”, Rutgers StateUniversity’, Advances in Nursing Science, 19, 2, 1-16.

Noorderhaven, N G (1999). ‘Interculturaldifferences: Consequences for the physicaltherapy profession’, Physiotherapy, 85, 9, 504-510.

Robinson, L (1998a). ‘Race’, Communicationand the Caring Professions: ‘Race’, health andsocial care, Open University Press, Buckingham,pages 43-44.

Robinson, L (1998b). Op cit, page 60.

Stengelhofen, J (1993). Teaching Students inClinical Settings, Chapman and Hall, London,chap 1.

Strauss, C and Quinn, N (1997). A CognitiveTheory of Cultural Meaning, CambridgeUniversity Press, page 7.

620-629Stewart 19/9/02 7:19 am Page 628

Physiotherapy October 2002/vol 88/no 10

629Scholarly paper

US Department of Health and HumanServices, Office of Minority Health, Resourcesfor Cross Cultural Healthcare (2000). AssuringCultural Competence in Healthcare:Recommendations for national standards and anoutcomes-focused research agenda.

Websites

www.DoH.gov.uk/race_equality Race Equalityin the Department of Health.

www.hhs.gov US Department of Health andHuman Services.

Key Messages

� Government policy and legislationrequires the development of culturalcompetence within undergraduatehealthcare education and within thecontext of professional practice.

� Cultural competence is a littleunderstood term in healthcare thatassumes the recognition of culturaldiversity.

� The assumption that a clinicallycompetent healthcare practitioner isalso culturally competent is open toquestion.

� Cultural competence is vital to theachievement of effective healthcarefor all.

� The development of standards andguidelines for achieving culturalcompetence needs to be establishedwithin specific contexts.

� As part of professional development,practitioners need to address theirown cultural competence.

620-629Stewart 19/9/02 7:19 am Page 629