Five Cross Cultural Capabilities for Clinical Staff

1. Self-Reflection: Understanding Self

Before you can gain insight into diverse communities, individuals, and groups, you need to understand and know your own culture and identity, whether this is your personal ethnic, spiritual, or cultural heritage or your professional or organisational affiliations. Evidence has shown that our attitudes, whether we are conscious of them or not, have a direct and significant impact on the people around us.

Critical self-reflection involves being aware of your own culture and value systems to avoid biases or making assumptions about cultures or groups that are seemingly different from your own. Through self-reflection, healthcare providers can acknowledge their own cultural beliefs and values, including their beliefs about health, allowing them to make adjustments, where appropriate, to work competently and sensitively across cultures.

"Only a self-aware physician can completely understand his/her reactions to or expectations of a patient, judge the extent to which personally held biases might influence the situation, and attempt to manage that bias."

Self-reflective practice avoids the common pitfall of ascribing differences to a cultural other.

Ethnocentrism is a term used to describe the imposition of your own cultural values and beliefs onto another individual culture. It occurs when a way of doing things, outside your own personal worldview, is deemed invalid and inferior, and your culture is seen as the standard or the norm.

Stereotyping occurs when cultural groups are reduced to core characteristics and seen as a 'type' devoid of unique personal characteristics. It is important to remember that stereotypes can be positive or negative,     and stereotypes are, in themselves, neither true nor false. Indeed some individuals do fit stereotypes. Steve Irwin, for example, in many characteristics conformed to stereotypes of Australian identity. Stereotypes, on the whole, overlook the complexity of individuals, and the individuality within groups.

Self-reflective practitioners are able to think about the 'strangeness' of their own cultural norms and practices before labelling a culture or way of doing things different from their own as strange or radically different. In doing so, they avoid exoticism – the tendency to view different cultures as inherently mysterious and incompatible with their own. Exoticism also often involves romanticising different cultures or seeing a different culture as inherently benign or simplistic.

In practice, the consequences of self-reflection would allow individuals to avoid making conclusions about difference and value judgements about behaviours or actions. Self-reflection allows staff to reflect on their own cultural background and preferences and to also illuminate shared practices across cultures. It also allows individuals to query their own assumptions and bridge divides or barriers between cultural groups.

• Self-reflection is a competency specification of the Australian Government's Cultural Competency in Health: A Guideline for Policy, Partnerships and Participation. It is also the first competency employed by a number of health services, including New South Wales Health Department (South-East Illawara Area Health Services and Eastern Sydney Multicultural Unit).
  
  It is included in training modules delivered by the Victorian Centre for Ethnicity and Health and Judith Miralles and Consultants, and in many international cultural competency modules such as Health Canada and the United States. The Victorian Department of Human Services' Aboriginal and Torres Strait Islander Cultural Competence Framework also include self-reflection as a critical first step in developing cross-cultural skills.
  

Self-reflection has long been central to nursing practice but has also been established as a starting point for cross-cultural work, more generally, across disciplines.

• Self-reflection is the starting point for cultural capability. It is an established foundation of many disciplines and is considered best practice in cross-cultural work.
  
• Self-reflection should be integrated into all cultural competency training.
  
• Self-reflection starts by providing tools for developing a sophisticated framework for thinking about intercultural communication and engagement. It may then be practiced situationally, or as the need arises.
  
• Self-reflection increases individual cultural awareness knowledge and skills.
  

Examples of Self-Reflective Practice in Other Training Materials and in a Health Context

How to reflect on your own culture:

Think about a time when you were with a group of people from another country or even another part of Australia. What were the similarities and differences in culture?

What would you describe as your culture? How would you rank the following in order of importance: ethnicity, family, work, the future, diet and religion? Do you believe that your clients have the same priorities?

Consider the areas where cultural variations in beliefs and values frequently occur. Can you immediately determine your preferences? What about the preferences of a friend or current client? Would your choices in your role as a XX differ from those for yourself or someone you care about?

Do you believe it is appropriate to discuss health issues with a client's family and friends? Why? What about discussing health issues such as menstruation, pregnancy, and sexually transmitted diseases with members of the opposite sex?

What does your body language say about you? How might a client from another culture interpret your posture, eye contact, and tone of voice? Could your body language be communicating something different from your words?

As an individual, how do you value personal independence, family, freedom, meaningful work, spirituality, etc.? How does this have an impact on your relationships with clients? Continually reflecting on your reactions to your and your clients' cultures will assist you in providing culturally capable care.

Questions to Develop Self-Reflective Practice

What client behaviours or practices make me feel uncomfortable?

How do I respond when I am frustrated?

What are my biases and prejudices?

What keeps me from understanding or putting myself in others shoes?

Do I believe other beliefs are valid?

When I judge others, what am I feeling?

Do I reflect on my status and how this might affect communication and interaction with others?

How do I feel when others make judgments or statements about me based on my race, culture, ethnicity, gender, or sexuality?

Summary of Why Understanding Self is a Capability

The first step to recognising and having the capacity to respond to the needs of others is to be aware of your own needs and biases and how you may perceive others as a result. Providing the best health care to all people means understanding biases and using self-reflection to deepen your understanding of culture to avoid making assumptions or stereotypes about cultures other than your own. In addition, reflecting on one's own identity, status, position and belonging in the organisational culture will allow a standard of professional and ethical conduct that supports and values diversity in the workplace.