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Diversity is being increasingly recognized as an area of emphasis in health care. The term cultural humility is used frequently but society's understanding of the term is unclear. The aim of this article was to provide a concept analysis and a current definition for the term cultural humility. Cultural humility was used in a variety of contexts from individuals having ethnic and racial differences, to differences in sexual preference, social status, interprofessional roles, to health care provider/patient relationships. The attributes were openness, self-awareness, egoless, supportive interactions, and self-reflection and critique. The antecedents were diversity and power imbalance. The consequences were mutual empowerment, partnerships, respect, optimal care, and lifelong learning. Cultural humility was described as a lifelong process. With a firm understanding of the term, individuals and communities will be better equipped to understand and accomplish an inclusive environment with mutual benefit and optimal care. © The Author(s) 2015.
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Journal of Transcultural Nursing
2016, Vol. 27(3) 210 –217
© The Author(s) 2015
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DOI: 10.1177/1043659615592677
Theory Department
The value and understanding of the term diversity has
evolved and progressed over the past several decades.
Diversity has been increasingly recognized as an area of
emphasis or core value in health care through leading organi-
zations such as the Institute of Medicine (2010) and the
National League for Nursing (2013). To attend to the increas-
ing diversity in a globally connected society, there has been
a movement of use of the terms cultural sensitivity and cul-
tural competency to that of embracing cultural humility.
Cultural humility has been endorsed as more profound and
politically correct than cultural competency, but this shift
begs the question, “What is cultural humility?”
Rodgers and Knafl (2000) advocated the importance to
understand the meaning behind terms as they morph and
change over time. Performing a concept analysis is one way to
determine society’s current meaning and understanding of a
term. A concept analysis involves a systematic approach of
reviewing the literature to tease out the antecedents, attributes,
and consequences of a term. Concept analysis involves a
search and exploration with the goal of achieving a definition.
The aim of this article was to conduct a concept analysis and
provide a current definition for the term cultural humility.
In 1998, Tervalon and Murray-García suggested that cultural
competency be distinguished from cultural humility. In this
sentinel document that has been cited over 600 times, the con-
cept of cultural humility in the context of physician training
was discussed. They summarized that “cultural humility
incorporates a lifelong commitment to self-evaluation and
critique, to redressing the power imbalances in the physician-
patient dynamic, and to developing mutually beneficial and
non-paternalistic partnerships with communities on behalf of
individuals and defined populations” (p. 123). They empha-
sized that cultural humility was a more suitable goal than cul-
tural competence in multicultural medical education.
Campinha-Bacote (2002) developed a model of care
called The Process of Cultural Competence in the Delivery of
Healthcare Services. The constructs of the model included
cultural awareness, cultural knowledge, cultural skill, cul-
tural encounters, and cultural desire. Cultural competence
was deemed a process and applied across areas of practice
including the clinical setting, administration, research, pol-
icy development, and education.
Chang, Simon, and Dong (2012) described cultural humility
using the QIAN model influenced from the work of Chinese
philosophers. They used the acronym QIAN, or “humble-
ness” in Chinese, to summarize the core values of cultural
592677TCNXXX10.1177/1043659615592677Journal of Transcultural NursingForonda et al.
1Johns Hopkins University, Baltimore, MD, USA
Corresponding Author:
Cynthia Foronda, PhD, RN, Johns Hopkins University, 525 N. Wolfe
Street, Baltimore, MD 21205, USA.
Cultural Humility: A Concept Analysis
Cynthia Foronda, PhD, RN1, Diana-Lyn Baptiste, DNP, RN1,
Maren M. Reinholdt, MSN, BSN, RN1,
and Kevin Ousman, MSN-HSM, BSN, RN1
Diversity is being increasingly recognized as an area of emphasis in health care. The term cultural humility is used frequently
but society’s understanding of the term is unclear. The aim of this article was to provide a concept analysis and a current
definition for the term cultural humility. Cultural humility was used in a variety of contexts from individuals having ethnic and
racial differences, to differences in sexual preference, social status, interprofessional roles, to health care provider/patient
relationships. The attributes were openness, self-awareness, egoless, supportive interactions, and self-reflection and critique.
The antecedents were diversity and power imbalance. The consequences were mutual empowerment, partnerships, respect,
optimal care, and lifelong learning. Cultural humility was described as a lifelong process. With a firm understanding of the
term, individuals and communities will be better equipped to understand and accomplish an inclusive environment with
mutual benefit and optimal care.
cultural humility, nursing and cultural competence
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Foronda et al. 211
humility in health care professional education and training.
The Q stood for the importance of self-questioning and cri-
tique, the I stood for bidirectional cultural immersion, the A
stood for active listening, and the N stood for the flexibility
of negotiation. They recommended cultural humility be
incorporated into medical education to enhance cross-cul-
tural clinical encounters.
Foronda (2008) performed a concept analysis of the term
cultural sensitivity. She uncovered attributes of knowledge,
consideration, understanding, respect, and tailoring. The
antecedents of cultural sensitivity were diversity, awareness,
and an encounter. The consequences were effective commu-
nication, effective intervention, and satisfaction. A formal
concept analysis of cultural humility within the past 5 years
was lacking within the literature; thus, this concept analysis
was warranted.
Search Strategy
The databases of CINAHL Plus, Academic Search Complete,
Anthropology Plus, ERIC, Human Resources Abstracts;
Humanities Full Text and PsycINFO were explored using the
search terms of “cultural humility” or “culturally humble”
yielding 123 citations. PubMed was investigated using
search terms of “cultural” or “culturally” combined with
“humility” or “humble” revealing 154 more citations.
Duplicates were removed resulting in 206 articles. Articles
published prior to 2009 were removed resulting in 116 arti-
cles published from 2009 to 2014. Book chapters and articles
written in languages other than English were excluded. The
remaining 108 articles were read for relevance and 46 more
articles were excluded as they did not discuss cultural humil-
ity within them; thus, 62 total articles were included in the
Rodgers and Knafl’s (2000) method of concept analysis was
used to guide the process.
The articles were divided among the four team members
for analysis. Each member read the articles, searching for
keywords and phrases that related to cultural humility. These
keywords and phrases were combined and sorted into a mas-
ter grid having categories of antecedents, attributes, and con-
sequences. After establishing findings independently, the
team discussed repetitive keywords and phrases. Through an
iterative process of synthesis and consolidation, the attri-
butes of cultural humility surfaced.
The authors felt it was important to reveal select details that
may have influenced their interpretation of the data in the
interest of disclosing potential bias to enhance reader perspec-
tive. The research team comprised four nurses, three female
and one male. The researchers self-identified as African (one
Black), Euro-American (two White), and Haitian (one
Black). Diversity of the team in the areas of socioeconomic
status, age, sexual orientation, and disability was lacking.
The term cultural humility was used in a variety of contexts
from individuals having ethnic and racial differences, to differ-
ences in sexual preference, social status, interprofessional roles,
to health care provider–patient relationship. The following attri-
butes were discovered: openness, self-awareness, egoless, sup-
portive interactions, and self-reflection and critique. Cultural
humility was described as a lifelong process (Figure 1).
Openness. The first attribute identified was openness. An
individual must have an open mind or be open to an interac-
tion with a culturally diverse individual for cultural humility
to take place. Openness is defined as possessing an attitude
that is willing to explore new ideas. This word was expressed
in contexts including physician-clinicians in a teaching
capacity, social workers training child welfare workers,
practicing medicine with diverse patients, physical therapist
life histories, a minority occupational therapist working with
patients of the majority group, and preparing nurses to work
with lesbian, gay, bisexual, or transgendered patients (Bea-
gan & Chacala, 2012; Brennan, Barnsteiner, de Leon Siantz,
Cotter, & Everett, 2012; Dobransky-Fasiska et al., 2009;
Hilliard, 2011; Mahant, Jovcevska, & Wadhwa, 2012; Ortega
& Coulborn, 2011; Tilburt, 2010; Vogt, 2011). Descriptive
phrases discovered were having an open-minded posture,
being open, having openness, unpretentious openness, and
an open stance or open-mindedness (Aghababaei, Wasser-
man, & Hatami, 2014; Beagan & Chacala, 2012; Brennan et
al., 2012; Coulehan, 2011; Dobransky-Fasiska et al., 2009;
Hilliard, 2011; Mahant et al., 2012; Ortega & Coulborn,
2011; Rew, 2014; Tilburt, 2010). Having openness was one
of the initial steps in the process of cultural humility.
Self-Awareness. The second attribute was self-awareness.
Self-awareness is defined as being aware of one’s strengths,
limitations, values, beliefs, behavior, and appearance to oth-
ers. The exact terms of awareness and self-awareness were
noted repeatedly throughout the literature. Self-awareness
was used in contexts including medicine, medical education,
clinical research, nursing, nurse education, physical thera-
pists, community health, psychotherapy, and social worker
education (Alsharif, 2012; Brennan et al., 2012; Coulehan,
2010, 2011; Graham-Dickerson, 2011; Groll, 2014; Hilliard,
2011; Isaacson, 2014; Jennings et al., 2012; Ma, Li, Liang,
Bai, & Song, 2014; Ortega & Coulborn, 2011; Rew, 2014;
Ross, 2010; Tilburt, 2010; Vogt, 2011; Yeager & Bauer-Wu,
2013; Zanetti, Dinh, Hunter, Godkin, & Ferguson, 2014).
Additional descriptors included understanding one’s abilities
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212 Journal of Transcultural Nursing 27(3)
and limitations and possessing self-knowledge (Jennings
et al., 2012; Mahant et al., 2012). When working with others
from different cultures, an individual must be aware of one’s
values, beliefs, and behaviors. After having this self-aware-
ness, the individual can continue with the process of cultural
Egoless. The third attribute was titled egoless. This heading
encompassed various terms that referred to one requiring
humbleness or throwing away ego. Descriptive terms included
requiring modesty, being egoless, humble, down to earth,
having neutrality, having humble attitude, being equitable,
having a quiet ego, humility, approach (others) as equals, and
lack of superiority (Aghababaei et al., 2014; Alsharif, 2012;
Beagan & Chacala, 2012; Dobransky-Fasiska et al., 2009;
Groll, 2014; Kesebir, 2014; Levi, 2009; Owen et al., 2014).
Egoless is defined as being humble; viewing the worth of all
individuals on a horizontal plane. The poignant descriptors
illustrate a more grand concept than just humility; they illus-
trate one must enact a belief system of equal human rights and
flatten any hierarchy or power differential.
Supportive Interaction. The fourth attribute heading was sup-
portive interaction. This term was chosen because it was
broad enough to encompass the many different types of
engagements and actions that occur when cultural humility is
being implemented. Supportive interactions are defined as
intersections of existence among individuals that result in
positive human exchanges. The actions that fall under this
heading include the following: interactions of two persons,
interaction, intersectionality, sharing, taking responsibility
for interactions with others, interactions, supportive interac-
tions, engage, engaging, and engaged/active (American
Association of Diabetes Educators, 2012; Beagan & Cha-
cala, 2012; Butler et al., 2011; Groll, 2014; Hilliard, 2011;
Isaacson, 2014; Kamau-Small, Joyce, Bermingham, Roberts,
& Robbins, 2014; Metzl & Hansen, 2014; Nazar, Kendall,
Day, & Nazar, 2014; Ross, 2010). A supportive interaction
between individuals must occur as part of the process.
Self-Reflection and Critique. The final attribute was self-
reflection and critique. This attribute is defined as a critical
process of reflecting on one’s thoughts, feelings, and actions.
Terms used that fall under this heading included self-reflec-
tion, self-critique, thinking critically about one’s self, self-
evaluation and critique, self-reflection and discovery,
self-questioning and critique, reflection, self-reflective pro-
cess, knowledge acquisition and reflective practice, reflec-
tive openness, and introspection (American Association of
Diabetes Educators, 2012; Chang et al., 2012; Clark et al.,
2011; Coulehan, 2010; Fahey et al., 2013; Foster, 2009;
Hammell, 2013; Hilliard, 2011; Isaacson, 2014; Ma et al.,
2014; Miller, 2009; Morton, 2012; Nazar et al., 2014;
Reynoso-Vallejo, 2009; Ross, 2010; Schuessler, Wilder, &
Byrd, 2012; Vogt, 2011; Yeager & Bauer-Wu, 2013). The
self-reflection and critique was described as a journey or
endless process of continual reflection and refinement.
Antecedents referred to the concepts or situations that pre-
ceded the instance of the concept of cultural humility
(Rodgers & Knafl, 2000). Across the disciplines and con-
texts that surfaced in the literature review, the antecedents
were diversity and power imbalance. Diversity, or multicul-
turalism, referred to the existence of many cultures in the
broadest sense. Diversity was expressed in terms of values
and belief systems, social group membership, social power,
social class, social injustice, oppression, health disparities,
different conceptualizations of sickness and health; health
care demands, linguistic differences, multiple viewpoints,
heterogeneity of attitudes, material privilege, various ideas,
customs, lifestyles, taboo, and different ethnicities, religion,
or group affiliation (Aghababaei et al., 2014; American
Association of Diabetes Educators, 2012; Beagan & Chacala,
2012; Berg, 2014; Brennan et al., 2012; Butler et al., 2011;
Chang et al., 2012; Clark et al., 2011; Jennings et al., 2012;
Ma et al., 2014; Sheridan, Bennett, & Blome, 2013; Vogt,
2011; Zanetti et al., 2014).
The second antecedent identified was power imbalance.
This attribute overlapped with diversity. The power imbal-
ance was reflected in different venues of social injustice. The
following terms were found that illustrate this worldview of
power imbalance in the context of cultural humility: inequal-
ity, systemic oppression, social power, social group member-
ship, inequity, nondominant culture, privilege, injustice,
power, cultural imposition, stigma, superiority, stereotyping,
biases, unequal distribution of power, entitlement, and power
differential (American Association of Diabetes Educators,
2012; Berg, 2014; Chang et al., 2012; Hammell, 2013;
Hilliard, 2011; Jennings et al., 2012; Ma et al., 2014; Metzl
& Hansen, 2014; Owen et al., 2014; Reynoso-Vallejo, 2009;
Ross, 2010; Schiff & Rieth, 2012; Schuessler et al., 2012;
Tilburt, 2010).
Consequences referred to what occurs after the event of cul-
tural humility or as a result of achieving cultural humility.
The following consequences were identified: mutual empow-
erment, partnerships, respect, optimal care, and lifelong
learning. Respect, mutual empowerment, and partnerships
overlapped and were reflected in the following descriptions:
respect, respectful partnerships, connections, trust, sustain-
able partnerships, mutually beneficial relationships, benefi-
cial partnerships, patient–clinical dynamic, building honest
and trustworthy relationships, mutually respectful dynamic
partnerships, mutual understanding, collaboration, profes-
sional relationship, care relationship, and advocacy partner-
ships (American Association of Diabetes Educators, 2012;
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Foronda et al. 213
Butler et al., 2011; Chang et al., 2012; Clark et al., 2011;
Foster, 2009; Graham-Dickerson, 2011; Groll, 2014;
Gruppen, 2014; Hilliard, 2011; Hook, Davis, Owen,
Worthington, & Utsey, 2013; Isaacson, 2014; Kools,
Chimwaza, & Macha, 2014; Levi, 2009; Morton, 2012; Rew,
2014; Reynoso-Vallejo, 2009; Schuessler et al., 2012; Vogt,
2011; Yeager & Bauer-Wu, 2013). The consequence heading
of optimal care was chosen as cultural humility resulted in
effective treatment, decision making, communication, under-
standing, quality of life, and improved care (Aghababaei,
2014; Alsharif, 2012; American Association of Diabetes
Educators, 2012; Brennan et al., 2012; Butler et al., 2011;
Carter & Swan, 2012; Chang et al., 2012; Chun, Jackson,
Lin, & Park, 2010; Clark et al., 2011; Ellis, 2012; Fahey et
al., 2013; Groll, 2014; Hammell, 2013; Hilliard, 2011; Hook,
Owen, Worthington, & Utsey, 2013; Karnieli-Miller, Frankel,
& Inui, 2013; Kools et al., 2014; Ma et al., 2014; Morton,
2012; Ross, 2010; Schiff & Rieth, 2012).
The final consequence heading was lifelong learning.
Lifelong learning encompassed terms including transforma-
tion, lifelong commitment to self-evaluation, and self-cri-
tique; reflection, self-reflection, and reflexivity (American
Association of Diabetes Educators, 2012; Clark et al., 2011;
Coulehan, 2011; Dietsch & Mulimbalimba-Masururu, 2011;
Ellis, 2012; Kools et al., 2014; Kutob et al., 2013; Loue,
2012; Morton, 2012; Rew, 2014; Schiff & Rieth, 2012; Vogt,
2011; Yeager & Bauer-Wu, 2013). Lifelong learning over-
lapped with the attribute of self-reflection and critique. The
literature emphasized cultural humility entailed a continuous
process of self-reflection and learning.
An unexpected finding, the authors gleaned a better under-
standing of the term cultural humility by viewing what it was
not. That is to say, powerful words were noted in relation to
cultural humility specifically when the opposite of it
occurred. Some antonyms used were prejudice, oppression,
intolerance, discrimination, stereotyping, exclusion, stigma,
inequity, marginalization, misconceptions, labeling, mis-
trust, hostility, misunderstandings, cultural imposition, judg-
mental, undermining, and bullying (American Association of
Diabetes Educators, 2012; Beagan & Chacala, 2012; Berg,
2014; Chang et al., 2012; Clark et al., 2011; Hyde, Kautz, &
Jordan, 2013; Jennings et al., 2012; Kutob et al., 2013; Loue,
2012; Ma et al., 2014; Metzl & Hansen, 2014; Ortega &
Coulborn, 2011; Tilburt, 2010). Discussing the antonyms
was beneficial to fully understand the concept of cultural
In a multicultural world where power imbalances exist, cul-
tural humility is a process of openness, self-awareness, being
egoless, and incorporating self-reflection and critique after
willingly interacting with diverse individuals. The results of
achieving cultural humility are mutual empowerment,
respect, partnerships, optimal care, and lifelong learning.
Model Case
To provide an example of cultural humility in action, the fol-
lowing case is presented in the context of interprofessional
diversity. A nurse calls to notify a physician about a subtle
change in patient status and suggest an order for a medica-
tion. The nurse feels uncomfortable providing a suggestion
to the physician due to a perceived hierarchy and having less
education, but she was trained to provide a thorough report
including a recommendation when communicating with phy-
sicians. The physician hears the nurse’s report and is frus-
trated because the nurse is taking too long to get to the point
and disagrees with the recommendation. However, the physi-
cian considers the power imbalance and recognizes that phy-
sicians and nurses have different training. With a sense of
cultural humility, the physician recognizes the nurse has
more face-to-face or “front-line” interaction with the patient
and is open to hearing her opinion. She is aware of the nurse’s
position in the hierarchy and takes care to exude an egoless,
approachable demeanor. The physician addresses the nurse’s
concern. Although she disagrees with the nurse’s recommen-
dation, she provides rationale and educates the nurse in a
nonthreatening manner. After the interaction, the physician
reflects about her actions and how the nurse responded. The
physician reflects and notes what went well and what could
be improved in the interaction. Based on this reflection, she
continually modifies and tailors her communications with
nurses in a demonstration of lifelong learning. The nurse and
physician feel empowered because they have strengthened
their partnership, have respect for each other, and have
reached a plan of optimal care for the patient.
Similarly, the nurse reflects on how the communication
transpired, considers the rationale provided as well as how
she felt afterward. She has learned to make future communi-
cations more concise and will continue to attempt to frame
her communications in a way that physicians will appreciate.
Because the physician responded in a respectful manner, the
nurse feels empowered to continue to communicate with
physicians regarding her patients’ needs. As cultural humility
is a process, the physician and nurse will continue to learn,
modify, and build in their respective knowledge-bases
throughout their journey as practitioners.
Contrary Cases
The following example is provided to illustrate when cultural
humility is not exuded. As noted above, the nurse calls the
physician to notify of a patient’s change in status. This time,
the physician becomes annoyed at the nurse’s lengthy report
and cuts her off saying, “Get to the point already.” The nurse,
who already feels disempowered states her recommendation.
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214 Journal of Transcultural Nursing 27(3)
The physician disagrees with her recommendation and gives
her orders for a different medication followed by ending the
call abruptly without explanation. The nurse loses confi-
dence, reflects, and has learned to avoid calling the physician
and avoid providing recommendations. The physician
reflects and determines that nurses are incapable of drawing
out the critical information to convey.
This second example is provided in a public health context.
An American nurse visits a developing country with the inter-
est of providing health care screening to a community. The
nurse approaches an individual to ask about participation. The
native inhabitant becomes irritated with the nurse and refuses
to communicate; thus, removing himself from the opportunity.
The nurse becomes frustrated and feels like returning to her
home country. In this case, the native inhabitant viewed the
nurse as someone different. She was an outsider with privilege
and due to historical precedents of injustice, pain, and oppres-
sion, viewed this person as someone to be distrusted and
avoided. The nurse recognized the diversity and power imbal-
ance in the vein of socioeconomic status, however, she failed
to respect the cultural values of the community and attend to
the process of obtaining the approval of gatekeepers. She was
not fully self-aware, open, or supportive in her interactions
because of this unintentional ignorance. Although there are
additional complex phenomena that are oversimplified in
these examples, the outcomes of mutual empowerment, part-
nerships, respect, optimal care, and lifelong learning are
clearly impeded when cultural humility is not achieved.
Implications and Recommendations
After constructing a concept analysis and definition of the
term cultural humility based on society’s usage of the term
throughout the literature, the authors purport that instead of
focusing on skills and information about various cultures, the
movement toward cultural humility implies one must strive
for learning at the highest level of learning; that of transfor-
mation (Mezirow, 1991). Cultural humility involves a change
in overall perspective and way of life. Cultural humility is a
way of being. Employing cultural humility means being
aware of power imbalances and being humble in every inter-
action with every individual. This process will not happen
immediately, but it is speculated that with time, education,
reflection, and effort, progress can be made.
After achieving a better understanding of the concept
through this concept analysis, it was clear that further work
in the area is needed. The term was mostly used in relation to
racial and ethnic differences; however, this concept should
be applied more broadly to encompass the pillars of diversity
and beyond. Cultural humility must occur within the work
environment intraprofessionally and interprofessionally.
Those of higher power status including administration and
individuals of all ranks must attempt to be humble to move
forward in this effort. Cultural humility should be employed
daily with all individuals in the basic interest of kindness,
civility, and respect.
Figure 1. A concept analysis of cultural humility.
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Foronda et al. 215
Development of a framework for cultural humility is rec-
ommended to serve as a foundation for education and
research purposes. Cultural humility is difficult to accom-
plish unless both individuals or groups are open to working
together. When one party is open and the other is closed due
to pain and resentment, anger and hostility persist and prog-
ress is halted. For this reason, education and cultural humil-
ity training in the workforce and community is important.
Leaders must consider evaluation methods and continuous
improvement in the area of cultural humility within organi-
zations. Guides and instruments to measure and evaluate cul-
tural humility are lacking but necessary.
A strength of this concept analysis was the diverse range of
disciplines and contexts covered through the broad search
strategy. Articles represented disciplines from medicine,
nursing, pharmacy, physical therapy, social work, and others.
This approach resulted in a broad and general understanding
of society’s meaning of the term. Additionally, cultural
humility was used in a variety of contexts including the les-
bian, gay, bisexual, and transgender community, battered yet
economically privileged spouses, faculty–student relation-
ships, minority occupational therapist serving patients in a
majority group, nurse–physician relationships, and patient–
physician relationships. Of note, many articles described cul-
tural humility from the standpoint of ethnic and racial
diversity. It was possible the general meaning of cultural
humility was mostly thought of in a narrow light with respect
to ethnic and racial diversity. Last, the diversity inherent in
the research team was deemed a strength to bring a varied
perspective regarding cultural humility.
The research team noticed many articles referred to Tervalon
and Murray-García’s (1998) definition of cultural humility;
thus, some of the keywords that consistently arose in relation
to cultural humility such as power imbalance, self-awareness,
reflective process, and lifelong learning were from the repeti-
tion of this sentinel work instead of individual commonalities
and may be overrepresented. On the other hand, the analysis
indicated that this work continues to be reflected today and is
applied in many contexts so it supports understanding of soci-
ety’s current meaning of the term. The research team com-
prised all nurses and this may have led to some similar
viewpoints and limited interpretation as nursing is a histori-
cally oppressed group. Although diverse in some ways, the
research team was limited in diversity in other ways including
age, socioeconomic status, and sexual orientation.
Through white papers, mission and value statements, and
national directives, the need to encourage and value diversity
was evident. This article served to provide an analysis of the
concept of cultural humility with a proposed definition to
attend to the needs of an increasingly connected multicul-
tural society. With a firm understanding of the term, indi-
viduals, health care providers, and communities will be
better equipped to understand and accomplish an inclusive
environment with mutual benefit and optimal care. Realizing
cultural humility is possible when one is open, self-aware,
humble, reflective, and supportive with others.
We would like to acknowledge Nathan Poole, instructional designer
at the Johns Hopkins University School of Nursing, for artistic
assistance with figure development.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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... Cultural humility is another class of cultural capability of professional care. Cultural humility may be defined as the process of being aware of how people's culture affects their health behaviors and consequently using this awareness to develop sensitive approaches to treating patients (24). Nolan et al. state that promoting cultural humility is every nurse's duty. ...
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Background: Medical tourists create an issue that needs to be investigated in different parts of the world. Increasing expectations of health tourists for health services improves the quality of nursing care services for foreign clients. Due to globalization, nurses are required to handle the increasing number of overseas visitors and immigrants. Objectives: This study was conducted to assess cultural capability in the professional care of nurses for medical tourists in Iran. Methods: We conducted 23 semi-structured interviews in 2021 - 2022 in this qualitative study. The interviewees included nurses from international wards and wards with international patients, patients, patient companions, and doctors. The interviews were conducted using a goal-oriented method. After recording, the data were analyzed using the conventional qualitative content analysis of Lundman and Graneheim. Results: In this study, a general theme (main theme) called “Cultural capability in professional care” was categorized into 8 categories: “Culture-oriented language communication,” “Culture-oriented communication interactions,” "Cultural humility," "valuing cultural diversity," "context-based client training," and "respectful communication.". Conclusions: Cultural capability in the professional care of nurses is important for providing comprehensive and quality care because patients come with different cultural beliefs and from different geographical areas.
... Students are taught to develop cultural humility defined by the following attributes, openness, self-awareness, egolessness, supportive engagement, self-reflection and critique. The benefits included mutual empowerment, partnerships, respect, and lifelong learning 9 . In Topophilia: A Study of Environmental Perceptions, Attitudes, and Values, geographer Yi-Fu Tuan underscores the linkage between self reflection on identity and efficacy at solving macro challenges 10 . ...
Conference Paper
In the environment of heightened neighborhood change, sparked by the pandemic and underlying social injustice, interdisciplinary approaches towards urban challenges are in dire need. Built environment professionals and Social Work practitioners have a unique opportunity to address these challenges through collaboration. This article highlights how educators in these fields can leverage existing best practices in collaboration and apply it to curricular design solutions focused on spatial justice.
... Clinicians must continue to develop knowledge and measurable skills in cultural humility [54], which includes a commitment to lifelong learning and self-reflexivity, mitigation of clinician-patient/community power imbalances, and institutional accountability [55,56]. Cultural humility allows intersectional identities to be honored through openness, demonstrable empathy and compassion, and an ethic of being oriented to the needs and individuality of the other person [57]. Thus, cultural humility supports clinicians to develop introspective and flexible practices to ensure person-centeredness that transcends racial and cultural differences. ...
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The aim of this study was to examine interdisciplinary clinicians’ perceptions of priorities in serious illness communication and shared decision-making with racially and culturally minoritized persons at end of life. Clinicians (N = 152) read a detailed case study about a patient self-identifying as Black and American Indian who describes mistrust of the healthcare system. Participants then responded to three open-ended questions about communication strategies and approaches they would employ in providing care. We conducted a thematic analysis of participants’ responses to questions using an iterative, inductive approach. Interdisciplinary clinicians from nursing (48%), social work (36%), and chaplaincy (16%), responded to the study survey. A total of four themes emerged: (1) person-centered, authentic, and culturally-sensitive care; (2) pain control; (3) approaches to build trust and connection; and (4) understanding communication challenges related to racial differences. Significant efforts have been made to train clinicians in culturally inclusive communication, yet we know little about how clinicians approach “real world” scenarios during which patients from structurally minoritized groups describe care concerns. We outline implications for identifying unconscious bias, informing educational interventions to support culturally inclusive communication, and improving the quality of end-of-life care for patients with cancer from minoritized groups.
Introduction In an increasingly diverse world, there has been a call for psychology educators to make efforts to integrate diversity into the psychology curriculum. Statement of the Problem Researchers who have surveyed psychology faculty have found the amount of time devoted to diversity content in nondiversity-focused courses is limited, with faculty citing barriers to integration such as a lack of relevance and time constraints. Literature Review Educators who have worked to incorporate diversity topics into their courses have found positive outcomes. Teaching Implications We describe our approach to integrating diversity into an introductory statistics course, highlight lessons learned, and provide special considerations for psychology educators. Conclusion Integrating diversity-related content into statistics is challenging; however, the effort is worth it, particularly if integrating diversity content into required courses may be the only exposure to diversity students get.
Technical Report
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This report is about helping youth thrive using an equity lens, developed as part of the National 4-H Program Leaders' Working Group, Access, Equity, and Belonging Committee. The report discusses the social conditions (positive and challenging) for American Indian/Alaska Native (AI/AN) youth, and competencies that are necessary to work effectively with this population.
Systemic racism continues to significantly influence health inequities and cause disproportionately adverse health outcomes in marginalized communities. The erroneous conceptualization of race as a biological construct leads to misguided assumptions that racial and ethnic health disparities (REHD) result from genetic predisposition. Race is a social construct and should not be applied in medical scenarios without considering the effect of historical contexts and social determinants of health on disease burden. Inaccurate portrayals of race in medical education have the deleterious ability to perpetuate physician bias, increase health inequalities, and negatively affect patient outcomes. As such, there is a critical need for medical educators to address REHD in their educational materials. This chapter will discuss the impact of race and racism on health outcomes, contextualize racial and ethnic differences, and establish that race is not an epidemiological determinant, risk factor, or shortcut for disease incidence, diagnosis, or treatment. Strategies and checklists to guide medical educators in developing inclusive educational content are provided. These practical recommendations serve as a resource to assist medical educators in helping students become more culturally competent and equity-minded healthcare professionals.KeywordsRaceEthnicityRacismHealth inequityHealth disparityHealth outcomesMedical educationDisease burdenRisk factorSocial determinants of healthCultural competence
In recent years, medical institutions have begun to incorporate curricula that address and acknowledge health inequity. Despite training in diversity, equity, and inclusion, some faculty may still feel ill-equipped to adequately discuss race and racism in the classroom. This chapter will discuss common challenges and dilemmas provoked by these discussions including lesson management, emotional labor, institutional policy, and curriculum constraints. Cultural humility is proposed as an approach to guide classroom interactions that are introspective, empathetic, and vulnerable. Similar to cultural competency, cultural humility improves cross-cultural communication and professional relationships. These two concepts will be further explored and contrasted. By adopting a cultural humility approach to discussions about race and racism, medical educators are better able to model race-conscious behavior for their students.KeywordsMedical educationRaceRacismPedagogyCritically oriented discussion Emotional laborWhite resistanceCultural competenceCultural humilityStrategic empathySelf-reflection
Translating policy into practice is a challenging task for many fields, including education. Despite the legal foundations aimed to support families' involvement in special education, culturally and linguistically diverse (CLD) families and schools experience cultural, political, and linguistic barriers. The pathologized conceptions of difference and ability, racialized politics of parent involvement, and the culture of compliance preclude schools and educators from engaging effectively with CLD families. Racist and ableist practices nested within involvement strategies must be interrogated to shift from colonial engagement to building equitable partnerships with CLD families. This shift requires disrupting deficit-oriented systems of thinking, breaking the culture of compliance cycle, including CLD families in decision-making, and building culturally sustaining relationships with CLD families.
Importance: Outcomes research on the impact of seating and mobility services delivered using a short-term medical mission (STMM) model is limited. Objective: To evaluate the impact of seating and mobility services on the occupational performance of individuals with disabilities in El Salvador. Design: One-group retrospective pretest-posttest. Setting: Clinical (El Salvador). Participants: Individuals with disabilities in El Salvador. Outcomes and measures: Survey and the standardized Wheelchair Outcome Measure (WhOM) for those who received a wheelchair as their mobility device. Method: Participants rated satisfaction with performance of preferred in-home and out-of-home occupations on the WhOM before and after receiving seating and mobility services. Results: For most survey questions assessing the impact on activities of daily living, more than 86% of the respondents selected agree or strongly agree. Nearly half of the respondents reported that questions regarding work and education were not applicable. Participants' WhOM scores (n = 86) demonstrated a statistically significant improvement in performance satisfaction for both in-home (p < .001; d > 1) and out-of-home (p < .001; d > 1) occupations after they received services, with a huge effect size (d > 2). Conclusions and relevance: The findings suggest that seating and mobility services provided by rehabilitation professionals in El Salvador improved occupational performance for people with disabilities. Compared with STMMs that solely provide equipment, the findings emphasize the importance of professional service provision with education and training as best practice. What This Article Adds: Seating and mobility services delivered through a STMM model may improve occupational performance for individuals with disabilities. However, STMMs should be carefully planned in collaboration with in-country partners, provide customized seating systems, and include education and training from licensed rehabilitation professionals.
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Client perceptions of their therapists' cultural hiunil-ity have been associated with positive therapy outcomes; however, it is unclear whether these positive effects are consistent across clients. In particular, this study examines the extent to which clients' religious commitment moderates the association between their perceptions of their therapists' cultural humility and therapy outcomes. The sample included 45 clients, all of whom identified their religion/spirituality as the most salient aspect to their cultural identity. The results demonstrated that perceptions of cultural humility were positively associated with therapy outcomes. However, this effect was moderated by clients' religious commitment. The relationship between perceived cultural humility and outcomes was positive for clients with higher religious commitment, whereas it was not different from zero for clients with lower religious commitment. Implications for research, theory, and practice are offered.
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Objectives To evaluate impact a multicultural interclerkship had on students’ perception of knowledge, interview skills, and empathy towards serving culturally diverse populations and role student demographics played in learning. Methods Data extracted from students’ self-reported course evaluations and pre/post questionnaires during multiculturalism interclerkship across 11 academic years. Inquired students’ opinion about four areas: effectiveness, small group leaders, usefulness, and overall experience. Subscale and item ratings were compared using trend tests including multivariate analyses. Results During studied years, 883 students completed course evaluation with high overall mean rating of 3.08 (SD=0.45) and subscale mean scores ranging from 3.03 to 3.30. Trends in three of four subscales demonstrated clear uptrend (p<0.0001). Positive correlations between ratings of leaders and “usefulness” were observed (p<0.0001). Pre/post matched dataset (n=967) indicated majority of items (19/23) had statistically significant higher post interclerkship ratings compared to pre scores with nine of 19 having statistically significant magnitudes of change. Questionnaire had high overall reliability (Cronbach alpha=0.8), and item-to-group correlations ranged from 0.40 to 0.68 (p <0.0001). Conclusions By increasing students’ exposure and interaction with diverse patients, their knowledge, attitude, and skills were increased and expanded in positive manner. These findings might inform those who are interested in enhancing this important competence. This is especially true given increasing scrutiny this global topic is receiving within and across healthcare professions around the world.
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Introduction Literature in occupational therapy, although paying increased attention to cultural differences and diversity, has largely ignored the situation of therapists who are themselves members of social and cultural minority groups. ‘Difference’ is assumed to be exclusively an attribute of the client. Method This qualitative study explored the professional experiences of 12 occupational therapists in Ireland who self-identified as disabled or ethnic minority group members. Findings Participants reported challenges with colleagues and managers, which revolved primarily around cultural differences in the norms and expectations guiding social interactions, communications and practice styles. Overt discrimination was reported only by disabled therapists. With clients, again there were clashes of cultural values, but participants also experienced overt and covert prejudice and intolerance. This was particularly difficult to respond to in the context of client-centred practice. Conclusion Cultural competence, as the prevailing approach to diversity, emphasises suspending one's own values to facilitate those of clients. This demand may be inappropriate for minority therapists who may face prejudice and discrimination. In contrast, cultural humility and critical reflexivity emphasise negotiating values in the context of social power relations, an approach that may better position occupational therapy to benefit from a diverse workforce.
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An international team of Singaporean and American researchers conducted a qualitative investigation of the multicultural competencies of Singaporean master therapists. Six Singaporean master therapists, previously studied and identified through an extensive peer nomination sampling procedure (Jennings et al., 2008), were re-interviewed to explore how these therapists conceptualize and conduct cross-cultural counseling. Utilizing data analytic procedures from consensual qualitative research (CQR) and grounded theory, four themes (Self Knowledge, Cultural Immersion, Cultural Knowledge, and Knowledge of Systemic/Historic Oppression) were organized under the Multicultural Knowledge category. Another four themes (Respect, Cultural Misunderstandings Lead to Humility and Growth, Ask, Don’t Assume, and Suspend Judgment and Avoid Imposing Values) were organized under the Multicultural Skills category. Recommendations for research and practice are offered. One recommendation is that a new definition of master therapist be formulated to include the concept of cultural competence.
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Introduction: The General Medical Council (GMC) expects that medical students graduate with an awareness of how the diversity of the patient population may affect health outcomes and behaviours. However, little guidance has been provided on how to incorporate diversity teaching into medical school curricula. Research highlights the existence of two different models within medical education: cultural competency and cultural humility. The Southampton medical curriculum includes both models in its diversity teaching, but little was known about which model was dominant or about the students' experience. Methods: Fifteen semi-structured, in-depth interviews were carried out with medical students at the University of Southampton. Data were analysed thematically using elements of grounded theory and constant comparison. Results: Students identified early examples of diversity teaching consistent with a cultural humility approach. In later years, the limited diversity teaching recognised by students generally adopted a cultural competency approach. Students tended to perceive diversity as something that creates problems for healthcare professionals due to patients' perceived differences. They also reported witnessing a number of questionable practices related to diversity issues that they felt unable to challenge. The dissonance created by differences in the largely lecture based and the clinical environments left students confused and doubting the value of cultural humility in a clinical context. Conclusions: Staff training on diversity issues is required to encourage institutional buy-in and establish consistent educational and clinical environments. By tackling cultural diversity within the context of patient-centred care, cultural humility, the approach students valued most, would become the default model. Reflective practice and the development of a critical consciousness are crucial in the improvement of cultural diversity training and thus should be facilitated and encouraged. Educators can adopt a bidirectional mode of teaching and work with students to decolonise medical curricula and improve medical practice.
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Cultural competency in the delivery of health care to diverse population groups has become an urgent need in the United States. Yet, despite the incorporation of cultural competency education into nursing curricula, inequities in health care remain. The purpose of this mixed-method study was to identify if differences in perceptions of cultural competence were present in senior nursing students (N = 11) before and after cultural immersion experiences on an Indian reservation. Preimmersion results revealed that the majority considered themselves culturally competent, whereas after immersion, there was a downward shift in scores. Triangulation of the quantitative results alongside a hermeneutic phenomenological analysis of the students' reflective journals revealed a paradox. Students perceived themselves as culturally competent, yet their journals demonstrated many negative stereotypes. Three common themes emerged: seeing with closed eyes, seeing through a fused horizon, and disruption to reshaping. These combined results revealed the misperceptions regarding the concept of cultural competency. Efforts must be made in nursing education to teach students the importance of adopting an ethic of cultural humility, where we emphasize attentive listening and openness to other cultures, and stress the importance of self-reflection and self-critique in our interactions with others.
The field of social work pathologizes marginalized cultures by neglecting to explicitly identify cultural factors in the lives of women with systemic privilege due to race, class, and sexual orientation. This article discusses the importance of examining privilege as a strategy for advancing cultural competency in the treatment of battered women. Cultural factors in the lives of White European-American, middle-class, heterosexual women in intimate partnerships with men who share their privileges, referred to as "dominant culture women," are explored. Additional scholarship which identifies cultural factors placing this population at risk is needed to advance cultural competency in domestic violence interventions.
Background The Canadian Model of Occupational Performance and Engagement depicts individuals embedded within cultural environments that afford occupational possibilities. Culture pertains not solely to ethnicity or race but to any dimension of diversity, including class, gender, sexual orientation, and ability. Purpose This paper highlights specific dimensions of cultural diversity and their relationships to occupational engagement and well-being. Key issues Cultural variations constitute the basis for a socially constructed hierarchy of traits that significantly determine occupational opportunities and impact mental health and well-being. Cultural humility is an approach to redressing power imbalances in client-therapist relationships by incorporating critical self-evaluation and recognizing that cultural differences lie not within clients but within client-therapist relationships. Implications It is proposed that theoretical relevance would be enhanced if culturally diverse perspectives were incorporated into theories of occupation. Cultural humility is advocated as an approach to theoretical development and in efforts to counter professional Eurocentrism, ethnocentrism, and intellectual colonialism.
Conference Paper
BACKGROUND AND SIGNIFICANCE: As professional nurses we are constantly serving others from a diverse background with varied perspectives on health and illness as it relates to their culture. These traditions grounded within one's culture makes it imperative to provide the appropriate preparation for student nurses and continued in-services to keep the profession abreast of how to ensure quality health care for the population being served. Trevalon (2003) states that this means we must “…incorporate a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in “our society”-inter personal dynamics, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations”. The core of the education needed is founded in understanding cultural humility as defined by Trevalon and others in the literature (Racher & Annis, 2007). Teaching strategies that integrate experimental learning is one way as well as encouraging the learner to become self aware of his/her own being and how that awareness affects the care delivered. The purpose of this project is to provide a variety of strategies for nurse educators to implement in a course(s) that will increase the understanding and meaning of cultural humility within the health care arena. LEARNER COMPTETENCIES: By utilizing the proposed strategies, the learner will be able to: analyze philosophical, historical, and cultural trends and issues influencing the development and evolution of the field of trans-cultural health care and its impact on many areas of nursing; analyze different emic (language and/or behavior) and etic cultural beliefs, values, and practices of Western and non-Western cultures using anthropological, clinical, and specific trans-cultural health care concepts, theories, and research relevant to different cultures; Discuss the use of major trans-cultural health care concepts, principles, theories, and research findings to advance and improve nursing care throughout the lifespan; Consider “How ought we to live?” based on the professional nursing values and the Jesuit philosophy in service to others who represent diverse peoples. TEACHING STRATEGIES: Using cultural panel presentations, experiential learning (literature and other art forms, storytelling, videos, music, and reflective journaling, community based activities, cross cultural interviews, and self assessment), and the learner will gain an enhanced understanding of the true meaning of cultural humility and its place in health care delivery. The ultimate outcome being the key to attaining quality health care for all as we progress through the 21st century.
Objective The purpose of this article is to report on the evaluation process of a multi-disciplinary interactive teaching-learning workshop implemented in a college of nursing baccalaureate program.Design and SampleA 6-hr workshop on cultural humility and care equity was implemented using educational theater to bring clinical situations involved in community/public health practice into the classroom. One hundred and forty-nine students participated in the workshop. Stages of Change (Prochaska and DiClemente [2005] Handbook of psychotherapy integration. New York: Oxford University Press) and the Learning Transfer Barriers Framework (Price, Miller, Rahm, Brace, & Larson [2010] Journal of Continuing Education in the Health Professions, 30, 237–245.) provided conceptual underpinnings for project evaluation.MeasuresNursing students completed a quiz, postworkshop online surveys at 2 and 8 weeks, and a clinical application report (CAR). Survey data provided information on barriers to the transfer of knowledge from theory class to the clinical setting. Qualitative methods were used to audit the CARs. Each CAR was independently reviewed to determine the Stage of Change reflected in the narrative.ResultsWorkshop evaluation outcomes provide evidence that cultural humility skill building has created behavior change in clinical practice for new health care community/public health nursing providers.