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Introduction

The Importance of Transcultural (Intercultural) Comptetence in Health Care

The Federal Office of Public Health (FOPH) in Switzerland claims that one of the inadequacies of the Swiss health system is the qualified staff’s «lack of transcultural skills and inadequate sensitization to the specific health problems of the migrant population» (2008, p. 17). The research of Casillas et al. (2014) on cultural competencies of health care providers in Swiss hospitals also supports the need for improvement of cultural competency among health care providers. Further, the FOPH states that investing in the health of the migrant population is not just a noble gesture; it is worthwhile in terms of cost effectiveness. For example, in a study conducted in the USA by LaVeist, Gaskin and Richard (2009) it becomes clear how costly health care can be when health disparities remain. They state, «Researchers have determined that between 2003 and 2006 the combined direct and indirect costs of health disparities in the US was $1.24 trillion» (p. 6). This figure only reflects the monetary cost, not the personal suffering of the patients and their families. Napier et al. (2014) claim that «the systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest standard of health worldwide» (p. 1610). Failure of health professionals to acknowledge ethnicity, language, cultural beliefs and values in the provision of health services exacerbates health disparities, creates distrust and reduces health care quality specifically pertaining to noncompliance, inaccurate diagnosis and treatment, and ultimately causes poor health outcomes (IOM, 2010; Casillas et al., 2014; Purnell, 2014). So, what is this hidden elusive aspect called culture?

What is Culture?

For the purpose of this booklet, culture will be broadly defined as the «learned and shared patterns of beliefs, behaviours, and values of groups of interacting people» (Bennett, 1998, p. 197). So, culture does not just refer to persons who come from another nation. Sharing a common language, behaviour patterns and values allows individuals to predict the responses of others. Coming into contact with individuals who are culturally different may increase the chances of cultural misunderstanding because these individuals interact in ways that are not predictable (Bennett, 1998, p. 2). Unfortunately, behaviours that are effective or correct in one culture can be considered the opposite in another culture. Utilising one’s own cultural norms is indicative of a more monocultural or ethnocentric perspective in comparison to a more intercultural or ethnorelative mindset where cultural differences and commonalities in their own and other cultures are recognised and adaptation takes place. Individuals with a monocultural perspective make sense of cultural differences and commonalities based on their own cultural values and practice – this perspective does not allow for culturally sensitive patient care.

Bhawuk and Brislin (as cited in Altshuler, Sussman & Kachur, 2003) argue that intercultural sensitivity is regarded as an attitudinal forerunner to successful intercultural encounters and a predictor of cultural competence. Bennett (2004) supported this with the view that the potential for more intercultural competence is related to the development of intercultural sensitivity. Hammer, Bennett, and Wiseman (2003) explained that «the crux of the development of intercultural sensitivity is attaining the ability to construe (and thus to experience) cultural difference in more complex ways» (p. 421–443). In 1986, Bennett introduced a six-stage developmental model of intercultural sensitivity (DMIS) to explain one’s ability to experience cultural difference, as illustrated in Figure 1.

Figure 1: The Developmental Model of Intercultural Sensitivity (Bennett, 2004)

Note: You can find a more detailed description of the model in the analysis of Critical Incident 10.

What is Intercultural Competence?

Intercultural competence in health care is not just about a positive attitude or common sense or using an interpreter or matching staff to the patient population or learning about specific cultures, or dos and don’ts. In a Delphi study of intercultural experts, the favoured definition of intercultural competence is «the ability to communicate effectively and appropriately in intercultural situations based on one’s intercultural knowledge, skills, and attitudes» (Deardorff, 2006, p. 247). Intercultural competence is indispensable for providing safe and effective health care; it is also about patients having real options that are acceptable to them and it is about them being valued for the person they are. The lack of intercultural competence in health care professionals creates a need to develop intercultural competence. The Institute of Medicine in the US recommends the «integration of cross-cultural education into the training of all current and future health professionals» (Smedley, Stith & Nelvson, 2003, p. 21).

The Critical Incident Method

For this booklet, multiple sources contributed to the critical incidents – lecturers, undergraduate and international students at the ZHAW and health professionals in Switzerland. Each critical incident is accompanied by four or five possible explanations and an analysis. The critical incidents require careful analysis and reflection. The analyses include culture-specific and culture-general knowledge from the intercultural field. Recommended solutions are based on interviewees’ best practice, literature as well as recommendations from intercultural experts.

The critical incident approach is recognised as an effective tool used in intercultural training (Bhawuk & Brislin, 2000; Landis, Bennett & Bennett, 2004). It is useful for health care professionals to become conscious of their own cultural pattern and of the interpretation process in intercultural encounters and to suspend judgement long enough to allow for the contemplation of multiple interpretations. The basic rule is «You might be right, but probably you are wrong».

The introduction section was kindly provided by Susan Schärli, 2017.

What Is a Critical Incident?

Critical incidents are descriptions of situations where people from different cultures experience misunderstandings which are caused by another culturally different background. The CIs are followed by at least four possible alternative explanations of why the member of the other culture has acted in a specific way. The reasons for the likelihood of each alternative are then explained in the rationale for alternative explanations section. The possible options are selected and checked against the option that is the most appropriate in the other culture, based on research by the CI creator (Herfst, van Oudenhoven & Timmermann, 2008). Each incident is short but it clearly highlights at least one area for potential miscommunication or challenge faced in health care professions.

Why Use Critical Incidents?

(Adopted from Fowler & Blohm, 2004, p. 59)

–They engage participants at a personal level in examining attitudes and behaviour that will be critical to their effectiveness.

–They can be written for a variety of situations.

–They require analysis and reflection, decision-making; reduce idea of answers being available from an «expert».

–They require short reading time; move quickly into reflection.

–They can be used singly or grouped to illustrate concepts or processes.

–They can lead to role-playing and situational exercises to provide practice.

–They appeal to concrete experience and reflective observation learning styles.

How to Use Critical Incidents

1.The incident should be read carefully before the alternative explanations are evaluated. Each alternative explanation should be considered, as there could be more than one alternative explanation that may be considered appropriate for the situation described in the critical incident. This is congruent with the fact that there could be more than one explanation for incidents encountered in everyday life.

2.Each alternative explanation should be marked with the following words:

–Very likely

–Likely

–Unlikely

–Very unlikely

3.The responses made by the reader should be compared with the rationales for the alternative explanations for the particular critical incident, which are available on the next page following the alternatives.

4.If training takes place in a group, readers can compare results with each other, discuss their responses to the alternative explanations or role-play some of the incidents.

5.Readers could take notes and reflect on how the points raised in the incidents may be related to their own intercultural experiences.

Steps to use critical incidents for self- or group-study are illustrated in Figure 2.

Figure 2: Steps to use critical incidents for self- or group-study (adapted from Gan & Tan, 2017)

The Critical Incident section (What is a Critical Incident? Why Use Critical Incidents? How to Use Critical Incidents?) was kindly provided by Hwei Sue Gan and Jie Min Tan, 2017.