[Translation : EPALE France]

Cultural competence, a driver of reflection for the health executive and teacher in the field of nursing

“The cultural aspect of healthcare involves taking into account the patient's culture in order to personalise and adapt their care and to avoid going against practices.” (3rd-year nursing student, 25 years old)

“It’s about a person’s perceptions, which should be taken into account in healthcare. It depends on the person’s origins, social perceptions and experiences. It is part of the person's identity.” (3rd-year nursing student, 21 years old)

Interview with Ms Aurélie Tschaban, health executive and teacher, nursing department, Le Havre Paramedical Training Institute (76)

Hello Ms Tschaban, interculturalism and cross-cultural skills are increasingly common issues. From your background, your research and the projects you have carried out, I would like you to tell me more and share your experience on these cross-cultural aspects.

These themes are important for professionals and anyone involved in education, training and healthcare who come to the EPALE/Erasmus + platform

To begin, can you tell us a little about yourself?

I am a nurse, a health executive and a teacher. I have been working in a paramedical training institute since 2016. I work with nursing students, nursing assistant students and childcare assistants. I am jointly responsible for the development of internships outside of France for students at the institute.

What led you to take an interest in and work on the issue of interculturalism?

Several things led me to this choice. Firstly, my personal history and educational values guided me towards this subject. My taste for travel, for the simplest and most authentic encounters, made me think about these things.  

My career path then allowed me to develop my caregiving skills, to create my professional identity based on solid values such as respect, non-judgment and dignity. I have met and treated patients from different backgrounds, ages, genders, origins and social status. I have worked in France and in Réunion. I learned to adapt, and to think about how I adapt. I also had the chance to follow Walter Hesbeen's courses when I was completing a university degree in nursing for rehabilitation and physiotherapy. I remember something he once said to us, which has remained with me throughout my career: “Who am I to tell someone else who they are?”  This question highlights the uniqueness of each person, my own uniqueness, that of the person I am caring for, our personal perceptions of care, illness and health.

Finally, more recently, I have been working on cultural competence in health care as part of my training as a health executive and the Master II EMOIS (Education, Management of Organisations and Engineering in Health). The starting point for this research has been the support of students doing their internships outside of metropolitan France, and the analysis of the situations these learners experience during their internships. This research has allowed me to look more closely at concepts of social perceptions linked to healthcare, culture, cultural identity, cross-culturalism at the heart of healthcare and reflection as a resource for the student in cross-cultural care.

You talk about cultural competence and cultural security, how do you situate them and what differences do you make between them?

I have worked on the notion of cultural competence in healthcare. This is not currently recognised as such in the reference framework for nurses in France, as it is in New Zealand, for example. The cultural side of things is disseminated in the daily life of caregivers and sometimes seems difficult to objectify. However, authors such as Irena Papadopoulos, Mary Tilki and Gina Taylor and Josepha Campinha Bacote have worked on the concept of cultural competence and have enriched Madeleine Leininger's initial research. They explain different stages such as the awareness of one's own and other people's culture. They question ethnocentrism, the development of specific knowledge, cultural awareness that can lead to cultural competence. It is about knowing how to act in a particular healthcare context to meet the specific needs of the patient, taking into account their culture and social perceptions.

The ultimate stage of cultural competence leads to cultural security that promotes health equity and social justice.

Amélie Blanchet Garneau and Jacinthe Pépin propose a critical reflection on this concept, highlighting the individual biases that influence our perceptions as caregivers in the evaluation and analysis of healthcare situations during cross-cultural encounters. This includes not creating stereotypes but focusing on the uniqueness of each individual.

They explain that cultural security promotes free will and decision-making abilities. It also plays a major role in the efficiency and quality of care, involving criteria of equity and results without discrimination against the rest of the population.

This is where the notion of interculturalism is important. In interculturalism, there is the notion of an encounter between two beings, two systems of values, norms, perceptions, conceptions, individual or social representations, experiences and subjectivity.

Interculturalism rejects the idea of stigmatisation and stereotypes linked to general, un-personalised knowledge. It involves the awareness of a cross-cultural encounter between two individualities.

Why is this cross-cultural aspect so important in the healthcare sector?

It seems essential to take interculturalism into account in healthcare, for different reasons.

On the one hand, the current social context of mobility, where societal phenomena enrich the mix of populations received in healthcare services, forces us to question the impact of culture in the care of users.

Current public health issues also lead us to deepen this approach. Chronic diseases are on the rise. At the same time, the educational approach is being enhanced and extended. It places the patient or healthcare user at the heart of the system, based on their individual needs in the implementation of their healthcare and their life project. If we do not recognise the individual as a unique person with specific needs, then the proposed healthcare plan will not be personalised and will therefore be inappropriate. This will limit the empowerment of the patient, the resident, or the user. The risk here lies in the difficulties or refusal to comply with the care and treatment offered, delays in treatment, and a lack of recognition of the healthcare system and its missions in the interests of the beneficiary.

It is also for this reason that it seems essential that carers have or become aware of their own culture and that in every care setting there is an intercultural encounter between two individuals: the carer and the person being cared for.

Taking into account this dimension of interculturalism is not only about geography or ethnicity. It is based on individual and social values and norms. Each component of an individual's culture must be a vector for thought in adapting the plan for healthcare.

Marie Françoise Collière, in “Soigner... le premier art de la vie” (Caring... the first art of life), explains that approaching the healthcare user from a socio-cultural perspective means “learning to read and become aware of everything that connects the different aspects of the same care situation in order to identify what is significant for caring, i.e. for helping people to live” (Collière, Marie Françoise, Soigner... le premier art de la vie, Masson Editeur, January 2001, p.153). This reinforces the notion that interculturalism cannot be neglected in our professional care practices.

What ideas, avenues or reflections exist for the training of health professionals?

In 2017, I was entrusted with the task of developing internships outside of France for students at our training institute, in association with a fellow health executive. Supporting students in preparing their internships, particularly in putting together a documentary file, is an important aspect of analysis and reflection. Through their research, learners are expected to write a piece about their preferred overseas country/region for their internship. They describe the historical, geographical, political and economic situation of the chosen location, elements relating to cultural aspects, the health system and organisation, prevalent diseases, the potential internship location, their personal internship objectives and thoughts on the feasibility of their project.

This in-depth research work allows them to prepare for their departure and to work on their social perceptions linked to the individuals and situations they will encounter on the internship. By learning about the history of the people and their country, the value system, the customs and organisations, the students are enriched with information that will help them to avoid stereotypes and prejudices. Our objective as an institution is to facilitate encounters with others, either the person receiving the care or the health professional, in order to avoid mistakes and to adapt the healthcare relationship.

The feedback sessions are also important moments for questioning and reflection. For this reason, we propose that students who have completed these internships outside of France share their learning and experience with students throughout the institute.

However, the question of interculturalism is also an integral part of all the tools and teaching activities during the training course. It seems essential to approach interculturalism by questioning sociology and anthropology, ethics and clinical reasoning. Interculturalism does not only concern internships outside metropolitan France. It is echoed in every care situation that the healthcare provider encounters. Our aim is to help students become aware of the fact that they each have their own culture, as do each of the patients they work with. And that in each encounter with a user, there is a cross-cultural encounter to which we must be sensitive in order to adapt our care.

I believe that today, healthcare centres and training institutes have a role to play in taking into account interculturalism and cultural safety in both initial training and lifelong learning. To this end, several avenues of research can be explored, particularly in initial training. Work on clarifying the approach of the healthcare executive and teacher in their teaching practices during analysis sessions would be one way of doing this. Another would be to include the development of cultural safety in initial training. This ambition will be clear in my pedagogical intentions. Thus, my future professional research projects will be related to this issue.

Thank you so much for this discussion and your contribution.

Thierry Ardouin