Contesting competency: cultural safety in advanced nursing practice

professional

issue

Contesting competency: cultural safety in advanced nursing practice A central tenet of the competency approach to nursing education and regulation is that it ensures the safe care of clients and communities with whom nurses work. However, the competency approach is problematic in its conception and application to nursing. Incorporation of this framework into advanced practice requires that its limitations are acknowledged so that current interpretations and applications can be challenged and resisted. Through exploring the concept of cultural competence some of the problems associated with the application of the competency approach to professional nursing practice will be exposed. The issues revealed in this exploration prompt the question whether the competency framework is the best way to ensure competent professional practice. By Clare Carberry, RN, RM, B.A. (La Trobe), Dip. Hum. (La Trobe), B.Ed. (La Trobe), MHS {La Trobe in progress). Lecturer Primary Health Care/Women's Health, School of Nursing La Trobe University Bundoora. The

of

r e p r e s e n t i n g c o m p l e x n u r s i n g activity.

competence in professional nursing practice

purpose

of

this

discussion

As is n o t e d e l s e w h e r e (Rees & R o d l e y

is to q u e s t i o n

1995) t h e c o m p e t e n c y framework

the a d e q u a c y

of

the

is

c o m p e t e n c y a p p r o a c h w h e n a p p l i e d to

a n o t h e r manifestation of t h e e c o n o m i c

nursing. My concerns are first, that this

rationalist/business

approach deals poorly with the workings of

d o m i n a n t in t h e western world. In this

power

environment the product of worker activity

in

the

client/practitioner

relationship, which

is an

especially

ethos

currently

or, alternatively worker performance itself,

i m p o r t a n t issue w h e n n u r s i n g c a r e is

is disproportionately paramount. In this

m e d i a t e d by cultural difference. In this

c o n t e x t m y d e c i s i o n to use t h e t e r m

context

cultural

'cultural competence' is prompted by the

c o m p e t e n c e a n d culturally safe nursing

what

conviction that 'competency' is a part of a

c a r e , will b e e x a m i n e d .

l e g i t i m i s i n g d i s c o u r s e ( M a r c u s e 1964,

competency

constitutes

approach

Whether is

the

a

best

Foucault 1980, Haraway

1985/1990)

framework to ensure competent care in this

presently s h a p i n g nursing practice. It is

area is considered.

therefore crucial that we are active in the

Secondly, the competency approach by

debate about a competency approach for

focusing on the individual, underscores the

nursing, so t h a t t h e i n t r o d u c t i o n of an

importance of the workplace environment

inappropriate system can be challenged,

as a key factor to competent professional

resisted and changed.

practice. Thirdly, while t h e c o m p e t e n c y

the formulation of competences and their

Competency: a problematic approach for the professions?

assessment,

Clark

approach excludes the client voice in both

its

credibility

remains

questionable.

(1995),

writing

about

the

introduction of a c o m p e t e n c y a p p r o a c h

T h r o u g h o u t this paper I use the term

to social work, articulates s o m e of m y

competency but 1 am distinctly ill at ease

concerns claiming that competency alone

in d o i n g so because, as I a r g u e h e r e , I

is 'dangerously insufficient' (p564) as the

believe it to represent a not c o m p l e t e l y

o r g a n i s i n g p r i n c i p l e of

satisfactory nor 'safe' discursive term for

k n o w l e d g e . She mounts an argument in

professional

Collegian Vol 5 No4 1998 9

professional

issue

favour of professional education within a

assurance measures. For this reason it is

between client and practitioner have not

discipline.

useful

important that professional competence be

jeopardised

distinction that formation within a

l i n k e d to a p r o c e s s w h i c h e n s u r e s a

experienced by the client.

discipline fosters a person-centred rather

competent

workplace.

Therefore,

than a performance-centred

a r t i c u l a t i o n of s p e c i f i e d

professional

Clark

makes

the

approach.

t h e q u a l i t y of c a r e

as

Cultural competence

Clark (1995) claims that dealing with the

competences should occur alongside

T h e term cultural c o m p e t e n c e has been

unpredictable and complex issues that are

articulation

of r e q u i r e m e n t s

the

promulgated elsewhere (Ramsden 1990,

p r e s e n t in p r o f e s s i o n a l w o r k r e q u i r e s

workplace

which

such

D o w d & E c k e r m a n n 1992, C a m p i n h a -

'high levels of discipline and imagination

professional practice.

of

facilitate

Bacote 1995, Rorie et al 1996). T h e aim of

... n o t c a p t u r e d w i t h i n a n y r e a s o n a b l e

culturally competent nursing practice is to

interpretations of the idea of competence'

The client

deliver culturally safe care. To complement

( p 5 7 9 ) . Clark also claims that

the

Notably absent from the discussion of the

the nursing specific knowledge and skills

c o m p e t e n c e a p p r o a c h is c o n c e p t u a l l y

development

of

relevant to an area of practice, it demands a

muddled

empirical

professional competences is the client. T h e

dynamic reflexiveness where nurses divests

validation in the job context and reliable measures

and

lacks

assessment

client as a participant in health care can

themselves of the 'power...over (Hindess

assessing

individual

provide perspectives on the process and

1995 p7) position implicit in a professional

All

issues

for

competences.

both

and

these

arc

outcome of care that we do not experience

role. It refers to qualities which ensure that

represented in the debate surrounding the

because

t h e p o w e r p r e s e n t in t h e r e l a t i o n s h i p

c o m p e t e n c y a p p r o a c h in t h e n u r s i n g

professional location. As c o m p e t e n c y is

between

literature ( T h o m p s o n 1991, T h o m p s o n

focused on the measurement of outcome,

negotiated with dignity, that the client is

1992, Dent 1994, Sutton & Arbor 1994,

the outcome needs to be considered from

treated as a human being worthy of respect

Maynard 1994, W h i l e 1994).

various perspectives:

and is not exoticised as 'culturally other'

• the practitioner, where a knowledge/skill

(Marshall 1992, Stubbs 1993).

of

our

own

cultural

and

Other components of

construct may be inferred in a particular

the competency equation:

episode of care (DEET 1990),-

professional

and

client

is

Clients, by mere virtue of the fact that they are usually excluded from the expert

The workplace

• the workplace, where the competency of

knowledge of health professionals (Fahy

Professional practice can be positively or

the

1995), are frequently

workplace

(the

facilitating

or

'othered',

so

negatively affected by the environment in

mitigating environment) is considered,- and

c o m p e t e n c e in how we negotiate power

which the nurse works. Quality assurance

• the client, where the experience of care

w i t h c l i e n t s per sc is not c o n f i n e d vo

programs and accreditation procedures aim

is located.

situations where cultural differences exist.

to provide an environment which supports

Otherwise

the

assessment

of

However,

cultural

difference

can

excellent professional practice. W h e n

professional practice as competent, is not

exacerbate and extend the imbalance ol

o p e r a t i o n a l ised,

only partial, but inherently flawed.

p o w e r in the professional r e l a t i o n s h i p

processes

need

quality to

assurance

actually

foster

b e c a u s e it b u i l d s o n i n d i v i d u a l

and

Cultural safety

institutionalised e t h n o c c n t r i s m (Stubbs

always the case? For example, it is not only

C u l t u r a l l y safe c a r e in t h i s p a p e r is

1 9 9 3 , F o n g & C i b b s 1995).

vital that an agency has a language service

understood to embrace both professional

competent professional practice but, is this

policy and protocol (quality indicators),

r e s p o n s i b i l i t i e s a n d t h e r i g h t s of t h e

Does culture and competency

b u t t h a t t h e r e is an a d e q u a t e b u d g e t

c l i e n t ( R a m s d e n 1990, R a m s d e n 1993,

equal cultural competence? If a competency framework aims to ensure

Clients, by mere virtue of the fact that they are usually excluded from the expert knowledge of health professionals (Fahy 1995). are frequently ^othered9..*

regulated and safe, high quality care then issues of h o w culture affects the health caring process require consideration,human rights considerations insist that we d o so ( F e d e r a l R a c e

Discrimination

allocation to support operationalisation of

C o o n e y 1993). T h e vital c o m p o n e n t s of

Commissioner H R E O C 1995). In tenns of

the policy. A positive organisational

such care are that best care is provided

client

culture w h i c h e n c o u r a g e s staff to work

and that human dignity and respect arc

c o m p e t e n c y which addresses cultural

safety,

the

importance

of a

w i t h i n t e r p r e t e r s is a n o t h e r i m p o r t a n t

preserved t h r o u g h o u t . It can be said of

matters in professional practice should be

contextual factor which may escape quality

such care that cultural

self-evident - informed consent, advice

10 Collegian Vol 5 No4 1998

differences

in t h e 'sensitive care as an end' m o d e l .

p r o j e c t t o w a r d c u l t u r a l safety in N e w

T h e y are not distant from the essence of

Zealand, confronting ethnocentrism is the

good nursing care for any person, just that

first s t e p , n o t l e a r n i n g a b o u t c u l t u r a l

particular

culturally

specifics. T h a t is, e x a m i n i n g o u r o w n

different h e a l t h p r a c t i c e s or beliefs is

e t h n o c e n t r i s m a n d the implications for

necessary and that the nurse must exert a

care at both the individual and structural

particular

knowledge

effort

to

of

respect

those

differences. As Cooncy suggests (1993) it

level (how our institutions work), is where cultural competence begins.

is t h e 'outsider' view (Said 1978)- T h e nurse looks on at the culturally other (de

Uncertainty: a vital part

Beauvoir 1975, Spivak 1987, Ebert 1991)

of cultural competency

w h o is different, i n f o r m i n g herself of

Becoming

cultural differences and being sensitive in

e t h n o c e n t r i s m a n d h o w it s h a p e s o u r

h e r care t o w a r d s 'that difference'. T h e

t h i n k i n g ( S h a m a n s k y & G r a h a m 1994),

ANCI competency document

aware

of

our

own

(1993)

t h e q u e s t i o n s w e ask or don't ask, o u r

offers cues for sensitive practice: respect

availability and receptivity to clients, are all part of delivering safe care to clients. It

MI

is these elements which I suggest are not adequately

accounted

for

by

the

c o m p e t e n c y framework as w e presently interpret and apply it.

ws^

Working

ecr^npetefnee b e g i n s ,

with

clients

beyond

e t h n o c e n t r i s m can be a d e - c e n t r i n g health

process w h e r e p r o v i d i n g culturally safe

good

care requires that instead of approaching

c o m m o n e x a m p l e s . T h e r e is a b o d y of

interpersonal skills, p r o t e c t i o n of client

a client with 'health baggage' to be made

literature (Dowd & Eckermann

rights (ANCI

1 9 9 3 ) . All t h i s is to

culturally digestible in a sensitive manner,

regarding medication usage, preparation of

for a n d k n o w l e d g e of c u l t u r a l

p a r e n t s to c a r e for a sick c h i l d - are

p r a c t i c e s , u s e of i n t e r p r e t e r s ,

1992,

Federal

Race

b e a p p l a u d e d , h o w e v e r , it m i s s e s t h e

we a p p r o a c h the interaction with some

Discrimination Commissioner

HREOC

central core of c o m p e t e n c e in this area.

uncertainty. We may be unsure of what

1995, Pardy 1995, C a r v e t h 1995, Rorie

Cultural sensitivity should not be an end

m e a n i n g our h e a l t h advice, counsel or

Paine Barger, 1996) which tells of unsafe

in itself but is rather a process,- the end is

care will have to our clients. We may be

practice and harm being done to clients, as

n o n - r a c i s t care, or m o r e b r o a d l y n o n -

uncertain as to what sense it will make,

a result of the lack of cultural competence

discriminatory, culturally safe care (Stubbs

yet we remain expectant that through this

by health professionals. In this regard it is

1993). O n e can be culturally sensitive in

interaction, our own knowledge and

n o t a b l e t h a t as a specific c o m p e t e n c y ,

p r a c t i c e , but this a p p r o a c h may not

u n d e r s t a n d i n g of h e a l t h , w e l l n e s s a n d

cultural competence is not registered in the

deliver care which is experienced by the

illness may in fact be e n h a n c e d or even

Australian Nursing Council Incorporated

client as respectful and excellent; such an

changed. Most importantly the client will

competency document for new graduates

a p p r o a c h may i n a d v e r t e n t l y do harm

e x p e r i e n c e t h e b e n e f i t of

and enrolled nurses (ANCI 1993). While

(Rorie et al, 1996).

(Molina-Otarda 1994), high quality care.

Marshall

1992,

'friendly'

cultural issues are recognised to be a factor

Critical to what I am calling cultural

Therefore, in advanced practice, not

a f f e c t i n g c a r e , t h e a b s e n c e of d i s c r e t e

c o m p e t e n c e is t h e a s s u m p t i o n of t h e

only will we be aware of specific 'cultural

competences required for best nursing care

insider's

health practices' and use the interpreter,

of people from diverse communities could

C u l t u r a l l y s e n s i t i v e n u r s i n g c a r e is

n o t o n l y will w e b e r e s p e c t f u l

prompt

e t h n o c e n t r i c b e c a u s e it m a i n t a i n s t h e

respecting,

but

outsider position and the power-over that

interaction

with

goes with it. It is those of the dominant

different. As C o o n e y (1993) says, it is the

culture making allowances for 'the other'

insider position, where we are no longer

and cultural sensitivity

( t h e difference) w h e r e t h e subject a n d

viewing the client as other, but where we

As they are, the competences enunciated

o b j e c t p o s i t i o n s are m a i n t a i n e d . As

are able to participate with clients in a

in the ANCI document (1993) are located

R a m s d e n ( 1 9 9 0 , 1993) s u g g e s t s in her

s h a r a b l e a n d n e g o t i a b l e p l a c e . In this

the

charge

ol

professional

ethnoccnlrism.

Cultural competence

position

(Cooney

1993).

the

location

t h e c l i e n t will

and for be

Collegian Vol 5 N o 4 I9[J8 1 1

professional

issue

place the questions we ask of the client

client shared her fear of t h e b l o o d test

o u t c o m e in relation to the client being

are different to those we might ask from a

i n v o l v e d a n d t o l d t h e s t o r y of h o w

s c r e e n e d for H e p a t i t i s B. W h i l e b e i n g

culturally sensitive position. For example,

shortly after arrival in Australia she had

aware of this positive outcome I remained

we ask: "Do 1 need an interpreter, or d o

given birth to a new baby and had been

concerned that harm was done.

we?" r a t h e r t h a n t h e m o r e c o m m o n l y

very

renal

O n reflection I realised that I was working

framed, sensitive t h o u g h it be: "Do you

i n v o l v e m e n t r e q u i r i n g m o n i t o r i n g for

from an ethnocentric position. I had not

need an interpreter?" It is a place where

m o n t h s into the post-natal period. T h e

c o n s i d e r e d t h a t p e r h a p s crucial to t h e

our r e c e p t i v i t y is crucial ( n o t just o u r

client seemed troubled. We discussed this

i n t e r a c t i o n w a s a r e o r d e r i n g of m y

affective responses), so that our learning

period and the client's experiences a little,

priorities. W h i l e b e i n g sensitive to the

but its complexity was beyond the scope

w o m a n ' s specific s i t u a t i o n , my h e a l t h

of that consultation.

professional location h a d t h e s c r e e n i n g

and

development

as

advancing

p r a c t i t i o n e r s can be m a d e possible. By working

from

this

location

we

ill w i t h

eclampsia

with

T h e interpreter explained to me that

process as number one. T h r o u g h o u t the interaction

I

worked

with

this

acknowledge that our own ethnocentrism

the

e n g e n d e r s fear, which can deleteriously

apparently vital to the client's conception

unquestioned;

affect p r a c t i c e b y l e a v i n g i n t a c t the

of health. Losing blood would jeopardise

professional r e s p o n s i b i l i t y to p r o m o t e

powerful subject position of the dominant

that balance. Ah, I confidently thought,

health through such screening programs.

culture to which most of us belong. This

now we've got it, the cause of the client's

My assumptions about the screening

is a p o s i t i o n from w h i c h sensitive care

uneasiness is the blood test. With the aid

process remained unchallenged until later.

may be dispensed or indeed, withheld.

of t h e i n t e r p r e t e r I e x p l a i n e d

further.

From a professional position I had not

However,

seemed

questioned whether what wc were doing

that the question needs to be asked: "Can

b o t h e r e d , time was b e c o m i n g an issue,-

was r i g h t . A l t h o u g h effective, was t h e

the c o m p e t e n c y approach with its focus

she had left children in the fiat.

way in w h i c h we w e r e p r o m o t i n g a n d

It is w i t h t h e s e issues as a b a c k d r o p

balance

of

the

yin

and

client

yang

still

was

of

such

professional

attributes?"

all

it w a s

my

conducting the Hepatitis B campaign

on performance, foster and nurture the development

after

appropriate, where clients had screening

Reflection If we appraise the scenario with the issues

foisted onto them as they came for dental

in m i n d t h a t I raised earlier w e m i g h t

a p p o i n t m e n t s ? To w h a t extent did such

A scenario from practice

concur that the workplace e n v i r o n m e n t

health promoting activities create anxiety

supported

a n d c o n f u s i o n , as was clearly t h e case

I recall a consultation which took place in

in

a c o m m u n i t y setting with a client ( w h o

competent

practice. A

with t h e client I saw on this occasion?

had come to Australia as a refugee), and an

t r u s t e d i n t e r p r e t e r was available,- t h e

Could the health promotion screening

experienced and trusted interpreter/ethnic

consultation was not rushed; privacy was

program have been conducted in another

worker. T h e client had presented to me

assured. W e might also concur thai the

way? and if so, what does the nurse need

being referred by the dentist as part of a

p r o f e s s i o n a l c o u l d b e j u d g e d to h a v e

to do about it?

s c r e e n i n g program for H e p a t i t i s B. T h e

conducted a competent consultation.

client seemed a little non-plussed by this

Knowledge

appropriate

nurse work at a n u m b e r of levels. T h e

manoeuvre,

so

1 spent

some

time

this

instance

indeed

professional

(and

the

Cultural competence requires that the

application of knowledge) regarding b o t h

readiness of the practitioner to examine

e x p l a i n i n g t h e n a t u r e of t h e s c r e e n i n g

Hepatitis

was

their own ethnocentrism and be prepared

program, its rationale, the actual process

demonstrated.

lateral

to work with ambiguity and uncertainty at

of screening. T h e client asked questions,

t h i n k i n g o c c u r r e d in r e l a t i o n t o t h e

t h e client/practitioner level, is a crucial

a n d t h e i n f o r m a t i o n was d i s c u s s e d in

specific

where

element. An equally important dimension

detail.

The

presence

of

a

woman

B

and

eclampsia

Critical

contextual

and

factors,

knowledge of different health beliefs was

of c u l t u r a l c o m p e t e n c e is t h e nurse's

interpreter, known to the client facilitated

appropriately

readiness

this interaction,- t h e r e was time

incorporated

and

and

capacity

to

assess

for

c o n s i d e r a t i o n of t h e w o m a n ' s , s o c i a l

ethnocentrism when installed in the very

questions and discussion. T h e agency was

s i t u a t i o n ( t h e c h i l d r e n in t h e flat, t h e

structure of processes for delivering care

local and well-known to the client and the

participation of a female interpreter), was

(Stubbs 1993). T h e way health services

consultation room assured privacy.

shown.

are offered can m a i n t a i n intact

our

professional

e t h n o c e n t r i s m and impact deleteriously

responses I asked the interpreter to tease

performance may be judged by some to

upon individual episodes of care (Marshall

out some knot in the interaction. I sensed

be c o m p e t e n t . T h e o u t c o m e was the

1992), as p e r h a p s was t h e case in t h e

a p r o b l e m . W i t h further discussion the

d e s i r e d o n e if we are just c o n s i d e r i n g

scenario above.

T h r o u g h close attention to the client's

1 2 Collegian Vol 5 No 4 1998

In t h i s i n s t a n c e t h e

Facilitating the consumer voice in the planning of health programs is another aspect of competence in this area- Such competence requires the nurse to enter the uncertain territory of questioning what is considered to be 'normal', r

acceptable and culturally

sensitive

practice both at the individual 'micro' level and the 'macro' level of the health screening campaign. Mindful of the assessment focus on performance, how would a competency approach do justice to the process of reflection and learning (a dynamic, essential to advanced practice) that such a consultation prompts? The capacity to reflect on the micro situation (client/practitioner), with an analysis that extends to the macro level (program/organisation/political) and prompts action, is essential. However, even more pertinently how can a competency approach account for the client's experience of care? If performance is to be the criteria for judgement of competence,

then

how

care

is

experienced by the client must figure in the assessment process. For professions where the interpersonal is an essential part of therapeutic interactions, to judge an example of care as competent without a mechanism for client input seems a nonsense. Summary My endeavour has been to challenge the competency framework as it is presently interpreted and applied in nursing. I agree with Clark (1995) that competence is the substance of our discussion and that 'there is no argument for incompetence' (p579). This is why in this paper, drawing on the work of others, 1 have mapped some of the c o m p o n e n t s of c o m p e t e n c e in relation to the provision of culturally safe care.

As

part

of

the

process

of

engagement and resistance toward change (Ebert,

1991), I have made

some

recommendations for action, being: • the involvement of clients or their

Federal Race D i s c r i m i n a t i o n C o m m i s s i o n e r H R E O C 1995 Slate of ffee nation, a report on people evaluation of professional competences,of non-English speaking backgrounds. Australian Government Publishing Service, Canberra • linking professional competences to Fong L G W, Cibbs J T 1995 Facilitating services specified quality assurance processes to to multicultural communities in a dominant culture setting, an organisational perspective. ensure that a workplace actually supports Administration in Social Work 19(2): I -24 Foucault M 1980 T h e confession of the flesh. In: competent professional practice. G o r d o n C ( c d ) Power/Knowledge: Selected In presenting these arguments my goal interviews & other writings 1972-1977 by Michel Foucault. Pantheon Books, New York, ch 11 has been to productively resist the G o r d o n C (ed) 1980 Power/Knowledge- Selected m(eri>ien>s & other lurifin^s 1972-1977 by Michel legitimising imperative of the competency Foucault. Pantheon Books, New York movement. Whether the competency H a r a w a y D 1990 A m a n i f e s t o for c y b o r g s : science, technology, and socialist feminism in framework for nursing education and the 1980s. In: N i c h o l s o n L (cd) practice alone, can foster and nurture the Feminism/postmodernism Routledge, New York, ch 9 (Reprint Socialist Review 1985 80) professional attributes required to deliver Hindess B 1996 Discourses of power, from Hobbes to competent care, remains disturbingly Foucault. Blackwell Publishers, Oxford. Marcuse H 1964 One dimension*]! man studies in the questionable. ideology of advanced industrialised society. Routledge & Kegan Paul, London Note: culture as defined by ethnicity, is the Marshall H 1992 Talking about good maternity care in a multicultural context, a discourse sense in which the word is being employed in analysis of the a c c o u n t s of midwives and this paper. 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