On Cultural Competency and Ethical Practice
American Occupational Therapy Association Ethics Commission's Advisory Opinion on Cultural Competency and Ethical Practice
Joan, a pediatric therapist, is asked to make a home visit to a Vietnamese child who was recently burned. On examination of the child, she notes red, round, coin-sized marks over the child's back. The mother is never asked about the marks. After leaving the home Joan wonders if the mother is using a traditional healing treatment. "How can I give this child ethical and quality care while allowing the mother to continue with this harmful practice?"
Introduction
People face problems, dilemmas, and issues with ethical significance that necessitate action or nonaction every day. Doing the right thing in practice is always a challenge. In an increasingly pluralistic society, health care providers are finding themselves confronting choices that may depend more on moral and ethical values than on medical knowledge. Joan's dilemma is not a question of what intervention method should be used, but whether quality ethical care can be provided. Culturally competent practitioners realize that behaviors are shaped and defined differently by every culture. Rather than being distressed by another culture's health practice, a culturally competent practitioner welcomes collaboration and cooperation in making sound ethical decisions.
This paper will outline and discuss those provisions within the most recent version of Occupational Therapy Code of Ethics (2005) (American Occupational Therapy Association [AOTA], in press) that address culturally competent services. Vignettes are presented to demonstrate the range of ethical concerns that cultural encounters can generate. This advisory paper is developed to provide guidance to the AOTA membership so that they can provide ethically and culturally appropriate services to all populations while recognizing their own cultural or linguistic background or life experience and that of their clients, colleagues, or students.
Cultural Competence
Cultural competency is a journey rather than an end. It refers to the process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different persons (AOTA, 1995). It is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations (Cross et al., 1989). Cultural competence entails "understanding the importance of social and cultural influences on patients' health beliefs and behaviors; considering how these factors interact at multiple levels of the health care delivery system; and finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations" (Betacourt et al., 2003, p. 297).
Clinically, cultural competence means having the self-awareness, knowledge, skills, and framework to make sound, ethical, and culturally appropriate decisions. It is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services, thereby producing better outcomes (Davis & Donald, 1997). In Vignette 2, the therapist does not take into account the socioeconomic level, living environment, or culture of Mrs. Jones before training her to use a variety of adaptive equipment. A culturally competent practitioner is not afraid to ask the client culturally pertinent questions upfront.
Competence in practice means learning new patterns of behaviors and effectively applying them in appropriate settings. Examples (Wells & Black, 2000) include the following:
(a) Involve the extended family in the intervention process
(b) Address elderly persons more formally (by their last name and title) than younger clients
(c) Acknowledge and work with traditional and/or faith healers
(d) Be cautious about touching
(e) Small talk at the beginning of a session will be considered good manners and keeps from appearing too rushed
(f) Conduct the session in the preferred language of the client or arrange for a professional interpreter
(g) Add culturally related questions during the evaluation process
Cultural competence is key to effective therapeutic interactions and outcomes. It implies a heightened consciousness of how clients experience their uniqueness and deal with their differences and similarities within a larger social context. It enhances the occupational therapy provider's knowledge of the relationship between sociocultural factors and health beliefs and behaviors. It equips providers with the tools and skills to manage these factors appropriately, with quality occupational therapy delivery as the gold standard. Cultural competence is an evolving and developing process that depends on self-exploration, knowledge, and skills.
Vignette 2:
Mrs. Jones is in her mid 60s and of Hispanic ethnicity. She is dependent for her existence on food stamps and Supplemental Security Income Benefits provided. Somewhat hard of hearing, she has a slight tremor in her voice and arthritis in her hands. The three-bedroom house in which she lives is in poor condition. The house is unkempt. For meals she relies on her neighbors and junk food.
Mrs. Jones is admitted to the rehabilitation unit after experiencing a mild stroke that leaves her impaired on the right side. Her treatment sessions consist of transfer training, learning one-handed cooking, and dressing with adaptive equipment. A variety of equipment and devices are recommended and ordered for her. At the discharged planning session, the occupational therapist states, "Mrs. Jones has refused all the equipment even though she is able to use them safely and properly."
Ethical Conflicts
There are several Western bioethical principles and concepts that may be in opposition to certain cultural values and beliefs. These can be the source of some ethical conflicts and dilemmas. There are many therapist-client interactions in which culture affects health, but they are not perceived as culturally or ethically related. Western bioethics places the "self" at the center of all decision-making (autonomy). However, there are many cultures that place the family, community, or society above the rights of the individual. The disclosing (truth-telling) of a diagnosis of serious illness or disability to the client is not universally accepted. Many believe that the family, not the client, should make important health care decisions. Some people believe that health is maintained and restored through positive language. When disclosing risks of a treatment or approach, health care providers speak in a negative way (informed consent). Questions of race, ethnicity, and cultural beliefs have become part of the equation when resources are finite or scarce (justice). Some cultures believe that it is the duty of the family to care for its sick member (self-independence). When the therapist promotes independence in self-care or activities of daily living, the role of the family may be negated (Wells, 2005).
Ethical dilemmas can be further complicated by the unequal distribution of power in the relationship between the client and therapist. Clients and families faced with medical decisions are often subject to being over- or underinfluenced by the health care system and providers (power and dominance). The therapist-client relationship is one in which the therapist has the ultimate responsibility for developing conclusions and proposing treatment. These issues can lead to dilemmas in which the practitioner must either accede to the family's wishes or withdraw care. Respect for autonomy grants clients, who have been properly informed in a manner appropriate to the client's beliefs and understanding, the right to refuse a proposed treatment (Wells & Black, 2000).
The Issue
In view of the changing demographics in the United States, occupational therapists and occupational therapy assistants will have the opportunity to work with a growing number and types of diverse clients. They will encounter individuals with different values and belief systems about health, well-being, illness, disabilities, and activities of daily living. Evaluation and intervention plans will be developed for consumers, who may not speak their language; differ on socioeconomic and educational levels, ethnicity and race, religion; and have diverse beliefs about and reactions to illness. Clients and families as well as practitioners bring many different cultures to the therapeutic setting. The interaction of clients and practitioners embodies a form of multiculturalism in which several cultures- the health care profession, institution, family, community, traditional culture, etc.-are all merged (Genao et al., 2003). Therefore, every therapeutic interaction is a cross-cultural interaction. It is this overlap and interaction of cultures and dialects that can create ethical conflicts and dilemmas in providing occupational therapy services.
Without cultural competence, one can easily imagine the possible adverse consequences that can result when distrust, miscommunication, and misunderstanding interfere with the therapeutic relationship. The outcome can range from frustration, confusion, or shame, to anger by the client, family, and practitioner. Cultural incompetence can result in compromised quality of care, noncompliance by the client, inability to recognize differences, fear of the new or unknown, denial, and inability to look in-depth at the individual needs of the client and their family (Wells & Black, 2000). On the other hand, cultural competence can produce a positive outcome, a feeling of professional satisfaction from knowing that you helped a client at a time of need.
Individual cultural beliefs affect how occupational therapy practitioners approach, speak to, and measure outcomes with clients. Within a personal context, we tend to make assumptions and judgments about individuals based upon their particular culture, ethnicity, race, religion, sexual orientation, language, disability or life experiences, and this can lead to improper intervention. In the clinical environment, the responsibility for making sound ethical decisions rests with the individual practitioner. Ethical situations can arise when the behavior of the practitioner is in conflict with the behavior of the client or family. When two values present themselves and we choose one rather than another, we are saying, based on our cultural context and beliefs, that one is more valuable than another (Iwana, 2003). Problems arise when the participants have a different interpretation of illness and treatment and use language or decision-making frameworks differently. As individuals and professionals, we take a particular action based on our own sense of right and wrong, values, knowledge, and skills.
Application of the Code
Professional codes of ethics provide a moral framework for and define the ideal standard of practice. They and associated documents provide guidelines and standards for resolving ethical conflicts, dilemmas, and issues. The relevant ethical principles of the Occupational Therapy Code of Ethics (2005) valid for culturally competent occupational therapists, occupational therapy assistants, and students are contained under the following:
Principle 1: Occupational therapy personnel shall demonstrate a concern for the safety and well-being of the recipients of their services. (Beneficence)
Occupational therapy personnel shall:
A. Provide services in a fair and equitable manner. They shall recognize and appreciate the cultural components of economics, geography, race, ethnicity, religious and political factors, marital status, age, sexual orientation, gender identity, and disability of all recipients of their services
This principle speaks directly to the prohibition of discrimination in the delivery of professional services. This principle holds the welfare of those we serve as paramount. Occupational therapists and occupational therapy assistants must consider all relevant contexts that influence the performance, skill, and patterns that determine the behaviors of their client. According to the Occupational Therapy Practice Framework (AOTA, 2002), "the cultural context, which exists outside of the person but is internalized by the person, also sets expectations, beliefs, and customs that can affect how and when services may be delivered" (p. 614). The entire process of service delivery begins with a collaborative relationship with the client and family; therefore, incompetence in cross-culture interaction, knowledge, and skill can lead to unethical decision-making.
Principle 4: Occupational therapy personnel shall achieve and continually maintain high standards of competence. (Duty)
This principle reminds practitioners of the importance of and duty to lifelong learning to develop the knowledge and skills required to provide culturally appropriate service. It also speaks to requiring occupational therapy practitioners to strive to deliver culturally competent services to an increasingly broad range of clients. It also holds practitioners accountable for continuing their professional development and seeking knowledge throughout their careers, which is required to provide culturally competent care. Principle 4.F prohibits delegation of tasks that are beyond the competence of the designee and requires that the certified individual provide adequate supervision. This is especially important when linguistic differences exist and bilingual assistant, aides, and interpreters are used.
Principle 7: Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity. (Fidelity)
This principle provides guidance on interactions with individuals, colleagues, and students from diverse backgrounds. It bars discrimination against these individuals on the basis of race, ethnicity, gender, age, religion, sexual orientation, gender identity, national origin, or disability. Culturally diverse students and practitioners bring a special skill and knowledge to the profession. They are entitled to professional equity and should not be exploited or debased because of their differences. They should not be held to different expectations, roles, or behaviors. Discrimination in any professional interaction and against any individual with whom we interact ultimately debases the profession and harms all those within the practice.
The Guidelines to the Code of Ethics (AOTA, 1998) specifically state that "Occupational therapy personnel shall develop an understanding and appreciation for different cultures in order to be able to provide culturally competent service. Culturally competent practitioners are aware of how service delivery can be affected by economics, ethnic, racial, geographic, gender, religious and political factors, as well as marital status, sexual orientation, and disability [4.4]," and "In areas where the ability to communicate with the client is limited (aphasia, different language, literacy), occupational therapy personnel shall take appropriate steps to ensure comprehension and meaningful communication [4.5]." Under the Core Values and Attitudes of Occupational Therapy Practice (1993), the concepts that are related to cultural competence are equality, justice, dignity, and truth.
Discussion
The Occupational Therapy Code of Ethics (2005) recognizes that culture may influence how individuals cope with problems and interact with each other. The way in which occupational therapy services are planned and implemented need to be culturally sensitive to be culturally effective. Cultural competence builds on the profession's ethical concepts of beneficence, nonmaleficence, autonomy, justice, veracity, fidelity, and duty, adding inclusion, tolerance, and respect for diversity in all its forms.
The direct service provider, educator, supervisor, researcher, and professional leader must be mindful of the impact of cultural diversity in interactions with clients, families, students and colleagues. Some materials and approaches may be inappropriate and even offensive to some individuals. Clients and families may choose complementary and alternative medicine or traditional or faith healing practices as opposed to mainstream therapeutic approaches. Colleagues and students will approach issues and events from their own cultural perspective.
Cultural competence requires occupational therapy practitioners to enter into the therapeutic relationship with awareness about their own culture and cultural biases, knowledge about other cultures, and skills in cross-communication and intervention (Wells & Black, 2000). Practitioners need a nonjudgmental attitude toward unfamiliar beliefs and health practices. They should be prepared to be open and flexible in the selection, administration, and interpretation of intervention approaches. They must be willing to negotiate and compromise when conflicts arise. And when cultural or linguistic differences may negatively influence outcomes, practitioners must be ready to refer to or collaborate with others who have the needed knowledge, skill, and experience. Cultural competence requires occupational therapy practitioners to detect and prevent exclusion or exploitation of diverse clients. This includes monitoring cultural competence among agencies, policies and procedures, and delivery systems.
Vignette 3:
You are attending a lecture about a disabling condition and its effect on specific populations. A multitude of groups and populations are presented and discussed. The only time that gays and lesbians are mentioned is in connection with the total number of deaths resulting from the condition. When asked by an attendee about the effects of this condition on the gay and lesbian population, the speaker ignores the individual and goes on to another question.
Cautions must be taken not to attribute stereotypical characteristics to individuals. Rather an attempt should be made to gain better understanding of the culture of clients, colleagues, and students. Practitioners should devise a plan to continually acquire the training and education necessary to be culturally competent. The Occupational Therapy Code of Ethics (2005) clearly shows that occupational therapists and occupational therapy assistants have an ethical responsibility to be culturally competent practitioners.
Conclusion
To effectively reach diverse populations, the field of occupational therapy must have culturally competent professionals. Cultural competence is a basic reminder to all practitioners of their responsibility in protecting the rights of clients and their families and to act as their advocates. Recognizing the link between trust, cultural competence, and the therapeutic relationship is critical to providing ethical care. Being culturally competent can help occupational therapy practitioners develop intervention approaches, health delivery systems, and health policies that fully recognize and include the effects of culture on the ethics of health decisions. It can aid practitioners in integrating fair and equitable services of all people and the holistic, contextual, and need-centered nature of such services. It can assist practitioners in achieving their goals of providing sound ethical decision-making, practice, and care to all persons.
Ethical considerations dictate that cultural competence should be consider in activities such as hiring practices, teaching, evaluation, and supervision of staff and students. There is an equally important need for all occupational therapists and occupational therapy assistants to continually improve their level of cultural competence and to establish a mechanism for the evaluation of competence-based practice. Guided by the AOTA Occupational Therapy Code of Ethics (2005), occupational therapists and occupational therapy assistants should take the leadership role not only in disseminating knowledge about diverse client groups but also in actively advocating for fair, equitable, and culturally appropriate treatment of all clients served. This role should extend within and outside the profession. It is through the principles of the Occupational Therapy Code of Ethics (2005) that therapists have a framework to guide their decisions when cultural conflicts arise.
References
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Wells, S. A. (2005). An ethic of diversity. In R. B. Purtilo, G. M. Jensen, & C. B. Royeen (Eds.), Educating for moral action: A sourcebook in health and rehabilitation ethics, [pp. 31-41]. Philadelphia: F. A. Davis.
Author
Shirley A. Wells, MPH, OTR, FAOTA, Chairperson, SEC (2001-2004)
Last Updated: 8-9-05