Clinical Researcher—February 2024 (Volume 38, Issue 1)

PEER REVIEWED

Jessica Fritter, MACPR, ACRP-CP; Bashar Shihabuddin, MD, MS

 

 

 

As applied to the clinical research enterprise, “cultural humility” is a continuous process of self-orientation toward caring for others based on self-reflection and assessment, appreciation of others’ experiences, and expertise on the social and cultural context of their lives, with an openness to establishing strong relationships within the research team and with study subjects. Applying cultural humility training to a clinical research infrastructure provides open awareness of biases, privileges, and the limitations of one’s own knowledge. These insights may enhance one’s approaches to interactions with potential subjects during recruitment and with actual subjects during study conduct while complementing existing cultural competency training and, in turn, supporting diversity among team members and research subjects.

Background

Diversity training predates the concept of cultural competency and humility. Workplace diversity training was launched in the 1960s prompted by legislation related to discrimination.{1} In many instances, these training sessions evolved into employee questionnaires with little feedback, as well as hiring tests with the only product being a list of “do” and “don’t” recommendations.

The term “cultural competence” was first introduced in 1989 in a report titled: “Towards a culturally competent system of care.”{2} the authors of which concluded that cultural differences could lead to inequitable care when medical organizations and staff are not culturally competent. Since that time, cultural competency training has become ubiquitous in healthcare settings, various businesses, and academic institutions, with the belief that more knowledge about another’s culture results in more competent practice.

However, cultural competency training often assumes that learning about some aspects of someone else’s culture or experiences results in a competent person, suggesting that once one attains this knowledge through training, they are culturally competent. This design treats culture as rigid not fluid, while in fact culture is a concept affected by various structural, systematic, and personal elements. Furthermore, cultural competency training may become tedious and leave no lasting impact, and some participants may harbor animosity toward the training or its elements, resulting in more harmful attitudes. It has been suggested that cultural competency training does not impact any aspect of teamwork nor client relations.{3}

Cultural Competency vs. Cultural Humility

Cultural humility builds on cultural competence. Cultural competence provides a foundation of knowledge and awareness of various backgrounds, attributes, and historical events. Cultural humility translates that knowledge and awareness into the process of accountability aimed at personal and systematic change.{4}

The Cultural Humility Process

Cultural humility is a lifelong process of learning from others and self-reflection focusing on mitigating power imbalances and creating accountability at various levels: personal, team, institution, etc. This is achieved by encouraging reflection on one’s own beliefs, values, and biases—both explicit and implicit. In turn, the impact of one’s own culture on research team interactions and subject recruitment can be assessed using a person-centered stance, open to and respectful of others’ views. This continuous fluid dialogue and process orientation promotes real partnerships internal to the team and external to the community where subject recruitment occurs.{5}

Achieving partnerships by being culturally humble allows engagement with people who are different on a personal and experiential level, with a curiosity and empathy about others lived experiences that are different from one’s own. This could range from a simple endeavor, for example learning to pronounce names, to more complex ones, for example talking about experiences with racism, sexism, and classism. It is important to approach all these endeavors with the beginner’s mind and to listen nondefensively, particularly when in a leadership position. This will allow one to show appreciation and respect for other cultures.{6}

Cultural Humility and Team Cohesiveness

It is important to know and understand one’s own cultural background and how it influences perceptions and potential biases. The process of cultural humility in a team setting starts with leadership and the ability to be vulnerable, which leads to team cohesion.

Cooks-Campbell showed five ways a team can practice cultural humility in terms of team bonding, coaching, conversing, using what you learn, and understanding limitations.{7} Team bonding is a time for the team members to get to know one another better and through common activities. A way to practice cultural team bonding may be eating different cuisines or learning about other languages. Coaching is helpful in identifying self-awareness and challenging expectations. When in conversation, it is essential to allow others to lead the conversation and share their experiences. Using what you learn means when you identify something of concern within your institution, you hold all partners involved accountable and advocate for change. Understanding limitations means recognizing the fact that culture is evolving, and people are going to change.{7}

Cultural humility is just as important in leadership. Leading by example and modeling learning and self-reflection demonstrate empathy and respect to the team. Engaging in difficult and critical conversations allows for open dialogue and facing assumptions head on. Practicing inclusive leadership and advocating for diversity and staff development are key components to practicing cultural humility as a leader.{8}

So how do you practice cultural humility within your clinical research team? Let’s think about how this works when talking about subject recruitment. As a team, you can discuss each member’s experiences with subjects of varying cultures. What were their experiences as patients and subjects in research studies? What setbacks did they experience and how did they overcome any obstacles? What was successful and allowed them to be present and engaged with the subject and family?

A recent study of clinical research coordinators (CRCs) in a large collaborative pediatric emergency medicine research network found that most felt that their various races and ethnicities, as well as their ability to speak languages other than English, made them more successful overall in study recruitment. However, some CRCs felt that their gender hindered their sense of belonging in the research team.{9} This study highlights how cultural humility can lead to discussions revealing not only diversity among research teams, but also supporting team members who may be struggling due to personal factors or characteristics.

In turn, cultural humility may improve community engagement, increase a community’s knowledge of research studies, and support the design of clinical research projects with a focus on the subjects, not just the science.{5} In one examination of the topic, authors provided critical information on how research does have local spillover into the community, and how it is important for research to mirror its community. They discovered that, on average, every additional publication can reduce local mortality from a disease by 0.35%.{10}

Conclusion

Cultural competence provides knowledge and an opportunity for self-awareness while cultural humility emphasizes accountability and change. Cultural humility is a continuous process of learning and self-reflection. Applying cultural humility to your teams allows for vulnerability, accountability, growth, and learning. It is important to have open communication to discuss cultures and reflect on those interactions. Moving forward, it is imperative to understand and practice cultural humility in your research setting.

The authors report no conflicts of interest and have no funding to declare.

References

1. McKenzie K. 2008. A historical perspective of cultural competence. Ethnicity and Inequalities in Health and Social Care 1(1):5–8. https://doi.org/10.1108/17570980200800002
2. Cross T, Bazron B, Dennis K, Isaacs M. 1989. Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. ERIC. https://eric.ed.gov/?id=ED330171
3. Beagan BL. 2018. A Critique of Cultural Competence: Assumptions, Limitations, and Alternatives. In: Frisby C, O’Donohue W. (eds). Cultural Competence in Applied Psychology. Springer, Cham. https://doi.org/10.1007/978-3-319-78997-2_6
4. Stubbe DE. 2020. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus 18(1):49–51. doi:10.1176/appi.focus.20190041
5. Yeager KA, Bauer-Wu S. 2013. Cultural humility: essential foundation for clinical researchers. Applied Nursing Research: ANR26(4):251–6. https://doi.org/10.1016/j.apnr.2013.06.008
6. Principle 1: Embrace cultural humility and community engagement. (cdc.gov)
7. Cooks-Campbell A. 2022. How cultural humility versus cultural competence impacts belonging. Better Up. https://www.betterup.com/blog/cultural-humility-vs-cultural-competence
8. Bourke J, Titus A. 2021. The key to inclusive leadership. Harvard Business Review. https://hbr.org/2020/03/the-key-to-inclusive-leadership
9. Shihabuddin BS, Fritter J, Ellison AM, Cruz AT. 2022. Diversity among research coordinators in a pediatric emergency medicine research collaborative network. Journal of Clinical and Translational Science 7(1):e46. https://doi.org/10.1017/cts.2022.448
10. McKibbin R, Weinberg B. 2021. Does Research Save Lives? The Local Spillovers of Biomedical Research on Mortality. National Bureau of Economic Research Working Paper Series. doi:10.3386/w29420

Jessica Fritter, MACPR, ACRP-CP, (fritter.5@osu.edu) is Associated Faculty of Clinical Practice at The Ohio State University College of Nursing, works as a partner in BJE Consultants, and serves as the ACRP Content Committee Vice Chair for 2023 as well as Chapter President for the Ohio Chapter of ACRP. She also works in workforce development for The Ohio State University Center for Clinical Translational Science.

Bashar Shihabuddin, MD, MS, (bashar.shihabuddin@nationwidechildrens.org) teaches and practices in the Pediatrics and Emergency Medicine areas of Nationwide Children’s Hospital in Columbus, Ohio, and is an Assistant Professor at The Ohio State University College of Medicine.