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Abstract

The influx of migrants to Canada has resulted in a shift in the country's demographic landscape. Individuals often interpret and approach health and wellness through the lens of their cultural heritage, which has led to stereotyping behaviors and discriminatory practices, exacerbating the notion of “Othering”. Immigrant older adults are likely to experience discrimination in a more dreadful way in the form of societal isolation and marginalization due to the collective systems of power such as ageism, ableism, and racism. This paper results from continuous thought-provoking discussions initiated by the first author (AM) in her doctoral program at the University of Western Ontario for the Philosophy of Nursing Science course, taught and facilitated by the second author (SM). After studying the course materials on “revolutionary science” and reflection on the process of paradigm shift introduced by Thomas Khun and engaging in critical discussions on a range of relevant philosophical concepts such as bio-power, othering, silencing and ignorance, marginalization, oppression, neoliberalism, health equity, and social justice, we have been prompted to rethink the concept of cultural competence in nursing education and healthcare practices, particularly in the context of nursing care of older adults. Therefore, in this paper, we will critique the concept of cultural competency in the context of an anti-racist and anti-oppressive lens and suggest a pivotal response to move towards an inquiry-driven approach based on cultural humility and respect in the nursing care of older adults.

Keywords

Cultural competency older adults competency-based education marginalization intersectionality health inequalities

Introduction

The practice of self-reflection is a potent technique that plays a vital role in the development of nursing professionals (Zarrin, Ghafourifard & Sheikhalipour, 2023). The process of introspection enables nurses to gain a deeper understanding of their profession's inherent strengths and challenges, thereby fostering critical thinking skills that are essential for their personal and professional growth (Matshaka, 2021). As nurse researchers, examining our positionality is vital in determining our research topic, shaping our methodology, and interpreting study results. We acknowledge our role as nurse scholars and educators and our social identity as racialized women with migrant status and Muslim backgrounds. Reflecting on and recognizing our intersectional identity and positionality enables us to comprehend and identify equity-related challenges within the Canadian context. Our professional and clinical experiences have influenced this discussion paper, which critically analyzes the notion of cultural competency in nursing education and practice for older adults. The lead author's background as a gerontology nurse working with older adults drives her motivation in pursuing her doctoral studies, which examine ways to enhance nursing care quality through an equity-oriented lens for older adults.

This paper results from continuous thought-provoking dialogues initiated by the first author (AM) in her doctoral program at the University of Western Ontario for the Philosophy of Nursing Science course, spring-summer 2023, taught and facilitated by the second author (SM). After studying the course materials on “revolutionary science” and reflecting on the process of paradigm shift introduced by Thomas Khun (Khun, 1962) and engaging in critical discussions on a range of concepts such as bio-power, racism, othering, silencing and ignorance, marginalization, oppression, neoliberalism, health equity, and social justice, we have been prompted to rethink the concept of cultural competence in nursing education and healthcare practices. We encourage nurses to question if the concept of cultural competence suffices to address discriminatory practices in the Canadian healthcare system or if an alternative conceptualization is needed to capture structural issues impacting marginalized populations such as older adults from racialized backgrounds. Therefore, in this paper, we critique excessive use and reliance on the concept of cultural competency in the context of anti-racist and anti-oppressive works and suggest a pivotal perspective to move towards an inquiry-driven approach based on cultural humility and respect for the nursing care of older adults.

Nursing care of older adults

The influx of migrants to Canada has resulted in a shift in the country's demographic landscape. According to Statistics Canada, Canada's population is aging. The number of Canadians aged 65 and over increased by 18.3% between 2016 and 2021, reaching seven million. By 2051, this number might rise to about 12 million, nearly one-quarter of the population (Hallman, 2022). Additionally, the Government of Canada (2021) reported that the number of older adults is expected to triple in the next 30 years, rising from 861,000 to 2.7 million. Canadian seniors currently account for 19% of the total population, with 30% of them being immigrants.

The Concept of Intersectionality in Nursing Care of Older Adults. Older adults belonging to ethnic minority groups frequently experience significant discrimination in healthcare and social support services. For example, older adults with dementia are often subjected to what is known as the “triple stigma” - a combination of ageism, discrimination against those with dementia, and prejudice against minority groups (Zhong & Chiu, 2023). Ageism against older adults from minority groups occurs at different levels, including institutional, social, and individual levels, and in different settings (Dolberg, Sigurðardóttir & Trummer, 2018). Migrant older adults are likely to experience discrimination in more extreme ways in the form of societal isolation and marginalization due to collective discriminatory and oppressive practices such as immigration policies, systemic racism, and xenophobia (Zhong & Chiu, 2023). According to Seong-gee (2021), there is significant discrimination among the aging population in many Canadian long-term care settings. This discrimination affects racialized migrant seniors, those with English as a second language and those who practice minority religions. Gender, race, and ethnicity are examples of social variables that influence individuals’ psychological states. Having multiple identities creates a unique experience and may result in different forms of discrimination (O’Reilly, 2020). The concept of “intersectionality” helps us understand how multiple systems of power intersect with a person's social identity. Intersectionality, also known as “intersectional theory,” was initially introduced in 1989 by Kimberlé Williams Crenshaw, an American civil rights activist and a leading scholar in critical race theory. It discusses how various categorizations, including race, age, class, gender, and immigration status, intersect and influence prejudice or privilege for individuals or groups (Cohen, 2021). Intersectionality examines how social structural dynamics and oppressive systems such as racism, sexism, capitalism, and heteropatriarchy intersect and reinforce one another, categorizing and controlling minoritized groups by shaping their way of life (Tobin, Gutiérrez, Farmer, Erving, & Hargrove, 2023). Tobin et al. (2023) argue that Intersectionality theory, as a critical framework, may be especially important for understanding the health and aging of minoritized populations who experience issues as both older adults and members of marginalized racial or ethnic communities. When ageism is combined with other prejudices, disadvantages multiply, exacerbating the impact on the health and well-being of aging minoritized populations. Therefore, the authors suggest incorporating the intersectional lens into nursing education and practices to gain a better understanding of equitable nursing care for older adults. When we employ an intersectional approach to address health and social inequities among marginalized aging populations, we can better identify the specific combinations of the sociopolitical determinants of health and contexts these marginalized aging populations experience and the structural processes resulting in health inequities (Tobin et al., 2023). Healthcare professionals and institutions should integrate intersectional considerations into individual assessments, with a specific emphasis on recognizing privilege and power differentials within relationships. This approach has the potential to enhance their comprehension of patients’ experiences and ultimately contribute to improved health outcomes for patients (Fitzgerald & Campinha-Bacote, 2019; O’Reilly, 2020).

The notion of “Othering” in the nursing care of older adults. As Chowdhury, Baiocco-Romano, Sacco, El Hajj and Stolee (2022) and Almutairi, Dahinten and Rodney (2015) stated, individuals often interpret and approach health and wellness through the lens of their conscious or unconscious biases, which has led to stereotyping behaviors and discriminatory attitudes and practices, exacerbating the notion of “Othering.” Othering, according to Cherry (2023a), occurs when some people or groups are identified and stigmatized for differing from the standards of a particular social group. The act of “othering” entails inferiority toward humanity, resulting in disrespect and indignity, and further marginalization (Cherry, 2023). This notion of othering can be perpetuated in the healthcare practice of older adults and impact their sense of belonging and trust in the system (Roberts & Schiavenato, 2017). The power imbalance observed between healthcare providers and minority patients can also perpetuate the notion of othering and place patients in a further marginalized position, making it more challenging for them to advocate for their needs and concerns and to resist structural discriminatory practices (Vestgarden, Dahlborg, Strunck & Aasen, 2023). This is particularly daunting when ‘abnormal’ conditions such as racism and ageism are normalized and overlooked. Many Canadian long-term care facilities are ill-prepared to address the unique requirements of older migrant adults from diverse racialized or religious backgrounds. Consequently, elderly patients from various cultural backgrounds are more susceptible to feelings of loneliness, anxiety, and isolation, which could result in additional obstacles to person-centered care (Chaze, Giwa, Groenenberg & Burns, 2019; Laher, 2017).

The concept of “bio-power” in nursing care of older adults. The COVID-19 pandemic has exacerbated the existing discriminatory practices in healthcare among older adults from minority groups, evidenced by higher rates of COVID-19 infection, mortality, and hospitalizations among ethnically diverse communities and in long-term care facilities (Wang, Liu & Walsh, 2021). This has unwittingly brought to light the notion of bio-power (Espina & Narruhn, 2021). Bio-power, according to Agamben, “is the socially constructed power over life to determine who lives and who dies” (Espina & Narruhn, 2021, p. 186). Connecting the concept of care for older adults to Agamben's theory of Bio-power (Georges, 2008) and fatality rates in long-term care centers during the COVID-19 pandemic, we can understand the role of authoritarian regimes in determining which lives were deemed valuable and which were deemed expendable or disposable. Furthermore, the COVID-19 pandemic led to restrictions on visitors and caregivers in long-term care (LTC) facilities as part of wider public health policies aimed at promoting physical distancing, leading to a negative impact on the psychological well-being of the aging population (Rangel, Holmes, Perron & Miller, 2022). The Canadian Military Humanitarian Mission reported that more than half of all deaths in Canada during the first wave of COVID-19 were senior residents in LTC homes, with many dying due to neglect rather than COVID-19 without the presence of their loved ones (Howlett, 2021).

The COVID-19 pandemic resulted in the further marginalization and de-prioritization of older adults’ needs and voices, who were unjustly deemed less valuable members of society (Søraa et al., 2020). This can be explained by the concept of Homo sacer, introduced by Giorgio Agamben (1998), the Italian philosopher, in which a human move from bios to zoe to allow biopower to exist (Peters, 2014). Because homo sacer has no ontological rights, they can be killed with “impunity,” have their rights taken away at any time, and lose their political citizenship and belonging (Espina & Narruhn, 2021, p. 186). According to Agamben, Zoê is a natural life governed by the rules of nature and also called the life of the homo sacer, and bios is a life based on the praxis of being a subject with civic responsibilities in society. Both Zoe and Bios are made by those with authority and power. Agamben uses a Zoe-Bios dichotomy based on Aristotelian thought to expand more fully the idea of the position of “homo sacer” in a Eurocentric society (Georges, 2008, p. 8). Agamben emphasizes that the Zoe-Bios Dichotomy informing Western cultural practices and compliance with healthcare professionals and the primacy of maintaining employment in a capitalist society are examples of the “Zoe-Bios Dichotomy.” We can use COVID-19 as an example to explain how Zoe and Bios are connected to bio-power. We can also see the exercise of sovereignty in healthcare to determine the lives worth saving and those deemed to die.

According to Červený, Kratochvílová, Hellerová and Tóthová (2022) and Wang, Xiao, Yan, Wang and Yasheng (2018), with the rapidly increasing rate of globalization and the shifting demographics of many societies, it is essential for nurses to possess the knowledge to effectively care for patients from diverse backgrounds. However, we argue that cultural competence alone is insufficient. Nursing practice has placed too much emphasis on competency-based education in cultural values, which may result in the ongoing perpetuation of biases, othering, and stereotyping. In addition, nursing regulatory bodies have called for action on cultural competency in healthcare provision (Fitzgerald & Campinha-Bacote, 2019). Therefore, we must encourage the practice of unlearning in nursing education by sharing the power with the patients to narrate their stories and move away from the notion of nurses’ solely acquiring competence in their patients’ cultures.

The harmful narrative of cultural competency

To elaborate more on the detrimental effects of the cultural competency-based narrative in nursing care, we first need to examine the evolution of this concept and its implications for the care of older adults. Llorente and Valverde (2019) define cultural competence care as the ability of healthcare providers to deliver services that cater to patients’ social, cultural, and linguistic needs. This idea recognizes the unique cultural aspects of an individual's identity, which can affect the type of care they receive. The use of this concept has been supported in the learning and professional development of health professionals to reduce health inequalities and enhance the quality of care for older adults (Llorente & Valverde, 2019). Our argument is that utilizing the competency-based approach alone as a means to address discrimination and oppression experienced within the diversity of the healthcare system can potentially result in negative consequences by perpetuating a culturalist essentialism approach failing to go far enough in challenging the status quo. According to Yalcinkaya, Estrada-Villalta and Adams (2017), cultural essentialism is a belief that specific, distinct cultural patterns—such as values, beliefs, practices, and lifestyles—are linked to a particular group of people with a certain visible minority identity. These cultural patterns are considered to permanently and definitively influence the psychological traits that distinguish members of one marginalized group from another, such as associating South Asians with diabetes in nursing books and African women with genital mutilation. Essentialist and culturalist perspectives have a minimal understanding of what is at stake when it comes to the system of power and oppression and intersectional factors leading to marginalization; they view culture as something exotic that a group possesses, foster divisive patterns, presumptions and stereotypical behaviors in society (Roy-Michaeli, 2011). Similarly, Browne, Varcoe and Ward (2021) argue that “culturalist discourses” refer to complex practices and philosophies that employ stereotyped and popularized representations of culture—often confused with ethnicity—as their primary analytical tool to explain supposed distinctions between different groups. This notion also confuses “Race” with “Racism” and sees the underlying issues of illness and marginalization into race or ethnicity of individuals rather than systemic oppression and racism.

Cultural Appropriateness. Critiques have raised concerns about over-reliance on cultural competency-based initiatives in the health care of older adults, citing its narrow focus on increasing the transactional exchange of knowledge, skills, and attitudes and its failure to address complex social justice issues in a system. Such initiatives may also perpetuate the concept of “cultural appropriateness,” whereby the term “culture” is used as a simplistic substitute for an individual's entire identity, reducing them to their cultural background. This reductionist approach can reinforce prejudices and exploit marginalized populations. The reductionist approach is based on the idea that dismantling a complicated behavior or phenomenon and examining each fundamental part would enable us to understand it better (Cherry, 2023). The act of cultural appropriation, in which aspects of a different culture are utilized without proper recognition or respect for other intersectional aspects of an individual's identity, can have similarly harmful effects (Campinha-Bacote, 2019; Curtis et al., 2019; Murphy, 2023). Hence, the cultural competence approach may not be entirely sufficient in addressing health inequities faced by older adults from marginalized backgrounds. This is because it tends to often conflate culture with race or ethnicity. Moreover, it overlooks the diversity that exists within groups and may erroneously attribute a patient's health concerns to their cultural heritage; some examples of this wrongdoing are associating sick cell disease with Black individuals’ health in nursing textbooks (Boghossian et al., 2023).

Acculturalism and Transculturalism. Similarly, certain approaches, such as acculturation and transculturalism, may have unintended consequences that perpetuate problematic overemphasis on cultural differences. For example, acculturation entails forsaking one's native culture in favor of a new one, which can result in marginalized communities experiencing psychosocial stress, anxiety, depression, and post-traumatic stress disorder and interrupting their sense of belonging (Buscemi, 2011, p. 39; Fox, Thayer & Wadhwa, 2017). Correspondingly, transcultural nursing can lead to cultural conflicts as nurses may react differently based on their own cultural perspectives, resulting in detrimental ethnocentrism and stereotyping behavior that impacts the therapeutic nurse-patient relationship (Değer, 2018). In Canada, there is still a tendency for political propaganda to emphasize the concept of a “melting pot” regarding multiculturalism rather than recognizing and celebrating the diverse values and identities of individuals. This issue has been highlighted in certain provinces, such as Quebec, where the prohibition of religious symbols like hijabs, turbans, and yarmulkes in public sectors has sparked considerable debate (Canadian Civil Liberties Association (CCLA), 2022; Westfall, 2019).

The Neoliberal Notion of Competency-based Education. Neoliberalism is a political and economic practice that promotes individual entrepreneurial freedoms and skills within a framework of strong private property rights, free markets, free trade, and minimal government involvement (Gatwiri, Amboko & Okolla, 2020). However, in the health sector, neoliberalism and its policies tend to legitimize structural discrimination that harms marginalized groups by perpetuating socioeconomic and racial inequities (Vaismoradi, Moe, Ursin & Ingstad, 2022). Additionally, neoliberal practices prioritize the free market and profits over the human right to healthcare for all, leading to the privatization of healthcare, which exacerbates health inequities primarily affecting systemically marginalized individuals, such as older adults from marginalized groups (Gatwiri et al., 2020; Sakellariou & Rotarou, 2017). The integration of competency-based education into the nursing discipline, as introduced by neoliberal practices, has allowed for greater control over and commodifying academic knowledge and the transformation of universal healthcare systems. Public services, including healthcare, have increasingly been governed and highly regulated directly and indirectly through contracts, agreements on objectives, best practices, outcome-based payments, and inspections and audits for measuring service capabilities and cost-effectiveness (Foth & Holmes, 2017, p. 5). However, the privatization of the Canadian healthcare system has led to a significant increase in healthcare costs and the commodification of nursing care, resulting in growing health inequities. While cultural competence training is institutionally imposed to improve the standard of care and reduce health inequalities, research shows that it has little impact on eliminating health inequalities and addressing macro-level discriminatory policies and practices (Lekas, Pahl & Fuller Lewis, 2020). Although the concept of cultural competency proposes good intentions to combat health inequities, the disconnection of narrative from the structural systems of power and oppression is concerning.

Inquiry-Driven care toward cultural humility and respect

The approach of inquiry-driven care prioritizes reflection, critical thinking, ongoing processes of unlearning, relearning, respect, and cultural humility, which enable healthcare providers to build honest and trustworthy relationships with their patients (Yeager & Bauer-Wu, 2013). To address the health inequities affecting older adults from marginalized backgrounds, it's essential to acknowledge the pervasive systems of power and oppression that contribute to discriminatory practices, including racism, Islamophobia, ableism, ageism, and sexism (Churchwell et al., 2020; Vaismoradi et al., 2022). However, merely focusing on the behavior of healthcare providers through cultural competency training is not the solution to address the deeper roots of injustice established in a system. Instead, we must confront the systemic issues rooted in the legacy of colonization, genocide, violence, and all forms of political and social constructs that perpetuate discrimination against marginalized communities.

In order to promote an equity-oriented lens and cognitive abilities among nursing learners and trainees, it is essential for nursing education to integrate advocacy and social justice activism into the curriculum and strategic planning of school direction. Racism extends beyond individual biases and is deeply rooted in societal structures and governance. As nurse scholars, it is our duty to foster a culture that challenges victim-blaming language and addresses systemic issues that perpetuate discriminatory practices. Therefore, it is of utmost importance to prioritize reforms that dismantle colonial imperialist race-making policies, programs, and procedures that further oppress older adults from marginalized backgrounds.

To better serve older adults from marginalized communities, we must move beyond the notion of relying solely on competency-based education in the nursing discipline. It's simply impossible to fully comprehend all the intricacies of a culture if one is not from that background. Instead, we should prioritize building cognitive skills in our nursing students to build authentic and trustworthy therapeutic relationships with their patients, share power and amplify their voices by advocating for their needs, values, and preferences and encouraging involvement in social justice and activism initiatives aim to reform healthcare. To improve health outcomes for older adults from marginalized populations, we must foster an intersectional lens based on cultural humility and respect. This approach emphasizes patient-centered care and personhood in care planning and strives to overcome colonial and Eurocentric ways of knowing and doing that limit our understanding of patients’ needs from diverse backgrounds. By examining power dynamics, practicing reflexivity, and empowering patients based on their unique values and preferences, we can gain a better understanding of their experiences and share power in the care planning and delivery process. Ultimately, cultural humility is about being receptive to learning from patients and valuing their perspectives as significant sources of knowledge.

This discussion paper aimed to spark a critical dialogue about the essential role of an inquiry-driven approach based on considering intersectionality in the context of cultural humility and how it can guide our efforts towards antiracism, anti-oppression, anti-ageism, and post-colonialism initiatives in nursing education and practice. As nursing scholars, healthcare providers, policymakers, and leaders, it is crucial that we ourselves first become more engaged in advocacy initiatives for social justice to create a philosophical and organizational shift that promotes a deeper understanding of cultural humility within antiracism, anti-oppression, and anti-ageism initiatives.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Amany Farag Hassan Mohamed

Author Biographies

Amany Farag Hassan Mohamed, PhD Student, Arthur Labatt Family School of Nursing, MA (Education, Curriculum Studies) University of Western Ontario.

Shokoufeh Modanloo, Assistant Professor, Arthur Labatt Family School of Nursing University of Western Ontario.

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Re-thinking the Concept of Cultural Competency in Nursing Care of Older Adults

Abstract

Keywords

Introduction

Nursing care of older adults

The harmful narrative of cultural competency

Inquiry-Driven care toward cultural humility and respect

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

Author Biographies

References