Cultivating Cultural Competence in the Workplace, Classroom, and Clinic The latest U.S. Census reports that one in every three Americans belongs to a racial/ethic minority group. This deepening ethnic texture challenges speech-language pathologists and audiologists to become knowledgeable about cultural diversity and its impact on our professions. Developing respect for cultural diversity is essential for success in the workplace, ... Features
Free
Features  |   April 01, 2002
Cultivating Cultural Competence in the Workplace, Classroom, and Clinic
Author Notes
  • Cheryl K. Tomoeda, a senior research specialist in the department of speech and hearing sciences and the National Center for Neurogenic Communication Disorders at the University of Arizona, is a “sansei,” third-generation Japanese-American. With Bayles, she has produced a videotape series, organized workshops, and participated in local and national committees on issues related to cultural diversity. Contact her by email at cherylt@email.arizona.edu
    Cheryl K. Tomoeda, a senior research specialist in the department of speech and hearing sciences and the National Center for Neurogenic Communication Disorders at the University of Arizona, is a “sansei,” third-generation Japanese-American. With Bayles, she has produced a videotape series, organized workshops, and participated in local and national committees on issues related to cultural diversity. Contact her by email at cherylt@email.arizona.edu×
  • Kathryn A. Bayles, is a professor and head of the department of speech and hearing sciences and associate director of the National Center for Neurogenic Communication Disorders at the University of Arizona. She has over 30 years of experience developing programs to meet the needs of individuals from various cultural groups. Contact her by email at bayles@email.arizona.edu
    Kathryn A. Bayles, is a professor and head of the department of speech and hearing sciences and associate director of the National Center for Neurogenic Communication Disorders at the University of Arizona. She has over 30 years of experience developing programs to meet the needs of individuals from various cultural groups. Contact her by email at bayles@email.arizona.edu×
Article Information
Cultural & Linguistic Diversity / School-Based Settings / Professional Issues & Training / Features
Features   |   April 01, 2002
Cultivating Cultural Competence in the Workplace, Classroom, and Clinic
The ASHA Leader, April 2002, Vol. 7, 4-17. doi:10.1044/leader.FTR1.07062002.4
The ASHA Leader, April 2002, Vol. 7, 4-17. doi:10.1044/leader.FTR1.07062002.4
The latest U.S. Census reports that one in every three Americans belongs to a racial/ethic minority group. This deepening ethnic texture challenges speech-language pathologists and audiologists to become knowledgeable about cultural diversity and its impact on our professions. Developing respect for cultural diversity is essential for success in the workplace, classroom, and clinic, and is the foundation for building intercultural competence.
Cultural Differentiations
Culture, says Goodenough, is “a shared way of perceiving, believing, evaluating, and behaving.” No individual can know all cultures, but understanding the critical features that differentiate them gives clinicians an essential treatment tool. According to Brislin, cultures are differentiated by nine basic parameters: the value placed on the individual vs. the group, views of time and space, roles of men and women, concepts of class and status, values, language, rituals, the significance of work, and beliefs about health. All nine parameters can have profound effects on the practice of speech-language pathology and audiology.
Individualism vs. Collectivism. When great value is placed on individuals and their decisions, the culture is said to be individualistic. When great value is placed on the group and membership in the group, the culture is said to be collectivist. In collectivist cultures, group membership reaches beyond the nuclear family to the extended family, with decisions and actions made that serve to support the group. Individualists emphasize individual accomplishments; collectivists emphasize teamwork and harmony. Individualists speak for themselves; the collective speaks for the individual. Individualistic cultures are found in Europe, North America, Australia, and New Zealand. Collectivist cultures are found in Asia, Latin America, and Africa.
When clients whose culture is individualistic receive diagnostic or therapeutic services, they will make decisions about their course of treatment (perhaps with input from members of the immediate family). In contrast, members of the family group will likely directly influence decisions about the course of treatment for clients from collectivist cultures.
In the workplace, individualists value personal accomplishments and recognition, are more comfortable with equal-status relationships, are at ease working alone, and may place little importance on gender and age. Collectivists, on the other hand, often are reluctant to “toot their own horn,” prefer to work in teams, and are slow to develop personal relationships. They may feel more comfortable with authority and titles recognizing the importance of vertical relationships.
Views of Time and Space. Cultures are often distinguished by how strictly they adhere to a schedule. Individuals in “clock-time” cultures organize their days around clocks and daily planners, and emphasize punctuality. Other cultures, including American Indian and Hispanic, are more event-oriented. Rather than adhering strongly to schedules, they emphasize completion of one event (however long that takes) before beginning another. Issues can arise when clients from event-oriented cultures do not adhere to appointment schedules or respond vaguely when asked questions about temporal events.
Cultural differences are also evident in the use of personal space (proxemics). People vary in how comfortable they feel when talking with clinicians in treatment settings. Among westerners, interpersonal distances are typically 0–18 inches for intimate interactions, 1.5–4 feet for general personal interactions, and 4–12 feet for social/public interactions. Asians prefer a greater conversational distance than Americans, who, in turn, may feel uncomfortable with the closeness of stance of individuals from other cultures (e.g., Middle Eastern, African American).
Roles of Men and Women. The roles of men and women vary substantially across cultures, influencing access to education, ownership, and choice of profession. In many cultures, it is the man who makes decisions for the woman. For individuals from certain Middle Eastern countries, gender roles may even affect whether a woman can receive treatment without a male family member being present. Gender roles also can affect the degree to which a woman’s body can be exposed during a clinical examination.
Concepts of Class and Status. Among Euro-American groups, social class typically is defined by income, job prestige, and level of education; status refers to one’s place of respect within a society. Americans tend to be egalitarian, whereas in other cultures hierarchies exist and individuals of higher class or status may expect privileges. Asians, who value professional achievements and who are comfortable with status distances and hierarchies, are likely to prefer that professionals use their titles and display degrees. However, a client who is Native American may not be impressed by professional degrees and may be more interested in clinicians’ personal qualities and relationships to their clan.
Values. The values that people of a culture share can be understood from the culture’s view of the relationship of man to nature and of human beings to other human beings, the importance of ancestors and of the environment, and the degree of materialism. When treating a Hispanic client, for example, clinicians need to have a sense of concepts such as “familismo,” indicating that the family relationship is paramount; “respeto,” treatment of authority figures (parents, elders, priests) with respect; and “personalismo,” a personal rather than impersonal interest in arelationship.
Language. Communication is the product of a verbal code and non-verbal acts. Clinicians are well aware of how the semantics, phonology, syntax, and pragmatics aspects of a language influence interpersonal communication. A factor that fundamentally affects communication is the degree to which context is crucial in deriving meaning. Communication differs among cultures in the amount of information implied by setting or context. Cultures differ on a continuum ranging from high to low context. In high-context cultures—for example, Japanese, African American, Mexican, and Hispanic—the contribution of the context, in addition to the words themselves, is very important to communicating meaning. In low-context cultures—German, Swedish, European-American, English—the words themselves are crucial. Computer language, in which every statement must be precise, is an extreme example of low-context language. When interacting with individuals from high-context cultures, culturally competent clinicians are cognizant of the nonverbal aspects of the communication exchange such as eye contact, gestures, space, use of silence, and touch.
Rituals. Rituals or ceremonies are accepted ways of commemorating meaningful historical events, life changes, and renewing commitment to shared values. Many rituals are rooted in religion. Most cultures have rituals associated with weddings, births, deaths, and religious worship. The clinician should be aware of events, festivities, ceremonies, and celebrations that the client observes that might coincide with scheduled sessions or affect compliance with a treatment recommendation.
Significance of Work. Americans are defined by their work. When a young woman becomes engaged, we ask about her husband-to-be, “What does he do? “ People in many other cultures are defined by the groups to which they belong and their role in the community. The impact of loss of work because of disease or trauma will be related to the client’s view of work. Clinicians need to consider this when delineating treatment goals or selecting stimuli and functional activities for clients from different cultures.
Beliefs About Health. Cultures differ in the ways disabilities are explained. Native Americans may view individuals with disabilities as special, or as Images of the Holy People (see Westby & Begay Vining in resources box on page 17), or as bewitched. Among certain Native American people, a person who suffers a stroke is thought to have been “hit by the wind.” In many cultures, illness occurs when an individual is out of harmony with nature or the universe. Cultural differences exist in determining the appropriate person to provide health care or restore well-being. Spiritualists, folk healers, herbalists, or witch doctors may be chosen over Western medical professionals.
In addition to the macrocultural values that bind people together, each individual belongs to several microcultures defined by variables such as age, geographic region, and education. It is useful for clinicians to be familiar with microcultures and their impact on cross-cultural interactions. Given our nation’s immigration patterns, it is critical that clinicians explore the client’s level of acculturation into mainstream American society, that is, the process of change associated with learning and using the rules of another culture. A simple method of measuring level of acculturation was delineated by Paniagua in which degree of acculturation can be determined by the client’s responses to the following three statements: My generation is __; The language I prefer to use is __; and I prefer to engage in social activities with __.
Cultural Characteristics and Clinical Decision Making
In the clinical setting, SLPs and audiologists are challenged to accurately diagnose clients’ problems, establish appropriate treatment, and motivate them to comply with the recommended course of treatment. Yet, our clients’ cultural beliefs will affect how they describe their health problems, the manner in which they present their symptoms, who they seek for health care, how long they remain in care, and how they evaluate the care provided.
Arthur Kleinman, a psychiatrist and medical anthropologist, advocates that clinicians ask patients to provide an explanation of the illness or disability, so that differences between the explanatory models of the client and the clinician can be identified and discussed. The clinician can then negotiate with the patient, as a therapeutic ally, about treatment and expected outcomes. Kleinman, Eisenberg, and Good (see resource box below) specify eight questions that can be used to elicit the patient’s explanatory model: What do you think has caused your problem? Why do you think it started when it did? What do you think your sickness does to you? How does it work? How severe is your sickness? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness?
To optimize patient outcomes, clinicians need to develop therapeutic relationships with all their clients, including those from cultures different from their own and, in many cases, the families of their clients. Success in this area is directly related to the clinician’s intercultural knowledge and skills. Clients are more responsive in culturally familiar environments and cultural markers evoke feelings of security. They expect that their cultural traditions will be respected. Clinicians must recognize how a client’s cultural and linguistic characteristics will influence the clinical decision-making process and determine how communicative competence and impairment are evaluated.
For example, in testing situations, clinicians should be aware that African American and Puerto Rican children tend to describe pictured objects rather than name them. Among Native American children, silence in response to a question may be a sign of respect rather than an inability to answer the question. In addition, clinicians must be aware of their own cultural characteristics and communication style. Are you direct or indirect? Do you use little or large gestures? Are you soft-spoken or loud? Your behaviors will affect your clients’ perceptions of you and the success of treatment.
Improving Your Intercultural Skills
To prepare yourself to meet the clinical challenges of providing treatment to culturally unique clients, it is important to learn about your own culture and about other cultures. Several excellent resources are available that provide information on the effects of culture on education and rehabilitation (see sidebar). Become a member of ASHA Special Interest Division 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations (for more information, visit Division 14’s Web site). Cultivate relationships with individuals who can serve as cultural informants, people whom you can question about the culture and verify your perceptions. Attend cultural events in your community to learn about rituals and values and demonstrate your interest to members of that culture’s community. Finally, be flexible in your intercultural interactions. Reserve your judgments about behaviors and intentions until you understand the cultural context in which they were generated. As with any other line of scientific inquiry, in intercultural encounters, culturally competent clinicians must collect data, objectively interpret them, and use this information to drive appropriate clinical responses.
References and Recommended Resources

Books and Articles

Battle, D. E. (2002). Communication disorders in multicultural populations. Boston: Butterworth Heinemann.
Battle, D. E. (2002). Communication disorders in multicultural populations. Boston: Butterworth Heinemann.×
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus and Giroux.
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus and Giroux.×
Goldberg, S. A. (1997). Clinical skills for speech language pathologists. San Diego: Singular. (See chapter on “Culture.”)
Goldberg, S. A. (1997). Clinical skills for speech language pathologists. San Diego: Singular. (See chapter on “Culture.”)×
Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech-language pathologists. San Diego, CA: Singular Publishing Group/Thomas Learning.
Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech-language pathologists. San Diego, CA: Singular Publishing Group/Thomas Learning.×
Goodenough, W. (1987). Multi-cuturalism as the normal human experience. in Effy, E. M. and Partridge, W. L. (Eds). Applied anthropology in America (2nd ed.) New York: Columbia University Press.
Goodenough, W. (1987). Multi-cuturalism as the normal human experience. in Effy, E. M. and Partridge, W. L. (Eds). Applied anthropology in America (2nd ed.) New York: Columbia University Press.×
Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.
Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.×
Kleinman, A., Eisenberg, L. & Good, B. (1978). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258.
Kleinman, A., Eisenberg, L. & Good, B. (1978). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258.×
Paniagua, F.A. (1994). Assessing and treating culturally diverse clients: A practical guide. Thousand Oaks, CA: Sage.
Paniagua, F.A. (1994). Assessing and treating culturally diverse clients: A practical guide. Thousand Oaks, CA: Sage.×
Roseberry-McKibbin, C. (1995). Multicultural students with special language needs. Oceanside, CA: Academic Communication Associates.
Roseberry-McKibbin, C. (1995). Multicultural students with special language needs. Oceanside, CA: Academic Communication Associates.×
Wallace, G. L. (Ed.) (1997). Multicultural neurogenics. San Antonio, TX: Communication Skill Builders.
Wallace, G. L. (Ed.) (1997). Multicultural neurogenics. San Antonio, TX: Communication Skill Builders.×
Westby, C., & Begay Vining, C. (2002). Living in harmony: Providing services to native American children and families. In Battle, D. E. (Ed.), Communication disorders in multicultural populations (3rd ed.). Boston: Butterworth-Heinemann.
Westby, C., & Begay Vining, C. (2002). Living in harmony: Providing services to native American children and families. In Battle, D. E. (Ed.), Communication disorders in multicultural populations (3rd ed.). Boston: Butterworth-Heinemann.×
Wlodkowski, R. J., & Ginsberg, M.B. (1995). Diversity and motivation: Culturally responsive teaching. San Francisco: Jossey-Bass.
Wlodkowski, R. J., & Ginsberg, M.B. (1995). Diversity and motivation: Culturally responsive teaching. San Francisco: Jossey-Bass.×
Yeo, G., & Gallagher-Thompson, D. (1996). Ethnicity and the dementias. London: Taylor & Francis.
Yeo, G., & Gallagher-Thompson, D. (1996). Ethnicity and the dementias. London: Taylor & Francis.×

Videotapes

Brislin, R. W. (1994). Understanding cultural diversity: A model (Videotape 1). Tucson, AZ: University of Arizona National Center for Neurogenic Communication Disorders.
Brislin, R. W. (1994). Understanding cultural diversity: A model (Videotape 1). Tucson, AZ: University of Arizona National Center for Neurogenic Communication Disorders.×
Brislin, R. W., Pacheco, M., Harris, J., Stauss, J., & Tomoeda, C. K. (1994). Understanding cultural diversity: The perspectives of minority professionals (Videotape 2). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.
Brislin, R. W., Pacheco, M., Harris, J., Stauss, J., & Tomoeda, C. K. (1994). Understanding cultural diversity: The perspectives of minority professionals (Videotape 2). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.×
Brislin, R. W., Stauss, J., Molina-Willhock, M., Loretto, H., & Cullen, Cullen (1994). Understanding cultural diversity: The challenge of providing health care to American Indians (Videotape 3). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.
Brislin, R. W., Stauss, J., Molina-Willhock, M., Loretto, H., & Cullen, Cullen (1994). Understanding cultural diversity: The challenge of providing health care to American Indians (Videotape 3). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.×
Perez, J. (1998). Understanding cultural diversity: Providing health care to Hispanic immigrant children (Videotape 4). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.
Perez, J. (1998). Understanding cultural diversity: Providing health care to Hispanic immigrant children (Videotape 4). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.×
Beardsley, L. M. (1999). Understanding cultural diversity: The importance of culture in building therapeutic relationships (Videotape 5). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.
Beardsley, L. M. (1999). Understanding cultural diversity: The importance of culture in building therapeutic relationships (Videotape 5). Tucson, AZ: University of Arizona, National Center for Neurogenic Communication Disorders.×
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
April 2002
Volume 7, Issue 6