Most of us are familiar with the terms cultural competence and cultural humility. These concepts address being sensitive and responsive to patients' racial, ethnic, gender-based, and sociodemographic differences and preferences, and recognition that such differences may influence and bias clinician-patient interactions (Tervalon & Murray-Garcia, 1998). Cultural humility is an active process that entails maintaining current knowledge about varied healthcare practices and beliefs as well as continuous self-reflection about one's own perspective and biases and their effect on one's views and reactions. It involves understanding that though a person's sociodemographic background may influence their needs and preferences, it is important to resist stereotyping and assuming that culture is the reason for a person's behavior. Failing to probe for the clinical significance of a person's symptoms and complaints may cause the clinician to miss important clinical clues (Tervalon & Murray-Garcia).
Structural competence stems from understanding that health is produced within a broad societal and institutional context that either supports or hinders a person's health and clinical status (Metzl & Hansen, 2014). Such effects are cumulative and perpetuated by forces beyond the individual's control. Structural impediments to optimal health include limited access to healthcare, healthy food, safe housing, transportation, childcare, and education, thus restricting choices, affecting decision-making, and hindering a person's opportunity to advocate for themselves and to pursue growth and development (Drevdahl, 2018). A clinician who views health status from this perspective can better identify barriers to optimal health and which aspects of a person's situation require structural interventions to provide appropriate support (Quesada et al., 2011).
Structural interventions may occur at multiple levels. Imagine caring for Elena, an obese, young Hispanic woman at 34 weeks' gestation, who has gestational diabetes mellitus (GDM) managed with insulin. She lives in a low-income neighborhood in a multigenerational household and works as a cashier at a fast food restaurant. She has not been consistently doing blood glucose (BG) checks or taking insulin as prescribed. The table below offers examples of cultural competence, cultural humility, and structural competence in this scenario.
Perinatal nurses can tailor care and supportive strategies by maintaining cultural competence, practicing cultural humility, and probing for structural barriers and risk factors inherent in each patient's unique situation.
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