Reading homework help

Social Work Education, 2015 Vol. 34, No. 2, 165-181, http://dx.doi.org/10.1080/02615479.2014.977244 i RoutledgeTaylor & Francis G roup
From Mastery to Accountability: Cultural Humility as an Alternative to Cultural Competence M arcie Fisher-Borne, Jessie M on tana Cain & Suzanne L. M a rtin
Cultural competency has been a long held ideal for social work educators and practitioners. However, definitions and approaches to cultural competency vary widely depending on worldview, discipline, and practice context. Within social work and beyond, cultural competency has been challenged for its failure to account for the structural forces that shape individuals’ experiences and opportunities. In contrast, the concept of cultural humility takes into account the fluidity of culture and challenges both individuals and institutions to address inequalities. This article takes a critical look at cultural competence as a concept, examining its explicit and implicit assumptions, and the impact these assumptions have on practitioners. It suggests that cultural humility may offer social work an alternative framework as it acknowledges power differentials between provider and client and challenges institutional-level barriers. The authors advocate a move from a focus on mastery in understanding ‘others’ to a framework that requires personal accountability in challenging institutional barriers that impact marginalized communities. Cultural humility, while a promising concept, has not been fully explored in social work. Therefore, the authors present a conceptual model of cultural competency along with strategic questions for providers and organizations to integrate into social work practice and education.
Keywords: Cultural Humility; Cultural Competence; Cultural Sensitivity; Diversity
Social work has long been dedicated to addressing the needs of all individuals, families, and communities [International Federation of Social Workers (IFSW), 2012a]. The emergence of culturally specific practices, designed to achieve cultural competence,
North Carolina State University, USA; University of North Carolina-Chapel Hill, USA Correspondence to: Marcie Fisher-Borne, Department of Social Work, Center for Family and Community Engagement, North Carolina State University, Campus Box 7639, 1911 Building Rm. 205B, Raleigh, NC 27695, USA. Tel: 919-513- 1801; Email: mmfishe2@ncsu.edu
© 2014 Taylor 8c Francis
 

 
166 M. Fisher-Borne et al.
was sparked by the awareness of growing diversity and research highlighting disparate health outcomes among historically marginalized populations. Specifically, clients from historically marginalized communities (e.g„ Racial and ethnic minorities, immigrants, and economically disadvantaged communities) are less likely to access or receive needed services due to a lack of culturally appropriate service provision (Hausmann et al, 2011; Paradies, 2006). Further, it is often noted that the services received by clients from marginalized communities, such as racial and ethnic minorities, are of poorer quality than those received by their White counterparts [Carpenter-Song, Schwallie, & Longhofer, 2007; Institute of Medicine (IOM), 2003].
This article begins with a broad discussion of the evolution of culturally specific work as a means of addressing disparities in the fields of medicine, nursing, psychology, and social work. Next we discuss cultural competence within health and human service professions and present critiques of the concept. Acknowledging the critiques of cultural competence, we then present cultural humility as an alternative. We conclude with a conceptual model and essential questions for cultural humility as a useful framework to move practitioners from a ‘mastery’ based model to one in which the social work practitioner pursues individual and institutional accountability in challenging the barriers that impact marginalized communities.
The Evolution of Culturally Specific Work
As a core tenet of social work, cultural competence emerged from culturally specific work within a wide array of fields including medicine, nursing, and psychology. We present an overview of early contributions to the conceptualization of cultural competency followed by a discussion of cultural competence as a framework.
Medicine
The etiology of cultural competency, as it is understood in medicine, can be traced to medical anthropology and the work of Arthur Kleinman. He argued for a client- centered, rather than a disease-based, approach to health and developed an Explanatory Model of Health and Illness to recognize and validate clients’ conceptions, explanations, and expectations of their experience of illness based on cultural beliefs and encounters (Kleinman, 1981). Though providers may identify illness from a purely biomedical perspective, individuals’ experiences of health and disease are more complex. The exploration of this complexity and the role culture plays, from both a provider and a client perspective, has provided the medical field with a foundation for understanding cultural competency.
Nursing
Since the early 1900s, the field of nursing has explored cultural aspects of health. In 1917, the Committee on Curriculum of the National League for Nursing published a curriculum guide that included content on social inequalities (DeSantis 8c Lipson,
 

 
Social Work Education 167
2007). In the 1950s, Madeline Leininger pioneered the field of transcultural nursing and provided the foundational concepts of cultural competency in the field of nursing (Leininger, 1991). The term cultural competency is currently used interchangeably with cross-cultural or transcultural nursing. Leininger (1991) asserted that understanding the learned, shared, and transmitted values as well as beliefs, norms, and life experiences of a particular group would help nurses provide culturally specific and congruent care. In 1983, the National League for Nursing developed criteria for nursing education curricula that addressed ethnic, racial, and cultural diversity (DeSantis & Lipson, 2007). In 1992, the American Academy of Nursing’s Expert Panel on Culturally Competent Care first defined culturally competent care as that which is ‘sensitive to issues related to culture, race, gender, and sexual orientation’ (American Academy of Nursing, 1992, p. 278). In 2007, the panel reconvened, citing an increased need to focus on cultural competency as a way to eliminate health disparities and, in an effort to ‘advance clarity and understanding of the concept’, offered new recommendations related to identifying an effective model of culturally competent care and furthering related research in the nursing profession (Giger et al., 2007, p. 96).
Psychology
While awareness of culture in the field of psychology includes the work of prominent scholars such as Carl Jung and Erik Erikson (Suh, 2004), the body of work by Deraid Sue and colleagues has set the standard for cultural competency in the field of mental health on an individual provider level (Sue, 2001; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982). Sue et al. (1982) developed multicultural counseling guidelines that are now considered standard cultural competency guidelines by six divisions of the American Counseling Association and two divisions of the American Psychological Association (Suh, 2004). General concepts of cultural competency focus on cross- cultural language skills, awareness of diversity, and providing effective care across lines of difference (Sue, 2001). Joseph Ponterotto has also made significant contributions in multicultural psychology and counseling. His work has challenged the methods used to examine culture, race, and ethnicity (Ponterotto, 2010a Ponterotto & Mallinckrodt, 2007). Noting the limitations of racial identity theories, Ponterotto (2010b) and his colleagues (Ponterotto, Ruckdeschel, Joseph, Tennenbaum, & Bruno, 2011) recently introduced a comprehensive theory of multicultural personality to better understand the clinician characteristics through the use of both quantitative and qualitative methods which has added to the field of multicultural psychology.
Social Work
Cultural competency has been at the core of social work theory and practice since the term was first introduced with the work of Sue et al. (1982) that formed the foundation for early cultural competency models in social work (Yan & Wong, 2005).
 

 
168 M. Fisher-Borne et al.
Terms related to culture and social work practice emerged in the literature in the early 1980s (Fong & Furuto, 2001). These terms included ethnic sensitive social work practice, cultural awareness, cross-cultural social work, ethnic competency (Devore & Schlesinger, 1981; Green, 1995), and a process-stage approach with people of color (Lum, 1986). According to Green (1995), ethnic competency represents a provider’s awareness of his or her limitations, being open to cultural differences, adopting a client-centered approach, and utilizing cultural resources. Lum (1999) introduced the term culturally competent practice to social work and provided a foundation for social workers to understand and evaluate multicultural counseling competencies with people of color.
Social worker Terry Cross and his colleagues provided pioneering work in the field of cultural competency (Cross, Bazron, Isaacs, & Dennis, 1989). To date, their description of cultural competence as ‘a set of attitudes, skills, behaviors, and policies enabling individuals and organizations to establish effective interpersonal and working relationships that supersede cultural differences’ (Cross et al., 1989, p. 3) is the most widely cited definition. They also expanded the discussion to include an institutional framework for assessing effective services for minority populations. Cross et al. argued that the same skills needed on an individual and clinical level were necessary on a macro level, which included the evaluation of an agency’s policies, procedures, and practices to assess their cultural compatibility with the populations they serve (Fong & Furuto, 2001).
Professional Mandates for Cultural Competence
Numerous accreditation bodies in medicine, public health, nursing education, and social work consider cultural competency a standard of care within their educational objectives [Accreditation Council on Graduate Medical Education (ACGME), 1999; American Public Health Association (APHA), 1998; Office of Minority Health, 2001], In the United States, the National Association of Social Workers’ (NASW) Code of Ethics (2000) includes a standard for Cultural Competence and Social Diversity which states that social workers should ‘understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability (NASW, 2000). In 2001, NASW established standards for culturally competent social work practice to provide specific guidelines for practitioners when working with diverse populations (NASW, 2001). While these standards concede ‘cultural competence is never fully realized, achieved, or completed’, but is rather ‘a lifelong process’ (NASW, 2001, p. 11), the practice of training practitioners for working with diverse clients often treats the process in a linear fashion that often suggests that ‘knowing’ about group differences alone is a sufficient strategy. The global standards developed by the International Federation of Social Workers state that central to the ‘core purpose of the social work profession’ is a professional’s ability to ‘address and challenge barriers, inequalities and injustices that exist in society’ and
 

 
Social Work Education 169
‘advocate changes in those policies and structural conditions that maintain people in marginalized, dispossessed and vulnerable positions’ (IFSW, 2012a).
Critiquing Cultural Competence
While cultural competence is included in numerous professional mandates, country- level policy guidelines, and deeply embedded in numerous educational curricula and training across health and social service disciplines, a growing body of literature has challenged the explicit and implicit assumptions of cultural competency (Abrums & Leppa, 2001; Dean, 2001; Duffy, 2001; Dunn, 2002; Furlong & Wight, 2011; Gregg & Saha, 2006; Jayaratne, Faller, Ortega, & Vandervort, 2008; Kleinman & Benson, 2006; Tervalon 8c Murray-Garcia, 1998; Wear, 2003). The major criticisms of cultural competency frameworks include: (a) the focus on comfort with ‘others’ framed as self- awareness; (b) the use o f ‘culture’ as a proxy for minority racial/ethnic group identity; (c) the emphasis on attempting to ‘know’ and become ‘competent’ in understanding another’s culture or cultures; and (d) the lack of a transformative social justice agenda that addresses and challenges social inequalities.
Focus on Self-Awareness— Getting Comfortable with ‘Them’
Although the majority of cultural competency models focus on increasing some level of self-awareness (Campinha-Bacote, 1999; Culhane-Pera, Reif, Egli, Baker, 8c Kassekert, 1997; Sue et al., 1992), the various models tend to focus on creating an environment where practitioners are more ‘comfortable’ (Purnell, 2005) with others as opposed to being self-aware of power differentials (e.g., between health care provider and client) or what bias and assumptions they may bring to the provider-client relationship when working with clients from different backgrounds and/or identities. Many cultural competency frameworks fail to encourage critical self-awareness that examines or challenges the inherent power imbalance between provider and client (Tervalon 8c Murray-Garcia, 1998) but instead focus primarily on exposing providers to different (i.e., non-dominant) cultural groups.
These frameworks often fail to explore ways in which cultural values and structural forces shape not only client experiences and opportunities but also providers’ approaches and capacity for care (Duffy, 2001; Tervalon 8c Murray-Garcia, 1998; Wear, 2003). For providers who are part of dominant mainstream culture (e.g., White, male, middle class), cultural competency must include recognition that among a dominant culture’s ‘deeply ingrained values are those that perpetuate separation and discrimination’ (Dunn, 2002, p. 107). Sue et al. (1992) provides the only model that discusses the role ethnocentrism may play in provider care.
Many current cultural competency models fail to account for the complex history and reality of present health, economic, and social inequalities. For example, within the Campinha-Bacote (2003) model of cultural competency, the stage of cultural desire states that providers must want to understand differences. In reality, constructs such as cultural desire are complex and must include an analysis of why
 

 
170 M. Fisher-Borne et al.
providers (particularly those who represent dominant culture) may not desire to understand differences. Dunn (2002) argues that providers must acknowledge that social/cultural values which privilege certain groups (i.e., White people) may translate into personal values and behavior that are discriminatory and unconsciously exclusionary.
Racial/Ethnic Group Identity as a Proxy for ‘Culture’
Although ‘culture’ is often defined as pattern of beliefs, customs, and values, a commonly voiced critique of cultural competency is that the term culture is often conflated with or used as a proxy for non-white racial identity. A focus solely on race and/or ethnicity often ignores disparities that exist in regards to other aspects of identity (e.g., gender, socio-economic status, disability, and sexual orientation). For example, the Purnell model (2005) labels sexual orientation and ‘gender issues’ as ‘secondary’ cultural characteristics attributed to ‘life’s circumstances’ (p. 14) as opposed to immutable primary characteristics. The separation of identities into individual and distinct categories with different values is problematic. Similarly, Sue’s model (2001) asserts that racial identity has primacy over other socio-demographic characteristics due to providers’ ‘greater discomfort’ (p. 792) with race. These assertions do not allow an individual to define their own salient identities nor do they account for intersections of identities such as race, gender, gender identity, and sexual orientation. More importantly, this framework treats culture as a static construct and assumes that culture does not shift over time (Ridley, Baker, & Hill, 2001).
Mastering Knowledge of the ‘Other’
Another core critique of cultural competency frameworks involves the explicit goal of competence itself (Dean, 2001; Kumagai & Lypson, 2009). Competence suggests that knowing broad descriptions of various group identities can translate into knowing the life experiences of an individual client. This ‘other’ focus also assumes that the ‘locus of normalcy is White, Western culture while the ‘other’ is defined as ‘nonwhite, non-Western, non-heterosexual, non-English-speaking, and non-Christian’ (Wear, 2003, p. 550). With this orientation, the only barriers between provider and client are ‘understanding’ and ‘awareness’, not systemic inequalities (Duffy, 2001). Dominant groups (e.g., White people) learn about non-dominant groups (often people of color) to characterize behavior in the name of understanding. With this orientation, learning a group’s history is seen as sufficient, with little need to strive for social justice to eliminate oppression.
The danger of this strategy is that it supposes ‘culture’ is monolithic and knowable and may create stereotypical composites of various group identities (Betancourt, 2003, 2004; Dunn, 2002). For example, Isaacson (2014) found that although the nurses in her study described themselves as culturally competent, they still held negative stereotypes about the groups they worked with. This demonstrates that cultural competency is not simply a technical skill, a communication technique, nor something that can be learned overnight
 

 
Social Work Education 171
(Kleinman & Benson, 2006). Rather, cultural competency ‘requires a fundamental change in the way people think about, understand, and interact with the world around them’ (Dunn, 2002, p. 107), which is an ongoing process without a finite endpoint.
The notion of intersectionality is an emerging concept within the social work literature that challenges the concept of culture as static. Intersectionality disrupts the idea of social identities (e.g., race, ethnicity, gender, etc.) operating in isolation, and instead posits that individuals should be understood as whole and complex (Davis, 2008). It has also been useful in understanding multiraciality (Jackson & Samuels, 2011; Samuels 8c Ross-SherifT, 2008). Going against cultural competence’s goal of mastery, Anastas (2013) recognizes that ‘it is impossible to understand all the intersectionalities that we, our students, and our clients inhabit and enact’ (p. 91), thereby calling for a more comprehensive model. Garran and Werkmeister Rozas (2013) challenged the field of social work to reconsider cultural competence as presently defined in order to acknowledge this complexity.
Failure to Challenge Systemic Inequalities
Jani, Pierce, Ortiz, and Sowbel (2011) warn that ‘by relying on cultural competence as a conceptual guide, social workers have neglected to pursue a transformative agenda and have defaulted to positions on practice that inadvertently reinforce the status quo’ (p. 296). This statement positions cultural competence as antithetical to its intended aim of addressing disparities among marginalized communities. The majority of cultural competency literature focuses specifically on practitioners learning about others as a means to combat inequality, though often fails to identify the structural forces, such as poverty and racism, that underlie health and social disparities (Betancourt, Green, 8c Carrillo, 2002; Jacobs, Kohrman, Lemon, 8c Vickers, 2003). While cultural competence has provided a springboard for conversations around what it means to provide quality care, specifically to those from historically marginalized communities, it has not resulted in a transformative agenda to address inequalities. On the other hand, cultural humility offers social work an alternative approach that focuses on knowledge of self in relation to others, acknowledges the dynamic nature of culture, and challenges barriers that impact marginalized communities on both individual and institutional levels.
Distinguishing Cultural Humility from Cultural Competency
Cultural Humility, attributed to Tervalon and Murray-Garcia (1998), is a process of ‘committing to an ongoing relationship with patients, communities, and colleagues’ that requires ‘humility as individuals continually engage in self-reflection and self-critique’ (p. 118). Cultural humility takes into account the fluidity and subjectivity of culture and challenges both individuals and institutions to address inequalities. As a concept it challenges active engagement in a lifelong process (versus a discrete endpoint) that individuals enter into with clients, organizational structures, and within themselves (Tervalon 8c Murray-Garcia, 1998).
 

 
172 M. Fisher-Borne et al.
Both cultural competence and cultural humility are similar in their aim to address existing disparities in how care is delivered but differ greatly in their approach. Cultural competence models emphasize knowledge acquisition while cultural humility emphasizes the need for accountability, not only on an individual level, but also on an institutional level. Cultural humility addresses many of the critiques leveled against cultural competency models. For example, the cultural humility approach explicitly acknowledges power differentials between provider and client and asserts that problems do not often arise ‘from a lack of knowledge but rather the need for a change in practitioners’ self-awareness and attitudes toward diverse clients’ (Tervalon & Murray-Garcia, 1998, p. 118). Instead of engaging providers in a descriptive process of ‘the other’, this approach advocates for self-reflection on ‘unintentional’ patterns of ‘racism, classism, and homophobia’ (p. 119). Overall, the approaches differ in their perspective on culture, assumptions, components, stakeholders, and critiques. See Table 1 for a detailed comparison of both models.
The cultural humility concept offers a deeper foundation to begin the work of eliminating inequity compared to other cultural-specific models. Cultural humility seeks to cultivate self-awareness on the part of providers and acknowledges the ways in which cultural values and structural forces shape client experiences and opportunities. As such, this approach accounts for structural inequalities and the
Table 1 Comparison of Cultural Humility and Cultural Competence
Cultural competence Cultural humility Perspective • Acknowledges the layers of cultural on culture identity
• Challenges stereotypes • Difference is seen in the context of
systemic discrimination
Assumptions • Assumes the problem is a lack of < knowledge, awareness and skills to work across lines of difference
• Individuals and organizations develop < the values, knowledge and skills to work across lines of difference
Components • Knowledge < • Skills < • Behaviors «
Stakeholders • Practitioner (primarily) <
Critiques • Focus on knowledge acquisition • Issues of social justice not inherent • Regarded as a ‘cookbook’ approach • Leads to stereotyping the ‘other’ • Suggests an endpoint
1 Acknowledges the layers of cultural identity
1 Recognizes that working with cultural differences is a lifelong and ongoing process
1 Emphasizes not only understanding the ‘other’ but understanding ourselves as well Assumes that in order to understand clients, we must also understand our communities, colleagues, and ourselves Requires humility and recognition of power imbalances that exist in client- provider relationships and in society Challenging power imbalances Institutional accountability Ongoing critical self-reflection Practitioner Client Community Institution/Organization Lack of empirical data Lack of conceptual framework
 

 
Social Work Education 173
complexities of culture in a way that is absent from many of the existing cultural competency models and strengthens our social justice commitment as social work practitioners.
Cultural Humility in the Literature
While cultural humility provides a theoretical re-visioning of traditional cultural education efforts, it is less developed than current cultural competency models. However, a recent growth of medical literature documents the positive impact of cultural humility and reported improved patient outcomes (Alsharif, 2012; Chang, Simon, & Dong, 2012; Juarez et al., 2006). Chang and his colleagues (2012), through the use of a client-rated measure, found that cultural humility training led to improved practitioner-client relationships and health outcomes. Other studies document positive changes in providers. For example, Juarez and her colleagues (2006) implemented a year-long medical curriculum that included cultural humility and reported an increase in patient involvement and attention to patient’s contexts.
Similarly, Ross (2010) described a training module within a community development and planning graduate program, which integrated cultural humility principles into the course to allow students to examine their attitudes and beliefs on issues of power, privilege, and diversity. She found that students increased their knowledge of inequities and awareness of themselves. She posited that ‘students’ insights about community dynamics and their own biases would lead to new ways of working with community members’ (p. 328).
While other fields are beginning to embrace cultural humility, literature in social work is limited, with only one article (Ortega 8c Faller, 2011) reporting an explicit cultural humility focus. In their article, Ortega and Faller (2011) argue that cultural humility is needed for child welfare workers engaging with families and requires a paradigm shift in how workers approach cultural differences. The authors see cultural humility as a ‘complement’ to cultural competence to ‘liberate workers from expectations of cultural expertise’ (p. 27). While this article brings the conversation regarding cultural humility into the field of social work, we seek to both challenge and extend their recommendation regarding the importance of cultural humility within social work education and practice.
First, we argue that cultural humility is actually an alternative rather than a ‘complement’ to cultural competency. As we discussed in the previous section, each concept operates under distinct paradigms. Most notable is cultural humility’s three components: reflection, institutional and individual accountability, and the mitigation of systemic power imbalances. While there is burgeoning literature documenting the positive impact of cultural humility in educational trainings, acknowledgement of how institutional accountability and the mitigation of systemic power imbalances factor into the core model of cultural humility are missing from the literature. These two components are critical to addressing social and economic disparities in the field of social work. In the section that follows, we offer a
 

 
174 M. Fisher-Borne et al.
conceptual model of cultural humility and strategies that place equal emphasis on all three components. We present this model to highlight the cyclical ongoing nature of cultural humility through the presentation of a conceptual framework for cultural humility.
Moving from Mastery to Accountability: A Conceptual Model for Cultural Humility
The cultural humility approach includes three core elements: institutional and individual accountability; lifelong learning and critical reflection; and mitigating power imbalances. These elements, each depicted in Figure 1, comprise our proposed conceptual model for cultural humility. The model depicts that at the core of cultural humility is a sense of accountability, which differs immensely from a sense of mastery. Accountability means a commitment to self-reflection that is active and responsible. Institutional and individual accountability are presented as inter-related gears, having to work in concert with one another in order to incite long-term change. The next element, ongoing learning and critical reflection, is essential to keeping the cogs of accountability moving and to mediate the movement from accountability to shifting power imbalances.
Additionally, the gears communicate that cultural humility is a process of lifelong learning and critical reflection for both individuals and institutions. The final element within the conceptual framework, an ever-present yet permeable circle, represents individual and structural power imbalances, which are malleable when power is recognized and leveraged. Unlike many culturally specific frameworks, within this model, individual and institutional accountability are interconnected and weighted
Power Imbalances
Institutional Accountability
Ongoing Learning & Critical Self-Reflection
Ongoing Learning & \ Critical Self-Reflection ‘•
Power Imbalances
Figure 1 Core Elements of Cultural Humility.
 

 
Social Work Education 175
equally. This is a critical distinction as many of the existing models of cultural competency in the empirical literature focus almost exclusively on individual-level changes and fail to adequately communicate how individual and organizational change are interconnected. While social work practitioners and educators may individually speak and train on both individual and organizational cultural competency, the literature reflects a dearth of models and interventions that adequately highlight the importance of organizational-level change strategies also addressing issues of power and privilege.
The Culturally Humble Practitioner and Organization
Shifting from a sense of mastery to accountability requires asking challenging questions to move towards more responsible, culturally humble work that is in line with the Social Work profession. As social workers, we are called to ‘promote change while working to support the empowerment and liberation of people to enhance well-being’ (International Federation of Social Workers, 2012a). We are further called professionally to challenge ‘negative discrimination, distribute resources equitably, and challenge unjust policies and practices’ (International Federation of Social Workers, 2012b). As such, we should ask questions that move us beyond simplistic and reductionist conversations about difference and ask more of our institutions and ourselves. For example, Table 2 reflects a series of questions we see as essential for self-reflection and addressing power imbalances on both the individual and institutional levels.
Essential questions for critical reflection are designed to encourage both practitioners and institutions to a deeper understanding of the communities and clients they support. In their work with students, Isaacson (2014) and Ross (2010) found that awareness of biases is not sufficient. In these research studies, students experienced growth, evident through changes in their values, attitudes, and beliefs, through confronting their biases. The essential questions presented in Table 2 move individuals and institutions deeper by asking challenging, ongoing questions of individuals, institutions, and communities as they continue to evolve.
Cultural humility requires an understanding of self on a deeper level and an analysis of power and privilege. The questions we propose aim to encourage practitioners to become self-aware and self-critical in order to understand how their own identities, beliefs and practices impact on their interactions with clients. Practitioners must also ask what structural forces come into play when addressing client issues and how to engage around these issues in meaningful ways. These questions can be used to evaluate an institution’s effectiveness and guide staff training, professional development, and strategic planning. Accountability differs from mastery in that action is required. Mastery asks individuals to ‘understand’ others while accountability calls individuals and institutions to act. How we motivate individuals and organizations to ask these questions and move to action on power imbalances is a critical next question. We believe this type of model is a first step needed to help social work begin to have these important conversations that will inspire individual and organizational change.
 

 
176 M . Fisher-Borne et al.
Table 2 Individual and Organizational Questions to Assess Cultural Humility
Essential questions for critical self- Essential questions to address power reflection imbalances
Individual- level
Institutional- level
• What are my cultural identities? • • How do my cultural identities shape my
worldview? • How does my own background help or •
hinder my connection to clients/ communities?
• What are my initial reactions to clients,* specifically those who are culturally different from me?
• How much do I value input from my • clients?
• How do I make space in my practice for clients to name their own identities?
• What do I learn about myself through listening to clients who are different than me?
• How do we organizationally define • culture? Diversity?
• Does our organization’s culture encourage respectful, substantive discussions about difference, • oppression, and inclusion?
• How does our hiring process reflect a • commitment to a diverse staff and leadership?
• Do we monitor hiring practices to • ensure active recruitment, hiring, and retention of diverse staff?
• Does our staff reflect the communities we serve?
• Is our leadership reflective of the • populations/communities we serve?
What social and economic barriers impact a client’s ability to receive effective care? What specific experiences are my clients having that are related to oppression and/or larger systemic issues? How do my practice behaviors actively challenge power imbalances and involve marginalized communities? How do I extend my responsibility beyond individual clients and advocate for changes in local, state, and national policies and practices?
How do we actively address inequalities both internally (i.e., policies and procedures) and externally (i.e., legislative advocacy)? How do we define and live out the core social work value of social justice? What are the organizational structures we have that encourage action to address inequalities? What training and professional development opportunities do we offer that address inequalities and encourage active self-reflection about power and privilege? How do we engage with the larger community to ensure community voice in our work? What organizations are already doing this well?
Practical Considerations in Teaching Cultural Humility
With an understanding of cultural humility and the interaction among the three components as depicted in Figure 1, the questions presented in Table 2 are critical in that they provide a framework for assessment in Social Work Education. Within our schools and programs of social work, and as educators, we must commit to ‘reformulate a definition of cultural competence that acknowledges power and privilege in relationships’ (Garran & Werkmeister Rozas, 2013, p. 108). We believe the concept of cultural humility can provide this reformulation as our institutions begin to ask challenging questions about our organizational structure, our curriculum content and our pedagogy. Adding these questions to our program assessments, as clear topics within our annual retreats, or as a tool to incorporate into our strategic
 

 
Social Work Education 177
planning meetings are some ideas for how to practically integrate these critical questions. In the classroom, the questions outlined in Table 2 can guide curriculum and course development such that they are not seen as an add-on but are embedded in the program. The questions can also serve as an assessment tool for students to not only use to understand themselves, but also to assess their field practicums as a space for organizational transformation around oppression and inequality. Throughout their preparation students should reflect on these questions, so that they become a natural part of their professional identity. The critical questions we have included can also be integrated into training and continuing education opportunities for social work professionals in order to focus the conversation and begin to identify individual and organizational next steps in moving towards more culturally humble practices.
Summary and Practice Implications
In this article we introduced a conceptual model of cultural humility that highlights the intersections of individual and organizational accountability as a starting point for individuals and institutions committed to embodying cultural humility, the field of social work needs to prioritize the needs of the most vulnerable and oppressed, beginning with a framework that confronts the systemic forces that drive the health, economic, and social inequalities that oppress and marginalize on both the individual and institutional levels. Cultural humility offers both a personal and organizational model to address these systemic inequalities.
Inequality is a human generated problem and therefore can be changed. Data continue to show that inequalities exist and they will continue without concerted efforts to address power dynamics (Abrams 8c Moio, 2009; Ross, 2010). Focusing on cultural competence as a strategy to address inequality is no longer sufficient if our profession is going to engage, lead, and ultimately change outcomes for our clients and communities. We turn to cultural humility as a promising alternative to cultural competence to support these goals, as it makes explicit the interaction between the institution and the individual and the presence of systemic power imbalances. It further calls upon practitioners to confront imbalances rather than just acknowledge they exist. Cultural humility challenges us to ask difficult questions instead of reducing our clients to a set of norms we have learned in a training or course about ‘difference’. We believe that asking critical questions, such as the ones presented in this article, challenge our own practice as well as our organizations and institutions and will provide a deeper well from which to approach individual and community change and effective long-term practice.
Acknowledgements
Thank you to Dr Karen Bullock and Dr Jodi Hall at North Carolina State University and Dr Traci Wike at Virginia Commonwealth University for their thoughtful feedback on this article.
 

 
178 M. Fisher-Borne et al.
References
Abrams, L. S., & Moio, J. A. (2009). Critical race theory and the cultural competence dilemma in social work education. Journal of Social Work Education, 45, 245-261.
Abrams, M., & Leppa, C. (2001). Beyond cultural competency: Teaching about race, class, gender, and sexual orientation. Journal of Nursing Education, 40, 270-275.
Accreditation Council of Graduate Medical Education (ACGME). (1999). ACGME Outcome Project. Retrieved April 21, 2006, from http://www.acgme.org/outcome/comp/compFull.asp
Alsharif, N. Z. (2012). Cultural humility and interprofessional education and practice: A winning combination. American Journal of Pharmaceutical Education, 76(7). Article 120. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448458/pdf/ajpe767120.pdf
American Academy of Nursing. (1992). AAN Expert Panel Report: Culturally competent health care. Nursing Outlook, 40, 277-283.
American Public Health Association. (1998). Policy #9819: The need for public health research on gender identity and sexual orientation (pp. 444-445). Retrieved January 17, 2007, from http:// www.pubmedcentral.nih.gov/articlerender.fcgilartikN 1508587
Anastas, J. W. (2013). Teaching in social work: An educators’ guide to theory and practice. New York, NY: Columbia University Press.
Betancourt, J. R. (2003). Cross-cultural medical education. Academic Medicine, 78, 560-569. Betancourt, J. R. (2004). Cultural competence — marginal or mainstream movement? New England
Journal of Medicine, 351, 953-955. Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural competency in health care: Emerging
frameworks and practical approaches. New York, NY: Commonwealth Fund, Quality of Care for Underserved Populations. Retrieved January 20, 2006, from http://www.cmwf.org/usr_doc/ betancourt_culturalcompetency_576.pdf
Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competency in health care. Journal of Nursing Education, 38, 203-207.
Campinha-Bacote, J. (2003). Cultural desire: The key to unlocking cultural competency. Journal of Nursing Education, 42, 239-240.
Carpenter-Song, E. A., Schwallie, M. N., & Longhofer, J. (2007). Cultural competence reexamined: Critique and directions for the future. Psychiatric Services, 58, 1362-1365.
Chang, E. S., Simon, M., & Dong, X. (2012). Integrating cultural humility into health care professional education and training. Advances in Health Sciences Education, 17, 269-278. doi:l 0.1007/sl0459-010-9264-1
Cross, T. L., Bazron, B. J., Isaacs, M. R., & Dennis, K. W. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Center Child Health and Mental Health Policy, CASSP Technical Assistance Center. Retrieved from http://csmha.umaryland.edu/how/ cultural_competency_2001
Culhane-Pera, K. A., Reif, C., Egli, E„ Baker, N. J., 8c Kassekert, R. A. (1997). A curriculum for multicultural education in family medicine. Family Medicine, 29, 719-723.
Davis, K. (2008). Intersectionality as buzzword A sociology of science perspective on what makes a feminist theory successful. Feminist Theory, 9, 67-85.
Dean, R. G. (2001). The Myth of Cross-Cultural Competence. Families in Society: The Journal of Contemporary Social Services, 82, 623-630.
DeSantis, L. A., 8t Lipson, J. G. (2007). Brief history of inclusion of content on culture in nursing education. Journal of Transcultural Nursing, 18, 7S-9S.
Devore, W., & Schlesinger, F. G. (1981). Ethnic-sensitive social work practice. St. Louis, MO: Mosby. Duffy, M. E. (2001). A critique of cultural education in nursing. Journal of Advanced Nursing, 36,
487-495. Dunn, A. M. (2002). Culture competence and the primary care provider. Journal of Pediatric Health
Care, 16, 105-111.
 

 
Social Work Education 179
Fong, R., & Furuto, S. (Eds.)- (2001). Culturally competent social work practice: Skills, interventions and evaluation. Boston, MA: Allyn 8c Bacon.
Furlong, M., & Wight, J. (2011). Promoting “critical awareness” and critiquing “cultural competence”: Towards disrupting received professional knowledges. Australian Social Work, 64, 38-54.
Garran, A. M., & Werkmeister Rozas, L. (2013). Cultural competence revisited. Journal of Ethnic and Cultural Diversity in Social Work, 22, 97-111.
Giger, J., Davidhizar, R. E., Purnell, L., Harden, J. T., Phillips, J., & Strickland, O. (2007). American Academy of Nursing Expert Panel Report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. Journal of Transcultural Nursing, 18, 95-102.
Green, J. (1995). Cultural awareness in the human services: A multi-ethnic approach (2nd ed.). Toronto: Allyn and Bacon.
Gregg, J., & Saha, S. (2006). Losing culture on the way to competence: The use and misuse of culture in medical education. Academic Medicine, 81, 542-547.
Hausmann, L. R. M., Hannon, M. J., Kresevic, D. M., Hanusa, B. H., Kwoh, C. K., 8c Ibrahim, S. A. (2011). Impact of perceived discrimination in healthcare on patient-provider communication. Medical Care, 49, 626-633.
Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care: Executive summary. Washington, DC: National Academies Press. Retrieved from http:// www.allhealth.org/BriefingMaterials/UnequalTreatment-56.pdf
International Federation of Social Workers. (2012a). Definition of social work. Retrieved from http:// ifsw.org/policies/definition-of-social-work/
International Federation of Social Workers. (2012b). Statement of Ethical Principles. Retrieved from http://ifsw.org/policies/statement-of-ethical-principles/
Isaacson, M. (2014). Clarifying concepts: Cultural humility or competency. Journal of Professional Nursing, 30, 251-258.
Jackson, K. F„ & Samuels, G. M. (2011). Multiracial competence in social work: Recommendations for culturally attuned work with multiracial people. Social work, 56, 235-245.
Jacobs, E. A., Kohrman, C„ Lemon, M., 8c Vickers, D. L. (2003). Teaching physicians-in-training to address racial disparities in health: A hospital-community partnership. Public Health Reports, 118, 349-356.
Jani, J. S., Pierce, D., Ortiz, L„ 8c Sowbel, L. (2011). Access to intersectionality, content to competence: Deconstructing social work education diversity standards. Journal of Social Work Education, 47, 283-301. doi:10.5175/JSWE.2011.200900118
Jayaratne, S., Faller, K. C., Ortega, R. M., 8c Vandervort, F. (2008). African American and white child welfare workers’ attitudes towards policies involving race and sexual orientation. Children and Youth Services Review, 30, 955-966. doi:10.1016/j.childyouth.2007.11.018
Juarez, J. A., Marvel, K., Brezinski, K. L., Glazner, C., Towbin, M. M., 8c Lawton, S. (2006). Bridging the gap: A curriculum to teach residents cultural humility. Family Medicine, 38, 97-102.
Kleinman, A. (1981). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, CA: University of California Press.
Kleinman, A., 8c Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3, e294.
Kumagai, A. K., 8c Lypson, M. L. (2009). Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Academic Medicine, 84, 782-787.
Leininger, M. M. (1991). Culture care diversity & universality: A theory of nursing. New York, NY: National League for Nursing Press.
 

 
180 M. Fisher-Borne et al.
Lum, D. (1986). Social work practice and people of color; A process-stage approach. Monterey, CA: Brooks/Cole.
Lum, D. (1999). Culturally competent practice: A framework for growth and action. Pacific Grove, CA: Brooks/Cole.
National Association of Social Workers. (2000). Code of Ethics. Washington, DC: Author. Retrieved on March 18, 2013, from http://www.socialworkers.org/pubs/code/code.asp
National Association of Social Workers. (2001). NASW standards for cultural competency in social work practice. Washington, DC: Author. Retrieved on March 18, 2013, from http://www. socialworkers.org/practice/standards/NASWCulturalStandards.pdf
Office of Minority Health. (2001). National standards on culturally and linguistically appropriate services (CLAS) in health care. Federal Register, 65, 247. Retrieved January 24, 2007, from http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
Ortega, R. M„ & Faller, K. C. (2011). Training child welfare workers from an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90, 27-49. Retrieved from http://eds.a. ebscohost.com/ehost/pdfviewer/pdfviewer?sid=3de6a31e-780d-439c-98de-36d50fa33a0e% 40sessionmgr40028cvid=28chid=4208
Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology, 35, 888-901.
Ponterotto, B.G., 8c Mallinckrodt, J. (2007). Introduction to the special section on racial and ethnic identity in counseling psychology: Conceptual and methodological challenges and proposed solutions. Journal of Counseling Psychology, 54, 219-223.
Ponterotto, J. G. (2010a). Multicultural personality: An evolving theory of optimal functioning in culturally heterogeneous societies. The Counseling Psychologist, 38, 714-758.
Ponterotto, J. G. (2010b). Qualitative research in multicultural psychology: Philosophical underpinnings, popular approaches, and ethical considerations. Cultural Diversity and Ethnic Minority Psychology, 16, 581-589.
Ponterotto, J. G., Ruckdeschel, D. E., Joseph, A. C., Tennenbaum, E. A., 8c Bruno, A. (2011). Multicultural personality dispositions and trait emotional intelligence: An exploratory study. The Journal of Social Psychology, 151, 556-576.
Purnell, L. D. (2005). The Purnell model for cultural competence. Journal of Multicultural Nursing & Health, 11, 7-15.
Ridley, C. R„ Baker, D. M., 8c Hill, C. L. (2001). Critical issues concerning cultural competence. The Counseling Psychologist, 29, 822-832.
Ross, L. (2010). Notes from the field: Learning cultural humility through critical incidents and central challenges in community-based participatory research. Journal o f Community Practice, 18, 315-335.
Samuels, G. M., 8c Ross-Sheriffi F. (2008). Identity, oppression, and power: Feminisms and intersectionality theory. Affilia, 23, 5-9.
Sue, D. W. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29, 790-821.
Sue, D. W., Arredondo, P., 8c McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20, 64-88.
Sue, D. W„ Bernier, J. E„ Durran, A., Feinberg, L„ Pedersen, P., Smith, E. J., 8c Vasquez-Nuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10, 45-52.
Suh, E. E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15, 93-102.
Tervalon, M., 8c Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125.
 

 
Social Work Education 181
Wear, D. (2003). Insurgent multiculturalism. Academic Medicine, 78, 549- 554. Yan, M. C., & Wong, Y. R. (2005). Rethinking self-awareness in cultural competence: Toward a
dialogic self in cross-cultural social work. Families in Society: The Journal of Contemporary Social Services, 86, 181-188.
 

 
Copyright of Social Work Education is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.