Mechanisms Driving Postgraduate Health and Social Science Students' Cultural Competence: An Integrated Systematic Review

Abstract

Purpose: The COVID-19 pandemic revealed a global urgency to address health care provision disparities, which have largely been influenced by systematic racism in federal and state policies. The World Health Organization recommends educational institutions train clinicians in cultural competence (CC); however, the mechanisms and interacting social structures that influence individuals to achieve CC have received little attention. This review investigates how postgraduate health and social science education approaches CC and how it accomplishes (or not) its goals.

Method: The authors used critical realism and Whittemore and Knafl's methods to conduct a systematic integrated review. Seven databases (MEDLINE, CINAHL, PsycINFO, Scopus, PubMed, Web of Science, and ERIC) were searched from 2000 to 2020 for original research studies. Inclusion criteria were: the use of the term "cultural competence" and/or any one of Campinha-Bacote's 5 CC factors, being about postgraduate health and/or social science students, and being about a postgraduate curriculum or a component of it. Thematic analysis was used to reveal the mechanisms and interacting social structures underlying CC.

Results: Thirty-two studies were included and 2 approaches to CC (themes) were identified. The first theme was professionalized pedagogy, which had 2 subthemes: othering and labeling. The second theme was becoming culturally competent, which had 2 subthemes: a safe CC teaching environment and social interactions that cultivate reflexivity.

Conclusions: CC conceptualizations in postgraduate health and social science education tend to view cultural differences as a problem and CC skills as a way to mitigate differences to enhance patient care. However, this generates a focus on the other, rather than a focus on the self. Future research should explore the extent to which insight, cognitive flexibility, and reflexivity, taught in safe teaching environments, are associated with increasing students' cultural safety, cultural humility, and CC.

Figure 1

PRISMA flow diagram showing the selection process used for a 2020 integrated systematic review of the literature on CC. Abbreviations: CC, cultural competence; SS, social science.

Figure 2

Model illustrating how racialized boundaries of (A) perceived notions of culture precede cultural competence. In this process, cultural competence becomes (B) professionalized pedagogy, which constructs (or reinforces) the prescriptive authority of clinicians as cultural competence. This generates pedagogical tendencies (mechanisms) to reproduce social structures of discrimination, stigma, and racism. In doing so, clinicians use culture as a management strategy to directly treat foreign patients, which prompts (C) othering and (D) labeling. Hence, outcomes of this process result in (E) internationalization and (F) conformity to professional and legal requirements. This model was developed based on the findings of a 2020 integrated systematic review of the literature on cultural competence.

Figure 3

Model illustrating the process of (A) becoming culturally competent, which precedes conceptualizations of (B) culture. Culture then becomes a lens to actively reinterpret preconceptions about cultural groups in relation to oneself. In this process, it is necessary to create (C) a safe cultural competence teaching environment to prompt (D) social interactions that cultivate reflexivity. This process allows for the development of the mechanisms of insight and cognitive flexibility to address countervailing social structures of identity and stigma. In doing so, the application of reflexivity in clinical settings may occur. This model was developed based on the findings of a 2020 integrated systematic review of the literature on cultural competence.