Critical Conversations: Cultural Awareness, Sensitivity, and Competency
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* Janice Conway-Klaassen
* Lisa Maness

1.  Janice Conway-Klaassen, PhD, MT(ASCP)SM, FACSc⇑
    1.  Program Director, University of Minnesota, Medical Laboratory Sciences Program, Minneapolis, MN

2.  Lisa Maness, PhD, MT(ASCP), AMT
    1.  Winston-Salem State University, School of Health Sciences, Department of Clinical Laboratory Science, Winston-Salem, NC


1.  ***Address for Correspondence: Janice Conway-Klaassen, PhD, MT(ASCP)SM, FACSc,** Director, Medical Laboratory Sciences Program, Mildred King Rohwer Chair in Medical Technology, University of Minnesota, 420 Delaware St. SE, MMC 711, Minneapolis, MN 55455, 612-626-9408, jconwayk{at}umn.edu* 

1.  Describe the population demographics of the United States and how they are changing.

2.  Define microaggression and implicit bias. Provide an example for each.

3.  Discuss the importance of having a culturally competent health care workforce.

## Abstract

The United States of America has always been a country comprised of many different cultures and identities. According to the US census bureau, no single ethnic group will be in the majority by the year 2044. In addition to the changes in racial and ethnic identities, US demographics are also rapidly changing related to age, gender identity, and other social constructs. With evolving demographics, it is essential that all healthcare practitioners are able to adapt to the needs of patients and families, colleagues, and beyond. A patient's background and culture can impact how they view health, disease, treatments, and their interactions with healthcare systems; likewise, diversity among colleagues can impact the working environment. Working with colleagues in a constructive manner and valuing the patient's needs above our own biases promotes an environment for optimal health care delivery.

**ABBREVIATIONS:** LGBT - Lesbian, Gay, Bisexual, Transexual

INDEX TERMS
*   Microaggression
*   cultural competency
*   implicit bias

## INTRODUCTION

> “We do not see things as they are; we see things as we are.” The Talmud

Have you ever heard someone say that they would not recommend hiring a candidate because they were not sure they “would fit in?” Has someone said that a student applying to your educational program may not be a “good fit” for our laboratory profession? These are not unusual comments in many employment and school settings and yet, this is actually a significant form of bias called microaggression. Microaggressions are biased assumptions based on personal perspectives of what is “normal” or expected. Why is the statement about “fitting in” a type of microaggression? It assumes the culture where you work, your educational environment, and values must be maintained in their current form, without change and without variation. This belief presumes that the outsider must be able to conform to your views. It assumes that the way things are now is already optimal and cannot be improved or that someone who is different will bring disruption rather than value to a group. This is prejudice in its most subtle or implicit form.1,2

For the most part, microaggressions and other forms of implicit bias are quite unintentional. Many healthcare practitioners do not harbor explicit or overt discriminatory views or if they do, they understand that they should not be expressed in the work environment. However, many people may not realize they may be expressing an unintentional bias that can be just as harmful to the targeted individual. Current literature on prejudice and discrimination is beginning to examine the concept of implicit bias or the underlying assumptions that influence our judgment, our beliefs, and our actions.

> Unexamined bias is a form of stereotyping that is often unintentional, automatic, and outside of our awareness. Often contradicting our conscious beliefs. Also called subtle or implicit bias. Framing it specifically as “unexamined” puts the onus for change on the person who harbors or acts on bias, holding them accountable. Center for Institutional Change, University of Washington 3

### Cultural and Population Evolution in the US

The US census bureau predicts that by the year 2044 people of White ancestry will no longer be the majority demographic of the American population. In fact, Census analysts predict that no single group will be in the majority by that year.4 The non-White population is projected to reach 56 percent by 2060 compared to only 38 percent of the population in 2014. This change is due in part to an increase in Hispanic and Asian-American population growth rates and a decline in the White population growth rate while the African-American population growth rate is predicted to remain about the same. The shift in population diversity is already being seen in the public schools where the overall minority enrollment reached 50.3 percent for the 2014-2015 school year.5

Racial and ethnic diversity are not the only cultural transformations occurring in our society. The American population is aging as the Baby Boomers reach retirement age. Almost 20 percent of Americans will be over age 65 by 2030.4 There are also significant cultural shifts in the mainstream acceptance of differences in gender and racial identity. The most dramatic Census shift is expected in the “two or more races” category. This category is projected to show a 225 percent increase by 2060 since its official recognition began in the 2000 U.S. Census. The increase is due in part to more social acceptance of mixed race couples since the civil rights decision invalidating laws against interracial marriage and the children resulting from these marriages.4,6 After the Supreme Court ruling in favor of same-sex marriage, there has seemingly been a greater tolerance of homosexuality; although acceptance is sharply divided by generations and political or religious affiliation.7

### Discrimination in the Workplace

In spite of these shifts in population demographics or perhaps because of these somewhat dramatic shifts, we continue to see the negative impact of prejudice and discrimination across multiple environments and social group demographics. A retrospective review of justice related issues found that there are still disparities related to race and gender bias in wages, health care benefits, and with regard to protection against violence in the home and in the workplace.8 There are also documented cases and controlled studies that show subtle and yet persistent discrimination in hiring practices, workplace environments, and career advancement.9 A study conducted in 2003 by the National Bureau of Economic Research sent out identical resumes with names that were traditionally associated with African-Americans or White applicants.10 In this study, the White applicants received 50% more call-backs than the same resume with an African-American sounding name. A similar study used different non-work related activities on the resume to indicate that the applicant might belong to the LGBT community, such as being a member of Gay Pride.11 Those individuals also received fewer contacts and hires. A recent commentary published in an urban newspaper highlighted the same issue with Hispanic sounding names and identical resumes.12 These situations document that in spite of superficial progress on diversity and efforts supporting inclusion, many people harbor subliminal or implicit biases that influence their daily interactions.

Within higher education, patterns of biased practice are evident and they impact both faculty and students. Medical School faculty, from five different institutions, were surveyed about experiences during their academic careers. A number of themes emerged from minority faculty, which documented disparities related to achievement expectations by leadership, lack of mentoring, and lack of support for community-based or minority-centric research.13 These were not only expressed by minority faculty but also supported by statements from non-minority faculty at these institutions. Numerous cases are listed within the legal briefs related to discrimination and professional school admissions practices. Lawsuits have been both for and against Affirmative Action with little change to our actual conditions.14 So, with our current legislation in place, why do these disparities persist?

Despite the preponderance of legislation against discrimination in the workplace and beyond, much of which began with the Civil Rights Act of 1964, stereotypes endure in the American population and in turn are influencing our actions and reactions. A 2012 survey conducted by the Associated Press, University of Michigan, and the University of Chicago showed that about 51 percent of Americans expressed explicit or overtly racist views; an increase from 48 percent seen in a 2008 survey. Over this same time frame, an increase from 49 to 56 percent was seen for the expression of implicit racist attitudes. Similar results were seen for anti-Hispanic views. A research study in 2009 found that there were very little, if any, “systematic” changes in explicit or implicit racial views after the beginning of President Obama's first term in office.15 Television and social media have also played a significant role in perpetuating blame for the country's problems on minorities, immigrants, and those outside the majority demographic. To quote Psychology Today, “[t]he success of fear-based news relies on presenting dramatic anecdotes in place of scientific evidence, promoting isolated events as trends, depicting categories of people as dangerous and replacing optimism with fatalistic thinking.”16

### Cultural Awareness in Healthcare

Education can guide us toward awareness and understanding, which can in turn lead to changes in perception and action or reactions. Most healthcare practitioners are aware that they should focus on the needs of the patient and there have been plenty of seminars and workshops about the need for cultural awareness and sensitivity when it relates to quality of patient care and safety. Because the laboratory is an essential component of quality healthcare delivery, awareness and sensitivity of cultural differences are important here too. A patient's cultural upbringing can change how they interact with a health care provider or navigate through healthcare systems. It can impact how they view their overall health and what they believe are the causes of good health or illness and whether they trust their healthcare providers. It can dramatically impact their ability to get well and heal especially when they do not trust or are even fearful of their healthcare providers. Healthcare advocates have begun to understand the value of these differences instead of expecting everyone to adapt to the dominant culture of the country. Being aware and respectful of patients' beliefs and needs helps us provide an environment for optimal health care delivery. Over the past few years and with the help of federal legislation and related payment incentives (i.e. Affordable Care Act), organizations and individuals know that it is not only essential to deliver quality care from the perspective of healthcare practitioners or healthcare systems, but more importantly from that of the patients and their families.

## CONCLUSIONS

It is essential to have a culturally competent workforce in the laboratory, in academia, or in other organizations where laboratorians may be employed. A diverse workplace that promotes cultural competency can lead to a welcoming social work environment, which in turn, can stimulate cooperation, increased productivity, and improved quality of work. Although the backgrounds and cultural ideals that each employee bring to the workplace may initially create tension or conflict, if managed well, it can also create opportunities for growth. Increased diversity can also result in innovations and creative problem solving as employees or students bring new ideas together.17,18 As individuals from different backgrounds work successfully together over time, the differences between them as individuals can eventually become foundation of strength rather than sources of conflict.

This series of Focus articles brings forward a sometimes sensitive topic, but at the same time, this is a critical conversation that we all must have. The demographics and social norms of society are changing rapidly. Now more than ever success in our field, in our lives, and for our futures relies on our ability to work together and to create an environment for mutual benefit and success. The good news is that cultural awareness and sensitivity, along with self-reflection of our own unexamined biases and the impact these beliefs may have on others, can improve our cultural competency. Becoming culturally competent is not a final product; you don't just attend a workshop and mark a check box as “training completed.” Instead, attaining and maintaining cultural competence is a life-long growth process.

Through the articles in this Focus series, we will examine the legislation that supports a culture of diversity and inclusion, discuss and explore best practices for personal and professional development toward cultural competency, and examine some case studies which highlight scenarios we might encounter in our workplace and educational settings. With the increase in the diversity of our student applicant pools and subsequent employment applicant pools, we need to acknowledge our cultural differences and our internal biases. It will take hard work and diligence, self-awareness, and a willingness to change. Because, as laboratorians, we know that one thing is constant; tomorrow will bring change.

*   © Copyright 2016 American Society for Clinical Laboratory Science Inc. All rights reserved.

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