Culture in Nursing DQ 14

 

Read the attached document that it is related to the chapter 14 of our class textbook.  Once done present an analysis of the article expressing your point of view of the “Cultural Competence in Ethical Decision Making”.  Make sure you include the different areas where cultural competence in  ethical decision making is use.  

 APA format word document, APA required font attached to the forum in the discussion tab of the blackboard titled “Week 15 analysis” and the SafeAssign exercise in the assignment tab of the blackboard which is a mandatory requirement.  A minimum of 2 evidence-based references (besides the class textbook) no older than five years must be used.  You must post two replies on different dates to any of your peers sustained with the proper references no older than five years as well and make sure the references are properly quoted in your assignment. The replies cannot be posted on the same day; I must see different dates in the replies.   A minimum of 800 words is required and not exceeding 1,000 words (excluding the first and reference page).  Please make sure to follow the instructions as given and use either spell-check or Grammarly before you post your assignment.

Please check your assignment after the week is due or after it is graded because I either made comments or ask for clarification in some replies or the assignment that required your response.

Due dates:  Assignment – Wednesday, August 5, 2020, at 11:59 PM in the discussion tab of the blackboard, and in the SafeAssign exercise in the assignment tab of the blackboard.

Humanities and Social Sciences
2016; 4(2-1): 41-52

http://www.sciencepublishinggroup.com/j/hss

doi: 10.11648/j.hss.s.2016040201.17

ISSN: 2330-8176 (Print); ISSN: 2330-8184 (Online)

Cultural Competence and Ethical Decision Making for
Health Care Professionals

Brenda Louw

Department Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, USA

Email address:
louwb1@etsu.edu

To cite this article:
Brenda Louw. Cultural Competence and Ethical Decision Making for Health Care Professionals. Humanities and Social Sciences. Special

Issue: Ethical Sensitivity: A Multidisciplinary Approach. Vol. 4, No. 2-1, 2016, pp. 41-52. doi: 10.11648/j.hss.s.2016040201.17

Received: November 30, 2015; Accepted: January 15, 2016; Published: May 13, 2016

Abstract: Cultural competence and ethical decision making are two separate, yet intrinsically related concepts which are
central to services rendered by all health care professionals. Cultural competence is based on ethical principles and informs

ethical decision making. In spite of this important connection, the interrelationship of these two concepts does not receive the

attention it deserves in the literature. This issue is addressed by appraising the training and assessment of cultural competence

and ethical decision making in the health care professions. The integrated relationship of these two concepts is illustrated

within the broader contexts of higher education, research and clinical practice. Health care professionals who incorporate

cultural competence and ethical decision making will be empowered to provide the best services to their clients/ patients in

multicultural contexts to ensure optimum outcomes.

Keywords: Cultural Competence, Ethical Decision Making, Health Care Professionals, Higher Education, Research,
Clinical Practice

1. Introduction

Cultural competence and ethical decision making are two

separate, yet intrinsically related concepts which are central

to services rendered by all health care professionals. For the

purposes of this article cultural competence is described as a

dynamic, complex and continual evolving process of skill

development by health care professionals to respond

appropriately to their clients’/patients’ unique combination of

cultural variables (which may include e.g. ability, age, beliefs,

customs, ethnicity, language, gender and gender identity,

sexual orientation, religion etc.) to ensure efficacy in working

within the cultural context of their clients/patients.

Ethical decision making can be defined as a complex

process used by health care professionals to resolve ethical

dilemmas. It is dependent on and involves many different

factors such as ethical principles, morals, values, beliefs,

regulations, legal issues and personal and professional

experiences. Ethical decision making involves ethical

sensitivity, ethical judgement and ethical choice. The

decision making process should follow a sequence of logical

steps to guide and support health care professionals.

The importance of cultural competence for health care

professionals has been formalized by the inclusion thereof in

professional codes of ethics, such as stated in e.g. the

American Speech-Language Hearing Association Code of

Ethics, Cf. the Ref [1]. These codes require competent

services be provided to all populations and recognition of the

cultural/linguistic and life experiences.

Recent developments such as changes in health care

systems, evidence based practice, new technology used in the

delivery of health care and international migration have

accentuated the significance of cultural competence. In

addition, political correctness and diversified health

professional workforces are important factors which

necessitate cultural competence, Cf. e.g. the Ref. [2].

Research findings in different health care professions have

led to the recognition that culture may influence

clients’/patients’ communication styles, beliefs about health,

and their attitudes towards health care which can include help

seeking behavior and treatment compliance, Cf. e.g. the Refs.

[3] and [4].

Culturally competent health care requires respectful

responses to individual clients’/patients’ values, preferences

and languages. Health care professionals need to develop

42 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

appropriate responses to diversity by understanding culture in

all its facets, Cf. the Ref. [5]. Provision of culturally

appropriate services to individuals and their families is a

basic role of all health care professionals, which requires

cultural competence and ethical conduct. This is only

possible when health care professionals are educated and

trained in developing cultural competence, ethical practice,

and continue to increase their effectiveness through clinical

experiences and continuing education. Both of these

constructs are dynamic and ongoing processes, which need

constant attention during professional careers.

There is an abundance of research on cultural competence

and professional ethics in the various health care professions.

However, the ethical underpinnings of cultural competence

has received limited attention in the literature. E. Donate-

Bartfield and L. Lausten, Cf. the Ref. [6], describe the

historical ethical underpinnings of the multicultural

movement. They highlight the morality thereof in that the

movement intended to enhance the dignity, rights and

recognized worth of marginalized groups. They point out that

the multicultural movement went beyond the understanding

of different views and perspectives, to include a social justice

aspect as it supports equal access and opportunity.

Health care professionals have an ethical obligation to

respect cultural differences in all health care settings, Cf. the

Ref. [6]. Basing cultural sensitive care on ethical principles

will provide additional clinical reasoning tools when faced

with ethical dilemmas related to different cultural values. M.

Paasche-Orlow, Cf. the Ref. [7], points out that the literature

on cultural competency seldom explicitly discusses the role

of ethics. He proposes that the essential principles of cultural

competence are the acknowledgement of culture in people’s

lives, respect for cultural differences and minimization of any

negative consequences of cultural differences, Cf. the Ref.

[7]. It is clear that cultural competence and ethical decision

making are interconnected and interdependent, but that this

interrelationship does not receive the overt attention it

deserves. Contemplating the interrelatedness of cultural

competence and ethical decision making, and the significance

for health care professionals, it is postulated that these

constructs be viewed multi-dimensionally in a broad context.

Figure 1. Interrelatedness of cultural competence and ethical decision

making.

The purpose of this article is therefore to address the

interrelationship of cultural competence and ethical decision

making. An overview of the constructs of ethical decision

making and cultural competence are provided, and their

interconnectedness is described in three contexts relevant to

health care professionals as illustrated in figure 1, namely

higher education, research and clinical practice.

2. Ethical Decision Making

Professional ethics is inherent to all health care

professional practice. Health care professionals are required

to be knowledgeable about ethical principles and rules that

govern their practice such as e.g. their professional ethical

codes, scope of practice documents workplace code of

conduct or licensing laws. According to A. M. Naudé and J.

Bornman, Cf. the Ref. [8], maintaining a high level of

professional ethics has become more difficult due to

competitive pressure and productivity requirements of the

health care environment. Throughout their careers, health

care professionals are likely to face ethical dilemmas which

will need to be resolved. In addition to their personal

knowledge base and resources provided by their professional

associations, they will also need to rely on their own ability

to reflect critically and make immediate ethically responsible

decisions, Cf. e.g. the Ref [9].

Ethical decision making in the health care professions is a

multifaceted process that involves a range of simple to

complex professional issues. As stated earlier, the process of

ethical decision making entails ethical sensitivity, ethical

judgement and ethical choice. Ethical principles that guide

decision making in health care are respect for autonomy,

beneficence, nonmaleficence and justice, Cf. e.g. the Ref.

[10]. Health care professionals are further guided by models

of ethical decision making described in the literature, see the

Ref [10].

Common themes and steps have been identified to

facilitate the process of making decisions to resolve ethical

dilemmas. These include describing the external and internal

factors that are relevant to the situation. The steps of the

process are generally accepted as identifying and gathering

relevant information; identifying relevant ethical issues and

possible violations, identifying possible courses of action,

identifying the need for external consultation and studying

the impact of each action, selecting a plan of action, and

implementing that plan, see the Ref. [10]. Critical analysis

and definition of the situation is a crucial skill that needs to

be developed as the first step in the process of ethical

decision making and practice, Cf. e.g. the Ref. [9].

For years the issue of whether ethics can actually been

taught has been discussed and debated in various fields and

forums. The general conclusion was reached that education

can indeed enhance and guide students’ and professionals’

ethical development. Health care professional training

programs are required by professional associations and

boards to include ethics training. It appears to be most

effective when infused into the curriculum in both theoretical

courses and clinical practica, and presented through the use

of case studies in a problem based learning approach.

Humanities and Social Sciences 2016; 4(2-1): 41-52 43

Strategies such as active listening, role play, visualization of

others’ viewpoints and discussion of innovative solutions to

define and respond to ethical issues will facilitate the

development of an ethical framework in which ethical

reasoning abilities can develop. Ethical sensitivity can also

be developed by enhancing prosocial behaviors, which are

relationship skills that encourage other people to feel positive

and engage in interaction. According to A. M. Naudé, Cf. the

Ref. [9], prosocial skills facilitate reflective emotional

regulation which in turn enhances effective ethical decision

making. She argues that training of ethical sensitivity is the

first step and is key to educating students and health care

professionals to identify and resolve ethical dilemmas in

clinical practice, Cf. the Ref. [9].

Seven skills of ethical sensitivity were described by A. M.

Naudé, Cf. the Ref. [9], namely controlling social bias, taking

the perception of others, relating to others, understanding

emotional

expression, perceiving and responding to diversity,

interpreting ethics in situations and effective verbal and non-

verbal communication. These skills relate to three main

functions of basic cognitive processes that can be taught,

namely acquiring information about the ethical situation

(perception, inference), organizing the information (critical

thinking and reflection) and using or interpreting information

(divergent thinking, prediction).

The assessment of health care professionals’ development

of ethical decision making is challenging across disciplines.

Traditionally written and oral exams focusing on case studies

involving ethical rules such as e.g. confidentiality and respect

have been used for evaluation. A. M. Naudé, Cf. the Ref. [9],

explored the importance of ethical sensitivity and developed

an innovative multidisciplinary Measuring Instrument for

Ethical Sensitivity in the Therapeutic Sciences (MIEST). This

tool can be applied to audiologists, occupational therapists,

physical therapists and speech-language pathologists. The

assessment is based on a series of vignettes which were

custom developed to portray ethical dilemmas that can be

encountered by health care professionals, and includes

vignettes on ethical issues in different cultures. The MIEST

can also be used as an instructional tool in a multitude of

ways to e.g. assess the impact of the training on trainees, to

monitor the development of ethical sensitivity and by using

the custom-developed vignettes for training workshops based

on problem- based learning principles, Cf. the Ref. [9].

Health care professionals often collaborate with

interpreters and translators when working in culturally

diverse contexts. Interpreters’ and translators’ roles are

diverse and include being a cultural broker, client/patient

advocate, co-therapist, team member and institutional gate

keeper. It is often health care professionals’ responsibility to

train interpreters and translators working under their

supervision in procedures and ethics. Health care

professionals are responsible for the actions of interpreters

and translators and to ensure that they act ethically, which

may not always be easy to implement, Cf. e.g. the Ref. [11].

Interpreters’ and translators’ are required to respect for all

involved, respect confidentiality, interpret accurately, convey

cultural information and remain impartial. Case studies and

role play can be used to assess ethical principles and decision

making skills of interpreters and translators. They should also

be encouraged to follow a code of ethics. H. W. Langdon and

T. I Saenz, Cf. the Ref. [11], suggest that the National Code

of Ethics for Interpreters in Health Care be applied and

adapted for different professions. Interpreters and translators

need to be encouraged to participate in continuing education

to develop and grow in their vital roles.

Should an ethical dilemma arise during such collaborations,

the health care professionals, interpreters and translators all

need to participate in identifying the ethical issue and

collectively following the steps recommended in the

literature to seek a solution to the dilemma. Healthcare

professionals, interpreters and translators form a team that

can most effectively serve clients/patients and their families

in a multicultural context.

3. Cultural Competence

3.1. Cultural Competence Framework

Health care professionals around the world who work in

settings in which diverse populations are served, need to be

aware that multiculturalism goes further than race and

ethnicity. The concept of multiculturalism has advanced

beyond the conceptualization of multiculturalism involving

primarily ethnicity and language to include e.g. ability, age,

gender, gender orientation, SES, religion etc. There has been

a shift from interpreting multicultural as “special” and

limited to certain populations or groups of people to an

acknowledgement that we are all multicultural, Cf. e.g. the

Ref. [12]. Self-awareness of one’s own culture is the first step

in developing cultural competence, Cf. e.g. the Ref. [11].

Health care professionals need to develop skills to interact

and communicate with clients/ patients and families from a

variety of cultures with a myriad of cultural and linguistic

variables, and should be able to communicate appropriately,

both verbally and non-verbally, in each culturally different

context, Cf. e.g. the Ref. [5].

Many different terms are used to describe these skills such

as intercultural competence, multicultural competence, cross-

cultural competence, cultural sensitivity, global competence,

global citizenship and cultural proficiency. For the purposes

of this article the term cultural competence will be used.

Intercultural competence is defined as the ability to

communicate effectively and appropriately in intercultural

situations based on one’s [inter] cultural knowledge, skills

and attitudes, Cf. the Ref [13]. Cultural competence involves

knowledge of others; knowledge of self; skills to interpret

and relate; skills to discover and/or to interact; valuing others’

values, beliefs and behaviors; and relativizing one’s self.

Cultural competence is an essential component in rendering

effective and culturally responsive services to diverse clients.

Becoming culturally competent can help health care

professionals understand, appreciate, and support their

clients/patients and their families more effectively, and

44 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

enable them to develop and implement culturally appropriate

services. Culturally competent care improves client, patient

and family outcomes. Many different descriptions have been

proposed of how individuals develop cultural

competence.

The models of J. Campinha-Bacote and M. J. Bennett, Cf. the

Refs. [14-16], will be described since they can be directly

related to the education and assessment of cultural

competence.

The Process of Cultural Competence in the Delivery of

Healthcare Services (PCCDHS) model of Campinha-Bacote,

Cf. the Refs.[14] and [15] holds that cultural competence is a

process, not an event and health care professionals should

view themselves as becoming culturally competent rather

than being cultural competent. The model divides cultural

competence into five interdependent constructs: cultural

awareness, cultural knowledge, cultural skill, cultural

encounters and cultural desire.

Cultural awareness is described as the self-examination

and exploration of one’s own cultural and professional

background, and recognition of one’s own beliefs. This is

important to avoid biases, prejudice and assumptions when

working with clients and patients. Cultural knowledge is the

process of developing insight and knowledge about disease

incidence and prevalence amongst cultures, as well the

ability to appreciate and understand clients’/patients’ values,

beliefs and health-related beliefs. Cultural skill is the ability

to conduct and accurate and culturally appropriate history,

assessment and examination. Cultural encounters refer to the

process that encourages health care professionals to

competently engage in cross-cultural interactions with clients

and patients from diverse backgrounds. Cultural encounters

also involve an assessment of the client’s/patient’s linguistic

needs. These are mindful interactions with presence, which

refers to health care professionals being open or available.

Cultural desire is the motivation of health care professionals

to want to, rather than have to, engage in the process of

becoming culturally competent. Campinha-Bacote, Cf. the

Refs. [14] and [15], identifies cultural desire as the key to

unlocking cultural competence.

The constructs of cultural awareness, cultural knowledge,

cultural skill, cultural encounters, and cultural desire have

an interdependent relationship with each other, and no

matter when the health care professional enters into the

process, all five constructs must be addressed and/or

experienced. The PCCDHS is a cyclical model that begins

and ends with the seeking and experiencing of many

cultural encounters, to develop cultural competence. In

conclusion the PCCDHS model provides a framework for

health care professionals to render culturally competent and

culturally responsive healthcare to all clients and patients,

see the Refs. [14] and [15].

M. J. Bennett’s Developmental Model of Intercultural

Sensitivity (DMIS), Cf. the Ref. [16], focuses on how

attitudes towards intercultural sensitivity can be related to

intercultural competence. The model proposes a continuum

of six stages of increasing sensitivity to difference. It

identifies the underlying cognitive orientations individuals

use to understand cultural difference. Each position along the

continuum represents increasingly complex perceptual

organizations of cultural difference, which in turn allow

increasingly sophisticated experiences of other cultures. By

identifying the underlying experience of cultural difference,

predictions about behavior and attitudes can be made and

education can be tailored to facilitate development along the

continuum. The first three stages (denial, defense and

minimization) are ethnocentric as an individual views their

own culture as central to reality. Along the continuum, one

develops a more ethnorelative point of view, through

experiencing one’s own culture as in the context of other

cultures. Ethnorelative views develop in the next three stages

of the model, namely acceptance, adaptation and integration,

which allows for the integration of cultural awareness in

everyday interactions, Cf. the Ref. [16].

The skills required for ethical sensitivity, as described

earlier, namely controlling social bias, taking the perception

of others, relating to others, understanding emotional

expression, perceiving and responding to diversity,
interpreting ethics in situations and effective verbal and non-

verbal communication, see the Ref. [9], can be directly

applied to developing cultural competence. The

interrelatedness of the two constructs is unequivocal.

There is a close relationship between the level of

competence of health care professionals and their ability to

provide culturally responsive health care services, which is

deemed to be sound ethical practice. Health care

professionals need to be trained to develop skill sets for

serving diverse populations in a variety of settings and both

on pre-professional and professional levels.

3.2. Facilitating the Development of Cultural Competence

Through Training

Cultural competence is also viewed to be a graduate

attribute, an outcome of internationalization of the

curriculum, a requirement for effective global citizenship and

a professional competency, see the Ref. [13]. Programs in

higher education have an ethical responsibility to train future

health care professionals to develop cultural competency in

order to empower them to provide appropriate services to

diverse populations and to function efficiently in the

diversifying health service professional workforce.

Training programs for the various health care professions

are committed to facilitating the development of cultural

competence of their students, as required by their

professional Code of Ethics. Professional associations

support this endeavor and provide resources and policy

documents for this purpose. Training programs are required

to include cultural competence in both the classroom and

clinical experiences. They need to provide opportunities for

students to develop clinical skills with multicultural

populations. Working with interpreters and translators is a

key in providing cultural competent care, see the Ref. [11],

and health care professionals require training to collaborate

with interpreters and translators. Aspects such as how to

adequately prepare interpreters and translators in conveying

Humanities and Social Sciences 2016; 4(2-1): 41-52 45

their questions and concerns and how to bridge the

communication gap between the professionals and clients/

patients, and their families due to language barriers need to

be addressed. Attention also should be paid to resolving

ethical issues which may occur during these collaborations.

A plethora of approaches to the training of cultural

competence for health care professionals are available in the

literature. For example P. R. Rose, Cf. the Ref. [2], discusses

key components and different approaches to cultural

competence training for health care professionals in a generic

manner. Others are discipline specific e.g. R. Lubinski and M.

A. Matteliano, Cf. the Ref. [17], developed a guide as a

resource for integrating cultural competency education

throughout speech-language pathology curricula.

Educational approaches addressing cultural competence

have evolved from the additive teaching model (teaching

content includes global concepts), to the integrated teaching

model (some elements of global concepts are embedded

within teaching) to the transformative model in which

teaching and learning experiences are embedded throughout

teaching within a dynamic and interactive approach, see e.g.

the Ref. [18]. The transformative model is widely supported

as evidence-based education. Irrespective of the approach

followed, all training should be evaluated regularly to ensure

that training modules, courses and programs on cultural

competence are of a high standard.

The PCCDHS model of Campinha-Bacote, Cf. the Refs.

[14] and [15], described earlier, can be used to guide

curriculum development for cultural competency for health

care programs. This model is ideally suited to curricula as it

views cultural competence as a developmental process, and

not a onetime event. R. Lubinski and M. A. Matteliano, Cf.

the Ref. [17], implemented the PCCDHS model into

curriculum design for transdisciplinary instruction for

cultural competence, which can be adapted for

implementation by any health care training program. Their

educational approach is one of integration of cultural

competency into existing courses, rather than the creation of

new courses. They developed a series of exercises, Cf. the

Ref. [17], to provide students with positive cultural

experiences that improve their confidence, engage their

interest, develop their ability to emphasize, and result in the

desire to provide culturally responsive rehabilitation services

across settings. Specific strategies to facilitate the

development of cultural competence have been proposed in

the literature such as engaging in open dialogue with students

to discuss culture and biases and personal perspectives; self-

exploration of own values and biases and how that may

influence their behaviors; respect and effective listening;

service learning activities critical reflection of their

development of cultural competence, Cf. the Ref. [4]. Formal

cultural competence training can prevent health care

professionals from engaging in discriminatory practices and

providing services which are not culturally and linguistically

appropriate and sensitive, Cf. the Ref. [2], and therefore

unethical.

The explicit role that ethics plays in cultural competence

curricula has been lacking, see the Ref. [7]. E. Donate-

Bartfield and L, Lausten, Cf. the Ref. [6], recommend that

teaching culturally sensitive care should integrate an

understanding of ethical issues and that culturally sensitive

care be viewed as consistent with core ethical principles. The

integrated approach, Cf. the Ref. [17], is validated by H.

Minkoff, Cf. the Ref. [3], who cautions that if cultural

competence and ethics are presented separately from other

content areas, they risk becoming de-emphasized as fringe

elements or of marginal importance.

When teaching cultural competence, integrating an

understanding of ethical issues is crucial. For example

respecting differences is not only important to establishing

rapport with clients and patients, and promotes compliance,

but it is consistent with the core ethical principles of

intervention, see the Ref. [6]. The ethical underpinnings of

cultural competence need to be explicitly linked to the ethical

principles of health care service delivery, namely autonomy

which is the respect of clients’/patients’ decisions, justice

which requires health care professionals to treat

clients/patients fairly and beneficence which requires

working for the clients’/patients’ well-being by engaging in

competent delivery of services with consideration of the

needs, desires and values of clients/patients. Justice and

beneficence combined with cultural sensitivity facilitate

ethical practice as health care professionals will be mindful

of the discrepancy in social power between themselves and

their clients/patients, and not use their role to impose their

own values and beliefs. Cross-cultural communication skills

enable health care professionals to consider the

clients’/patients’ viewpoints and denote beneficence.

Integrating the teaching of ethical principles and cultural

competence will better prepare health care professionals to

deal with conflicts that may arise in clinical

practice.

According to M. Paasche-Orlow, Cf. the Ref. [7] and H.

Minkoff, Cf. the Ref. [3] conflicts between autonomy and

cultural sensitivity may arise in clinical practice and students

need to be prepared for ethical decision making. For instance

clients’/ patients’ beliefs may involve practices that interfere

with established best practice of health care professionals.

Cultural competence involves understanding of the

importance of cultural differences, respect for those

differences and minimization of the consequences of such

differences, Cf. the Ref. [3]. Health care professionals may

perceive a conflict between ethical practice and cultural

sensitivity to the mores of other cultures. In developing

cultural competence health care professionals need to

understand and appreciate that in some cultures other moral

domains such as community (emphasizing importance of

family roles) and sanctity (emphasizing sacred and spiritual

side of human nature) hold equal value. In order to be able to

reconcile such differences, students require practice in ethical

reasoning through e.g. analyzing case studies, and class

discussions to practice weighing autonomy, justice and

beneficence in seeking solutions to ethical dilemmas in a

culturally competent manner. This will enable them to fully

understand the complexity and interrelatedness of cultural

46 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

competence and ethical decision making. The skills required

for ethical decision are similar to those of cultural

competency e.g. controlling for social bias addresses both

ethical sensitivity and cultural competence, as do adopting

the perspective of others and relating to others. These skills

can all be trained, Cf. the Ref. [9]. Recognizing this

relationship will facilitate training in an integrated manner.

Focusing on ethical decision-making when facilitating the

development of culturally competent care places the

emphasis on individual clients/ patients, their values, beliefs

and needs and stresses the importance of communication, see

the Ref. [6].

Disparities between diverse populations exist in terms of

access to and quality of care due to social, economic and other

factors. Training in cultural competence makes health care

professionals aware of these disparities and equips them to

meet the diverse needs of such populations, see the Ref. [2].

Finally, health care professional boards require their

members to participate in continuing education. Continuing

education programs address cultural competence in

innumerable ways. However, such offerings also need to

integrate ethical principles and decision making to ensure

that health care professionals are supported in their cultural

desire to provide the best services to the populations they

serve, Cf. the Ref. [17].

3.3. Assessment of the Development of Cultural

Competence

Cultural competence is viewed to be an outcome of the

curriculum which needs to be assessed as such in training

programs. However, the assessment of the development of

cultural competence is a controversial topic and poses a

challenge, especially as cultural competence is an ongoing

process. A panel of internationally known intercultural

scholars discussed the assessment of cultural competence, see

the Ref. [13]. Their conclusion was a recommendation to use

a mix of quantitative and qualitative methods to assess

[inter]cultural competence, including objective measures,

interviews, observation, and judgment by self and others.

There is an abundance of qualitative assessment tools for

health care professionals in the literature, which range from

informal to formally researched surveys. For example J.

Campinha-Bacote’s PPCCDHS model, Cf. the Refs. [14] and

[15] includes self-examination questions regarding the

personal level of awareness, skill, knowledge, encounters and

desire. The ASKED mnemonic model assists health care

professionals with informally assessing their level of cultural

competence. Campinha-Bacote, Cf. the Ref. [15] later

developed a formal and robust self-assessment tool, based on

the PCCDHS model, namely The Inventory for Assessing the

Process of Cultural Competence among Health Care

Professionals. P. S. Seibert, P. Stridh-Igo and C. G.

Zimmerman, Cf. the ref. [19], developed a checklist to

facilitate cultural awareness and sensitivity consisting of 10

items. In the development of their checklist a primary theme

that emerged was the significance of verbal and non-verbal

communication. This finding resonates with the

communication skills required to develop ethical sensitivity.

Quantitative assessment tools include the Cultural

Competence Assessment Survey developed by P. R. Rose, Cf.

the Ref. [2]. This tool consists of three surveys, namely the

Executive Team and Management survey; Staff survey and

Health Professionals survey. Research results established the

reliability and validity of the tool which can be used to

determine the level of cultural competence preparedness of

health care professionals. The Intercultural Development

Inventory (IDI), Cf. the Ref. [20] is a quantitative instrument

that measures stages within a developmental model of

intercultural sensitivity that progress through ethnocentric to

ethnorelative orientations, as descried by M. J. Bennett, see

Ref. [16]. The IDI measures cognitive structure rather than

attitudes, which makes it a more stable and generalizable test

that is less susceptible to situational factors. It has 50 items

that can be taken on-line or in a paper and pencil form. It has

been translated into fifteen languages and is widely used in

higher education.

In conclusion assessment of cultural competence should be

an integral part of both training and clinical practice in order

to assist health care professionals in the continued process of

developing cultural competence. Results can be used to

address weaknesses and strengthen the development of

cultural competency. A. M. Naudé, Cf. the Ref. [9], applied

the stages of developing cultural competence to the

development of ethical sensitivity, and concluded that

training to facilitate the development cultural sensitivity can

enhance ethical sensitivity which is crucial to ethical decision

making.

4. Cultural Competence and Ethical

Decision Making Within the Higher

Education

Context

4.1. Internationalization of Higher Education

According to Figure 1, the context of higher education is

important when reviewing cultural competence and ethical

decision making within a broader framework. Two aspects of

higher education are addressed in this section: the

internationalization of the curriculum and the integrated

training of cultural competence and ethical skills.

Internationalization of higher education is viewed to be a

response to globalization. It has gained momentum and

cultural competence is viewed as one of the outcomes of

internationalization, Cf. the Ref. [13]. Internationalization

within the higher education context can be traced back to the

1960’s and has evolved into a global phenomenon. It has

become a powerful and persistent driver in education around

the world during the past two decades, Cf. the Ref. [21].

Reference to internationalization can be found in e.g.

university strategic plans, national policy statements,

international declarations, and academic articles which,

according to Knight, Cf. the Ref. [22], all indicate the

centrality of the concept in higher education.

Humanities and Social Sciences 2016; 4(2-1): 41-52 47

The concept has been debated extensively and different

terms and definitions have been used to describe this

phenomenon in higher education over the past 50 plus years.

According to Knight. Cf. the Ref. [22], Internationalization

is the term most often used. There are a plethora of

definitions and descriptions which reflect debates and

different perspectives on the topic, but all add in different

manners to the application of the concept to higher education.

Knight, Cf. the Ref. [22] proposed a neutral definition: “the

process of integrating an international, intercultural or global

dimension into the purpose, functions or delivery of post-

secondary education” to reflect the richness, breadth, and

depth of internationalization. Hudzik, cf. the Ref. [23],

relates internationalization to the mission of higher education

by stating that, “Comprehensive internationalization is a

commitment, confirmed through action, to infuse

international and comparative perspectives throughout the

teaching, research, and service missions of higher education.

It shares institutional ethos and values and touches the entire

higher education. It shapes institutional ethos and values and

touches the entire higher education enterprise.”

Comprehensive internationalization not only impacts all of

campus life, but the institution’s external frames of reference,

partnerships, and relations, Cf. the Ref. [23].

Various authors have identified key aspects of the

internationalization of higher education, which include e.g.,

the increasing number of international students and scholars

with greater mobility; interest in producing globally

competent graduates; new quality assurance and accreditation

regulations; increasing emphasis in cooperative networking

among higher education institutions; global higher education

ranking systems and increased privatization, and

commercialization of higher education systems. Political and

economic rationales for national policies on

internationalization appear to be increasing at the cost of

academic and cultural motivations, which could be

detrimental to the process, Cf. the Refs. [21] and [22].

In spite of internationalization being debated around the

world and being implemented in different ways, it is viewed

as a positive response to globalization as international

connections are enriching and offer a fresh cultural insights,

Cf. the Ref. [13]. Cultural competence is central to

internationalization in higher education since it is one of the

desired outcomes.

4.2. Internationalization of the Curriculum (IoC)

A new focus has emerged within the broader institutional

approach to internationalization, namely the

internationalization of the curriculum (IoC) which

emphasizes the implementation of internationalization for

teaching and learning. Different approaches have been

described to the IoC e.g. across-border education,

internationalization at home, translational education,

transnational education and people mobility. However,

according to B. Leask, Cf. the Ref. [13], IoC is poorly

understood and has been a low priority in many disciplines to

date. IoC requires that academics think outside of these

traditional restrictive, boundaries and recognize that

disciplinary knowledge is not culture-free, Cf. the Ref. [13].

IoC is based on an understanding of the cultural foundations

of knowledge and practice within disciplines and related

professions which frequently requires members to challenge

commonly held beliefs. Encouragement of and support for

students to engage productively with difference, including

different ways of thinking, both within and beyond the

classroom.

B. Leask, Cf. the Ref. [13] proposed a conceptual

framework for IoC. It situates the disciplinary teams who

construct the curriculum as the center of the process. The

framework contains layers of context namely institutional,

local, national, and gglobal. The interaction of these layers

determines how internationalization is conceptualized and

enacted in the curriculum. The framework includes

curriculum design. The key components of IoC can be

summarized as engagement of students with internationally

informed research, cultural and linguistic diversity and the

purposeful development of students’ international and

cross-cultural perspectives. The foundation of knowledge

remains within the context of the discipline, but the

complexity of the problems must be understood from a

broader perspective that acknowledges cultural, social, and

linguistic diversity, as well as an international viewpoint of

the field of study, Cf. the Ref. [13].

Internationalization of curricula for health care

professionals aims to facilitate the acquisition of broader

international perspectives through an awareness of culture

and intercultural communication skills. Topics such as equity,

access to healthcare, public health and the burden of disease

address a global perspective. Development of cultural

competence, as mentioned earlier, is a key outcome, and

together with professional skills, will allow graduates to be

empowered to serve communities in the best way possible,

Cf. the Ref. [18].

Two frameworks for internationalization were proposed by

J. Knight, Cf. the Ref. [22], one for “Internationalization At

Home” and one for “Cross-Border Education”. She identifies

categories of each, provides descriptions of activities and

stipulates forms or conditions of mobility for these

frameworks. It is clear that cultural competence plays a

central role within both of these frameworks. On a personal

level, students would be required to evidence cultural

competence to e.g. interact with international students, to

participate in study abroad programs or international

internships, collaborate on research projects and take on-line

courses offered by institutions in other countries. Cultural

competence could be facilitated by students participating in

extracurricular activities e.g. social clubs, international days

on campus and by liaising with local community based

cultural and ethnic groups. Faculty would require cultural

competence to e.g. authentically infuse existing curricula

with international and cultural content, participate in teaching

exchanges, conduct collaborative international research,

spend a sabbatical in a different country, teaching distance

education courses across borders and, participate in

48 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

international visits for quality control purposes as an external

evaluator, Cf. the Ref. [22].

A. L. Williams, B. Louw, M. Keske-Soares, K. M. Bleile, I.

Trindade, T. Kessler, L. Maximino, and A. P. Fukushiro, Cf.

the Ref. [24], approached IoC in a different manner. They

adopted the concept of scientific multiculturalism as the core

of their international curriculum. Scientific multiculturalism

refers to the differences in research cultures across countries

with regard to student training models, interactions between

faculty and students, and interactions among students, Cf. the

Ref. [25]. In addition to research cultures, research can be a

mechanism for students to not only gain knowledge of the

professions, but also to develop cross-cultural competence. As

part of a multi-institutional collaboration jointly funded by the

U. S. Department of Education Fund for Improvement of

Postsecondary Education (FIPSE) and the Brazilian Ministry

of Education (CAPES), a research-based global curriculum

was developed with the dual goals to foster research and

culturally competent practitioners, Cf. the Ref. [12].

Through a research-based study abroad program, the

students learned social and cultural differences that exist in

working with families from a bioecological model of child

development; Cf. the Ref. [26], understand communication

disorders from a holistic perspective (International

Classification of Functioning, Disability and Health:

Children and Youth Version (ICF-CY), Cf. the Refs.[12] and

[24]; and assess the impact of communication disabilities

within the unique socio-cultural contexts of families and

communities that exist in different countries. This research-

focused approach to study abroad showed students that

science in their field is not the exclusive domain of

researchers in the U. S. Research was the nexus between

cross-cultural competence and professional knowledge of the

field and provided a safe environment for active discovery of

cultural differences and/ or similarities. It fosters change

from an ethnocentric perspective on scientific discovery to a

broader perspective, or cultural relativism. Exploring

international literature expands students’ world perspective

and motivates them to become culturally aware, acquire

cultural knowledge and skills, and foster a cultural desire, Cf.

the Refs. [2] and [14].

4.3. Internationalization and Ethical Decision Making

Implementing internationalization in higher education

poses ethical challenges to administration and educators alike.

According to L. E. Rumbley, P. G. Altbach and L. Reisberg,

Cf. the Ref. [21], although internationalization in higher

education has the potential of enormous opportunities and

benefits, the global playing field is inherently uneven.

Institutions with more resources have the advantage with

more opportunities to internationalize which leads to inequity

in terms of the quality and quantity of internationalization

activities. B. Leask, Cf. the Ref. [13] cautions against

universities exacerbating the negative effects of

internationalization such as inequities between collaborators.

A call for ethical implementation of internationalization to be

guided by core principles of ethical engagement is made, Cf.

the Ref. [21]. Internationalization requires a commitment to

fundamental values such as transparency, quality of programs

and support services, academic freedom, fair treatment of

partners and stakeholders and respect for local cultures. They

recommend that principles should exist to guide ethical

decision making in internationalization with a long term

perspective firmly rooted in ethics and quality, Cf. the Ref.

[21]. J. D. Heyl and J. Tullbane, Cf. the Ref. [28], address the

issue of ethics in international educational leadership.

Educational leaders are faced with the complexity of

interactions with global partners, different legal systems, and

cultures when required to make critical decisions regarding

internationalization. It is their responsibility to identify risks

for new partnerships and endeavors and to make transparent,

ethically based decisions in the best interest of all

stakeholders.

Given the centrality of cultural competence in higher

education, practical ethical decision making is challenging

and wide ranging. It could involve issues such as e.g. policies

and procedures on student admission criteria; the choice of

pedagogical approaches to address cultural competence, e.g.

selecting a transformative teaching model in which teaching

and learning experiences are embedded throughout teaching

within a dynamic and interactive approach as opposed to the

traditional additive teaching model where global aspects are

included, Cf. the Ref. [18]. Ethical sensitivity is just as

appropriate in this context as in the clinical context. The

ethical dilemma needs to be identified and choices made

regarding the resolution of issue.

In conclusion, internationalization of higher education has

become an attainable goal but remains complex and needs to

be based on sound values of ethics and quality. Including

cultural competence and ethical decision making as

competencies in training programs in higher education,

provide an essential foundation for clinical ethical decision

making as these skills are considered to be central to

providing appropriate care.

5. Cultural Competence and Ethical

Decision Making in Research

Cross-cultural and international research have become a

hallmark of the health care professions. This development

can be attributed t o a multitude of diverse factors such as

e.g., the development of evidence based practice; treatment

outcomes research, disparity in access to health care services,

international networking, the WHO Report on Disability, Cf.

the Ref. [29], and the International Classification of

Functioning, Disability and Health, Cf. the Ref. [27]. In spite

of the proliferation of multicultural research in the health

care professions, gaps in knowledge remain within and

across countries regarding issues ranging from incidence of

disability to treatment outcomes. It is commonly accepted

that there is an ethical imperative to ensure cultural

sensitivity in cross-cultural and international research.

Despite this need, there is a lack of practical guidance based

Humanities and Social Sciences 2016; 4(2-1): 41-52 49

on empirical results to conduct culturally sensitive research,

Cf. the Ref. [30].

Research ethics and cultural competence are separate

concepts yet interrelated as illustrated in Figure 1. M.

Paasche-Orlow, Cf. the ref. [7], points out that the literature

on cultural competency seldom discusses the role of ethics. It

is suggested that the general ethical research principles

namely, autonomy, beneficence, and justice be mapped on to

the essential principles of cultural competence. According to

M. Paasche-Orlow Cf. the ref. [7], the essential principles of

cultural competence are acknowledgement of culture in

people’s lives, respect for cultural differences, and

minimization of any negative consequences of cultural

differences. Linking research ethics and cultural competence

has major implications for teaching curricula and research

conduct.

Curricula within the health care professions include

education in ethics for practice, research ethics, and cultural

competence. However cultural competence in research ethics

does not appear to be well integrated in training curricula.

Although cross-cultural and cross-linguistic research abounds

in the different health care professions, cultural sensitivity is

usually not addressed in research methods courses to any

significant degree. This results in many student researchers

either exploring the field independently as guided by their

research mentor, or the majority of students lacking culturally

sensitive research skills. Clinical practice in health care

professions around the globe calls for cultural competent care

which should be based on research evidence. Therefore,

including cultural competence in research courses will ensure

that researchers of the future are better equipped to conduct

cross-cultural and cross-linguistic research.

It is imperative that research courses in health sciences

address cultural competency as a focal point in the curricula.

This can be done in a myriad of ways. Cultural competence

needs to be integrated in both research ethics and research

methods, as they become inseparable in conducting research.

Challenges of and suggestions for conducting culturally

sensitive research can be included as a topic in research

course syllabi. Research ethical principles can be linked to

the ethics of cultural competence and examples can be

provided for example finding information about a specific

community, how to source appropriate literature, setting

inclusion and exclusion criteria, gaining informed consent,

establishing partnerships and gaining the trust of the

participants, Cf. the Ref.[31].

Unless researchers dedicate time and effort in planning

research projects to address cultural issues, the use of

research methods and techniques developed in one culture,

then applied to another, can threaten the validity and

generalizability of research results. Research methods such as

ethnography, survey research by interview, and focus groups

are especially appropriate to use with culturally diverse

clients and families to elicit perceptions on opinions on

health related and treatment topics when conducting

culturally sensitive research, Cf. the Refs. [31] and [32]. The

relevance of cross-cultural research can be pointed out in the

classroom when presenting the different types of research

methods. According to M. B. Huer and T. I. Saenz, Cf. the

Ref. [31], conducting culturally sensitive research,

irrespective of the method used, is unique in that

modification of procedures and additional strategies that need

to be included into any given design in order to collect

relevant and usable data. The authors, Cf. the Ref. [31], offer

guidelines for preparing clinical research instruments,

methods for data collection, data analysis, and interpretation

of results when conducting cultural sensitive research. A

criticism that is levelled against research in the health care

professions in the minority world is that sampling is often not

representative of the general population and does not include

sufficient diversity. Issues and challenges need to be

identified and possible solutions sought to better prepare

future professionals for their role in ethically sound cross-

cultural research.

Another important issue that needs to be addressed in both

training and conducting cross-cultural and cross linguistic

research in an ethical manner, is working with interpreters

and translators. These individuals play a crucial role for

imparting verbal and cultural understanding to participants.

According to Y. Shimpuku and K. F. Norr, Cf. the Ref. [33],

the interpreters’ and translators’ role and their influences on

the findings are not always adequately described by

researchers, and therefore the credibility of qualitative

research study is weakened. It is generally recommended that

interpreters and translators selected for a research project are

both bilingual and bicultural in order to perform their role as

cultural brokers. Interpreters and translators are to be valued

as cultural brokers, who work with the participants on the

one side and the researcher on the other, to ensure that both

sides understand the research process according to their view

of the world. A key element in working with interpreters and

translators during research is to introduce and explain the

research ethical principles of autonomy, beneficence, and

justice. Interpreters and translators can be encouraged to

follow, “A National Code of Ethics for Interpreters in

Healthcare”, Cf. the Ref. [11]. This code includes nine

principles and could be adapted to a code of ethics for

interpreters in Health Care Research. It is essential to inform

interpreters of the purpose and aims of the research project

and researchers are required to train interpreters regarding

their required roles in the project.

It is important to be flexible when working with

interpreters and translators in conducting research.

Researchers need to be able to adapt the usual processes of

translation/back-translation when appropriate to the cultural

context and the specific situations of the translators. Such

practices may also apply to the clinical context when health

care professionals work with bilingual and bicultural

interpreters and translators e.g. when communicating with

persons who have limited literacy in their first language, are

hearing impaired or non-verbal.

C. E. Burnette, S. Sanders, H. K. Butcher, and J. T. Rand,

Cf. the Ref. [30], conducted a two part qualitative research

study on cultural sensitivity in research. In Part 1, they

50 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

identified strategies for cultural sensitivity in research in a

descriptive qualitative study. They then applied the strategies

to a rigorous critical ethnography with indigenous

communities in Part 2 of their study. Based on their results,

the authors, Cf. the Ref. [30], describe a toolkit for ethical

and culturally sensitive research. The themes from part one

of their study inform the toolkit, which includes the impact of

history, relational research, incorporating cultural sensitivity

and strengths, demonstrating patience, and negotiating

multiple perspectives. This toolkit can be used when teaching

and /or conducting research with different communities and

cultures.

Ethical decision making in research is guided by ethical

codes and rules, but students require training, experiences

(real or simulated), and examples of culturally sensitive

research to learn how to act and make decisions should an

ethical dilemma arise in a multi-cultural context. Responsible

Conduct of Research (RCR) is defined as encompassing

overlapping concepts related to the discovery and

dissemination of knew knowledge, research, responsible

science, scientific integrity, and responsible researchers, Cf.

the Ref. [34]. Only by including cultural competence in

research courses can future health care professionals truly

become responsible researchers.

Cultural competence enhances the quality and usefulness

of research, which is better able to address the pressing

problems experienced by some communities, Cf. the Ref.

[30]. Increasing the amount of culturally sensitive research

has the consequence of enabling health care professions to

better serve their consumers, Cf. the Refs. [30] and [35], and

will lead to improved health care of individuals from all

cultures.

6. Cultural Competence and Ethical

Decision Making in the Clinical

Context

According to figure 1, the third context in which cultural

competence and ethical decision making for health care

professionals are integrated is the context of clinical practice

itself. Evidence Based Practice (EBP) requires that health

care professionals have the necessary knowledge, skills and

attitude to provide competent care to clients/patients for a

range of diverse cultures, Cf. the Ref. [36]. More recent

developments in approaches to multicultural care such as

ethnography and narratives, may facilitate the development

of cultural competency.

Practicing from a culturally sensitive ethical perspective in

a multicultural context is essential for good practice. Health

care professionals need to understand that strict adherence to

professional ethical codes may result in ethical dilemmas

when providing services to individuals from a variety of

cultures. This may lead to less optimal care of clients/patients

from different backgrounds. Health care professionals need

to be equipped with skills to resolve such ethical dilemmas

First and foremost they need to be able to communicate

effectively and to understand each client’s/patient’s unique

background and beliefs, and make decisions that will meet

each client’s/patient’s needs in a thoughtful, sensitive and

effective manner. As discussed earlier, a common ethical

dilemma arises when respect for autonomy and cultural

sensitivity collide. For instance when a spouse makes an

intervention decision for a client/patient which the health

care professional may interpret as a bad decision.

Reconciling the sense that the client/patient had not freely

exercised his/her autonomy with the desire to be culturally

sensitive by respecting the value of community in a culture,

Cf. the Ref. [3]. Health care professionals may use a number

of resources to address ethical dilemmas in multicultural

contexts, such as the frameworks for ethical decision making

proposed by e.g. Cf. the Refs. [10] and [37]. Ethical decision

making frameworks typically begin with developing ethical

sensitivity, which is the ability to recognize that an ethical

issue exists.

A. M. Naudé, Cf. the Ref. [9], describes the key

characteristics of ethical sensitivity as moral perception

(identify client and situational needs), affectivity (putting self

in place of clients to identify and weigh comparable reactions)

and dividing loyalties (awareness of moral and ethical

principles, their significance in the context, stakeholders’

needs and interests). These attributes enable health care

professionals to recognize, understand and evaluate ethical

elements in clinical practice. The more skilled a health care

professional is in terms of ethical sensitivity, the easier it is to

use a framework for ethical decision making, Cf. the Ref. [9].

Various authors identify cultural awareness as the first step

in developing cultural competence, Cf. the Refs. [5], [14] and

[15]. A crucial skill in developing ethical sensitivity is

controlling social bias. This involves understanding,

recognizing and opposing prejudice. Mastering these skills

results in an appropriate response to diversity, Cf. the Ref. [9].

It is generally accepted the health care professionals should

approach clinical situations with caution and a sense of

cultural incompetence in order to actively be open to strive to

address that feeling in the process of developing cultural

competence. Understanding cultural differences and how

those can lead to conflict and misinterpretation, will

empower health care professionals and positively impact on

their relationships with clients/patients. Cultural competence

and ethical decision making are inseparable in clinical

practice.

Another framework which health care professionals can

apply to facilitate both culturally competent services and

ethical decision making is the International Classification of

Functioning, Disability and Health (ICF), Cf. the Refs. [9]

and [27]. The ICF and ICF-CY, Cf. the Refs. [12] and [24],

provide a framework for the holistic assessment and

intervention of clients/patients. They are based on the

biopsychosocial model and are divided into two parts, which

encompass four components. Part 1 consists of Functioning

and Disability, with the components Body Functions and

Structures, and Activities and Participation. Part 2 consists of

Contextual Factors, including the components Environmental

Humanities and Social Sciences 2016; 4(2-1): 41-52 51

Factors and Personal Factors, Cf. the Ref. [27]. This

framework respects client/patient autonomy and emphasises

the importance of a health care professional’s ability to

recognize not only how physiological factors influence the

client’s/patient’s perceptions, expectations and behavior, but

also how psychological, social and environmental factors

affect the manner in which a client/patient perceives his/her

ability to function as a member of society. Using this

framework health care professionals can adapt their

assessments and interventions in accordance with the values

and needs of clients/patients from various socioeconomic,

ethnic, racial, religious backgrounds and a range of gender

and sexual identities, Cf. the Ref.[9]. Positive cultural

experiences increase confidence, engage interest and result in

a desire to become culturally competenent, thus enabling

health care professionals to provide culturally responsive

services across settings.

7. Conclusion

In conclusion cultural competence and ethical decision

making are both based on respect for and understanding of

the different values that clients/patients and health care

professionals give to various moral domains. It is clear that

ethical sensitivity, the crucial first step in making ethical

decisions, is interwoven with cultural competence. This

necessitates that health care professionals need to be trained

in both cultural competence and ethical decision making in

an integrated manner, both pre-professionally and during

continuing education.

Educating future health care professionals has become a

formidable task due to the expanding knowledge fields of the

disciplines. Training programs need to ensure that the

curriculum is balanced and that appropriate pedagogical

training and clinical experiences in cultural competence and

professional ethical issues are provided. Such training will

empower heath care professionals to consistently and

effectively deal with ethical decision making which will

present during their future professional careers. Cultural

competence and ethical decision making need to be viewed

as interrelated within the broader contexts of higher

education and research to ensure that health care

professionals are able to function efficiently in clinical

practice in both situational and global contexts. Health care

professionals need to balance their professional ethics with

cultural competence to provide services that are responsive to

the cultural and linguistic needs of individual clients/patients

so as to ensure the best intervention outcomes.

References

[1] American Speech-Language-Hearing Association, Scope of
practice in speech-language pathology [Scope of practice].
www.asha.org/policy (2007).

[2] P. R. Rose, “Cultural Competency for the Health Professional”.
Jones & Bartlett Publishers (2013).

[3] H. Minkoff, “Teaching Ethics: When Respect for Autonomy
and Cultural Sensitivity Collide”. American Journal of
Obstetrics and Gynecology, 210, vol. 4, 298-301 (2014).

[4] D. E. Battle, “Communication Disorders in Multicultural and
International Populations”. 4

th
ed. Elsevier: St. Louis,

Missouri, USA

(2012).

[5] E. W. Lynch, and M. J. Hanson, “Developing Cross-Cultural
Competence a Guide for Working with Children and Their
Families”. 4

th
ed., Paul H. Brookes Pub, Baltimore, USA (2011).

[6] E. Donate-Bartfield, and L. Lausten, “Why Practice Culturally
Sensitive Care? Integrating Ethics and Behavioral Science”.
Journal of Dental Education, 66, 1006-1011 (2002).

[7] M. Paasche-Orlow, “The Ethics of Cultural Competence.”
http://gateway.tx.ovid.com/sp-3.17.0a/ovidweb.cgi Academic
Medicine, 79, vol. 4, 347-350 (2004).

[8] A. M, Naudé, and J. Bornman, “A Systematic Review of
Ethics Knowledge in Audiology”.” American Journal of
Audiology, 23, vol. 2, 151-157 (2014).

[9] A. M, Naudé, “Exploring ethical sensitivity in the SA context:
developing and implementing a measure in the therapeutic
sciences”. Unpublished doctoral thesis, University of Pretoria,
South Africa (2015).

[10] D. Irwin, M. Panbacker, T. W. Powell and G. T. Vekovius,
“Ethics for Speech-Language Pathologists and Audiologists.
An Illustrated Casebook”. Thomson Dellmar learning: Clifton
Park, NY, USA (2007).

[11] H. W. Langdon, T. I. Saenz, “Working with interpreters and
translators: A guide for speech-language pathologists and
audiologists”. Plural Publishing, (2015).

[12] A. L. Williams, B. Louw, N. J. Scherer, K. M. Bleile, M.
Keske-Soares, and I. Trindade, “Academic and clinical
preparation in speech-language pathology and audiology: A
global training consortium for US-Brazil students”.
Contemporary Issues in Communication Sciences and
Disorders, 40, pp. 40-49 (2013).

[13] B. Leask, “Internationalizing the Curriculum”. Routledge:
New York, NY, USA. (2015)

[14] J. Campinha-Bacote, “The process of cultural competence in
the delivery model of healthcare services: A model of care”.
Journal of Transcultural Nursing, 13, 181-184 (2002).

[15] J. Campinha-Bacote, “Coming to know cultural competence:
an evolutionary process”. International Journal of Caring, 15,
3, 42-48 (2011).

[16] M. J. Bennett, “Becoming Interculturally Competent”. In J. S.
Wurzel (Ed). Toward multiculturalism: A reader in
multicultural education. Intercultural Resource Cooperation:
Newton, MA, USA (2004).

[17] R. Lubinski and M. A. Matteliano, “A Guide to Cultural
Competence in the Curriculum: Speech Language Pathology”.
Center for International Rehabilitation Research Information
and Exchange, 1-68 (2008).

[18] D. Murdoch-Eaton, A. Redmond, and N. Bax, “Training
Healthcare Professionals for the Future: Internationalism and
Effective Inclusion of Global Health Training”. Medical
Teacher, 33, 562-569 (2011).

52 Brenda Louw: Cultural Competence and Ethical Decision Making for Health Care Professionals

[19] P. S Seibert, P. Stridh-Igo and C. G. Zimmerman, “A Checklist
to Facilitate Cultural Awareness and Sensitivity”. Journal of
Medical Ethics, 28, 143-146 (2002).

[20] M. R. Hammer, “The Intercultural Development Inventory
Manual (v. 3)”. IDI, LLC: Ocean Pines, MD, USA (2007).

[21] L. E. Rumbley, P. G. Altbach and L. Reisberg,
“Internationalization within the higher education context”. in.
D. K. Deardorff, H. De Wit, J. D. Heyl and T. Adams, The.
SAGE Handbook of International Higher Education. SAGE:
Thousand Oaks CA, USA (2012).

[22] J. Knight, “Concepts, rationales and interpretive framework in
the internationalization of higher education”. in. D. K.
Deardorff, H. De Wit, J. D. Heyl and T. Adams, The. SAGE
Handbook of International Higher Education. SAGE:
Thousand Oaks CA, USA (2012).

[23] J. K. Hudzik, “Comprehensive Internationalization”.
Institutional Pathways to Success. Routledge: New York, NY,
USA (2015).

[24] A. L. Williams, B. Louw, M. Keske-Soares, K. Bleile, I.
Trindade, T. Kessler, L. Maximino, and A. P. Fukushiro,
“Nexus of Research-Cultural Competence: A Twist on Study
Abroad”. Poster presented to the American Speech-Language-
Hearing Association Annual Convention, Orlando, USA,
November 19-21 (2014).

[25] E. Plante, “Establishing a lab environment for the responsible
conduct of research: research, participants, scenarios and
challenges in identifying vulnerabilities and creating a plan to
mitigate risks”. CREd Library 3.1 (2014).

[26] U. Bronfenbrenner, S. J. Ceci, “Nature-nurture
reconceptualized in developmental perspective: A
bioecological model”. Psychological review 101, 568 (1994).

[27] World Health Organization “International Classification of
Functioning, Disability and Health”. World Health
organization: Geneva, (2007).

[28] J. D. Heyl and J. Tullbane, “Leadership in International
Higher Education”. The SAGE Handbook of International
Higher Education, 113 (2012).

[29] World Health Organization and the World Bank, “World
Report on Disability”. Geneva: World Health Organization,
(2011).

[30] C. E. Burnette, S. Sanders, H. K. Butcher, and J. T. Rand, “A
toolkit for ethical and culturally sensitive research: An
application with indigenous communities”. Ethics and Social
Welfare, 8, 364-382 (2014).

[31] M. B. Huer and T. I. Saenz, “Challenges and strategies for
conducting survey and focus group research with culturally
diverse groups”. American Journal of Speech Language
Pathology, 12, 209-220 (2003).

[32] G. M. A. Higginbottom and L. Serrant-Green, “Developing
culturally sensitive skills in health and social care with a focus
on conducting research with African Caribbean communities
in England”. The Qualitative Report, 10, 4, 662-686 (2005).

[33] Y. Shimpuku, and K. F. Norr, “Working with Interpreters in
Cross‐Cultural Qualitative Research in the Context of a
Developing Country: Systematic Literature Review”. Journal
of advanced nursing, 68, vol. 8, 1692-1706 (2012).

[34] J. Horner and F. D. Minifie, “Research Ethics I: responsible
conduct of research (RCR)-historical and contemporary issues
pertaining to human and animal experimentation”. Journal of
Speech, Language and Hearing Research, 54, S303-S329
(2011).

[35] C. Qualls, “Multicultural and International Research on
Communication Disorders: Past, Present, and Future”. In D.
Battle, Communication Disorders in Multicultural and
International Populations.” 4

th
ed. Elsevier, St. Louis, USA,

(2012).

[36] G. Roysircar, “Evidence-Based Practice and Its Implications
for Culturally Sensitive Treatment”. Journal of Multicultural
Counseling and Development, 37, 66-82 (2009).

[37] Z. Weber, “Working Towards Culturally Sensitive Ethical
Practice in a Multicultural Society”. The Journal of Practice
Teaching and Learning, 40-54 (2003).