Residents of the United States possess diverse multifaceted cultural identities. In your professional life or internship experience, you may find yourself in situations where you are a member of a cultural majority and other times where you are a member of a cultural minority. Dr. Pamela Hays (1996, 2008) developed the ADDRESSING framework, a model for recognizing and understanding our individual identities and how they intersect within us (figure 4.4).

Figure 4.4 The ADDRESSING model shows 10 major factors of cultural difference that are common in the United States (Hays, 2013).

You can use the ADDRESSING framework to reflect on how your cultural membership influences your ability to work with people of similar or dissimilar cultural backgrounds. ADDRESSING stands for the following identifiers that contribute to our complete understanding of our own cultural identity:

• A: Age
• D: Developmental disabilities from birth
• D: Disability acquired through disease or accident
• R: Religion
• E: Ethnicity
• S: Sexual orientation
• S: Socioeconomic status
• I: Indigenous group membership
• N: Nationality
• G: Gender

4.3.1 Understanding Implicit Bias

Implicit bias is a combination of unconscious beliefs and attitudes that we have toward certain groups of people, which can affect our work, relationships, and care decisions. We can overcome these biases by first examining and locating our blind spots. By questioning these unconscious beliefs, we can then actively work to get rid of those that affect how we interact with others (Kacie Berghoef Updated on June 21, 2019)

Scientific research on how the brain works has shown that automatic thought processes shape our behaviors, beliefs, and attitudes. These automatic processes lead us to form patterns based on small amounts of information. Later these patterns may be expressed as positive or negative attitudes. Although our brains allow us to organize and filter our perceptions, biases may influence our decision making and could create errors in our judgment. These unconsciously held sets of associations about a social group are also known as stereotyping. Implicit biases are learned associations and the result of social conditioning, usually beginning at an early age. Most people are unaware that they hold these biases.

When our behavior is guided by factors found in our implicit bias, it manifests negatively in the interactions we have with people in school, place of employment, and our legal system. Studies on implicit racial bias in educational settings indicate that biases create barriers for racial minorities to quality education and success in the classroom. In the economic sector, national and state labor laws prohibit workplace discrimination, yet implicit bias continues to be a significant factor in equal treatment. For example, a 2015 study examined the association people make with “Black-sounding names,” like DeShawn and Jamal, and “White-sounding names,” like Connor and Garrett. The study found that “participants tended to associate the Black-sounding names with larger, more violent people” (Lopez, G. (Mar 7, 2017) Vox.com Effects in the Legal System).In the judicial system, the Black and Hispanic population experience a different treatment, not only only in the courts where Black defendants are likely to receive harsher sentences than White defendants. In a jury trial,the jurors are more likely to be more biased toward a defendant whose race differs from the majority of the jury.

You can lessen the impact implicit bias has on others by learning about strategies that mitigate implicit bias. These strategies suggest methods to interrupt your thinking patterns to give you time to check for implicit biases. The strategies include slowing down before reacting to people and situations, considering the situation from multiple points of view, and practicing simple mindfulness strategies to help you stay focused on your present interactions. For an in-depth discussion of strategies, and some helpful resources, see The American Academy of Family Physicians Strategies to Combat our Implicit Biases.

4.3.2 Curiosity and Humility Versus Competence

Cultural humility refers to a tool originally used to educate medical personnel working with an increasingly diverse cultural, racial, and ethnic population in the United States, but the concept has been applied also to social service providers and researchers working with diverse populations. The underlying principle of cultural humility is the understanding that to work with other culturally different people, we must first examine our own cultural beliefs and identities through a self-reflection process (Tervalon & Murray-Garcia, 1998). As we develop cultural humility by examining our own background and social environment, we come to an awareness of how these have shaped our cultural experience. Cultural humility is “best defined not as a discrete end point, but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves” (Tervalon & Murray-Garcia, 1998, p. 118). The cultural humility process posits that because the nature of culture is mutable, always changing through various influences and locations. Individually we also move daily between several cultures, e.g. home/family workplace, school, social and religious group cultures. The process objective is to make us aware of the values and beliefs we learned from a combination of cultures that will help us to better understand others (Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: essential foundation for clinical researchers. Applied nursing research : ANR, 26(4), 251–256

4.3.2.1 Cultural Competence

Cultural competence has long been an integral training component in many organizations that require continuing education classes. The focus of many of these trainings is on how to care for disadvantaged racial and ethnic minority patients and how to ensure that their cultural beliefs and practices are not negatively impacted by the interaction with the medical or social service provider. The ultimate objective is to remove cultural barriers preventing access to health care.

Some researchers believe cultural compentence trainings might promote stereotyping (Kumagai & Lypson, 2009). A national survey of over 3,000 physicians found that one in five physicians reported not being prepared to work effectively with their patients’ socio-cultural issues, in particular religious beliefs, mistrust of the Western health-care system, new immigrants, and healing practices that conflict with conventional medicine (Weissman et al., 2005). Reviews of the most frequently used cultural competence tests found they contained many assumptions (culture is equivalent to ethnicity and race), and minimal attention was given to gender, class, geographic location, country of origin, or sexual preference (Kumas-Tan et al. 2007). In several tests, whiteness was understood and represented as the norm.

The goal of cultural competence is to produce confident, competent health-care providers with specialized knowledge and skills that can then serve the communities of ethnic or racial minority groups. Other terms such as cultural awareness, cultural knowledge, and cultural sensitivity often are supported by these same assumptions of cultural competence.