Cultural Competence: An Overview _____________________________________________________________
taged or produces inequities [20; 28]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages [28]. When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases [21]. Specific conditions or environmental risk factors have been associated with an increased risk for certain implicit biases, including [130; 131]: • Stressful emotional states (e.g., anger, frustration) • Uncertainty • Low-effort cognitive processing • Time pressure • Lack of feedback • Feeling behind with work • Lack of guidance • Long hours • Overcrowding • High-crises environments • Mentally taxing tasks • Juggling competing tasks ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE The study of implicit bias is appropriately interdisciplinary, representing social psychology, medicine, health psychology, neuroscience, counseling, mental health, gerontology, gen- der/sexuality studies, religious studies, and disability studies [28]. Therefore, implicit bias empirical research and curricula training development lends itself well to interprofessional collaboration and practice (ICP). The main characteristics of ICP allow for implicit and explicit biases to be addressed by the interprofessional team. One of the core features of ICP is sharing—professionals from differ- ent disciplines share their philosophies, values, perspectives, data, and strategies for planning of interventions [29]. ICP also involves the sharing of roles, responsibilities, decision making, and power [30]. Everyone on the team employs their expertise, knowledge, and skills, working collectively on a shared, patient- centered goal or outcome [30; 31]. Another feature of ICP is interdependency. Instead of working in an autonomous manner, each team member’s contributions are valued and maximized, which ultimately leads to synergy [29]. At the heart of this are two other key features: mutual trust/respect and communication [31]. In order to share responsibilities, the differing roles and expertise are respected.
BIAS: IMPLICIT AND EXPLICIT In a sociocultural context, biases are generally defined as nega- tive evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [19]. For example, an individual may openly endorse a belief that women are weak and men are strong. This bias is fully conscious and is made explicitly known. The individual’s ideas may then be reflected in his/her work as a manager. FitzGerald and Hurst assert that there are cases in which implicit cognitive processes are involved in biases and conscious availability, controllability, and mental resources are not [20]. The term “implicit bias” refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/ attitudes can negatively affect their behaviors [21; 22; 23; 24]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [24]. Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessar- ily change in accordance to these outward expressions [25]. Because implicit biases occur on the subconscious or uncon- scious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [26]. According to Georgetown University’s National Center on Cultural Competency, social characteristics that can trigger implicit biases include [27]: • Age • Disability • Education • English language proficiency and fluency • Ethnicity • Health status • Disease/diagnosis (e.g., human immunodeficiency virus [HIV]) • Insurance • Obesity • Race • Socioeconomic status • Sexual orientation, gender identity, or gender expres- sion • Skin tone • Substance use An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvan-
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