How to improve cultural competence in pharmacy practice

Everyone has a culture and ethnicity, regardless of their race or whether they originate from inside or outside of the UK. Cultural competence extends beyond having friends belonging to different cultures or having the desire to learn more about their cultures; it involves moving beyond good intentions to accepting, appreciating and accommodating cultural differences. It requires an awareness of how our own culture, beliefs, ideas, values and concerns can negatively bias how we relate to others. It also involves recognising and avoiding words, phrases and language that can cause people hurt, insult or offence, whether intentionally (conscious bias) or unintentionally (unconscious bias). This article outlines the legal and professional requirements for demonstrating culturally competent, person-centred communication in pharmacy and the outcomes for patients and the profession.

Terminology

The first step in developing culturally competent, person-centred communication is understanding the meaning of the terminology involved. Terms such as culture, race and ethnicity are complex concepts with no single definition achieving consensus in the literature. Individuals are likely to apply different definitions to these concepts; therefore, it is important to develop your awareness of the relevant terminology and to establish shared understanding when using these terms with patients or colleagues. It is also important to be aware of the difference between legal definitions that are fixed and other definitions that are more open to interpretation.

• Race — according to the Equality Act 2010, physical traits that are inherited, such as skin colour, hair texture, facial features, nationality and ethnic or ancestral national origins are indications of a person’s race;
• Culture — the Oxford Dictionary definition of culture is ‘the way of life of a people, including their attitudes, values, beliefs, arts, sciences, modes of perception, and habits of thought and activity’;
• Ethnicity — the Cambridge Dictionary definition of ethnicity is ‘a large group of people with a shared culture, language, history, set of traditions, etc., or the fact of belonging to one of these groups’;
• Cultural competence — the University of Exeter’s definition of cultural competence is ‘the ability to understand and interact effectively with people regardless of difference’​[1–3]​.

Why is cultural competence important?

At a fundamental level, cultural competence is a legal requirement that all pharmacists and healthcare professionals have an obligation to adhere to. The Equality Act 2010 identified nine protected characteristics (see Box 1) and it is against the law to discriminate against anyone based on any of these.

The population in the UK is becoming increasingly diverse (see Figure)​[4]​. Ethnicity is one component of this diversity and data has shown how it can affect a person’s experiences of discrimination and exclusion, leading to unjustified disparity in health, wellbeing and life expectancy​[5]​.

These disparities attracted widespread attention when Public Health England confirmed that COVID-19 has had a disproportionate impact on people from black, Asian and other under-represented ethnic groups in the UK​[6]​. This has led to the publication of the ‘Joint national plan for inclusive pharmacy practice’ and a national ‘call to action’ to develop cultural competence in pharmacy​[7]​. Other forms of health inequality in the UK have also been established. For example, people in the UK who identify as lesbian, gay, bisexual or transgender (LGBT) experience higher rates of poor mental health and lower wellbeing than those who do not identify as LGBT​[8]​.

Addressing these health disparities is a priority for society and an important component of the ‘NHS long-term plan’, but positive change can only be delivered through sustained effort and will require a culturally competent workforce.

Identifying learning needs in cultural competence

The second step in improving cultural competence is to explore your existing strengths and areas that need development. There are several assessment tools available for evaluating cultural competence in a clinical context (e.g. the Centre for Pharmacy Postgraduate Education culturally competent self-reflection tool).

Barriers to developing culturally competent person-centred communication

Having established your individual learning needs, it is important to consider some of the potential common sources of anxiety and barriers to developing cultural competence. Common examples include:

• Inadequate language — feeling like you do not know the right words and phrases;
• Making mistakes with addressing people, pronouncing unfamiliar names or words;
• Fear of a person misinterpreting our intentions — we mean no harm but may end up doing so or causing offence;
• Lacking knowledge of different cultures and communities.

The following sections will address some of these barriers and provide some guidance on how you can begin to overcome them.

Problematic language

Problematic language consists of comments, questions or frequently used words that can be offensive, insulting or insensitive. It can lead to feelings of exclusion instead of belonging and can impact negatively on a person’s wellbeing. When used in a healthcare context, problematic language can lead to a lack of engagement as it creates the perception that healthcare services are not relevant to a person’s needs.

Consciously or unconsciously, the way we describe people reflects our own values or beliefs. The table below identifies some examples of common terms that can be either problematic or culturally appropriate when describing people.

Selecting the most appropriate language and judging the choice of words will depend, to an extent, on how well the people know one another. If a healthcare professional has established that a couple is married and living as husband and wife — for instance, if a person introduces or talks about their husband or wife — then it can be appropriate to use these terms, and adopting language they are comfortable and familiar with will help you to build rapport.

Respectful ways of describing people

There are respectful ways to describe people that do not refer to personal characteristics and are more likely to promote a sense of belonging rather than emphasising differences.

Box 2 contains links to two videos providing examples of this. The first video features Rob Moriarty, who lives with a disability, and describes his interactions with people when they see him using a wheelchair and how pharmacy professionals can make a difference. The second video illustrates cultural issues in the workplace relating to a person’s lived experience of dignity and respect for the role they do.

Asking for and using pronouns

Gender identity matters have become more visible in society, not just in the UK but in many countries around the world. Increasing numbers of people in the UK do not conform to traditional binary descriptions of gender and it is appropriate to avoid making assumptions and use gender-neutral terms until we know a person’s gender identity​[9]​. Another simple solution is to ask them politely how they like to be addressed or what pronouns they use (see the ‘Further resources‘ section for more information).

Pronouncing unfamiliar names

Pronouncing, or genuinely trying to pronounce a name correctly, demonstrates dignity and respect for that person. For pharmacists, it is important to learn about the different nationalities and ethnic groups who may reside in your local area and access health services. Understanding any specific health needs and taking the time to become familiar with the pronunciation of names are good ways to improve your cultural competency. The videos in Box 3 involve two people sharing their stories of people mispronouncing their name, their suggestions on how to get it right and what people can do when they do not get it right first time.

It can be easy to offend unintentionally when we do not know someone very well or at all. Sometimes, we may forget what is considered disrespectful or we might make a mistake. People will usually be genuinely forgiving if you have good intent. Usually, all that is required when we unintentionally say the wrong thing, appear insensitive or make a mistake, is to apologise, show empathy and commit to learning and improving.

Learning about diverse cultures and communities

Culture is not static; it continually evolves. People are an accumulation of their cultural background as well as life experiences​[10]​. People from the same cultural background, therefore, do not necessarily share the same values or beliefs, or adopt the same cultural behaviours. It is important not to make assumptions about a person’s values and beliefs based on their cultural background (otherwise known as stereotyping).

A simple way to learn about diverse cultures is to have conversations with people from different cultures and communities than your own. However, it is important to ask questions that develop a rapport and relationship with the person or establish facts to identify the support they need, rather than to satisfy curiosity, if we are to demonstrate dignity and respect. In Box 4, Rob Moriarty describes how to demonstrate dignity and respect towards people living with a disability.

Culturally competent person-centred care

It is not possible to know everything about all cultures but it is useful to have an awareness of the different cultural beliefs and values that can influence health behaviours​[10]​. Visit the Care Quality Commission’s website for examples of culturally appropriate care relating to things such as healthcare needs, food and drink preferences, religion or spiritual practice within diverse communities. The case study in Box 5 explores how pharmacists can go about this.

Health inequalities

The Royal Pharmaceutical Society’s policy on health inequalities was drawn up in January 2023 following a presentation by Michael Marmot, director of the Institute for Health Equity, at the RPS annual conference in November 2022. The presentation highlighted the stark health inequalities across Britain.

While community pharmacies are most frequently located in areas of high deprivation, people living in these areas do not access the full range of services that are available. To mitigate this, the policy calls on pharmacies to not only think about the services it provides but also how it provides them by considering three actions:

• Deepening understanding of health inequalities
  • This means developing an insight into the demographics of the population served by pharmacies using population health statistics and by engaging with patients directly through local community or faith groups.
• Understanding and improving pharmacy culture
  • This calls on the whole pharmacy team to create a welcoming culture for all patients, empowering them to take an active role in their own care, and improving communication skills within the team and with patients.
• Improving structural barriers
  • This calls for improving accessibility of patient information resources and incorporating health inequalities into pharmacy training and education to tackle wider barriers to care.