Critical Reflection

Abstract

Critical reflection, sometimes referred to as cultural self-awareness, is a purposeful, vital, careful evaluation of one’s own values, beliefs, and cultural heritage in order to have an awareness of how these qualities can influence patient care. However, critical reflection goes beyond solely awareness by examining and critiquing the assumptions of one’s values and beliefs. It includes an examination of one’s own cultural values that have the potential to be in conflict with the values of others and, as a result, hinder therapeutic relationships and effective patient care outcomes. A number of models related to critical thinking are reviewed and include Dewey’s model of reflective learning, Habermas’s model of critical reflection, Kolb’s model of experiential learning, and feminist theory. In addition, recommendations for clinical practice, administration, education and training, and research are addressed. Tools to help practitioners assess their views and values related to bias are included as appendices.

Guideline: Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage in order to have an awareness of how these qualities and issues can impact culturally congruent care.

Douglas et al. (2014: 110)

Appendices

Appendix 1: Promoting Cultural and Linguistic Competency

1.1 Self-Assessment Checklist for Personnel Providing Primary Healthcare Services

Please select A, B, or C for each item listed below.

• A = Things I do frequently, or statement applies to me to a great degree

• B = Things I do occasionally, or statement applies to me to a moderate degree

• C = Things I do rarely or never, or statement applies to me to minimal degree or not at all

1.1.1 Physical Environment, Materials, and Resources

• _____ 1. I display pictures, posters, artworks, and other decors that reflect the cultures and ethnic backgrounds of clients served by my program or agency.

• _____ 2. I ensure that magazines, brochures, and other printed materials in reception areas are of interest to and reflect the different cultures and languages of individuals and families served by my program or agency.

• _____ 3. When using videos, films, or other media resources for health education, treatment, or other interventions, I ensure that they reflect the culture and ethnic backgrounds of individuals and families served by my program or agency.

• _____ 4. I ensure that printed information disseminated by my agency or program takes into consideration accuracy and without bias.

1.1.2 Communication Styles

• _____ 5. When interacting with individuals and families who have limited English proficiency, I always keep in mind that:

  • * Limitations in English proficiency are in no way a reflection of their level of intellectual functioning.

  • * Their limited ability to speak the language of the dominant culture has no bearing on their ability to communicate effectively in their language of origin.

  • * They may neither be literate in their language of origin nor in English.

• ______ 6. I use bilingual/bicultural or multilingual/multicultural staff and/or personnel and volunteers who are skilled or certified in the provision of medical interpretation services during treatment, interventions, meetings, or other events for individuals and families who need or prefer this level of assistance.

• ______ 7. For individuals and families who speak languages or dialects other than English, I attempt to learn and use key words so that I am better able to communicate with them during assessment, treatment, or other interventions.

• ______ 8. I attempt to determine any familial colloquialisms used by individuals or families that may impact on assessment, treatment, health promotion and education, or other interventions.

• ______ 9. For those who request or need this service, I ensure that all notices and communiqués to individuals and families are written in their language of origin.

• _____ 10. I understand that it may be necessary to use alternatives to written communications for some individuals and families, as word of mouth may be a preferred method of receiving information.

• _____ 11. I understand the principles and practices of linguistic competency and:

  • * Apply them within my program or agency

  • * Advocate for them within my program or agency

• _____ 12. I understand the implications of health literacy within the context of my roles and responsibilities.

• _____ 13. I use alternative formats and varied approaches to communicate and share information with individuals and/or their family members who experience disability.

1.1.3 Values and Attitudes

• _____ 14. I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other than my own.

• _____ 15. I screen books, movies, and other media resources for negative cultural, ethnic, or racial stereotypes before sharing them with individuals and families served by my program or agency.

• _____ 16. I intervene in an appropriate manner when I observe other staff or clients within my program or agency engaging in behaviors that show cultural insensitivity, racial biases, and prejudice.

• _____ 17. I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of acculturation into the dominant culture.

• _____ 18. I understand and accept that family is defined differently by different cultures (e.g., extended family members, fictive kin, godparents).

• _____ 19. I accept and respect that male-female roles may vary significantly among different cultures (e.g., who makes major decisions for the family).

• _____ 20. I understand that age and life cycle factors must be considered in interactions with individuals and families (e.g., high value placed on the decision of elders, the role of eldest male or female in families, or roles and expectation of children within the family).

• _____ 21. Even though my professional or moral viewpoints may differ, I accept individuals and families as the ultimate decision-makers for services and supports impacting their lives.

• _____ 22. I recognize that the meaning or value of medical treatment and health education may vary greatly among cultures.

• _____ 23. I accept that religion and other beliefs may influence how individuals and families respond to illnesses, disease, and death.

• _____ 24. I understand that the perception of health, wellness, and preventive health services has different meanings to different cultural groups.

• _____ 25. I recognize and understand that beliefs and concepts of emotional well-being vary significantly from culture to culture.

• _____ 26. I understand that beliefs about mental illness and emotional disability are culturally based. I accept that responses to these conditions and related treatments/interventions are heavily influenced by culture.

• _____ 27. I recognize and accept that folk and religious beliefs may influence an individual’s or family’s reaction and approach to a child born with a disability or later diagnosed with a disability, genetic disorder, or special healthcare needs.

• _____ 28. I understand that grief and bereavement are influenced by culture.

• _____ 29. I accept and respect that customs and beliefs about food, its value, preparation, and use are different from culture to culture.

• _____ 30. I seek information from individuals, families, or other key community informants that will assist in service adaptation to respond to the needs and preferences of culturally and ethnically diverse groups served by my program or agency.

• _____ 31. Before visiting or providing services in the home setting, I seek information on acceptable behaviors, courtesies, customs, and expectations that are unique to the culturally diverse groups served by my program or agency.

• _____ 32. I keep abreast of the major health and mental health concerns and issues for ethnically and racially diverse client populations residing in the geographic locale served by my program or agency.

• _____ 33. I am aware of specific health and mental health disparities and their prevalence within the communities served by my program or agency.

• _____ 34. I am aware of the socioeconomic and environmental risk factors that contribute to health and mental health disparities or other major health problems of culturally and linguistically diverse populations served by my program or agency.

• _____ 35. I am well versed in the most current and proven practices, treatments, and interventions for the delivery of health and mental healthcare to specific racial, ethnic, cultural, and linguistic groups within the geographic locale served by my agency or program.

• _____ 36. I avail myself to professional development and training to enhance my knowledge and skills in the provision of services and supports to culturally and linguistically diverse groups.

• _____ 37. I advocate for the review of my program’s or agency’s mission statement, goals, policies, and procedures to ensure that they incorporate principles and practices that promote cultural and linguistic competence.

Reprinted with Permission: Tawara D. Goode • National Center for Cultural Competence • Georgetown University Center for Child & Human Development • University Center for Excellence in Developmental Disabilities, Education, Research & Service • Adapted Promoting Cultural Competence and Cultural Diversity for Personnel Providing Services and Supports to Children with Special Health Care Needs and their Families • June 1989 (Revised 2009).

SCORING: This checklist is intended to heighten the awareness and sensitivity of personnel to the importance of cultural and linguistic cultural competence in health, mental health, and human service settings. It provides concrete examples of the kinds of beliefs, attitudes, values, and practices which foster cultural and linguistic competence at the individual or practitioner level. There is no answer key with correct responses. However, if you frequently responded “C,” you may not necessarily demonstrate beliefs, attitudes, values, and practices that promote cultural and linguistic competence within health and mental healthcare delivery programs.

Appendix 2: Promoting Cultural and Linguistic Competency

1.1 Self-Assessment Checklist for Personnel Providing Services and Supports in Early Intervention and Early Childhood Settings

Directions: Please select A, B, or C for each item listed below.

• A = Things I do frequently, or statement applies to me to a great degree

• B = Things I do occasionally, or statement applies to me to a moderate degree

• C = Things I do rarely or never, or statement applies to me to minimal degree or not at all

1.1.1 Physical Environment, Materials, and Resources

• ______ 1. I display pictures, posters, and other materials that reflect the cultures and ethnic backgrounds of children and families served in my early childhood program or setting.

• ______ 2. I select props for the dramatic play/housekeeping area that are culturally diverse (e.g., dolls, clothing, cooking utensils, household articles, furniture).

• ______ 3. I ensure that the book/literacy area has pictures and storybooks that reflect the different cultures of children and families served in my early childhood program or setting.

• ______ 4. I ensure that tabletop toys and other play accessories (that depict people) are representative of the various cultural and ethnic groups both within my community and the society in general.

• ______ 5. I read a variety of books exposing children in my early childhood program or setting to various life experiences of cultures and ethnic groups other than their own.

• ______ 6. When such books are not available, I provide opportunities for children and their families to create their own books and include them among the resources and materials in my early childhood program or setting.

• ______ 7. I adapt the above referenced approaches when providing services, supports, and other interventions in the home setting.

• ______ 8. I encourage and provide opportunities for children and their families to share experiences through storytelling, puppets, marionettes, or other props to support the “oral tradition” common among many cultures.

• ______ 9. I plan trips and community outings to places where children and their families can learn about their own cultural or ethnic history as well as the history of others.

• _____ 10. I select videos, films, or other media resources reflective of diverse cultures to share with children and families served in my early childhood program or setting.

• _____ 11. I play a variety of music and introduce musical instruments from many cultures.

• _____ 12. I ensure that meals provided include foods that are unique to the cultural and ethnic backgrounds of children and families served in my early childhood program or setting.

• _____ 13. I provide opportunities for children to cook or sample a variety of foods typically served by different cultural and ethnic groups other than their own.

• _____ 14. If my early childhood program or setting consists entirely of children and families from the same cultural or ethnic group, I feel it is important to plan an environment and implement activities that reflect the cultural diversity within the society at large.

• _____ 15. I am cognizant of and ensure that curricula I use include traditional holidays celebrated by the majority culture, as well as those holidays that are unique to the culturally diverse children and families served in my early childhood program or setting.

1.1.2 Communication Styles

• _____ 16. For children who speak languages or dialects other than English, I attempt to learn and use key words in their language so that I am better able to communicate with them.

• _____ 17. I attempt to determine any familial colloquialisms used by children and families that will assist and/or enhance the delivery of services and supports.

• _____ 18. I use visual aids, gestures, and physical prompts in my interactions with children who have limited English proficiency.

• _____ 19. When interacting with parents and other family members who have limited English proficiency, I always keep in mind that:

  • ____ (a) Limitation in English proficiency is in no way a reflection of their level of intellectual functioning.

  • ____ (b) Their limited ability to speak the language of the dominant culture has no bearing on their ability to communicate effectively in their language of origin.

  • ____ (c) They may neither be literate in their language of original English.

• _____ 20. I ensure that all notices and communiqués to parents are written in their language of origin.

• _____ 21. I understand that it may be necessary to use alternatives to written communications for some families, as word of mouth may be a preferred method of receiving information.

• _____ 22. I understand the principles and practices of linguistic competency and:

  • (a) Apply them within my early childhood program or setting

  • (b) Advocate for them within my program or agency

• _____ 23. I use bilingual or multilingual staff and/or trained/certified foreign language interpreters for meetings, conferences, or other events for parents and family members who may require this level of assistance.

• _____ 24. I encourage and invite parents and family members to volunteer and assist with activities regardless of their ability to speak English.

• _____ 25. I use alternative formats and varied approaches to communicate with children and/or their family members who experience disability.

• _____ 26. I arrange accommodations for parents and family members who may require communication assistance to ensure their full participation in all aspects of the early childhood program (e.g., hearing impaired, physical disability, visually impaired, not literate or low literacy, etc.).

• _____ 27. I accept and recognize that there are often differences between language used in early childhood/early intervention settings, or at “school,” and in the home setting.

1.1.3 Values and Attitudes

• _____ 28. I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other than my own.

• _____ 29. I discourage children from using racial and ethnic slurs by helping them understand that certain words can hurt others.

• _____ 30. I screen books, movies, and other media resources for negative cultural, ethnic, racial, or religious stereotypes before sharing them with children and their families served in my early childhood program or setting.

• _____ 31. I provide activities to help children learn about and accept the differences and similarities in all people as an ongoing component of program curricula.

• _____ 32. I intervene in an appropriate manner when I observe other staff or parents within my program or agency engaging in behaviors that show cultural insensitivity, bias, or prejudice.

• _____ 33. I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of acculturation into the dominant culture.

• _____ 34. I understand and accept that family is defined differently by different cultures (e.g., extended family members, fictive kin, godparents).

• _____ 35. I accept and respect that male-female roles in families may vary significantly among different cultures (e.g., who makes major decisions for the family, play and social interactions expected of male and female children).

• _____ 36. I understand that age and life cycle factors must be considered in interactions with families (e.g., high value placed on the decisions or child-rearing practices of elders or the role of the eldest female in the family).

• _____ 37. Even though my professional or moral viewpoints may differ, I accept the family/parents as the ultimate decision-makers for services and supports for their children.

• _____ 38. I accept that religion, spirituality, and other beliefs may influence how families respond to illness, disease, and death.

• _____ 39. I recognize and understand that beliefs and concepts of mental health or emotional well-being, particularly for infants and young children, vary significantly from culture to culture.

• _____ 40. I recognize and accept that familial folklore, religious, or spiritual beliefs may influence a family’s reaction and approach to a child born with a disability or later diagnosed with a disability or special healthcare needs.

• _____ 41. I understand that beliefs about mental illness and emotional disability are culturally based. I accept that responses to these conditions and related treatments/interventions are heavily influenced by culture.

• _____ 42. I understand that the healthcare practices of families served in my early childhood program or setting may be rooted in cultural traditions.

• _____ 43. I recognize that the meaning or value of early childhood education or early intervention may vary greatly among cultures.

• _____ 44. I understand that traditional approaches to disciplining children are influenced by culture.

• _____ 45. I understand that families from different cultures will have different expectations of their children for acquiring toileting, dressing, feeding, and other self-help skills.

• _____ 46. I accept and respect that customs and beliefs about food, its value, preparation, and use are different from culture to culture.

• _____ 47. Before visiting or providing services in the home setting, I seek information on acceptable behaviors, courtesies, customs, and expectations that are unique to families of specific cultural groups served in my early childhood program or setting.

• _____ 48. I advocate for the review of my program’s or agency’s mission statement, goals, policies, and procedures to ensure that they incorporate principles and practices that promote cultural diversity, cultural competence, and linguistic competence.

• _____ 49. I seek information from family members or other key community informants that will assist me to respond effectively to the needs and preferences of culturally and linguistically diverse children and families served in my early childhood program or setting.

Reprinted with Permission: Tawara D. Goode • National Center for Cultural Competence • Georgetown University Center for Child & Human Development • University Center for Excellence in Developmental Disabilities, Education, Research & Service • Adapted Promoting Cultural Competence and Cultural Diversity for Personnel Providing Services and Supports to Children with Special Health Care Needs and their Families • June 1989 (Revised 2009).

SCORING: This checklist is intended to heighten the awareness and sensitivity of personnel to the importance of cultural diversity, cultural competence, and linguistic competence in early childhood settings. It provides concrete examples of the kinds of practices that foster such an environment. There is no answer key with correct responses. However, if you frequently responded “C,” you may not necessarily demonstrate practices that promote a culturally diverse and culturally competent learning environment for children and families within your classroom, program, or agency.

Appendix 3: Personal Self-Assessment of Antibias Behavior

Directions: Using the rating scale of NEVER to ALWAYS, assess yourself for each item by placing an “X” on the appropriate place along each continuum. When you have completed the checklist, review your responses to identify areas in need of improvement. Create specific goals to address the areas in which you would like to improve.

• 1. I educate myself about the culture and experiences of other racial, religious, ethnic and socioeconomic groups by reading and attending classes, workshops, cultural events, etc.

  Never ________________________Always

• 2. I spend time reflecting on my own upbringing and childhood to better understand my own biases and the ways I may have internalized the prejudicial messages I received.

  Never ________________________Always

• 3. I look at my own attitudes and behaviors as an adult to determine the ways they may be contributing to or combating prejudice in society.

  Never ________________________Always

• 4. I evaluate my use of language to avoid terms or phrases that may be degrading or hurtful to other groups.

  Never ________________________Always

• 5. I avoid stereotyping and generalizing other people based on their group identity.

  Never __________________________Always

• 6. I value cultural differences and avoid statements such as “I never think of you as______________,” which discredits differences.

  Never _________________________Always

• 7. I am comfortable discussing issues of racism, anti-Semitism and other forms of prejudice with others.

  Never __________________________Always

• 8. I am open to other people’s feedback about ways in which my behavior may be culturally insensitive or offensive to others.

  Never _________________________Always

• 9. I give equal attention to other people regardless of race, religion, gender, socioeconomic class or other difference.

  Never __________________________Always

• 10. I am comfortable giving constructive feedback to someone of another race, gender, age or physical ability.

  Never __________________________Always

• 11. The value of diversity is reflected in my work, which includes a wide range of racial, religious, ethnic and socioeconomic groups, even when these groups are not personally represented in my community.

  Never _________________________Always

• 12. I work intentionally to develop inclusive practices, such as considering how the time, location and cost of scheduled meetings and programs might inadvertently exclude certain groups.

  Never _________________________Always

• 13. I work to increase my awareness of biased content in television programs, newspapers and advertising.

  Never ________________________Always

• 14. I take time to notice the environment of my home, office, house of worship and children’s school, to ensure that visual media represent diverse groups, and I advocate for the addition of such materials if they are lacking.

  Never _________________________Always

• 15. When other people use biased language and behavior, I feel comfortable speaking up, asking them to refrain and stating my reasons.

  Never _________________________Always

• 16. I contribute to my organization’s achievement of its diversity goals through programming and by advocating for hiring practices that contribute to a diverse workforce.

  Never _________________________Always

• 17. I demonstrate my commitment to social justice in my personal life by engaging in activities to achieve equity.

  Never _________________________Always

This activity was adapted from “Commitment to Combat Racism” by Dr. Beverly Tatum & Andrea Ayvazian in White Awareness: Handbook for Anti-Racism Training by Judy H. Katz. ©1978 by the University of Oklahoma Press, Norman. Reprinted by permission of the publisher. All rights reserved.

Permission was also granted from the Anti-Defamation League, Education Division, A WORLD OF DIFFERENCE^® Institute © 2007 Anti-Defamation League: www.adl.org/education; email: education@adl.org.