What is the purpose of this guidance?

This guidance supports people working in mental health, learning disability and autism inpatient settings to deliver more culturally competent care.

It is 1 of 3 approaches which will support the practical implementation of the Culture of care standards for mental health inpatient services:

• Culturally competent inpatient care (this guidance)
• Autism-informed inpatient care
• Trauma-informed and harm-aware inpatient care

The Patient and carer race equality framework (PCREF) makes clear the necessity for a whole-system approach for mental health, learning disability and autism organisations to tackle race inequalities.

The framework outlines a systematic, effective approach to improving mental health services for people from racialised communities.

All organisations implementing the Culture of Care inpatient standards need to use the PCREF.

Likewise, embedding the Culture of Care standards, using these 3 approaches, will support organisations with realising the ambitions of the PCREF.

Why culturally competent care is needed

Far too many people who use mental health inpatient services face racial inequality throughout their inpatient experience.

When it comes to accessing inpatient care, Black people have more repeated admissions; are nearly 4 times more likely than White people to be detained; and are more likely to be subject to police holding powers under the Mental Health Act.

[See Mental Health Act statistics, annual figures – NHS England Digital and The Mental Health Units (Use of Force) Act, 2018 at Mental Health Units (Use of Force) Act 2018: statutory guidance for NHS organisations in England, and police forces in England and Wales.]

Once admitted, Black people are more than 4 times more likely to be the subject of ‘restrictive interventions’ such as being restrained or held in isolation while in hospital.

We know in some cases, poor quality care and the inappropriate use of force have resulted in serious harm and even death, in settings where racialised and ethnic minority communities are over-represented, particularly Black/Black British communities.

It is also important to consider the intersection of different inequalities and experiences – for example, people with a learning disability and autistic people are more likely to be subject to restrictive practices and this is likely to be compounded for individuals who are also from racialised groups.

While the causes of these poor experiences are varied, communities frequently report a number of consistent barriers, including:

• absence of cultural competence or cultural safety
  • that is: the ability of providers and organisations to examine themselves and the potential impact of their own culture on clinical practices and to effectively deliver healthcare services that meet the social, cultural, and linguistic needs of patients
• discriminatory behaviours (conscious and unconscious)
• lack of trust
• structural, institutional and clinical practices that disadvantage racialised groups

The Culture of Care inpatient standards focus on the therapeutic relationship as critical to delivering safe, humane, collaborative care.

Building a trusted therapeutic relationship with someone requires staff to:

• get to know the person they are supporting – their background, culture, and what matters to them
• understand their strengths and challenges
• build rapport with the person
• advocate for them and support them to have voice and choice in their care

What is culturally competent mental health care?

Cultural awareness and understanding of other’s perspectives and backgrounds

Cultural competency emphasises the need for healthcare systems and providers to be aware of and responsive to patients’ cultural perspectives and backgrounds.

This requires staff teams to understand the communities they serve and be educated in the cultural norms for their local populations.

Understanding the roles that family, religion, heritage, education, food, language and history play for different community groups is critical. Teams who possess such understanding can help the people they care for to be seen, understood and to feel welcome and supported.

This understanding is also critical for providing the full context of people’s mental distress. Some communities will experience shame and stigma about their mental health needs, preventing the person and their family from seeking help. For other people, religion will play an important role in their recovery. Without such understanding, it can be challenging for clinical teams to understand what an unusual belief may be and what may be a commonly held spiritual view, for example.

Cultural humility: honouring others and recognising our own biases

Cultural humility involves honouring another person’s beliefs, customs and values and is the second critical component of culturally competent care.

Achieving cultural humility in inpatient mental health care requires the individual staff member to recognise their own inherent biases and adopt a mindset of lifelong learning towards working with diverse communities.

Cultural humility is aligned with the framework of person-centred care as well as trauma-informed care, both of which are critical frameworks within the Culture of Care standards for inpatient care.

To achieve cultural humility, staff teams need psychologically safe spaces to explore their own inherent bias, to name personal challenges they face and to reflect on the challenge of being alongside someone while trying to keep them safe.

Delivering culturally competent mental health care

It is important to recognise that structural change is needed to enable the delivery of culturally competent care by hospital staff – it is therefore critical that trusts implement the Patient and carer race equality framework (PCREF) alongside the following recommendations.

Train and support staff to be culturally competent

Train and support staff to:

• recognise and understand the diverse cultural backgrounds of the communities and people they support
  • this should include an awareness of different generational experiences and perspectives, and being sensitive to those in providing care
• understand and explore issues related to discrimination, micro-aggressions, racial profiling and racism, and their potential impact on mental and physical health

Create psychologically-safe spaces for staff to reflect on their own identity, cultural backgrounds, biases, prejudices, beliefs, ideas, attitudes and privileges.

These spaces can also support staff to name personal challenges they face and to reflect on the challenge of being alongside someone while trying to keep them safe.

Create a workforce that is reflective of, and connected to, the communities it supports

Recruit a diverse workforce, representative of the local community, at all levels of the organisation.

Ensure that issues related to discrimination, micro-aggressions, racial profiling and racism with the staff team are understood and actively addressed.

Connect with organisations that support racialised communities, as well as those that address challenges associated with racial inequality, to enhance care on the ward as well as support effective discharge.

Ensure all voices are involved in service design

Ensure that ethnically and culturally diverse patients, carers and their chosen support networks are actively involved in the design, development and review of care pathways across all ages.

Engage with organisations that support racialised communities, as well as those that address challenges associated with racial inequality, to build knowledge of how best to engage and support people.

Understand the individual and their experiences

Make sure people feel welcome and can communicate – ensure everyone is made to feel equally welcomed to the ward and that interpreter services are available, if needed.

Take the time to learn more about patients’ backgrounds (ethnic identity, religious beliefs, spirituality, cultural values and gender aspects) to build a true picture of their experiences and perspective. This helps to avoid stereotyping and assumptions – racialised communities and people are not homogenous.

Understand the person’s family and relationships to help clarify family dynamics, cultural background and possible generational trauma. Confirm the person’s preference for family involvement.

Ask directly about experiences of discrimination, bullying, traumas or harassment.

Remember to not only focus on challenges – identify strengths, interests and resilience factors.

Co-produce culturally competent care plans

Ensure that ethnically and culturally diverse patients and their chosen support networks are treated as equal partners in decision making on their care and treatment plans, and actively involved in the design, development and review of care pathways across all ages.

• Make this explicit – state upfront that this is a collaborative process and that you welcome input on how you are working together and the plan itself.

Inquire about what the person feels would be helpful. Are there cultural practices they have already tried – and what was the result? Are there religious, cultural or individual convictions that affect choice of treatment?

After a 1-to-1 with the person, ask if they felt understood and if there is anything else he or she would like to add to be better understood.

For patients used to clinician(s) making all decisions, consider asking them to make a decision, however small. This will show that you want to know their preferences and helps them feel comfortable with making healthcare decisions and expressing their wants and needs.

When developing trauma-informed care approaches, ensure this considers an individual’s cultural perspective and background, including the impact of complex, intergenerational, historical, collective and individual trauma.

When considering medication, ensure staff are aware of evidence on the possible impact of ethnicity on the prescription, adherence, clinical response, emergence of side effects, to help make informed decisions in partnership with patients.

References

1. Mental Health Act Statistics, Annual Figures – NHS England DigitalThe Mental Health Units (Use of Force) Act, 2018. Available at: Mental Health Units (Use of Force) Act 2018: statutory guidance for NHS organisations in England, and police forces in England and Wales – GOV.UK (gov.uk)
2. Stubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus (Am Psychiatr Publ). 2020 Jan;18(1):49-51. doi: 10.1176/appi.focus.20190041. Epub 2020 Jan 24. PMID: 32047398; PMCID: PMC7011228
3. So, N., Price, K., O’Mara, P. and Rodrigues, M.A. (2024), The importance of cultural humility and cultural safety in health care. Med J Aust, 220: pp 12-13. https://doi.org/10.5694/mja2.52182
4. Kelsall-Knight L. Practising cultural humility to promote person and family-centred care. Nurse Stand. 2022 Jan 17. doi: 10.7748/ns.2022.e11880. Epub ahead of print. PMID: 35037443.)
5. Ranjbar N, Erb M, Mohammad O, Moreno FA. Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities. Focus (Am Psychiatr Publ). 2020 Jan;18(1):8-15. doi: 10.1176/appi.focus.20190027. Epub 2020 Jan 24. PMID: 32047392; PMCID: PMC7011220.
6. Fagrell Trygg, N., Gustafsson, P. E., & Månsdotter, A. (2019). Languishing in the crossroad? A scoping review of intersectional inequalities in mental health. International Journal for Equity in Health, 18(1), 115. https://doi.org/10.1186/s12939-019-1012-4
7. Cénat, Jude Mary: How to provide anti-racist mental health care (2020). The Lancet Psychiatry, Volume 7, Issue 11, 929 – 931. com/action/showPdf?pii=S2215-0366%2820%2930309-6
8. Stubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus (Am Psychiatr Publ). 2020 Jan;18(1):49-51. doi: 10.1176/appi.focus.20190041. Epub 2020 Jan 24. PMID: 32047398; PMCID: PMC7011228 

Publication reference: PRN01721_ii