Cultural Intelligence and the Proposed Cultural Understanding and Diversity Competencies in Health Information Management Education Curricula

by Thomas Hunt, PhD, RHIA, CHDA, FAHIMA

Abstract

Cultural intelligence (CQ) is the ability to adapt to and function effectively in culturally diverse situations. This capability can be developed and improved. The newest proposed American Health Information Management Association educational curricula for degree programs include the student competencies “examine behaviors that embrace cultural diversity” for undergraduate programs and “recommend strategies that promote cultural diversity” for graduate programs as part of the Organizational Management and Leadership educational domain. Globalization has increased the diversity and complexity of healthcare organizations in the United States and other countries, requiring professionals to be able to succeed in diverse environments. This literature review seeks to increase awareness of CQ as a potential topic in health information management education that may support the proposed educational competencies related to diversity and cultural understanding.

Keywords: cultural intelligence (CQ); health information management; education; American Health Information Association (AHIMA) curriculum; cultural diversity; AHIMA organizational management and leadership domain

Introduction

Cultural intelligence (CQ) focuses on the ability to adapt to culturally diverse situations1 and function effectively in these situations.2, 3 This topic has been studied in many contexts because globalization has increased the cultural diversity of workplaces, including healthcare organizations. Health information management (HIM) graduate, baccalaureate, and associate degree programs prepare graduates for careers in the healthcare industry. In the United States, graduates who wish to sit for the Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) certification examinations must complete a degree program following curriculum guidelines established by the American Health Information Association (AHIMA) Council on Excellence in Education (CEE) and accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).4 The AHIMA curriculum competencies include cultural understanding and diversity as required topics in the Organizational Management and Leadership domain.5 These competencies have been identified as important career advancement and leadership development skills for future HIM professionals in a globalized workforce. This literature review presents the four-factor CQ model as a potential topic to help prepare HIM graduates for diverse healthcare environments and seeks to advance awareness of CQ as a potential option to incorporate into assignments in educational programs seeking to adhere to the AHIMA curriculum requirements.

A literature review was conducted to investigate previous publications on this concept. Scholarly articles from the electronic databases ProQuest, OCLC FirstSearch, EBSCOhost, Elsevier ScienceDirect, and Gale were searched, as were textbooks regarding CQ. The CQ studies selected for inclusion were those significant to the development of CQ theory and those thought to be applicable to multiple professions in diverse settings both in North America and abroad. The final product is not an exhaustive account of all CQ research but an overview of both older and newer studies that may be relevant to HIM professionals and raise awareness of the potential application of CQ in HIM education. The literature regarding CQ continues to grow (one review6 found 60 peer-reviewed publications in 2016 and 2017), yet no sources that connected CQ specifically to HIM or healthcare professions were found. Even so, many studies addressed management, leadership, and communication in culturally diverse settings, and these topics do seem relevant to the roles of HIM practitioners in today’s healthcare organizations. For this reason, CQ was explored as a potential area for the development of future HIM professionals. The gap discovered in this review is an opportunity for researchers to pursue further study of CQ in HIM and healthcare settings to provide a clearer picture of the relevance of CQ to HIM education.

Background

Globalization is the predominant factor affecting business around the world,7 and its pace is increasing.8 Globalization is the intensified economic, social, technical, and political interdependence of cultures and nations,9 and it is changing business in various ways for almost every North American organization.10 The healthcare industry, including the HIM profession, is no exception. Leaders in healthcare need to be capable of leading people of increasingly diverse backgrounds.11 Leaders increasingly need to successfully operate with a diverse and cross-cultural set of patients, providers, customers, employees, suppliers, creditors, and competitors.12, 13 The challenge continues to grow as more partnerships and work groups are made up of individuals from different nations and cultures.14 Success in this environment “requires the ability to be open to others’ ideas and opinions. Being global is not just about where you do business.”15 Globalization has caused our communities and organizations to become far more diverse than they were in the past, and it has created the need and opportunity for leaders to become competent in cultural awareness, demonstrate CQ, and understand how it affects leadership performance.16, 17

The AHIMA CEE seeks to prepare future graduates for success in this environment by including a requirement to address specific competencies related to cultural understanding and diversity in programs accredited by CAHIIM. These competencies are in the Organizational Management and Leadership domain of the curricula and include “Recommend strategies that promote cultural diversity” as a graduate degree competency and “Examine behaviors that embrace cultural diversity” as a baccalaureate and associate degree competency.18 College and university programs may want to include CQ in activities and assignments to build the level of student learning of these competencies. Student learning is classified by a modified form of Bloom’s Taxonomy, which accompanies the curricular guidelines.

Cultural Intelligence

As noted in the introduction, CQ focuses on the ability to adapt to and function effectively in culturally diverse situations.19–21 It is an ability to interact effectively with people who are culturally different22 and requires the capacity to respond appropriately, which is more than simple knowledge of cultural dimensions or norms.23 This concept has recently emerged in academic studies and is reviewed here because it has been found to have benefits worldwide. Van Dyne, Ang, and Koh,24 as well as the Cultural Intelligence Center,25 assert that CQ is relevant for employees with both domestic and cross-border international responsibilities. Greater diversity in the workforce increases the need to work and interact regularly with those with different cultural or ethnic backgrounds,26, 27 which globalization is bringing to organizations that operate in international and domestic North American environments. Cultural intelligence is an asset for success not only in different national cultures but also in multiple organizational and professional cultures.28, 29 It can be thought of as possessing intelligence from the viewpoint of different cultures,30 regardless of geographic location. Leaders seeking a more global set of skills for success require both international and domestic perspectives, instead of one view or the other,31 as geographic and cultural boundaries become less distinguishable.32

Analytic intelligence (IQ) is often thought of first when a person’s ability to succeed is considered; however, other types of intelligences, including CQ, have been proposed to help explain success or failure beyond the traditional definition of intelligence.33 Social and emotional forms of intelligence are other proposed ideas that follow the theme that intelligence is inherently multidimensional, involving both behavioral and cognitive components.34 Leaders were already advised to develop a deep set of interpersonal skills35 long before the concepts of multiple intelligence (theories such as emotional intelligence, social intelligence, or Gardner’s multiple intelligences) were identified. These skills were identified as an element that differentiated effective leaders in multiple and different settings36 from those who were not as successful. Individuals with greater self-awareness and awareness of changes in the environment and in others are likely to have more constructive relationships.37 Recent studies have found CQ beneficial in relationships involving teamwork,38–40 knowledge-sharing behaviors,41 and communication.42

Cultural intelligence is suggested as a possibility to meet the needs of HIM graduates because it is a set of capabilities43 that can be developed44 as a possible resource to improve leadership skills in an increasingly diverse and environmentally complex workplace.45, 46 Even when people from the same cultural background interact, every relationship is unique.47 This fact suggests the importance of individually adaptable CQ in leadership as an approach that requires more than a superficial understanding of cultural dimensions. Kim and Van Dyne48 found that even for members of the cultural majority, prior contact with and knowledge of other cultures and CQ was especially beneficial when operating in diverse environments.

Dimensions of the Four-Factor Model

The dimensions of the four-factor model of CQ that is investigated in this review are strategy, knowledge, motivation/drive, and action/behavior.49, 50 Each aspect is important for progressing past a simple awareness or understanding of different cultures and is essential to meet learning competencies51 and to engage in effective cross-cultural leadership.52 CQ-Strategy, previously called Metacognitive CQ, is described as consciousness and awareness during interactions with those of different cultural backgrounds.53 It describes the ability to actively think about piecing together information gained about a new culture.54 CQ-Knowledge, or Cognitive CQ, is knowledge of different cultures and the norms, practices, and conventions that one must consider and understand when making decisions55 and when determining culturally appropriate behavior.56 CQ-Motivation, also sometimes referred to as CQ-Drive, is the capability to direct attention and energy toward cultural differences—the “drive and interest to learn and function”57 in new situations. CQ-Action, or Behavioral CQ, is often the most visible dimension, describing the ability to display appropriate verbal and nonverbal actions when interacting with different cultures.58 The ability to generate appropriate behavior in a new cultural setting is something that makes CQ unique59 from other types of intelligences. It can be described as adjusting to the local customs as opposed to forcing one’s own way of thinking and acting upon people.60 The four factors are displayed in Figure 1.

Developing cultural competencies has been a priority for many organizations to increase effectiveness61 for some time. Diversity of a workforce does not guarantee competitive advantage, as simply assembling people of different racial and cultural backgrounds is not enough.62 The diversity must be utilized and leveraged in multidimensional situations through leadership.63 This skill requires a set of cultural capabilities; the four factors of CQ seem to fit. A 20-item questionnaire titled the Cultural Intelligence Scale (CQS) has been developed to help measure CQ, with 4-6 questions regarding each factor.64 Participants rate themselves selecting an answer that best describes themselves on a seven-point scale from strongly disagree to strongly agree. The CQS is the most commonly used tool for measuring CQ65 and has been found valid and reliable.66 Each self-rated item on the seven-point scale and can be averaged overall or by dimension to help assess CQ. A higher overall or dimensional mean score indicates a higher level of CQ. Improving this skill set can help leaders not only be mindful of the differences and similarities among people they are working with, but also become more integrative and more effective communicators.67

Criticism of CQ

Cultural intelligence has a shorter history of empirical research studies68 than some other fields. For this reason, the names of the factors have evolved as more research has been sought to support the theory. Suggested topics for clarification in further research include examining the relationship of CQ to real-world business problems, such as leadership in multicultural environments69 and in settings that provide contexts for better understanding of adaptation,70 and investigating whether CQ is a universal ability or culturally specific.71 Blackburn72 articulates a concern regarding CQ by comparing it to old wine (interpersonal skills) in new bottles labeled cultural intelligence. Efforts to further define and refine the concept seem to be ongoing, although this is understandable because CQ is a recently developing research topic. Another question raised relates to the ability to develop CQ skills.73 Studies have found mixed results in multiple modes of training, yet no universal method of increasing individuals’ capability has been identified. Researchers have continued to develop tools to measure CQ, including the short form measure of cultural intelligence (SFCQ)74 and the Business Cultural Intelligence Quotient (BCIQ),75 asserting that these measures may be better suited to capturing a broader range of aspects and/or providing results that are more applicable to business settings. There is also the challenge of measuring what is intended to be measured, and the use of self-assessment tools may affect the results, as study participants may rate themselves in a more positive light than is warranted.76 As more empirical research is conducted, researchers may find that CQ is a concept that has always existed yet was unlabeled or mislabeled, or they may find that it has adapted because of the growing globalization of the world.

Discussion

The purpose of this review was to raise awareness of the CQ concept and its potential benefits for those working in culturally diverse settings. While no study that directly examined CQ in the HIM profession was found, benefits found in other settings may be relevant or useful to HIM program graduates. Research specifically regarding the needs of HIM professionals and the benefits of CQ in leadership, management, teamwork, and communication may provide an idea of the relevance to HIM programs.

Educational programs in HIM have many options to consider and pursue when seeking to meet the curricular requirements of examining behaviors that embrace cultural diversity and recommending strategies that promote cultural diversity. Programs need to prepare students to meet these competencies to a level of learning consistent with the adapted Bloom’s taxonomy of student learning77 outlined in Figure 2. Assignments, cases, activities, and experiences meeting the expected level of student learning will need to be developed for the proposed curricular competencies. Cultural intelligence is not the only avenue to pursue in efforts to meet the curricular requirements, and topics related to intercultural competence extend beyond CQ alone.78, 79 No studies specifically connecting HIM to the development of skills related to diversity or cultural understanding of any kind were found. Outside of HIM, studies relating to the successful development of students’ CQ capabilities included classroom-based instruction,80, 81 interactions with other cultures such as short-term exchange programs,82, 83 and online programs with culturally diverse participants.84 The results of cultural education and training in these studies suggest that degree programs can prepare graduates for culturally diverse workplaces by developing individuals’ CQ. The ability to use classroom lectures, online sessions, and short-term experiences, as opposed to requiring years of education abroad, could also be beneficial for programs seeking to incorporate activities that fit into the structure of the HIM program.

The literature suggests that CQ is a potential tool for professionals to leverage in complex environments, such as modern healthcare organizations. Individuals with strong CQ may possess a global outlook with a more complex and flexible line of thinking that enables them to function in complex and changing environments.85 The development of this capability in HIM educational programs through assignments, cases, activities, and experiences would seem to support graduates’ gaining the skill to both embrace cultural diversity and recommend strategies to promote cultural understanding and diversity. Further research on CQ in the field of HIM would provide specific evidence to determine whether CQ is a good fit to support the cultural understanding and diversity competencies in the leadership and management domain of HIM education.

 

Thomas Hunt, PhD, RHIA, CHDA, FAHIMA, is an assistant professor in the Department of Health Informatics at Rutgers University in Newark, NJ.

 

Notes

 

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