The Public Health Nursing Series is a 20-blog collection, written by William (Billy) Rosa, author of the forthcoming title, Nurses as Leaders: Evolutionary Visions of Leadership (June 2016), that sparks a dialogue about each and every nurse's role in advancing and creating the future of global health. With a focus on cultural considerations and the current status of healthcare in nations worldwide, nurses will learn how they are called to contribute to each of the United Nations' 17 Sustainable Development Goals, an international initiative that seeks to end poverty, protect the planet, and ensure prosperity for all over the next 15 years.This series makes the case that every nurse, regardless of title, position, or credential, is a public health leader.

A Word on Cultural Humility (Part 2)

The public health nurse is both a leader and advocate in service to the greater good. All too often, care providers, whether they be nurses, physicians, or physician assistants, can get caught up in their own vision of what idealistic care looks like to them and forget to prioritize the client’s health goals. There is, at times, an inherent arrogance in how we approach cultures of differing race, ethnicity, religious affiliation, sexual orientation, gender identification, socioeconomic standing, or age. This arrogance can be observed again and again in healthcare when we believe, as the “experts” in the field, that the information we possess is of greater importance or holds more validity than the client’s experiential values, norms, and traditions. We may subtly and unknowingly adopt a “greater than, less than” approach to care; where we as experts are “greater than” in resources and evidence, and those we serve are “less than” in their limited education of health, nursing, or medicine.

Who is to say that our science trumps their self-knowledge and cultural expertise? After all, the client, whether they be an individual, identified population, or country, knows far more about their health goals, needs, beliefs, and ethics than an outsider could ever understand. But we don’t always see it that way.

The term cultural humility was first coined by Tervalon and Murray-Garcia (1998) during research that looked at how to train medical students in their responses to culturally diverse clientele. Tervalon and Murray-Garcia (1998) suggested the attainment of cultural competence is a misnomer. They skillfully explain that there is no endpoint or goal of “competence” in learning to authentically and respectfully navigate the depth and dimension of another culture. In fact, they proposed that cultural humility is a process requiring the healthcare provider to commit to:

  • Self-reflection and lifelong learning in order to accept, understand, and incorporate differing beliefs and health practices
  • Patient-focused interviewing and care that replaces power imbalances seen in paternalistic provider-patient dyads
  • Community-based care and advocacy that leads to mutually beneficial partnerships for both providers and recipients of healthcare services.

It is vital to examine our own preconceived beliefs about our role as public health nurses and how we communicate those values to clients. As we begin to explore our willingness, or lack thereof, to remain flexible and open to other cultures and how health is perceived through their lenses, we begin to discover the places where we have become personally and professionally stagnant. Through this self-reflection, we bear witness to longstanding prejudices, opinions, and aversions. If we are able to confront ourselves with a gentle honesty and reserve self-judgment, it may be shocking to find just how many cross-cultural assumptions we possess to which we have become mindlessly habituated to over time. Some important questions to ask oneself might be:

  • Am I emotionally available and respectful to clients when they share with me their traditional health beliefs, practices, and rituals? Am I considerate and inclusive of their beliefs, practices, and rituals in the plan of care?
  • Do I believe that the nursing care and knowledge I provide is better for the client than what they believe is most important for themselves?
  • Do I see myself as the expert and the client as the novice?
  • Do I view my role as a teacher who imparts knowledge or as a coach that assists the client in their journey of self-discovery?
  • In my opinion, are mutually beneficial client partnerships a gateway to growth and optimal care or a nuisance requiring time and energy?

Be honest and understand that your answer may not be a black or white response; it will most likely occur on a spectrum. If you can spot your own arrogance, simply recognize it, acknowledge how it hinders your ability to be fully present to another person, and identify ways to surrender that outdated belief pattern to create a new one rooted in humility. Shedding light on the corners where arrogance lingers has the power to change us as individuals and nurses, helping us to return to our shared humanity and ethical obligation to procure dignified human-centered care.

I am currently working for the Human Resources for Health Program in Rwanda, a seven-year partnership between a consortium of United States hospitals and universities and the Rwandan Ministry of Health. There is frequently an unconscious mindset of arrogance on the part of Westerners working in service to global initiatives of this scale; one that says, “We are here to make you better, to teach you how to do it right.” I’ll never forget during my orientation when the Dean of the School of Medicine at the University of Rwanda said something to this effect: “You are not here to teach me how to fish. I already know how to fish. You just fish differently. Let us not waste time on who fishes better but learn from each other what we can so that we might both grow in the best ways possible. Let’s fish together.”

There it is: I am not here to teach anyone how to fish. I am here to be a partner, a student, and a teacher where appropriate. I am called to be a leader in partnership with other leaders and an advocate in coordination with collaborating advocates.

Soulé (2016) writes, “Humility… can be thought of as an accurate assessment of oneself, an ability to recognize and acknowledge limitations, and a willingness to be influenced by alternate values and worldviews. Humility… may actually be perceived as antithetical to competence, professionalism, and professional practice [in the United States].” If the public health nurse is to impact change, lead improvements in global healthcare access and delivery, and advocate for health equity for every man, woman, and child on the planet, we must cultivate awareness regarding how we see the world. Rather than walking blindly, we must face the fear that accompanies self-knowledge and self-truth and confront ourselves with both compassion and courage.

Unacknowledged arrogance blinds us from ourselves. Humility reminds us of who we really are.

The choice is yours.


Soulé, I. (2016). Flexible & responsive: Applying the wisdom of ‘It Depends.’ In W. Rosa (Ed.),

Nurses as Leaders: Evolutionary visions of leadership. New York, NY: Springer, in press.

Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.

More About the Author

William (Billy) Rosa, MS, RN, LMT, AHN-BC, AGPCNP-BC, CCRN-CMC, is currently Visiting Faculty, University of Rwanda and ICU Clinical Educator, Rwanda Military Hospital, Human Resources for Health Program in partnership with the New York University Rory Meyers College of Nursing. He currently has over 65 publications for refereed and non-refereed journals, newspapers, magazines, and national platform blogs and his book, Nurses as Leaders: Evolutionary Visions of Leadership, will be released by Springer in June 2016. Billy currently sits on the US Advisory Board for the Nightingale Initiative for Global Health, and most recently received the American Association of Critical-Care Nurses' 2015 National Circle of Excellence Award and the Association for Nursing Professional Development's 2015 National Change Agent/Team Member Award.

Quick Links 

Part 1 -  Understanding the Nurse as a Public Health Leader

Part 3 - Global Citizenship, Millennium Development Goals