CHAPTER 9:

NURSING CELEBRATES CULTURAL DIVERSITY

JOSEPHINE A. KAHLER, EDD, RN, CS

Culture adversity is not an obstacle; its a gift.

Chapter Motives:

Define and explain the concept of culture.

Explain the foundational impact of culture on nursing practice.
Discuss models describing cultural competence.
Analyze transcultural nursing perspectives as they pertain to the work
environment.
Evaluate the challenges of managing a culturally diverse workforce.

This chapter explores the concept of cultural diversity, along with theories
used to explain cultural differences. It offers guidance to nurses who are
providing leadership and care in an increasing diversity of team members.

Addressing the needs of an increasingly diverse population has become a

major challenge to all health-care providers. Cultural diversity concerns
can be viewed from two perspectives: (1) caring both physically and
spiritually for a diverse client population (2) providing a culturally diverse
workforce with positive work experiences.

CULTURAL TERMS:

Culture is a shared values, beliefs and practices of a particular

group of people that are transmitted from one generation to the next
and are identified as patterns that guide thinking and action.
Cultural Competence is providing effective nursing care to
patients from many cultures in a respectful and knowing way.
Cultural Diversity is differences in race, ethnicity, religion,
national origin, gender and economic status
 Stereotyping is assigning certain beliefs and behaviors to groups
without recognizing individually
Values are abstract standards that give a person a sense of what
is right or wrong and establish a code of conduct for living.

CULTTURAL CONCEPTS

Different Definitions of CULTURE:

It encompasses shared values, behaviors and beliefs that are

reinforced through social interaction, shared by members of a
particular group, and transmitted from one generation to the next
It exerts considerable influence over most of an individuals life
experiences, including illness
It can be perceived as a form of tradition for a group, which is
based on beliefs about survival of group mores and customs
It is deeply rooted within the group and within human
interpersonal dynamics that occur naturally within the groups
It is a system of learned patterns unique to members of a group
Differences and variety in customs and practices defined in social
groups

THREE LEVELS OF CULTURE (Schein, 1985):

1. The Visible Level

This includes physical space and social environment.
2. The Values
This includes elements of what ought to be.
3. The Basic Underlying Assumptions
This includes the actual guides to behavior that are deeply held and
not open to challenge or debate

Without understanding cultural diversity, nurses tend to respond to sick

people based on their own socialization, culture and education. Nurses may
also find their perceptions of appropriate personal space called into
question. (Note: Examples about clients and patients from America, Asia,
South Africa and America are provided in the book, page 317)

Values change as new generations adopt the new countrys views over
time. It is easy for health-care practitioners to overlook the impact that
cultural inheritance has had on both conscious and subconscious health
beliefs, however.

The classification of individuals into few groups does little to promote

understanding of the health beliefs, practices, needs and diversity that are
represented within each of these population classifications.

Thus, nurses should keep in mind that changes in lifestyles and health
habits work best when they are integrated into the persons own cultural
patterns and traditions, for it is hard to sustain new patterns if they go
against grain of ones social patterns.

IMPACT OF CULTURE ON NURSING PRACTICE

It is imperative today for the nurses to be aware of cultural

differences in their health-care delivery and practices. The role
expectations of nurses may even differ from culture to culture. (Note: An
example on Anglo-American was given on page 317)

Despite the fact that awareness of cultural diversity directly affects

diagnosis, assessment and intervention strategies, cultural diversity is
often not seen as an essential variable in how nurses mediate conflict,
communicate or interpret different behaviors. (Note: An example on
Navajo culture was given on page 317)

Communication is a vital part of the cultural interaction that takes place

between the health-care provider and client. Patterns of communication
are strongly influenced by culture and include not only language
differences but also verbal and nonverbal behaviors as well.
Nurses fail to provide culturally competent care to patients without a
sense of their own cultural values. Thus, nurses must culturally assess
each patient individually.

Culture directly affects client care. Differences are needed to be learned

by nurses who can be educated into being culturally competent caregivers.

MODELS OF CULTURAL COMPETENCE

Cultural competence models serve as frameworks for providing

effective nursing care to patients from many cultures in a respectful and
knowing way.
Cultural competence is a vital component for practicing effective
communication, valuing, understanding and caring in health care.

The following models are frequently used in health-care settings:

PURNELL AND PAULANKAs model (1998)

Th outer zone of the models circle represents global society; the second
zone depicts community; the third zone represents family; and inner
zone symbolizes the individual.

The interior of the circle is divided into 12 pie-shaped wedges depicting

cultural domains and their concepts, i.e., family organization, workplace
issues and health-care practices. The innermost center circle os dark,
depicting unknown phenomena.

Cultural consciousness is expressed in behaviors from unconsciously

incompetent-consciously incompetent-consciously competent to
unconsciously competent.

This model allows the nurse to use culturally competent care for the client
by analyzing the clients care plan and adapting treatment modalities to the
clients cultural needs.
 CAMPINHA-BACOTE MODEL (1994)

This model involves four constructs:

1. Cultural Awareness should be a deliberate process that assists the

nurse in becoming aware of and more sensitive to the clients cultural
differences while at the same timemaking caregivers more
conscious of their own cultural values so as not to impose them on
client.

2. Cultural knowledge can be obtained by education on different

cultures and accumulating knowledge base of transcultural nursing.

3. Cutural skills is achieved by the nurse learning how to cultural

assessment and identifying the clients beliefs, practices and
perceptions of health.

4. Cultural encounters are the actual face-to-face encounters and

interactions with the clients.
Campinha-Bacote also defines cultural competence as the process in
which the health-care provider continuously strives to achieve the ability to
effectively work within the cultural context of the client.

LEININGERS MODEL OF TRANSCULTURAL NURSING

This model depicts a relationship between the differences and

commonalities in health beliefs and practices among people from different
countries or geographical regions.
The SUN RISE MODEL embraces the idea that cultural constructs are
embedded in each other and their application is both broad and holistic.
The arrows in the model indicate influencers but are not causal
or linear relationships. They flow in different areas and cross major
factors to depict the interrelatedness of factors and the fluidity of
influencers.
The dotted lines indicate an open world or an open system of living
reflective of the natural world of most humans.

Leininger describes the upper part of model as being extremely

important but often challenging to nurses because it often leads to the
discovery of embedded, deeply valued and meaningful data about human
care and well-being.

Transculturism describes a nurse who is grounded in ones own culture

but has the skills to be able to work in a multicultural environment.

Leininger emphasizes that there is a greater need for cultural awareness

because of increased global mobility, the importance of cultural identity,
migration and role change.

Care should be viewed as culturally defined, with predictors defining

health or illness. It should be assumed that when persons are given
human caring, the persons cultural characteristics will be
addressed and incorporated into the overall plan of care.

Cultural care is defined as the synthesized and culturally constituted

assistive, supportive and facilitated caring acts toward self or others
focused on evident or anticipated needs for clients health or well-being or
to face disabilities, death or other human conditions.

Cultural assessment which is an important step in providing care to

diverse clients is defined as merely asking people their preferences, what
they think, who we should talk to in order to make a decision.

Culturally competent nurses take cultural differences into consideration

when doing assessments which in turn help them to interpret necessity for
developing a culturally congruent plan of care and to achieve outcomes.
Leininger identified the basic domains to review when conducting a cultural
assessment:

1. Lifestyle patterns
2. Cultural norms and values
3. Cultural taboos and myths
4. Ethnocentric tendencies and worldviews
5. Health and life care rituals
6. Caring behaviors
7. Degree of cultural change
8. General features that the client perceives as different from or similar
to other cultures
9. Folk and professional health-illness systems used

(Note: See Cultural Assessment Checklist on page 322)

CULTURAL COMPETENCE IN PRACTICE

The nurse must be sensitive to differences such as language,

interpretation of communication, eye-contact norms, gender issues,
touching and physical contact, food practiced, and caregiver acceptability
issues.

Attention to the spiritual domain in providing holistic care to the client

depends on beliefs and values of both the client and nurse. Nurses have an
obligation to identify the spiritual and religious beliefs in their clients and
respect them, no matter how unusual they may seem. It must be
recognized that spirituality is an integral part of culture.
(Note: See examples on page 322)

Clients often make cultural choices that are difficult for nurses to
understand and accept. When patients wishes are contrary to the nurses
with respect to spirituality and religion, nurses should pose their responses
to such situations in a holistic way.
Effective nursing practice recognizes that there is a need to adopt
nonjudgmental attitudes toward patients religious beliefs in order to
avoid conflicts and confrontation.

Collaboration and cooperation are key components to ensure that

patients receive optimal health care.

Culturally competent nurse demonstrates the following skills and

attributes:

1. Uses nursing concepts, principles and available research findings to

assess and guide practices
2. Understands and values the cultural beliefs and practices of
designate cultures so that nursing care is adapted to meet that
individual clients needs in a meaningful way
3. Knows how to avoid and prevent major cultural conflicts, clashes, or
hurtful care practices
4. Demonstrates the conficde3nce to be able to work effectively and
knowingly with clients from different cultures and is also able to
evaluate transcultural nursing care outcomes.

Clients receiving culturally based nursing care exhibit signs of satisfactions.

MANAGING A CULTURALLY DIVERSE WORKFORCE

Management has a responsibility to address cultural issues because of

the rapidly changing health-care workforce.

One alternative is to create equal worker partnerships that capitalize

on the best aspects of all cultures for an effective, harmonious work
setting. It can be accomplished by discussing cultural viewpoints as a part
of decision making and acknowledging and respecting differing cultures to
ensure equal participation and access to the agenda.
Management of issues that involve culture, whether gender, religious,
ethnic, or any other kind, requires patience, persistence and great deal of
understanding.

Culturally skilled nurse managers can provide cultural safety to patients by

making sure that messages about patient care are received and
understood. By addressing cultural diversity directly, the nurse manager is
offsetting future negative effects on performance and staff interactions.

Importance of Communication
Gestures, verbal tone, body movements and physical closeness when
communicating are all part of persons culture. Understanding these
cultural behaviors is imperative in accomplishing effective communication
within workforce population.

Nurses need to ensure that effective communication by staff with clients

and others does not lead to misunderstandings and eventual alienation.

Respect for different lifestyles must also be fostered.

The complexities of culture strongly influence opinions, perceptions and

generalizations.

There is a need for supervisors and nurse managers to be vigilant about

attitude and behaviors that encourage ethnic or racial stereotypes and that
inhibit trust and communication.

Experience working with a diverse staff may be the best educational

environment for learning about different cultures.

Cultural conflicts must be confronted and effective resolution must be

made.
ALL GOOD THINGS

All individuals have the need to be accepted by their health-care providers

and have their cultural interpretations of health acknowledgment be
respected.

Understanding cultural diversity and its impact on effective health-

care delivery requires a commitment on the part of all health-care
providers.

Transcultural nursing provides a theoretical base for nursing regarding

cultural competence. Nursing also needs to implement effective
strategies to reflect the cultural mix of society within the workforce. Thus,
with increased knowledge, sensitivity, respect and understanding, nurses
can provide the highest quality of health care for clients in our
multicultural society.