Module 15-Cultural Diversity & Nursing
Section 1
What is Culture?
1. A complex whole, encompassing knowledge, beliefs, values, practices, customs, and any
habits acquired by members of society.
2. Represents ways of perceiving, behaving, and evaluating the world.
Culture and Nursing Care
1. Leininger’s Theory of Culture Care Diversity includes concepts of culture care delineated
as preservation/maintenance, accommodation/negotiation, and repatterning/restructuring.
2. Health Traditions Model explores what one does to maintain, protect, and restore health
(physical, mental and spiritual) with in a framework of one’s ethno religious cultural
heritage.
3. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in
Health Care can be used by accreditation and credentialing agencies to assess delivery of
culturally competent services and assure quality care for diversity populations; these
standards must be met by most health care-regulated agencies.
4. Cultural phenomena that can affect health include the following factors:
a. environmental control (health practices and remedies)
b. biological (physical and genetic) variations
c. social organization (holidays, special events such as births and funerals)
d. communication (greetings, gestures, smiling, eye contact)
e. personal space (body language and distance)
f. Time orientation (punctuality, announced versus surprise visits from family and
friends).
5. In nursing, the prerequisites to delivering culturally competent care are understanding
one’s personal cultural values and health beliefs, being respectful and understanding of
client’s culture, and becoming familiar with health beliefs and practices held by
commonly encountered groups in health care agency’s service area.
6. Strategies that can be used to aid in the communication process of clients in various
cultures:
a. Assess English as a second language and make arrangements for an interpreter if
needed; speck directly to client even using an interpreter.
b. Use language free of slang or currently popular jargon; use simple, straight forward
sentences or requests. Rephrase if client does not understand.
c. Be attentive to body language that might offend the client.
d. Assess how the client would like to be addressed.
e. Prior to giving written material for health care education assess the client’s ability to
read; ability to read in any language can affect the client’s ability to learn health
information regardless of cultural background.
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Module 15-Cultural Diversity & Nursing
7. Religious laws may influence dietary practices, which in turn my influence nursing care
during illness. Refer to Table 1-1.
8. Religious beliefs may also influence views on health-related issues and events (Table 12).
9. Culturally based dietary preferences are lifelong habits and can significantly influence
health as well as compliance with medically recommended treatment (Table 1-3).
10. Cultural beliefs about maintaining or restoring health may clash with the
recommendation of treatment from the health care provider. It is important to remain
calm, nonjudgmental and work the client to incorporate client’s cultural health beliefs
and practices while assisting client health goals.
11. Avoid generalizing and stereotyping (an expectation that all people within same ethnic or
cultural group are alike and share same beliefs and attitudes).
We live in a country of many colors, many heritages, and many histories. Some refer to the
United States as a “melting pot” because people from so many different cultures live here. At
one end of the continuum are people who came to the United States from other countries and
have not changed their behaviors or beliefs. They live in small communities with people who
have a similar cultural heritage. At the other end of the continuum are people who came to the
United States from other countries and changed from the “old country” beliefs and behaviors to
those that better suit them. Between the two ends of this continuum are people with varying
behaviors and beliefs that represent a blending of foreign and American influences. Culture is
dynamic that results from human interactions among people of many beliefs. As individuals
interact with people and their physical and social environments, they create ways of naming,
understanding, and managing their worlds. As people interact with new individuals and new
environments, their culture may change. People within a culture share values, beliefs, and
expected behaviors that define what is right, normal, and appropriate as well as what is wrong,
abnormal, and inappropriate. Belief systems act as lenses on the world through which we filter
everything we view. When we gain new information that contradicts our beliefs, we may tend to
disregard that information rather than change beliefs. Unfortunately, some of our beliefs may be
based on incorrect or incomplete information.
Diversity refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation,
physical or mental disabilities, and social and economic status. As a health care professional, you
are challenged with the responsibility to work with and care for diverse individuals who may not
have the same skin color, language, health practices, beliefs, and values as your own. When this
occurs, the goal is not to force the client and his or her family to comply with your beliefs,
values, and health practices but instead to meet the client where he or she is and to work with his
or her belief and value system. The challenge occurs not when the client is of the same heritage
and speaks the same language as the nurse, but when the cultures and languages are different.
Consider the following scenario:

You are caring for a 72-year-old Hispanic woman, Rosa Martinez, who speaks Spanish as
her primary language. Conversing in broken English, she tells you that she has injured
her lower back and now has continuing aches and stiffness. She does not want to be at the
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clinic but is here because her daughter forced her to come. She says that she hasn't seen a
physician in years because Maria, her curandera, takes good care of her. When you
inquire whether she has seen Maria for her back, she replies yes and then goes on to tell
you that Maria had given her an herbal formula to take internally and had made herbal
poultices to use at home. The client tells you that she believes that these remedies are
working and she is not sure why her daughter made her come to the clinic.
The nurse caring for Mrs. Martinez is potentially challenged by three issues: (1) the language
barrier; (2) an alternative health care provider, Maria, the curandera, in whom Mrs. Martinez has
much confidence; and (3) the use of alternative folk remedies—the herbal formulas and
poultices. How the nurse interacts with this client and her family will depend partly on the
nurse's own heritage and culture and partly on her knowledge of and attitude toward other
cultures and other cultural health beliefs and practices.
Nurses working together from diverse cultures may practice nursing in different ways. Some
nurses who are Native American report that their nursing practice may be different from that of
other nurses because they perceive life through a view that is different and that guides them in
making their own sense of health care matters. As more nurses from other countries join the
nursing profession in this country, the need for learning about how other cultures practice
nursing gains new significance.
Because the diversity among us is so great, nurses are not responsible for knowing about the
health beliefs, practices, and values of all of the cultural and racial groups other than our own,
However, we are responsible for asking the client about his or her health beliefs, practices, and
values because knowing this information is essential for individualizing care. A person may be
from one of the major racial and cultural groups, such as Native American, African American,
Asian, white American, or Hispanic, or one of the often unrecognized cultural groups, such as
the homeless, migrant workers, gay men, or lesbians. To improve cultural awareness and
sensitivity, you can ask questions to gather information about the unique beliefs and value
systems of individuals of other cultures and backgrounds.
Know the Cultural Terms
Culture, ethnicity, and race are terms that relate to cultural awareness.
1. Culture is defined as all of the socially transmitted behavioral patterns, arts, beliefs,
knowledge, values, morals, customs, life ways, and characteristics of a population that
influence perception, behavior, and evaluation of the world.
2. Ethnicity refers to a social group within a cultural and social system that shares a
common social and cultural heritage, including language, history, lifestyle, and religion.
Cultural background is a fundamental component of one's ethnic background. Ethnicity is
indicative of some of the following characteristics that a group may share in some
combination: common geographic origin; race; language and dialect; religious beliefs;
shared tradition, values, and symbols; literature, folklore, and music; food preferences;
settlement and employment patterns; and an internal sense of distinctiveness.
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Module 15-Cultural Diversity & Nursing
3. Race is genetic in origin and includes physical characteristics such as skin color, bone
structure, eye color, and hair color. The Human Genome Project provides evidence that
all human beings share a genetic code that is more than 99% identical. Although less than
1% difference exists in genetic code, the differences are evident when performing health
assessments. People from a given racial group do not necessarily share a common
culture.
To emphasize the importance of culturally and linguistically appropriate services in health care,
the U.S. Department of Health and Human Services (USDHHS) Office of Minority Health
(OMH) issued national standards to ensure that all people entering the health care system receive
equitable and effective treatment. These 14 standards provide for culturally and linguistically
appropriate services (CLAS) to help eliminate racial and ethnic health disparities and to improve
the health of all people who live in the United States of America. Although the CLAS standards
are primarily directed at health care organizations, individuals in the health care systems are
encouraged to use the standards to make their practices more culturally and linguistically
accessible. The standards are organized around three themes: culturally competent care, language
access services, and organizational supports for cultural competence. As a nurse, you are affected
by Standard 1, which states that “healthcare organizations should ensure that clients/consumers
receive from all staff members’ effective, understandable, and respectful care that is provided in
a manner compatible with the cultural health beliefs and practices and preferred language”
(USDHHS, OMH, 2001). Improving cultural awareness, as well as meeting Standard 1 of CLAS,
requires that nurses take several steps: first, develop sensitivity to the differences between their
own culture and the client's; second, avoid stereotyping; and third, develop a template that may
be used for cultural assessment of the client and the family.
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Review of Section 1
1. Define Culture.
2. Define ethnithicity.
3. Define Race and give 3 examples.
a.
b.
c.
d.
e.
f.
Give examples of the Cultural phenomena that can affect health:
environmental control: _____________________________________________
biological variations: _______________________________________________
social organization: ________________________________________________
Communication: __________________________________________________
personal space: ____________________________________________________
Time orientation: __________________________________________________
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Module 15-Cultural Diversity & Nursing
Section 2
Table 1-1 Dietary Practices of Selected Religions
Religion
Buddhism
Hinduism
Islam
Jehovah’s Witness
Orthodox Judaism
Roman Catholicism
Russian Orthodox
Dietary Practices or Practices
Vegetarianism for some sects
Alcohol and drug use is not favored
Vegetarianism for some with beef and veal prohibited for all.
Fasting rituals vary depending on god worshipped.
Prohibited meats include pork and meats not slaughtered as part of
ritual.
Drug and alcohol use prohibited.
Meats that are allowed have been drained of blood; no foods that
blood has been added are permitted.
Kosher dietary laws allow fish that have scales and fins, cloven
hoofed animals, and animals that eat vegetables or are slaughtered
in a ritualistic manner.
Milk and Meat may not be combined in anyway.
Fasting during Yom Kipper (24 hours).
Meat is prohibited on Ash Wednesday, and Fridays during Lent
including Good Friday.
Fasting is done on Ash Wednesday and Good Friday, is optional
during rest of Lent.
Meat and dairy products are prohibited on Wednesdays, Fridays,
during Lent.
Fasting occurs during Advent.
Table 1-2 Religious Influence on Common Health Issues
Religion
Abortion
Baha’i
Not Allowed Allowed
with
Medical or
legal need
Mother’s
Allowed
condition
determines
Not allowed Allowed
Allowed
Blood/
Blood
Products
Allowed
Allowed
Allowed
Natural
means only
Allowed
Not Allowed Not usual,
family
decides
Allowed
Usually
not used
Buddhist
Roman
Catholic
Christian
Science
Autopsy
Birth
Control
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Medication
Use
Organ
Donation
Narcotics
Allowed
with
prescription;
vaccines
Allowed
Act of Mercy
Use if
Allowed
benefits out
way risks
None except Individual
vaccines to
choice
comply with
Module 15-Cultural Diversity & Nursing
Hindu
Islam
law
Allowed
Allowed
No policy
Allowed
Not Allowed Allowed
with
medical or
legal need
Not allowed Allowed
with legal
need
Allowed
Allowed
Allowed
Allowed
Allowed
except for
sterilization
Forbidden
Judaism
Therapeutic
allowed,
otherwise
varies within
groups
Allowed
except for
Orthodox
Jews
Allowed
Allowed
unless
derived
from blood
products
Allowed
Mormon
Not allowed
Incompatible
with beliefs
Allowed
Allowed
Allowed
Seventhday
Adventist
Therapeutic
only
Allowed
Allowed
Allowed
Allowed
Jehovah’s
Witness
Allowed
under some
conditions;
all body
parts must
be buried
together
Allowed
with next
of kin
consent
Allowed
Allowed
Controversial;
discuss with
family
Forbidden
Complex issue
consult rabbi
Often nurses care for clients who come from ethnic, cultural, or religious backgrounds that are
different from their own. Awareness of and sensitivity to the unique health and illness beliefs and
practices of others are essential for the delivery of safe and effective care. The acknowledgment
and acceptance of cultural differences with a nonjudgmental attitude are essential for providing
culturally sensitive care.
The belief underlying the NCLEX-PN test plan is that people are unique individuals and that
they define their own systems of daily living that reflect their values, motives, and lifestyles. The
Integrated Processes addressed in this chapter are Caring, Clinical Problem-Solving Process
(Nursing Process), Communication and Documentation, and Teaching and Learning.
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Module 15-Cultural Diversity & Nursing
Section 3
Cultural Considerations of Black/African Americans
A. Communication
1. English primary language
2. Direct eye contact may be considered inappropriate.
3. May use oculistics (eye rolling) in response to communication deemed inappropriate
4. May use silence in response to a question deemed inappropriate.
5. Verbal and nonverbal communication is integral in communication process.
B. Time orientation
1. Tend to be present rather than future oriented, thus, preventative health care may be
difficult to implement or maintain, however, time orientation varies with age,
subculture, and socioeconomic status.
2. May not be punctual for appointments if needs of the family or friends require
immediate attention.
C. Social roles
1. Extended family is important; tend to have large family supports
2. Strong sense of obligation to relatives
3. Value friendships
4. Many single-parent family households, typically headed by females.
5. Religious affiliation common.
D. Views of health and illness
1. Body, mind, and spirit are integrated.
2. Good health is a result of good luck; thus individual has little impact on health status
3. Illness maybe punishment from God or related to one’s harmony from God.
4. Voodoo may be considered a powerful cultural leader.
5. Practitioners use roots, herbs, oils, candles, and ointments may be used in the healing
process.
E. Health Risks
1. Lactose intolerance and lactase deficiency.
2. Hypertension and coronary heart disease (CAD)
3. Sickle Cell Anemia
4. Cancers, including breast, colorectal, esophageal, stomach, cervical, uterine, and
prostate.
5. Coccidioidomycosis
6. Diabetes
F. Nursing considerations
1. Include family in medical care if desired by client
2. Allow for flexibility in scheduling appointments.
3. Facilitate and encourage use of folk healers and spiritualists
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4. Encourage family to bring traditional diet if medically acceptable
Cultural Considerations for Asian Americans
A. Communication
1. Primary languages include Chinese, Japanese, Vietnamese, Korean, and English
2. May use silence to demonstrate respect for elders
3. If direct eye contact is considered impolite or aggressive, may look away as nurse
attempts to make direct eye contact.
4. Unlikely to criticize or disagree with others verbally
5. Consider word “no” to be disrespectful
6. Nodding head or smiling does not always mean agreement with what was said
B. Time orientation: tend to be present oriented while highly regarding past
C. Social roles
1. Respect aging members of society
2. Family bonds are important; large extended family networks exist with devotion to
tradition
3. Daughters and daughters-in-law may be expected to care for the older family
members as their health declines
4. Structured and hierarchical family unit, with men and elders being greatly respected;
women are expected to be subservient to men
5. Loyalty to family members is expected and highly regarded
6. Education is highly valued
7. Religious affiliation common, including Taoism, Islam, Buddhism, and Christianity
D. Views of health and illness
1. Chinese concept of yin and yang is a metaphor for forces of nature being balanced to
produce harmony.
2. Illness is a state of disharmony or imbalance of yin and yang
3. Foods are associated with concept of yin and yang; for example, yin foods are cold,
whereas yang foods are hot; cold foods and beverages are consumed for cold
illnesses, and hot food and beverages are consumed for hot illnesses.
4. Illnesses may be attributed to overexertion or to prolonged sitting or lying.
E. Health risks
1. Thalassemia
2. Lactase deficiency
3. G6PD deficiency
4. Hypertension
5. Cancer, with stomach and liver more common sites
6. Coccidioidomycosis
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F. Nursing Consideration
1. Clients are likely to be quiet and compliant during illness, thus placing them at risk for
not having needs met
2. Clients may wish to take medications with certain foods or beverages believed to
promote correct balance for health
3. Clients often do not trust health care providers and wish to include traditional healers
along with Western medicine practices
4. Clients may expect health care providers to be authorative
5. Limit eye contact and physical touching; touching a client’s head only with permission
from client or parent
6. Encourage and facilitate family involvement in care
7. Clients of Chinese descent may expect nurse to intuitively know their disease process
8. Alternative therapies such as acupuncture and herbal remedies are widely used
Cultural Considerations for Latino/Hispanic Americans
A.
1.
2.
3.
4.
5.
6.
7.
B.
C.
1.
2.
3.
4.
5.
Communication
Primary languages include Spanish and Portuguese
May utilize code switching, a systemic mixing of English and Spanish languages
Simpatia, a desire for smooth or harmonious interpersonal relationships, should be
considered; it is characterized by courtesy, respect, and absence of critical or
confrontational behavior; confrontational interaction is avoided
Eye contact reflects respect; in nurse-client relationship, eye contact may be expected of
nurse, although it may not be reciprocated by client
Tend to be verbally expressive
May engage in “small talk” or general conversation as a method of establishing rapport
Nonverbal communication plays important role in client assessment and interaction.
Time orientation: tend to present oriented, but varies according to age, subculture,
and socioeconomic status
Social roles
Family is most valued institution and is a primary source of personal identification
While nuclear families are common, extended families also exist
Father is likely to assume the head of household role and likely to make decisions for
family.
Collective achievement tends to be valued more than individual achievement
Religion is important; Catholicism is prevalent
D. Views of Health and Illness
1. Mal de ojo (evil eye) is a childhood disease characterized by fitful sleep, crying, and
diarrhea; a common belief among Latinos is that mal do ojo is caused by unconscious
energy of an adult flowing into child when adult simply looks at child
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Module 15-Cultural Diversity & Nursing
2. Health is thought to be the will of God
3. Curanderos, folk healers, may be consulted
4. Health may represent a state of equilibrium in world, which is characterized by balance
of hot, cold, wet, and dry; when an imbalance exists, treatment focuses on application of
opposite quality
E. Health risks
1. Diabetes mellitus
2. Hypertension
3. Pernicious anemia
4. Childhood obesity
F. Nursing Consideration
1. Clients may seek guidance from within family network rather than from health care
providers; include family members in health care education when appropriate
2. Male family member may be decision maker for family
3. Modesty is important, and measures should be taken to protect client’s privacy at all
times; clients may prefer to have a health care provider of the same gender.
4. Use of alternative therapies is prevalent and should be explored when client enters health
care system; if possible, facilitate continuation of such services.
5. Encourage family to bring traditional diet if medically acceptable
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Module 15-Cultural Diversity & Nursing
Review Sections 1-3
1. While examining an infant, a nurse notices that the infant is wearing a soiled piece of
braided yarn around the neck. Which action by the nurse is most appropriate?
a. Leave the yarn in place but wash it with a cloth and mild soap.
b. Ask about its significance and suggest that it be placed more safely on the body.
c. Explain that the yarn offers no benefit and ask the parents to remove it.
d. Remove the yarn because it is soiled and could lead to strangulation.
2.
The nurse accepted the position in an urban facility that services clients of many
different cultures. Which of the following is a prerequisite for the nurse, who wishes
to provide culturally competent care?
a. Acceptance of cultural diversity
b. Awareness of one’s personal biases
c. Appreciation of cultural diversity
d. Sensitivity to culturally diverse populations
3. A Chinese client with cancer is likely to prefer consuming which of the following
food items? Select all that apply.
a. Fried foods.
b. Green vegetables
c. Cold foods
d. Spicy foods
e. Bland foods
Answers: 1. B, 2. B, 3. A,D
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