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Cultural Diversity: Best Practices

Why appreciation of the influence of culture in nursing practice is important at all points of healthcare.

This offering expires in 2 years: December 3, 2009

The goal of this continuing education offering is to provide nurses with current information on cultural diversity and its role in patient care. After reading this article, you will be able to:

1. Discuss the rationale for culturally competent nursing care.

2. Identify three tips for developing cultural sensitivity.

3. Describe best practices related to cultural competence.

You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for LPNs, Learning Scope, 3100 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the PA State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

Tamika (not her real name) reported to her nurse she was feeling like she was "drowning" and didn't know how she could continue to manage her diabetes. Recently emigrated from Liberia with her family, she lived in a poor urban neighborhood where crime statistics were high and the community felt under siege.

She received care in a local health center. She assumed the staff would understand her values because they were primarily black. She didn't realize sensitivity and acceptance have more to do with cultural awareness and understanding on the part of the healthcare providers and the healthcare organization.

Many people in healthcare believe culture is the same as skin color or ethnicity. Current thinking is you will be culturally sensitive and competent when you work with clients from a certain group if you know about their culture and some of its traditions. Culture shapes individuals' experiences, perceptions, decisions and the way they relate to others. Understanding a person's cultural views is important in the delivery of healthcare; among other things, it influences the way clients respond to medical services and preventive interventions.

When considering culture within nursing practice, it is important to appreciate why it is important. Tamika thought she would be understood because the healthcare center's staff was black. While this may be true in some cases, it is not a universal truth.

Many factors contribute to cultural sensitivity and cultural competence. To know how best to address the needs of clients within our pluralistic society, we must first think about what we mean by the terms culture and cultural competence. It also is important to recognize the skills and behaviors of nurses that contribute to best practices related to culture. This article will focus on the definition of culture, what is meant by cultural sensitivity in nursing practice, why it is an important attribute for individuals, and what is needed to support best practice and competence within both the clinical setting and the healthcare system.


Culture may be defined as "the learned and shared beliefs, values and life ways of a designated or particular group that are generally transmitted intergenerationally and influence one's thinking and action modes."1 Many assume overcoming language barriers or having a basic understanding of some ethnic practices is enough to successfully address the needs of diverse clients within our practice. However, this is not the case.

Cultural competence is the capacity of individuals or services to incorporate ethnic/cultural considerations into all aspects of their work relative to health promotion, disease prevention and other healthcare interventions. It also is described as the ability to perform and obtain positive clinical outcomes when engaging in cross-cultural encounters. Acquiring skills related to culturally competent nursing practice is important for better client outcomes, satisfaction and quality of care.

Best practice related to cultural competence describes the process of systematically finding and appraising current research findings related to culturally competent practice, and using these findings as a basis for clinical decisions and actions. Best practice also could include nurses advocating for the resources necessary to establish culturally competent practices in the clinical setting. There is increasing information that speaks to the improved health outcomes of clients where there is integration of culturally relevant care.

Changing Demographics

The U.S. population is growing and becoming increasingly diverse. For example, it is estimated people of Hispanic origin constituted 15 percent of the nation's total population as of July 1, 2006, making them the nation's largest ethnic or racial minority. The U.S. Census Bureau predicts by the middle of the 21st century, the average U.S. resident will trace his ancestry to Africa, Asia, the Pacific Islands, Latin America or Arab countries.

It is essential for nurses, as part of the healthcare delivery system, to be aware and knowledgeable about the unique cultural issues related to providing care and treatment to people from different cultures. Nurses will need to know how to adapt their delivery of care to meet the diverse cultural needs of each client.2 These skills could involve attitudinal and behavioral changes that will enable nurses to engage clients more successfully.

Culturally Competent Practice

Cultural competence of the healthcare workforce and the healthcare delivery system is increasingly tied to improved client outcomes and quality of care provided. Financial reimbursement for care provided to clients can be negatively affected if there is not a system in place to support culturally competent delivery of care.

The federal government is one of the main purchasers of healthcare services through Medicare and Medicaid. These programs require their contractors to be culturally diverse and deliver culturally competent service and care. Medicare and Medicaid are significant sources of revenue for healthcare institutions, and these regulations are binding on providers who accept these funds.

Efforts to improve client outcomes and culturally cntered care have been championed by the Joint Commission. The national accrediting body for hospitals was represented on the committee that developed the National Standards on Culturally and Linguistically Appropriate Services. Its collaboration with government agencies led to additional cultural competency mandates being integrated within Joint Commission standards that ultimately impact all healthcare organizations. For example, Joint Commission Performance Standards: RI 2.10 Section B states, "Each patient has a right to have his or her cultural, psychological, spiritual and personal values, beliefs, and preferences respected."

Diverse Practitioners

Another reason for increasing cultural proficiency is the growing number of healthcare providers and workers from other countries who have become colleagues within the healthcare delivery system. Nurses are working with other members of the healthcare team who might have values, beliefs and cultural experiences very different from their own.

Practicing communication skills that acknowledge cultural awareness and behaviors that demonstrate cultural competence will be important within healthcare settings as diverse groups work together to improve healthcare delivery. Understanding cultural practices of colleagues can provide opportunities to clarify differences in styles of work and serve as a resource for information to better support patient-centered, culturally sensitive care.

In the past decade, there has been increasing pressure on institutions that educate healthcare professionals to include cultural competence education and training. For example, New Jersey's former acting Gov. Richard Codey signed legislation in March 2005 that requires New Jersey medical schools include cultural competency instruction in the curriculum. This mandate to educate and train physicians serves as a condition of licensure for all physicians in the state.

In its Health Care Agenda 2005, the American Nurses Association stated, "It is an important priority during the next decade to increase cultural competence within the nursing workforce and recruit ethnically and racially diverse women and men into nursing."3

Best Practices & Tips

What can be done to improve cultural awareness, sensitivity and competence? One of the first steps is to learn about the main cultures of the population you care for (see Figure 1). Some sources include the literature and contacts within the community, as well as clients and their families. By having a foundation of knowledge about individuals of diverse cultures, each nurse should strive to apply this knowledge in an ethical and caring way.

Another learning opportunity is for nurses to have ongoing involvement in cross-cultural encounters with clients or colleagues on a regular basis. Asking questions and using cultural assessment tools to better understand ethnically diverse clients provides a framework for shaping better healthcare interventions. During these interactions, it also is important to observe and evaluate the patients, communities and one's own responses while maintaining respect and openness within the encounter.

Nurses seeking to increase their cultural competence need to evaluate the care they administer to clients to identify best-practice strategies that lead to good client outcomes. Best-practice strategies will aid a client's ability to comply with and benefit most from healthcare advice and treatment. Clients must view services as relevant to their needs. Therefore, the behavior and approach of nurses and other healthcare personnel can largely influence a client's perception of these services' relevance.

Importantly, nurses should strive to individualize the care and treatment of every client. Though understanding cultural perspectives is significant, nurses must remember individuals bring their own values and cultural beliefs about health and illness with them into the clinical setting. They may not fully ascribe to the customs and beliefs of others of their nationality or background because of acculturation or self-identification.

Nurses need to listen carefully and actively to clients. When the person does not speak English, interpreters or other strategies to ensure accurate communication should be available. An effort to know about and avoid behaviors and recommendations that might be offensive, impractical or irrelevant to constituent clients is an added expectation and skill to be developed by nurses caring for diverse populations.

Most importantly, nurses should not rush to judgment when working with clients. Critical caring and respectful behavior need to be conveyed when providing care to clients, families, colleagues and the community. Consideration of consistencies as well as discrepancies in information about individual clients may help reduce the chances clinical judgments will be biased or faulty. Utilizing appropriate sources of support and advocating for clients' needs should assist nurses in truly appreciating each client's healthcare needs and social issues.


What gets in the way of nurses developing stronger skills in providing culturally competent care? The American Association of Colleges of Nursing has identified challenges nurses face when asked to implement culturally competent care.

One challenge is the nurses' lack of knowledge about the impact of immigrating and acculturation on the client's behavior and response to treatment. Another may be the nurses' lack of awareness about how cultural beliefs and attitudes about illness vary. Nurses view the behavior and responses of clients through a predominant value and belief system related to the Anglo-American. This may result in inappropriate assessment, clinical judgment or diagnosis in clients with diverse ethnic and cultural backgrounds. Nurses may be less open to nontraditional therapies in providing healthcare to individuals who come from impoverished backgrounds or with a different world view. See Figure 2 for strategies on how to overcome these obstacles.


1. Leininger, M. (2002). Transcultural nursing and globalization of healthcare importance, focus, and historical aspects. In M. Leininger & M.R. McFarland (Eds.), Transcultural nursing (3rd ed., pp. 3-43), New York: McGraw-Hill.

2. Eshleman, J., & Davidhizar, R. (2006). Strategies for developing cultural competency in an RN-BSN program. Journal of Transcultural Nursing, 17(2), 179-183.

3. American Nurses Association. (2005). ANA's health are agenda. Retrieved Nov. 25, 2007 from the World Wide Web:


Betancourt, J.R., et al. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499-505.

Joint Commission Resources. (2006). Providing culturally and linguistically competent health care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

Sullivan Commission. (2004). Missing persons: Minorities in the health professions (executive summary). Retrieved Nov. 25, 2007 from the World Wide Web:

Taylor, R. (2005). Addressing the barriers to cultural competence. Journal for Nurses in Staff Development, 21(4), 135-142

The Commonwealth Fund. (2005, Oct. 4). New Jersey cultural competency training. Retrieved Nov. 25, 2007 from the World Wide Web:

U.S. Census Bureau. (2007, May 17). Minority population tops 100 million. Retrieved Nov. 25, 2007 from the World Wide Web:

Wells, M. (2000). Beyond cultural competence: A model for individual and institutional cultural development. Journal of Community Health Nursing, 17(4), 189-199.

Priscilla Killian and Roberta Waite are assistant professors at the Drexel University College of Nursing and Health Professions, Philadelphia. <% footer %>


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