Introduction

Nurse leaders and managers are concerned with cultural diversity from two perspectives: (1) the care of a diverse patient population and (2) positive work experiences in a culturally diverse workforce. In its report to the Secretary of Health & Human Resources and Congress, the National Advisory Council on Nurse Education and Practice (NACNEP) (2000) addressed the need for a culturally diverse workforce to meet the healthcare needs of our nation. The Council defined that a national action-oriented agenda is needed to address the underrepresentation of racial-ethnic minorities in the workforce. To this end, the NACNEP solicited, through the Division of Nursing, an Expert Workgroup on Diversity to advise them on the development of the National Agenda. The Workgroup based its recommendations on the following four overarching goals:

If the aim of nursing is to reflect the population we serve, then we have a long way to go.

Effective leaders can shape the culture of their organization to be accepting of persons from all races, ethnicities, religions, ages, and genders. These interactions of acceptance should involve a minimum of misunderstandings. Multicultural phenomena are cogent for each person, place, and time. Connerley and Pedersen (2005) provided 10 examples for leading from a complicated culture-centered perspective. For example, “3. Explain the action of employees from their own cultural perspective; 6. Reflect culturally appropriate feelings in specific and accurate feedback” (p. 29). Therefore culture-centered leadership provides organizational leaders, such as nurse managers, the opportunity to influence cultural differences and similarities among their unit staff.

The American Nurses Association (ANA) has a long and vital history related to ethics, human rights, and numerous efforts to eliminate discriminatory practices against nurses as well as patients. The ANA Code of Ethics for Nurses with Interpretive Statements, Provision 8 states, “The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs” (2008, p. 23). This provision helps the nurse recognize that health care must be provided to culturally diverse populations in the United States and on all continents of the world. Although a nurse may be inclined to impose his or her own cultural values on others, whether patients or staff, avoiding this imposition affirms the respect and sensitivity for the values and healthcare practices associated with different cultures.

According to Noone (2008):

This author identified barriers reported from several studies that involved interviews with students of ethnically diverse backgrounds. The barriers related to “financial needs, academic needs, feeling isolated, and experiences with discrimination from faculty, peers and patients” (p. 135). One particular example cited by Noone was the different modes of communication, such as lack of assertiveness, difficulty with languages, and different customs. If this occurred with nursing students in an academic setting, do these barriers continue or do they change based on action strategies to modify them? The results will have either a positive or a negative impact on the future employment of these prospective members of the nursing workforce.

Health care in the United States has consistently focused on individuals and their health problems but has failed to recognize the cultural differences, beliefs, symbolisms, and interpretations of illness of some people as a group. Commonly, the patients for whom healthcare practitioners provide care are newcomers to health care in the United States. Similarly, new staff are neither acculturated nor assimilated into the cultural values of the dominant culture.

Currently, accessibility to health care in the United States is linked to specific social strata. This challenges nurse leaders, managers, and followers who strive for worth, recognition, and individuality for patients and staff regardless of their ascribed economic and social standing. Beginning nurse leaders, managers, and followers may sense that the knowledge they bring to their job lacks “real-life” experiences that provide the springboard to address staff and patient needs. In reality, although lack of experience may be slightly hampering, it is by no means an obstacle to addressing individualized attention to staff and patients. The key is that if the nurse manager and staff respect people and their needs, economic and social standings become moot points. Nurse managers must be cognizant of divergent views about health care as a right for all people rather than a privilege for a few.

Resources are a must for nurses to use to learn about working with culturally diverse staff and patients. D’Avanzo (2008) wrote a fitting resource book about a variety of cultural groups, their differences in worldwide views and concepts of reality, and their variety of social, political, economic, and religious values and many concepts of health and illness. They noted that diversity exists both within and between groups, which may lead to intragroup and intergroup conflict. Lipson and Dibble (2005) indicated that culture is influenced by intersections of forces larger than the individual and by shared values of what constitutes ethical, professional practice. They provide an excellent set of general guidelines to alert nurses in the hospital or community settings to the similarities and differences within and among the cultural and ethnic groups. They have expanded the types of cultural and ethnic groups to include Roma (gypsies), former Yugoslavians, Russians, and other former Soviet Union people. All the cultural groups were selected based on their size according to the U.S. Census (each numbering at least 100,000) and/or on the lack of readily obtainable information elsewhere about a particular group (Lipson & Dibble, 2005). Caring for Women Cross–Culturally (St. Hill, Lipson, & Meleis, 2003) is a rich, comprehensive resource of culturally relevant information about immigrant and minority women. Interspersed through each chapter are “notes to health providers.” These notes purport to alert the provider to potential problems the nurse may encounter at certain developmental stages or when dealing with a particularly sensitive topic. The authors suggest helpful ways to approach these issues.

The International Classification for Nursing Practice (ICNP) (International Council of Nurses, 2008) is a unified nursing language system that should be considered by nurse clinicians in the workplace and by nurse educators:

Translating a message in one language to another language to ensure equivalence includes maintaining the same meaning of the word or concept. Equivalency is accomplished through interpretation, which extends beyond “word-for-word” translation to explain the meaning of concepts. When providing care to a culturally diverse patient, the nurse must realize that the process of translation of illness/disease conditions and treatment is complex and requires certain tasks. Two important tasks are “(a) transferring data from the source language to the target language and (b) maintaining or establishing cross-cultural semantic equivalence” (International Council of Nurses, 2008, p. 5).

Meaning of Diversity in the Organization

Nursing as a profession has historically lagged the general demographics related to ethnic and gender diversity. These data can be tracked through a quadrennial survey by the Division of Nursing. The 2008 National Sample Survey of Registered Nurses (NSSRN), distributed by the Health Resources and Services Administration (HRSA) (2008), represents about 2% of all registered nurses. These data cover the number and characteristics of employment status and practice settings, racial/ethnic background, age-group, and education and training.

Recent data from the 2008 National Sample Survey of Registered Nurses (HRSA, 2010) show an estimated 3,063,163 licensed registered nurses in the United States. This number reflects an overall increase of about 5.3%, which is logical based on the significant increases in enrollments in schools of nursing and subsequent graduations over the past several years. Slightly less than 85% of the RN population is actively employed in nursing, with the majority employed full-time and in hospital settings. According to the 2008 data, approximately 84% of the RN population was white and non-Hispanic compared with 65.6% of the general U.S. population. The RN population comprising “Hispanic/Latino, any race” was 3.6%, whereas the percentage for the U.S. population was 15.4%. The RN population of “Black/African American, non-Hispanic” was 5.4% compared with 12.2% for the general U.S. population. Only those individuals identified as “Asian or Native Hawaiian or Pacific Islander, non-Hispanic” (5.8% of RNs) exceeded the percentage of the U.S. population in that category (4.5%) (Table 9-1). As these data show, the profession of nursing is not reflective of the population it serves. These facts have many implications from recruitment into the profession, such as programs to enrich the majority members’ understanding of diversity, as well as support of ethnic minorities in the workplace.

The numbers of men recruited into the profession have risen but not to the point of creating gender equality. Although stereotypes (e.g., “not smart enough for medical school”) have diminished over the years, the numbers of men in nursing still do not approach the proportional numbers of men in the United States.

Because nursing is not a particularly diverse profession, it is critical to provide support in employment settings for RNs in minority categories and to enhance the appreciation of the majority for culturally diverse workforces and care.

Health disparities between majority and racial ethnic minority populations are not new issues and continue to be problematic as they exist for multiple and complex reasons. Causes of disparities in health care include poor education, health behaviors of the minority group, inadequate financial resources, and environmental factors. Disparities in health care that relate to quality of care include provider/patient relationships, provider bias and discrimination, and patient variables of mistrust of the healthcare system and refusal of treatment (Baldwin, 2003). Health disparities in ethnic and racial groups are observed in cardiovascular disease, which has a 40% higher incidence in U.S. blacks than in U.S. whites; cancer, which has a 30% higher death rate for all cancers in U.S. blacks than in U.S. whites; and Hispanics with diabetes, who are twice as likely to die from this disease than non-Hispanic whites. In 2000, Native Americans had a life expectancy that was 5 years less than the national average, whereas Asians and Pacific Islanders were considered among the healthiest population groups. However, within the Asian and Pacific Islander population, health outcomes were more diverse. Solutions to health and healthcare disparities among ethnic and racial populations must be accomplished through research to improve care. Such research could include preventive services, health education and interventions, treatment services, and health outcomes (Baldwin, 2003). Consider how these disparities in disease and in healthcare services might affect the healthcare providers in the workplace in relationship to their ethnic or racial group. What should you know about the sick-leave policy based on acute or chronic disease/illness in your institution? Portillo (2003) wrote that “our leadership efforts will have to move beyond the beginning to reduce health disparities. A better understanding of the strengths and limitations of the concepts of race and ethnicity is a priority of nursing” (p. 5). It is necessary to increase healthcare providers’ knowledge so that they can more effectively manage and treat diseases related to ethnic and racial minorities, which might include themselves.

Leading and managing cultural diversity in an organization means managing personal thinking and helping others to think in new ways. Managing issues that involve culture—whether institutional, ethnic, gender, religious, or any other kind—requires patience, persistence, and much understanding. One way to promote this understanding is through shared stories that have symbolic power.

Staff who know what is valuable to patients and to themselves can act accordingly and feel good about work. Having a clear mission, goals, rewards, and acknowledgment of efforts leads to a greater productivity and work effort from a culturally diverse staff who aspires to unity and uniqueness (see the Research Perspective on p. 161). When assessing staff diversity, the nurse leader or manager can ask these two questions:

Box 9-1 lists some of the techniques that may be effective when managing a culturally diverse workforce.

Concepts and Principles

What is culture? Does it exhibit certain characteristics? What is cultural diversity, and what do we think of when we refer to cultural sensitivity? Are culture and ethnicity the same? Various authors have different views. Cultural background stems from one’s ethnic background, socio-economic status, and family rituals, to name three key factors. Ethnicity, according to The Merriam Webster Dictionary (Merriam-Webster Inc., 2005), is defined as related to groups of people who are “classified” according to common racial, tribal, national, religious, linguistic, or cultural backgrounds. This description differs from what is commonly used to identify racial groups. This broader definition encourages people to think about how diverse the populations in the United States are.

Inherent characteristics of culture are often identified with the following four factors:

For the nurse leader or manager, the characteristics of ethnicity and culture are important to keep in mind because the underlying thread in all of them is that staff’s and patients’ culture and ethnicity have been with them their entire lives. They view their cultural background as normal; the diversity challenge is for others to view it as normal also and to assimilate it into the existing workforce. Cultural diversity is the term currently used to describe a vast range of cultural differences among individuals or groups, whereas cultural sensitivity describes the affective behaviors in individuals—the capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people.

Spector (2009) addressed three themes involved with acculturation:

The overall process of acculturation into a new society is extremely difficult. According to Spector (2009):

Consider how you might adapt to a new country and its society.

Based on the Code of Ethics for Nurses (ANA, 2008), nurses believe that they must care for all patients regardless of differences—whether it be cultural, economic status, or gender. Providing care for a person or people from a culture other than one’s own is a dynamic and complex experience. The experience according to Spence (2004) might involve “prejudice, paradox and possibility” (p. 140). Using hermeneutic interpretation, her study consisted of accounts from 17 New Zealand nurses who delivered nursing care to patients in acute medical and surgical wards, public health centers, mental health settings, and midwifery specialties. Spence used prejudice as conditions that enabled or constrained interpretation based on one’s values, attitudes, and actions. By talking with people outside one’s “circle of familiarity,” one can enhance one’s understanding of personally held prejudices.

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