TWO Dynamics of Diversity: Becoming Better Health Care Providers Through Cultural Competence Diversity awareness will be most comprehensive if one recognizes the diversity of diversity and how various characteristics of diversity may influence the plan of care and/or professional collaboration. SNAPSHOT SCENARIO Nurse Constants: It’s nice meeting you all at this conference. Diversity’s not a problem in my hospital. Mostly all of the nurses are the same race as the patients who live and work in the nearby area. Occasionally we get a new graduate nurse from another part of the country who is diverse, but he or she never lasts long. Occasionally we get a diverse patient from the next town over, but he or she is usually an emergency department “drive through” patient and never comes back for follow-up care at our hospital. Nurse Always: We always have plenty of diverse patients. I always give the same care to all my patients, regardless of their background. I’m proud to be a good nurse and a good colleague. I always treat everyone the way I expect to be treated so why can’t others treat me right—just look me straight in the eye and be direct—tell it like it is. Nurse Light: Well, my patients and coworkers represent a diversity of diversity, necessitating different approaches and communication patterns to promote individualized patient care, professional collaboration, and teamwork. For example, six patients yesterday responded that they preferred family members and/or significant others present during patient teaching sessions; four of them preferred receiving patient teaching materials in languages other than English (French, Creole, Tagalog, and Korean). The patient and family who spoke Tagalog were surprised that I could communicate with them. Although I’m not of Filipino heritage by birth, my mother was in the U.S. military so I grew up in the Philippines and Germany. Expectations concerning eye contact, spatial distancing, facial expressions, touch, and other nonverbal communication patterns can vary. Also, the direct, indirect, or circular verbal communication patterns can vary based on such factors as religion, ethnicity, race, age, gender, and perceived status. I learned this very quickly when I moved from the Philippines to Germany and then to rural Mississippi and then to Queens, New York, before moving here. Some expectations were the same, some were different. My coworker who is from Haiti was helpful in finding reliable diet teaching materials that were culturally and linguistically appropriate for my newly diagnosed diabetic patient, a visitor from Haiti. Although it was fairly easy to find diabetic teaching material and sample diets in French, finding literature that was visually inclusive of Haitian traditions or featured Haitian traditional foods in the Haitian Creole dialect was challenging. Nurse Ed: The multidisciplinary literature emphasizes that more diverse nurses and other health care professionals are needed to mirror the populations served and to dismantle the disparities that exist in health and in health care. I’m a part-time adjunct instructor and preceptor at the local university and my clinical group last semester represented much diversity. Five students are first generation college students; one became interested in nursing while caring for a same-sex partner who died of AIDS; one is the primary caregiver of a terminally-ill aunt; one was adopted by a multiracial family during infancy; one didn’t learn to read until age 10 because of delayed diagnosis of dyslexia; three have prior health care experience as nursing assistants; and one is totally deaf in one ear following removal of a brain tumor 2 years ago. Nurse Constants: I never thought of diversity in that way. Now I do see we have some diversity. Many of our new graduate nurses are different now than years ago too. Some enter nursing after bouncing from job to job, retiring from other careers, or just hanging out and never working before. Nurse Frank: Over the years, I felt privileged to teach students and mentor new nurses of various ages. Retirees are really a diverse group too—in age and other ways. Some retirees who became nurses that come to mind right now include a Las Vegas dancer in her twenties; police officers and firefighters in their forties; two semi-professional ball players in their late thirties; a 55-year-old prison guard; a 30-year-old fashion model; an air force captain; and a 62-year-old mail carrier. Nurse Ed: Students change careers for many reasons. To emphasize that our university and profession embraces diversity and to create a culturally inclusive environment that promotes cultural safety, I ask students in my clinical group to share some information on an index card. Some of my career-change students have included a former physician from Russia, a speech pathologist from Brazil, a plumber, a deli owner, a mortician, a nun, an athletic trainer, a bartender at a biker bar, a social worker, a chemical engineer, a financial analyst from Wall Street, an accountant, a receptionist, a sanitation worker, an emergency medical technician, a licensed practical nurse, a massage therapist, a home health aide, and a secretary. Also, I had several homemakers attempting to enter the workforce for the first time, including a politician’s spouse and three students in the “welfare to work” program. Some of these students were full-time, others part-time. Nurse Law: Creating a culturally safe environment for health care consumers and employees has both ethical and legal implications. Mutual respect for diverse cultures should be an organizational mission and philosophy that is not just ideology on paper but is actually implemented in obvious, concrete ways. Nurses and other staff members have civil rights as well; however, institutions do not actively and publicly implement and evaluate strategies that include this dimension. Job-embeddedness literature indicates that the predominant reason for high nurse turnover is due to factors other than salary, such as creating feelings of professional and personal worth or value and human-connectedness. If a staff member is treated as an outsider, then he or she is not embedded within the institution. This adversely affects patient care, workplace morale, and staffing. The institution needs to actively promote an “I CARE/WE CARE” approach, recognizing that everyone’s culture matters while also being within the guidelines of the law and U.S. Constitution. Nurse Ponder: Listening to all of you got me thinking differently. I guess it’s easier to stay in one’s comfort zone instead of looking at the big picture and considering multiple perspectives. I thought I was providing the best care possible. Maybe I should have been doing some things differently. I wonder what can be done to promote diversity awareness. How can I become more aware and help others become more aware? What can I do to become a more culturally competent nurse in the workplace? What can be done to create a culturally inclusive and safe environment for patients, families, nurses, and staff? What can be done to create a mutually respectful environment where patients and families are also sensitive to diverse staff members? After reading the previous scenarios, what visual images popped into your head? What race, gender, age, weight, and other physical, mental, and professional attributes did you visualize/imagine for each of the main characters, nurses, and students mentioned? Why? What feelings were evoked as you read each scenario segment? Why? What impact can these images and feelings have on your interactions with diverse patients, families, communities, new graduate nurses, colleagues, nurses, staff members, employees, supervisors, students, and interdisciplinary health care providers? What impact could they potentially have on patient health outcomes, satisfaction, stress, trust, and continued use of health care services? What impact could they potentially have on nurses and nursing students’ health, satisfaction, stress, persistence, and retention? Every day, nurses and other health care providers have the potential to make a positive difference in human lives by providing high-quality health care. But how do nurses and other health care providers make the greatest positive difference? How MUST nurses and health care providers in the 21st century provide quality health care amid the increasingly multicultural and global society? The answer is twofold. First is the need to provide culturally competent—that is, culturally specific—nursing care, which is customized to fit with the patient’s own cultural values and beliefs (CVB), traditions, practices, and lifestyle (1–7). Quality health care can only occur within the patient’s cultural context. Second is the need to create workplaces that embrace diversity among health care professionals and that seek to promote multicultural workplace harmony and prevent multicultural workplace conflict. Both of these endeavors begin with diversity self-awareness and diversity awareness; each is defined below. Several poignant clinical and workplace examples illustrate the significance of actively weaving cultural competence throughout all aspects of health care settings. Later, the acronym COMPETENCE is presented to assist health care professionals in remembering essential elements for optimal cultural competence development. DIVERSITY AWARENESS What are your own cultural values and beliefs? How do you define diversity? Diversity self-awareness occurs when one engages in active reflection about one’s own cultural identity or identities, realizes one’s own CVB, and recognizes the differences within one’s own cultural group(s). Diversity awareness refers to an active, ongoing conscious process in which one becomes proactively aware of similarities and differences within and between various cultural groups, necessitating cultural assessment of patients and cultural sharing among health care professionals. Assessment and sharing should aim to maximize health outcomes and facilitate multicultural workplace harmony and collaboration. Diversity awareness will be most comprehensive if one recognizes the “diversity of diversity” and how various characteristics of diversity may influence the plan of care and/or professional collaboration. “Diversity may exist based on birthplace, citizenship status, reason for migration, migration history, food, religion, ethnicity, race, language, kinship and family networks, educational background and opportunities, employment skills and opportunities, lifestyle, gender, socioeconomic status (class), politics, past discrimination and bias experiences, health status and health risk, age, insurance coverage, and other variables that go well beyond the restrictive labels of a few ethnic and/or racial groups” (8, p. 5). What are the benefits of adapting a broad definition of diversity that recognizes the “diversity of diversity”? IS DIVERSITY AWARENESS REALLY THAT IMPORTANT FOR PATIENT CARE? How can diversity awareness influence patient care? Ignoring diversity and providing culturally incongruent nursing care can adversely affect patient outcomes and jeopardize patient safety. Let’s consider a nurse who has some knowledge about transcultural nursing but lacks self-confidence about performing cultural assessments and planning culturally specific care. The nurse then avoids conducting cultural assessments. Later, the nurse administers insulin and then leaves a tray of culturally forbidden foods with a diabetic patient. This nursing action is culturally incompetent and negligent. The patient will not eat the food. Even if a new tray is ordered, the time between insulin administration and eating will be delayed. Health outcomes will be adversely affected. Additionally, cultural pain (psychological stress that occurs from culturally inappropriate actions) (2–4, 9) is emotionally stressful and also affects metabolic rate and insulin needs. This potentially fatal situation could have been prevented by conducting a cultural assessment and by accommodating the patient’s CVB and food preferences into the plan of care. Equally negligent is a nurse who does not assess patients for folk medicine use. Let’s imagine a patient who regularly uses herbal teas with ginseng at home and that she has brought these with her to use in the hospital. Later, the nurse administers the heart medication digoxin. Use of ginseng in conjunction with digoxin can result in drug toxicity and death. Again, this culturally incompetent and dangerous situation could have been prevented by culturally sensitive and competent nursing actions. Lack of transcultural nursing knowledge, skills, values, and confidence can result in nurses avoiding culture care assessments when planning and implementing care. The consequences can be devastating. Resources to assist nurses and health care professionals evaluate the usefulness and safety of complementary and integrative health approaches include scholarly journal articles, the Journal of Ethnopharmacology, and the National Center for Complementary and Integrative Health. Overly confident nurses who think they do not need to adequately prepare, learn, or conduct routine cultural assessments can contribute to similarly devastating results. For example, making assumptions based on a patient’s physical appearance rather than performing an individualized cultural assessment can cause great cultural pain and set up long-lasting barriers in communication and care. Let’s consider a nurse in the coronary intensive care unit (ICU) who provides a patient with a booklet in Spanish titled “Mexican Foods for Heart Health” and a booklet on “Free Health Service Resources for Non-U.S. Citizens” to a multiethnic bilingual (English- and Spanish-speaking) patient who self-identifies as second-generation Puerto Rican and Italian American. These nursing actions are grossly inappropriate. Cultural insensitivity can cause the patient cultural pain and anguish, resulting in stress, elevated and irregular heart rate, high blood pressure, and other physiological manifestations that will adversely affect patient outcomes. When the patient is discharged, he or she may be reluctant to return for follow-up appointments due to the culturally insensitive care received (see “Educator-in-Action” vignette for more examples). Malpractice cases today may involve issues concerning cultural incompetence. Patients and family members are often winning settlements because culturally specific health care was not provided and then resulted in physical and/or emotional injury. Cases documenting the wrongful institutionalization or prolonged hospitalization of patients demonstrating severe side effects of certain medications should alert nurses and physicians to screen patients’ ethnic and genetic backgrounds. For example, Hispanics, Arabs, Asians, and African Americans may require lower doses of psychotropic medications (such as antidepressants) than the commonly published recommended doses (10). The growing field of pharmacological research has expanded to include biocultural aspects of disease, cultural differences in response to drugs, genetic differences in how drugs are metabolized among various ethnic groups, and effects of herbal remedies in complementary and integrative modalities (5, 10–15). Culturally competent nurses and physicians would also realize the importance of differentiating between the many subgroups within the broad ethnic/racial categories to avoid stereotypical cultural assumptions and to recognize ethnic-specific pharmacogenetic differences. Pharmacogenetic differences in response to certain asthma drugs between Mexicans and Puerto Ricans with asthma is one example attesting to the need for more research and detailed cultural assessments (16–17). It is also important to appraise whether or not studies have compared pharmacodynamics, pharmacokinetics, and other aspects of drug metabolism, use, and adherence within and between groups (and the number of studies conducted that present the same or different information). For example, noting that researchers reported similar pharmacokinetic and pharmacodynamic responses of insulin degludec in African American, White, and Hispanic/Latino patients with type 2 diabetes mellitus (18) provides important information for diabetes management and evaluation among various populations, including those for whom diabetes and health disparities are most prevalent. What actions can you take to enhance your diversity self-awareness and diversity awareness? What actions can you take to enhance the diversity self-awareness and diversity awareness of others? ACHIEVING CULTURALLY CONGRUENT CARE What is the relationship between enhanced diversity awareness and achieving culturally congruent care? What is culturally congruent care? What is cultural competence? The chapter’s case scenarios and the “Educator-in-Action” vignette illustrate the importance of culturally congruent care in meeting patient’s holistic needs. According to Leininger (9), culturally congruent nursing care refers to “those cognitively-based assistive, supportive, facilitative, or enabling acts or decisions that are tailor-made to fit with an individual’s, group’s, or institution’s CVB, and lifeways in order to provide meaningful, beneficial, and satisfying health care, or well-being services” (p. 49). To “assist, support, facilitate, or enhance” culturally congruent care, Leininger (9) proposed three modes for guiding nursing decision and actions: (a) culture care preservation and/or maintenance; (b) culture care accommodation and/or negotiation; and (c) culture care repatterning and/or restructuring. The goal of culturally congruent care can only be achieved through the process of developing (learning) cultural competence. Cultural competence is an ongoing, multidimensional learning process that integrates transcultural nursing skills in all three dimensions (cognitive, practical, and affective), involves transcultural self-efficacy (confidence) as a major influencing factor, and aims to achieve culturally congruent care (19). The acronym COMPETENCE is presented here to assist health care providers in remembering several essential elements for cultural competence development and achieving culturally congruent care. COMPETENCE refers to caring, ongoing, multidimensional, proactive, ethics, trust, education, networks, confidence, and evaluation (see Figure 2.1). Each of these are briefly described here. Caring: Demonstrate caring The essence of nursing is caring. Caring refers to actions and activities directed toward assisting, supporting, or enabling others with actual or potential needs to alleviate or improve a human condition or face death (9). Caring is essential for curing but curing is not essential for caring (9). Caring can only occur within the patients’ cultural context. Patients who perceive nurses as noncaring may perceive that they have not received “care” at all. Perceptions of caring (or noncaring) can positively or negatively affect patient outcomes. FIGURE 2.1 Cultural COMPETENCE Acronym for Patient Care Ongoing: Engage in ongoing cultural competence Cultural competence development is ongoing. Lifelong, ongoing cultural competence development is an essential professional expectation presently and in the future. Cultural competence is not an end point or product of learning. Cultural competence is an ongoing process in which one is always attempting to “become” more culturally competent (2–7; 20). Additionally, culturally congruent care must be individually appraised, applied, and modified in an ongoing fashion throughout all aspects of patient care. Effectively weaving culture-specific care interventions throughout the care plan requires ongoing commitment and energy but will result in high-quality, culturally congruent care. Multidimensional: Develop transcultural nursing skills in all three dimensions: cognitive, practical, and affective Cultural competence in nursing is a multidimensional learning process that integrates transcultural nursing skills in all three dimensions (cognitive, practical, and affective), involves transcultural self-efficacy (confidence), and aims to achieve culturally congruent nursing care. Transcultural nursing skills are those skills necessary for assessing, planning, implementing, and evaluating culturally congruent care. Transcultural nursing skills include cognitive, practical, and affective dimensions (21–25). The cognitive learning dimension focuses on knowledge outcomes, intellectual abilities, and skills. Within the context of transcultural learning, cognitive learning skills include knowledge and comprehension about ways in which cultural factors may influence professional nursing care among patients of different cultural backgrounds and throughout various phases of the life cycle. The practical learning dimension is similar to psychomotor learning, and focuses on motor skills or practical application of skills. Within the context of transcultural learning, practical learning skills refer to communication skills (verbal and nonverbal) needed to interview patients of different cultural backgrounds about their values and beliefs. The affective learning dimension is concerned with attitudes, values, and beliefs, and is considered most important in developing professional values and attitudes. Affective learning includes self-awareness, awareness of cultural gap (differences), acceptance, appreciation, recognition, and advocacy (21, 23). All components are essential for cultural competence development. Proactive: Conduct cultural assessments proactively on all patients upon initial encounter Systematic cultural assessments and culture-specific care plans should be routinely initiated at the first patient contact for all patients and regularly reappraised and modified throughout nursing care interactions with patients, families, and communities. Such a proactive approach aims to actively anticipate patient needs and is preferred to a reactive approach that passively waits for patient-initiated requests, problems, misunderstandings, and cultural clashes to occur. Ethics: Apply ethical principles in all patient encounters Culturally congruent health care is a basic human right, not a privilege (9; 26–36); therefore, every human being should be entitled to culturally congruent care. The International Council of Nurses’ Code for Nurses (33), the American Nurses Association’s code of ethics (26), and the National Standards for Culturally and Linguistically Appropriate Services in Health Care (37, 38) are several important documents that serve as reminders and provide guidance to health professionals. Not only are nurses and other health care providers ethically and morally obligated to provide the best culturally congruent care possible, but nurses and health care providers are legally mandated to do so. Increasing numbers of lawsuits with patients claiming that culturally appropriate care was not rendered by hospitals, physicians, nurses, and other health care providers attest to the complicated legal issues that may arise from culturally incongruent care. Furthermore, patients are often winning their cases in court (2). Within the scope of professional practice, nurses and other health professionals are expected to actively seek out ways to promote culturally congruent care. Trust: Establish mutual trust Gaining a patient’s trust is a necessary first step before patients willingly share their CVB, behaviors, and practices. Until the nurse (or nursing student) has gained the patient’s trust, shared information may not be entirely credible or true. Leininger (39) advocates “moving from a mainly distrusted stranger to a trusted friend in order to obtain authentic, credible, and dependable” information (p. 91). Education: Participate in ongoing cultural competence education All students and nurses (regardless of age, ethnicity, gender, sexual orientation, lifestyle, religion, socioeconomic status, geographic location, or race) require formalized educational experiences to meet culture care needs of diverse individuals (1–7, 20–21, 40–43). At the undergraduate level, examples of formalized education to enhance cultural competence development include taking a course or series of courses in transcultural nursing or attending a transcultural nursing conference/workshop taught by qualified individuals. Networks: Create collaborative networks Collaboration and networking with other nurses, health professionals, and organizations permit the shared pooling of necessary, specialized resources, skills, and knowledge. Within health care institutions, advanced practice nurses with a formalized educational background in general transcultural nursing skills provide on-site personal resources and referral. Advanced practice nurses with specialized education about a particular culture or cultures provide additional expertise about specific cultures. The Transcultural Nursing Society provides numerous local and global opportunities for collaboration and networking through their website (www.tcns.org), network of certified transcultural nurses, journal (Journal of Transcultural Nursing), newsletter, local chapter meetings and events, and annual conference. The Internet has made networking and dialogue with transcultural nurse experts easier than ever before. Confidence: Develop confidence to actively learn and perform transcultural nursing skills despite any obstacles and hardships. Avoid overly high or low confidence An individual’s perceived confidence (self-efficacy) for learning or performing specific tasks or skills necessary to achieve a particular goal is an important factor influencing commitment, motivation, learning, and outcome behaviors (44). Individuals with low confidence for transcultural nursing skills are at risk for decreased motivation, lack of commitment, and/or avoidance of cultural considerations when planning and implementing nursing care. Overly confident individuals are at risk for inadequate preparation in learning the transcultural nursing skills necessary to provide culturally congruent care. Individuals with strong, resilient, and realistic confidence (self-efficacy) will persist at cultural competence development despite obstacles and hardships, and will expend whatever energy is necessary (21). Evaluation: Use evaluation results to improve nursing practice Realistic, frequent self-appraisal of strengths, weaknesses, gaps, and barriers in the journey to develop cultural competence provides new direction for future growth and learning. Patient outcome evaluation, especially the evaluation of satisfaction and perception of culturally relevant care, provides valuable information to guide learning and nursing care decisions and actions.
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