The diversity of the population in northern Europe has increased dramatically over recent decades. This has both enriched our societies and also caused us to reconsider many practices that have been taken for granted. An example is given in Case history 5.1.

From this case history it becomes clear that the students’ wishes were being respected, but within the constraints of current knowledge about infection control and the need for patients to feel secure in the knowledge that the person caring for them was a legitimate practitioner. So let us consider how such radical changes have developed and impacted on everyday nursing practice.

It is clear that, since the formation of the National Health Service (NHS) in 1948, there have been changing needs in the health care requirements of the population of the UK. Prior to the formation of the NHS, provision of health care was from a mixture of local authority, charity and government sources – an eclectic mix of services which left many people lacking in provision and some with none at all. The National Health Service Act in 1946 effectively nationalized health care provision and brought the majority of services under the control of the Ministry of Health, with some under the control of local authorities. A reorganization of services in the early 1970s saw all services united under government control. The formation of the NHS was predicated upon a comprehensive service, free at the point of delivery to all. Very quickly it became clear that there were neither the monetary nor staff resources to meet the demand, and some staff shortages were met by recruiting heavily from Commonwealth countries in the 1950s and 1960s (Webster 2002).

Along with those recruited into the NHS from Commonwealth countries such as the West Indies, people, including health care workers, have come to the UK from many other countries since the inception of the NHS – for economic reasons, as invited workers, as political refugees, or to escape persecution because of their beliefs. From the 1960s, immigration into the UK increased, with people arriving from India, Pakistan, Bangladesh, Hong Kong and more recently from African and eastern European countries. The formation of the European Union (EU) further opened up opportunities for workers from EU countries to seek employment in the UK. Thus, in the early 2000s, the sociocultural make-up of the UK is such that the black and minority ethnic population of the UK constitutes 7.6% of the total population, up from 1% in 1950. The Department of Health (2003) stated that the Greater London area contains half of all people from the black and minority ethnic population of the UK, with the totals in individual London boroughs ranging from 5% to 50%. The West Midlands, Greater Manchester and West Yorkshire also have black and minority ethnic residents, with 84% of the total black and minority ethnic population of the UK living in the four areas mentioned. Leicester and Birmingham are predicted to increase their black and minority ethnic populations to a majority by 2010 (Department of Health 2003). This has important implications for health care provision in these areas and for nursing. But we must be in no doubt that, in this third millennium, the UK is a multicultural society and part of a multicultural world.

With increasing international travel and migration since the end of World War II, the majority of the world’s countries now contain more than one cultural or ethnic group. But multiculturalism is not just about different races and different colour of skin, it is also about the traditionally distinctive and diverse cultures of all countries of the world including the UK. Indeed, the islands that make up the UK have within their borders groups of people who each see themselves as culturally distinct from their neighbours. People are proud of their Scottish, Irish, Welsh or English ancestry, and of the cultural dimension of that ancestry. They are also as proud of the fact that they may be highland or lowland Scot, mountain or valley Welsh, Londoner, Liverpudlian or Bristolian English, rural or urban dweller. History tells us that over the years the UK has become a host country to many groups of immigrants. Even within one single society it can be argued that it contains many different cultures. Men and women and boys and girls, old and young, ill or healthy, all these groups in any society are expected to behave in ways that their culture determines is appropriate for them.

Cultures are also divided into subcultures. For example, the NHS can be said to be a subculture of British society, and, within the NHS, nursing, medicine and physiotherapy, for example, can be identified as further subcultures. Each subculture has its own clear and distinctive set of implicit guidelines for behaviour. New entrants to health care professions are often referred to as needing to be ‘socialized’ into their professions. It is clear that health professionals do form a separate cultural group within society, but can the same be said for patients? Is there a ‘patient’ culture?Helman (1994) states that society divides up its members according to their health status as ‘healthy’ or ‘ill’. However, this may be a label applied by a health professional to a person rather than by the person themself.

There are also other ways of dividing society up into categories of subcultures. The 1991 census was the first to elicit information about ethnic origins of the population of the UK, and the 2001 census added to this with questions about dis-ability and religious affiliation. The percentage of black and minority ethnic groups is not currently high, but according to James (1995) this is likely to double over the next 40–50 years. Without doubt, each different cultural and minority ethnic group adds value to the diversity and complexity of UK society. Valuing the cultural background of each and every client and patient is crucial in the provision of culturally aware, culturally sensitive and culturally competent nursing care. Valuing diversity in caring is an important and fundamental issue for health care provision and for nursing in the UK.

In order to explore the concept of diversity in caring, we first need to define what we mean by culture. Culture has many meanings. When some people talk of culture they are referring to art, opera and music; to others, culture can mean the distinguishing characteristics of a workplace. For example, we often talk of the culture of the NHS, the culture of the armed forces or of the civil service. From an anthropological perspective culture is taken as meaning the set of guidelines that individuals use and which tells them how to behave in their own particular part of society. We can tell from this definition that anthropology is the study of people and their relationships within their social setting. Helman (1994) uses the analogy of a ‘lens’ through which an individual perceives and understands his or her own world. Anthropology theory suggests that people’s behaviour is partly governed by the specific society in which they grow up and in which they live. Culture provides the guide for determining values, practices and beliefs within any given society. It determines how people accommodate themselves within their own culture because it is related to the way that people live. Culture relates to morality, beliefs, social norms and accepted behaviour. Individuals in any culture are expected to adopt and comply with that culture’s rules. What is acceptable in one culture may not be acceptable in another culture. For example, female circumcision (also known as female genital mutilation and normally abbreviated to FGM) is an accepted and deep-rooted practice in a number of African countries. Ng (2000) stated that, in the 1990s, some 50% of Kenyan girls were still being circumcised, and it was estimated in 1994 that this procedure had been performed on over 100 million girls and women worldwide (Henley & Schott 1999). In the UK, there is legislation in place (Prohibition of Circumcision Act 1985) which prohibits the practice, and the World Health Organization does not support it. However, it is important that nurses understand why such practices are still carried out and to know what practical help and advice they can provide to women and girls on whom this procedure has been performed; see Henley & Schott (1999), or read Waris Dirie’s (1998) personal account of female circumcision in her biography ‘Desert Flower’.

Culture determines how nurses and patients react and respond to the actions of nursing interventions. ‘Transcultural’ nursing, as the term implies, means that the provision of nursing care is to do with a meeting of two or more cultures: the culture of the nursing profession, the nurse’s own cultural background and the cultural background of the patient, and maybe even male/female culture and age/youth culture. Transcultural care thus focuses on issues to do with the way each cultural group understands what health is and the causes of illness, what treatment is intended to achieve and what contribution nursing care makes to the total picture. Our behaviours as people in all our roles in life are learned from observing others in our immediate society, and, in comparing what we do with what others do, we alter our own behaviour to fit in. This is a useful way of describing culture from a health care point of view since it allows us to look at our own nursing culture, and also be concerned with the cultural background of the individuals who become patients and clients of the health care services.