Nursing is no stranger to the issue of cultural diversity. Our society is becoming a kaleidoscope of racial and ethnic groups, behaviors, values, world perspectives, social customs, and attitudes. The professed gold standard is to guarantee culturally relevant care in a multicultural society where cross-cultural communication and cultural sensitivity are the norm, and care is provided by culturally competent nurses who were educated in programs with a culturally diverse student body and faculty. These programs place students in rural sites or culturally diverse, underserved areas for clinical experiences. Multicultural medical and psychiatric issues are incorporated into the curriculum. If nurses are to deliver culturally diverse care effectively, they need to reflect upon their values and beliefs, seek direction from their professional organizations, and modify their own behavior (Gooden, Porter, Gonzalez, & Mims, 2001).

Madeline Leininger, a nurse with a background in cultural anthropology, developed a theory of nursing based on the concept of culturally congruent care (Leininger, 1991). Leininger’s model uses worldview, social structure, language, ethnohistory, environmental context, and generic (folk) and professional systems to provide a comprehensive and holistic view of influences on culture care and well-being (Andrews & Boyle, 2003). According to Leininger, the nurse who plans and implements care for clients from diverse ethnic groups will do so using one of three culturally congruent nursing care modes. These modes are:

In cultural care preservation/maintenance, the nurse assists the client in maintaining health practices that are derived from membership in a certain ethnic group. For example, a client with a Chinese background may want foods that are considered “hot” to counteract an illness that is considered “cold.” The nurse helps the client select and obtain foods congruent with these beliefs.

In cultural care accommodation/negotiation, the nurse adapts nursing care to accommodate the client’s beliefs or negotiate aspects of care that would require the client to change certain practices. For example, a Native American client may wish to have a tribal healer visit him in the hospital and perform a healing ceremony. The nurse accommodates this wish and negotiates with the client about incorporating the rituals of the tribal healer into his medical treatment. If rituals and other spiritually focused activities are important to the client, clinicians must respect and work with, not against, this philosophy.

In cultural care repatterning/restructuring, the nurse educates the client to change practices that are not conducive to health. Lefever and Davidhizar (1991) describe how members of a particular Eskimo ethnic group believe that wrapping red yarn around the head can cure pain in the head. The nurse repatterns or teaches a client from this culture that if head pain persists, the continued wrapping of red yarn may delay needed treatment.

Regardless of the model of culturally competent nursing care used, the nurse demonstrates sensitivity
and respect for the individual client’s beliefs, norms, values, and health practices. The use of assessment and communication skills and nursing implementations that enhance and support cultural perspectives of the client are the means to deliver this care.

The U.S. mental health system was not designed to respond to the cultural and linguistic needs of diverse ethnic populations. In a historical review of U.S. psychiatric treatment, Moffic and Kinzie (1996) point out that treatment originally consisted of generic psychiatry (ie, assuming that humans the world over are no different and will react to given stressors in the same manner). The recognition that beliefs, values, family expectations, and other ingredients combine uniquely in various ethnic groups has been slow. Further, the values and beliefs of mental health care providers often differ from those of clients from diverse ethnic groups. The system itself, and most mental health providers, has a European American middle-class orientation, perhaps with biases, misconceptions, and stereotypes regarding other cultures (U.S. DHHS, 1999).

Nursing also tends to have the same values as the European American middle-class culture. DiCicco-Bloom (2000) reports that in 1996, nearly 90% of nurses reported themselves as white non-Hispanic, as compared with 72% of the U.S. population. The differences between providers’ and clients’ values, beliefs, health practices, and language contribute to the difficulties
in delivering services to people from diverse ethnic groups.

Emphasis being placed on the individual, versus on the relationship between the individual and society, illustrates how values of the provider and the client may clash. European American middle-class culture is primarily individualistic, emphasizing freedom of choice and personal responsibility. The dominant set of values is oriented toward individuals, who are viewed as accountable for decision-making, self-care, and many other self-oriented tasks. Privacy rights and personal freedom are based on the value of individualism. In many ethnic groups, however, individualism is not a primary value. Instead, these groups are sociocentric, emphasizing the mandatory responsibility of the individual to the family and larger society. For example, Hispanic, Asian, and African traditions typically paint a more social picture of life, emphasizing balance and cooperation over individualistic concerns (Mitchell, 2004). Consequently, psychiatric treatment’s emphasis on client self-responsibility is congruent with European American middle-class values, but not necessarily with the values of other ethnic groups. This essential difference in values can help account for the underuse of mental health services by ethnic groups, as well as the fact that when care is utilized, it is not perceived as helpful.

Guarnaccia (1998) provides an example of the effect of differences regarding individual and personal responsibility. A middle-aged Hispanic mother of a 25-year-old son with schizophrenia asked for advice from her support group, which consisted primarily of white members, about how to handle her son’s refusal to take his medication. Their advice was to not allow her son to live at home unless he agrees to take medication. If the support group were more culturally aware, they would have understood that interdependence is valued in Hispanic families, and the mother would not consider turning her son out of her home. Thus, the support group was not helpful to this woman’s situation.

The Surgeon General’s 1999 report stated that many racial and ethnic groups have limited financial resources (U.S. DHHS, 1999). There is an association between lower socioeconomic status (in terms of income, education, and occupation) and mental illness; however, no one is certain whether one influences the other. Certainly, substandard housing, unemployment or underemployment, poor nutrition, lack of preventive care, and limited access to medical care create severe stressors for affected families. Statistics from the 1990 U.S. census indicate that 23.4% of all foreign-born residents, including children and youth, who entered the United States between 1980 and 1990 are at or below the poverty level, as compared with 9.5% of the U.S.-born population (U.S. Bureau of the Census, 1993). This lack of finances can block needed psychiatric care from too many people, regardless of whether they have health insurance with inadequate mental health benefits, or are one of the 44 million Americans who lack any insurance (U.S. DHHS, 1999). More recent statistics indicate the following percentages of uninsured ethnic groups: white, 14.2%; African American, 21.2%; Asian and Pacific Islander, 20.8%; and Hispanic, 33.4% (U.S. Bureau of the Census, 1999). Thus, it is evident that many people from diverse ethnic groups lack adequate health insurance, are affected by poverty, or both.

Poor living conditions and lack of financial resources contribute to life stressors, thus affecting the need for psychiatric–mental health services. Although the need for services may be increased, help may not be accessible because of lack of finances. Even when available, services may not be used because of the substantial cultural differences between the providers and the users of these services.

Psychiatric–mental health care, like other health care, tends to occur as crisis intervention for those individuals without income sufficient to meet basic needs. The nurse working in the community or in a hospital emergency department encounters many clients who, because they are unable to pay for wellness care or early intervention, seek treatment only for severe illness. This is also true of psychiatric–mental health care. The psychiatric–mental health nurse encounters clients with multiple, complex problems related to the effects of poverty, whose insurance plans do not pay for psychiatric care or who are without family resources for payment.