Incorporating cultural diversity in nursing care: an action plan

ABNF Journal, The, Jan-Feb, 2003 by Betty Pierce Dennis, Ernestine B. Small

Abstract: This article examines the context of culture from the perspective of the increase in immigration and concomitant growth of diversity within the United States. It proposes that nurses who deliver culturally competent care are brokers of three cultures: their own; the health care system; and the client. The mechanism for creating approaches to care that utilize this concept is the nursing process. A culture-specific assessment can be achieved using the explanatory model of illness. The inadequacies of some frequently used strategies such as nursing diagnosis are also discussed with suggested changes.

Key Words: Culture, Diversity, Nursing Process, Competence

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It is essential to know man, it would seem before attempting to do him good.

--Nathaniel Hawthorne--

Nurses function in a health care environment that mirrors the diversity and cultural complexities of the larger society. The diversity of clients is varied and related to gender, age, socioeconomic status, education, physical and mental disabilities, regional locations, sexual life-style, and racial and ethnic backgrounds. It is beyond the scope of this paper to explore the range of issues and their implications for nursing care. This paper does, however, present an overview of the genesis of the evolving cultural diversity in the United States. It describes the essential role of the nurse in cultural transactions within health care, and proposes an approach to cultural inclusiveness crafted from the nursing process. The wave of new immigrants and the different existing groups underscores the need to do more than we have done in the past.

In addition to a fundamental approach to care, nurses must bring the will and commitment to change. Increasingly, we learn and practice in a global society. The United States is, and always has been, a nation of people representing multiple ethnic and cultural backgrounds who share a common subculture or "American experience. English settlers began the colonization of this country as an immigrant group. Today, the United States is perhaps the most diverse nation in the world and it has served her well. People throughout the world, with many talents and abilities, are attracted to her shores.

Until the decade of the 1960's America was viewed as a melting pot society. It was assumed that individual and group differences were replaced with a generic American identity. By the late 1970's the melting pot concept was clearly not supported. The early wave of immigrants to America was primarily of European descent from countries like England, Germany, Russia, Poland, Scandinavia, France, China, Italy, and the Netherlands. In large urban areas, distinct ethnic enclaves such as the Polish, Irish, Jewish, and Italian communities persisted. For example, many Germans settled in the Pennsylvania area. Individuals of English heritage populated the New England states. Some persons of Scottish-Irish descent were imported as indentured servants. Italians and Polish migrated in large numbers to New York and Chicago, respectively. Asian and Hispanic communities grew in California and New York. These enclaves were havens for the new immigrants. Although planted on new soil, they were able to maintain some of their traditional customs and practices while adopting new ones. It is fair to say that the differences in social structures, customs and beliefs of the various groups contributed to inter-group conflict, tension and discriminatory practices.

Two groups are notable exceptions to this immigration pattern: African Americans, who were captured and brought to America and forcibly enslaved; and native Americans, whose lands were appropriated, some tribes decimated to extinction and near-extinction, and way of life permanently changed. Today, native Americans may be the least dispersed with the vast majority living on reservations. African Americans originally lived in the southern states but many migrated to large cities in the northeast USA during the first half of the 20th century.

Eventually, the original English settlers and their offspring became the normative group whose values and customs were imposed as the standard of American culture. Over time, skin color replaced country of origin as a reference label. Europeans were combined into the category of white race as a reference label. Others were included based on "white" skin such as non-black Hispanics. Americans of African, Asian or other heritage were accordingly assigned. Thus, in the 21st century, American pluralism has emerged with a definite emphasis on ethnic identity and cultural diversity, in part, because of growing recognition that we are who we are because of our cultural heritage. As health care providers in a pluralistic society, nurses must incorporate cultural differences in the creation of nursing care approaches.

CULTURE AS A COMPONENT OF NURSING CARE

In our world with its many and mobile populations, the cultural mix can be expected to intensify. This is especially challenging to nurses because they will be expected to deliver care that encompasses these differences.