Defining the Terms

Before one can truly understand cultural diversity, it’s essential to appreciate what culture is. Madeline Leininger, RN, PhD, LHD, CTN, FAAN, nurse anthropologist and professor emeritus at Wayne State University, College of Nursing, Detroit, MI, defines culture as a way of life belonging to a certain group of people. Leininger, who is the founder of the field of transcultural nursing, believes that culture is a dynamic, learned, subconscious mode of behavior handed down from one generation to the next.³ The American work ethic is a good example of cultural difference. As Americans who gulp down their morning coffee and rush out the door to drive through traffic to work each day, we exhibit a schedule-based, strong work ethic that’s an integral part of our culture. Because culture is subconscious, it’s easy to think that the American work ethic is “the only way.” Yet a trip to a third-world country demonstrates that not everyone answers to an alarm clock or follows a timetable – even when it comes to work. The American “get things done right now” quickly fades into “things will get done when supply boats arrive or when the monsoon ends.”

The term cultural diversity recognizes that different ways of doing things or cultures exist and calls for the appreciation of these cultures. American Nurses Association (ANA) president Beverly Malone, RN, PhD, FAAN, says, “Nurses who are prepared to deal with differences are prepared to deal with diversity.”⁴ According to the ANA, cultural diversity refers to the differences between people based on a shared ideology and valued set of beliefs, norms, customs, and meanings evidenced in a way of life.⁵

Cultural Value in the Workplace

Culture has value. Leininger tells us that it provides security to people and can be a valuable factor to provide for the emotional, physical, and social well-being of a culture group.³ On the flip side, inattention to cultural competence in patient care leads, at best, to suboptimal patient outcomes and, at worst, to active harm. “When we fail to address issues of difference, such as language, ethnicity, and race, our patients will have lower levels of compliance with care instructions and longer hospital stays,” says Carla Serlin, RN, PhD, director of ANA’s ethnic/racial minority fellowship programs.⁶ “We can’t ensure the best possible patient outcomes without considering cultural competence to be an integral part of holistic nursing care,” says Malone, who believes that positive outcomes come not just from appropriate work with patients but with nursing colleagues as well.

The challenge is for nurses to learn how to understand and uphold the cultures of coworkers and to work toward making cultural diversity a positive force that can enhance the nursing team.

Communication Skills Key to Forging a Team

“It’s important to be sensitive to others, especially to those of other cultures,” says Dula Pacquiao, RN, EdD, associate professor and director of the Transcultural Nursing Institute at Kean University, Union, NJ. “But this is not enough,” Pacquiao says. “Nurses must learn how to understand and interpret culturally based behaviors and develop culturally competent communication skills.”

Pacquiao espouses impression management: the ability of nurses to manage the impression they make on those of other cultures. Rather than putting themselves first, nurses should observe and listen to others to facilitate communication. Impression management not only minimizes misunderstandings but is an effective way to achieve desired outcomes.

Nurses’ Viewpoints Can Add to the Complexities

In addition to cultural knowledge and skill, culturally sensitive communication requires an awareness of the role one’s own cultural values play in communication.⁷ Subconsciously, we use our own truth (culture) to judge the truths of others. This can add to the complexities of diversity.

In a culturally diverse workplace, unless nurses have nonjudgmental viewpoints, errors in judgment can occur. In a study, for example, European-American nurses saw the quiet, observant, tactful, patient, and slow-to-respond behaviors of Filipino nurses as unassertive. The Filipino nurses saw the outspoken, impatient, bold, and fast-moving behaviors of European-American nurses as crass and insensitive.⁸

“Minority nurses have prejudices. Majority nurses have prejudices. These prejudices follow you to the patient’s room, to the classroom, and to your team work,” says Serlin. “Unfortunately, the profession of nursing hasn’t traditionally valued cultural competence within the body of knowledge nurses need to know. And the information learned in nursing programs frequently is not carried over to practice,” she says.¹¹

Working with Other Cultures

Carmen Portillo, RN, PhD, professor of nursing at the University of California/San Francisco, says that the answer to working better with those of other cultures is “simple but also very difficult.” When dealing with clients of other cultures, Portillo quotes Florence Nightingale, who said, “Souls deserve to be cared for.” “But to care for souls and give quality nursing care, we need to understand their assumptions about who they are and their health,” Portillo says.

Taking time to learn about the population you serve and those with whom you work can be seen as an ethical obligation. If you don’t know who your clients or coworkers are, how can you build a nurse-patient, or nurse-nurse relationship that is so vital to effective healthcare?

With regard to working with nurses of other cultures, Portillo says that we often hear about cultural diversity training workshops or cultural competency training. Portillo believes that there will always be those who gravitate to these sessions, those who may think they have the answers and do not feel the need to attend one more session, those who refuse to attend, and those who simply do not recognize the need.

There are pitfalls in lunch-time presentations or a few hours of intense learning about cultures followed by a “let’s go home and shake it off” attitude. According to Portillo, it’s impossible to learn everything in a few hours of coursework, after a lifetime of ingrained values and beliefs.

Rather there should be open dialogue, over time in a positive environment, about what cultural competency means and what it means to be different. “Not until organizations integrate cultural diversity training as part of the macrosystem and not as an addendum, will nurses and healthcare professionals learn more effectively to care for other cultures,” Portillo says.