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Cultural Diversity


Cultural Diversity Initial Development: Mohamed Mikkawi, 2009 Revised by Yousef Aljawarneh, March 2011 * The Future of Cultural Diversity in Nursing Chalanda (1995 ... – PowerPoint PPT presentation

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Title: Cultural Diversity

Cultural Diversity
Initial Development Mohamed Mikkawi,
2009 Revised by Yousef Aljawarneh, March 2011
  • Define culture
  • Identify the components of an accurate cultural
  • Distinguish between primary and secondary
    cultural characteristics.
  • Identify the advancement of transcultural
  • List and define the key aspects of effective
    intercultural communication.
  • Identify the future aspects of cultural diversity
    in nursing.

What is Culture?
  • The sum total of the way of living includes
    values, beliefs, standards, language, thinking
    patterns, behavioral norms, communications
    styles, etc. Guides decisions and actions of a
    group through time (Tappan, Weiss Whitehead,
  • Groups acceptance of a set of attitudes,
    ideologies, values, beliefs, and behaviors that
    influence the way the members of the group
    express themselves (Catalano, 2009).

Characteristics of Culture
  • Culture is considered a photocopy machine that
    makes duplicates of the original document with
    minor differences.
  • Slight variation in the practices inevitably
    occurs when values, beliefs, and customs pass
    from one society to another.
  • Subcultures develop when members of the group
    accept outside values in addition to those of
    their dominant culture.

(Catalano 2009 Tappan, Weiss Whitehead, 2007 ).
What is Diversity?
  • Term used to explain differences between cultures
    such as psychological, physical, and social
    differences that occur among any and all
  • Example race, ethnicity, nationality, religion,
    economic class, age, gender, sexual orientation,
    mental and physical ability, and learning styles.
  • Primary Diversity nationality, race, color,
    religious beliefs.
  • Secondary Diversity socioeconomic status,
    education, occupation ( powerful , but hard to

(Catalano 2009 Leininger McFarland, 2002).
Trans-Cultural Nursing
  • A formal area of study and practice focused on
    comparative human-care ( caring) differences and
    similarities of the beliefs, values, and
    patterned life ways of cultures to provide
    culturally congruent, meaningful, and beneficial
    health care to people.
  • (Leininger McFarland, 2002)

Understanding Trans-cultural Nursing
  • Care needs to be systematically studied to learn
    about human care ( caring) in diverse and similar
    cultures in the world and environments.
  • Nurses are to be knowledgeable about their own
    cultural care heritage and of biases, beliefs,
    prejudices to work effectively with clients.
  • Nurses need to use trans-culture- specific and
    comparative knowledge to guide caring practices
    for culturally congruent care.
  • Maintaining an open learning discovery process
    about care and culture is imperative.
  • Nurses need creative ways to provide culturally
    congruent care practices.
  • ( Leinniger McFarland, 2002)

Advancement of Cultural Diversity in Nursing
  • A hallmark behavior and action that focused on
    cultural diversity within nursing gave rise to
    the transcultural nursing movement.
  • The early focus of the transcultural nursing
    movement was to bring sensitivity to the
    differences between nurses own culture and that
    of the people to whom they were providing care
  • (Leininger, 1979).
  • Successes of the transcultural nursing movement
    included incorporating culture to the nursing
    curricula and to the licensure and certification

Advancement of Cultural Diversity in Nursing
  • The advancement of cultural diversity is clear in
    the goal and mission of the ANA (1986, 1991),
    which is a commitment to serve the health needs
    of all people. In addition, the ANA has included
    cultural diversity as a priority in its strategic
  • Historically, cultural issues were addressed
    through the ANAs interaction with minority
    organizations and minority leadership within the
  • Cultural diversity issues have been addressed
    through ANA groups, such as the Committee on
    Intergroup Relations, Affirmative Action Task
    Force, and the Council of Cultural Diversity.

Advancement of Cultural Diversity in Nursing
  • The Nursing Workforce Development programs were
    developed to increase opportunities for
    individuals who are from disadvantaged
    backgrounds, including economically disadvantage
    families, as well as racial and ethnic minorities
    underrepresented in the nursing profession (ANA,

The Need for Tran-Cultural Nursing!
  • Leininger and McFarland (2002) discussed many
    reasons, but let us go through few
  • The steady marked increase in the migration of
    people worldwide.
  • The rise in cultural identities with health
    consumers expecting that their cultural beliefs
    will be respected, understood, and appropriately
    responded to in health care.
  • Increased signs of cultural conflicts and
    clashes, wars and violent acts among and between
    different cultures and nations influencing the
    health, survival, or death of people of diverse
  • The marked increased number of nurses,
    physicians, and other health care providers
    working in many different places in the world

How do you feel about your ethnic and/or
cultural and/or religious grouping stereotype?
  • Stereotyping
  • is an oversimplified belief, conception, or
    opinion about another person based on limited
    amount of information.
  • Respect for cultural diversity and intercultural
    dialogue is one of the surest guarantees for
    development and peace.
  • UNESCO (2006)

  • Many people cling tenaciously to their traditions
    (cultural practices) and language when they
    migrate to new country.
  • Healthcare providers need to be aware of and
    learn ways to adapt their practices to allow for
    these differences.

Developing Cultural Awareness
  • One of the most challenges for nurses who work in
    a culturally diverse environment is to understand
    clients perspective of what is happening in the
    healthcare setting.
  • Awareness starts with an understanding of ones
    own cultural values and healthcare beliefs.
  • Beliefs are based on knowledge and often
    religious beliefs. Ex, knowledge of bacteria.
  • Try changing the clients healthcare values by
    first, identifying his/her culture and practices
    that are similar or different from your
    practices, in order to decide whether it is
    desirable or possible to change.

Tappan, Weiss, Whitehead (2007) Marquis
Hustom (2003) Fawcett (2005).
Language Differences in UAE
  • In the United Arab Emirates, there are 800,000
    local Emiratis against 5 million expatriates,
    including Asians, Arabs, Americans, French, and
    Iranians among whom 10 only speak Arabic.

(Gulfnews. com)
  • Language Impact
  • The problematic in UAE healthcare units larger
    due to the absence of enough professional medical
    interpreters 30 of the population are locals
  • 70 divided between 10 (Arabs) and 90 (speakers
    of other languages)
  • Poor communication is a barrier to good patient
    centered care.
  • Non verbal communication taken for granted and
    can lead to false diagnosis
  • In emergency cases , language barriers can be

(The Emirates Center For Strategic Studies and
Research, 2008)
  • Language and culture barriers result in
  • Poor patient-healthcare provider relationships
  • Incorrect diagnosis
  • Lack of informed consent
  • Lower patient satisfaction
  • Malpractice suits
  • Marquis Hustom (2003)

  • Solutions
  • Needs for interpreters
  • Respect privacy
  • Cultural Competency awareness and emphasis for
    all parties involved in the process
  • Increase diversity of healthcare professionals
    (avoid bias/ethnocentrism/stereotyping
  • Training to support cross-cultural care

Providing a Cultural Competent Care
  • Cultural competence is the attitudes, knowledge,
    and skills necessary for providing quality care
    to diverse populations
  • Becoming culturally competent is an ongoing
    process in which an individual or organization
    develops along a continuum until diversity is
    accepted as a norm and the nurse has acquired
    greater understanding and capacity in a diverse
  • Acceptance of various beliefs, behaviors, and
    values in determining a persons physical and/or
    mental wellness/illness and incorporating those
    variables into the individuals assessment and

(AACN, 2008)
Providing Culturally Competent Care
  • Trans-cultural Understanding The primary skills
    required for cultural competence include
    communication, understanding, and sensitivity. It
    is an ongoing process that continues throughout
    the nurses career.
  • Trans-cultural Communication It is a highly
    complex process that requires both verbal and
    non-verbal exchanges.
  • a. Non-verbal Responses nurses must be cautious
    when interpreting the nonverbal responses from
    some cultural groups.

(Catalano, 2009)
  • b. Speech Patterns The use of silence by some
    cultural groups has led to misunderstanding in
    the health-care setting.
  • c. Personal patterns some groups are less
    willing to disclose private matters or personal
    feelings than others
  • d. Open-Ended language when the client trusts
    the nurse, then it will be possible to answer
    open-ended questions.
  • e. Touch Misinterpreted it is inappropriate in
    some cultures and it will lead to
  • f. Personal Space Zone that individuals maintain
    around themselves in most casual social
  • g. Eye Contact it communicates different
    messages to different cultures

(Catalano, 2009)
Individual Recommendations
  • The Registered Nurses Association of Ontario
    (2007) proposed that for each individual,
    embracing diversity means development of the
    following competencies and behaviors. Tools to
    assist in developing these skills are
  • 1. Self Awareness, To learn to embrace diversity
    in individuals.
  • 2. Communication, To develop communication skills
    that promote culturally diverse settings.
  • 3. New Learning, To attain cultural competence in

The Registered Nurses Association of Ontario
  • Self Awareness To learn to embrace diversity in
  • Perform self-reflection of ones own
    values/beliefs, incorporating feedback from
  • Identify cultural differences among clients and
    colleagues in the practice setting.
  • Acknowledge ones own feelings and behaviors
    toward working with clients, families and
    colleagues who have different cultural
    backgrounds, health behaviors, belief systems,
    and work practices.
  • Identify and seek guidance, support, knowledge
    and skills from role models who demonstrate
    cultural proficiency.
  • Recognize and address inequitable,
    discriminatory, and/or racist behaviors or
    institutional practices when they occur.
  • Acknowledge the presence or absence of
    individuals from diverse cultural backgrounds at
    all levels in the workplace, reflecting the
    cultural makeup of the clients or community being

The Registered Nurses Association of Ontario
  • Communication To develop communication skills
    that promote culturally diverse settings.
  • Are aware of different communication styles and
    the influence of culture on communication.
  • Are aware of ones preferred communication style,
    its strengths and limitations, and how it affects
    colleagues and recipients of care.
  • Seek feedback from clients and colleagues, and
    participate in communication validation exercises
    (e.g. role-playing exercises, case studies).
  • Use a range of communication skills to
    effectively communicate with clients and
    colleagues (e.g. empathetic listening,
    reflecting, non-judgmental open-ended
  • Seek and participate in learning opportunities
    that include a focus on communication and

The Registered Nurses Association of Ontario
  • New Learning To attain cultural competence in
  • Acquire knowledge of the range of cultural norms,
    beliefs and values relevant to clients and
    colleagues as a starting point to foster
    understanding and further inquiry.
  • Are aware of the disparities (e.g. health
    outcomes, access to care, economics, job
    opportunities) that exist for diverse populations
    and understand the factors and processes that
    contribute to them.
  • Recognize how culture and diversity influence
    behaviors and interactions.
  • Develop and apply cultural competence knowledge
    and skills in the areas of communication, care
    planning, conflict resolution and change
  • Access, utilize, and partner with cultural

The Registered Nurses Association of Ontario
Anticipated Outcomes
  • A workforce composed of nurses who are
    open-minded, inclusive, and respectful of all
    colleagues and recipients of nursing services.
    Individual members of the workforce identify and
    are co-operative with one another to address
    barriers to equity and diversity, and build
    practice environments in which every persons
    contribution is valued thus allowing the full
    potential of all to be maximized. These
    individuals refuse to participate in
    discrimination, harassment or bullying and
    address the issue in a way that will effect

The Registered Nurses Association of Ontario
Employee Orientation and Continuing Education
  • Orientation and ongoing continuing education need
    to address cultural competence ranging from
    awareness to skill building. A competency-based
    diversity model provides the conceptual framework
    for an organization to organize structured
    cultural competence education while attending to
    diverse learning styles and teaching approaches
    for culturally diverse groups.
  • Employees need to develop the relevant skills,
    including communication, conflict resolution and
    how to conduct a culturally appropriate
  • It is important that appropriate funding is
    allocated for cultural competence employee
    orientation, continuing education, and ongoing
    access to cultural diversity training.
  • The results need to be regularly monitored and
    acted upon as appropriate.
  • Health care organizations should ensure that
    staff at all levels and across all disciplines
    receive ongoing education and training in
    culturally and linguistically appropriate service

The Registered Nurses Association of Ontario
Healthcare Workers Responsibilities
  • Learn and use a few phrases of greeting and
    introduction in the patients native language.
    This conveys respect and demonstrates your
    willingness to learn about their culture.
  • Tell the patient that the interpreter will
    translate everything that is said, so they must
    stop after every few sentences.
  • When speaking or listening, watch the patient,
    not the interpreter. Add your gestures, etc.
    while the interpreter is translating your
  • Reinforce verbal interaction with visual aids and
    materials written in the clients language.
  • Repeat important information more than once.

Tappan, Weiss, Whitehead (2007) Marquis
Hustom (2003) Fawcett (2005).
Healthcare Workers Responsibilities
  • Always give the reason or purpose for a treatment
    or prescription.
  • Make sure the patient understands by having them
    explain it themselves.
  • Ask the interpreter to repeat exactly what was
  • Personal information may be closely guarded and
    difficult to obtain.
  • Patient often request or bring a specific
    interpreter to the clinic.
  • In some cultures it may not be appropriate to
    suggest making a will for dying patients or
    patients with terminal illnesses this is the
    cultural equivalent of wishing death on a
  • Avoid saying you must... Instead teach patients
    their options and let them decide, e.g., some
    people in this situation would...

Tappan, Weiss, Whitehead (2007) Marquis
Hustom (2003) Fawcett (2005).
The Future of Cultural Diversity in Nursing
  • To evaluate the movement of nursings cultural
    diversity intention, the attitudes and beliefs
    about cultural diversity should be examined for
    its impact on behavior and actions that have
    resulted in the operational definition and
    actualization of cultural diversity.
  • In process, reflection, and practice, nursing
    science should embody characteristics of cultural
    diversity in that way, the science would serve
    as a process for understanding all aspects of
    cultural diversity.

The Future of Cultural Diversity in Nursing
  • Nursing as a profession and discipline can
    conceptualize cultural diversity as more than
    just an awareness of diverse cultures through
    basic nursing curricula.
  • The curricula need to go beyond simply teaching
    categories of cultural content where categories
    of beliefs and practices of cultural
    characteristics are developed and implemented for
    nursing assessment and intervention purposes.
  • According to Zoucha and Housted the health care
    provider ought to treat a patient who happens to
    be from a particular culture, as an individual
    from a particular culture rather than, in effect,
    to treat the culture through the patient (2000,
    p. 326).

The Future of Cultural Diversity in Nursing
  • Future nurses need to be taught how to apply
    culture and diversity in the clinical setting.
    This will begin when nursing faculty are prepared
    in the cultural diversity dimension and are fully
    persuaded/ passionate about the cause.
  • Increasing the diversity among nursing faculty
    within nursings educational programs is needed
    so that students have diverse role models.
  • Diversity among nursing faculty can also help to
    disseminate and interpret cultural knowledge and
    needs of diverse nursing students. Additionally,
    nursing curricula need to reflect culturally
    diverse learning styles .
  • .(Crow, 1993 Lowe, 2002).

The Future of Cultural Diversity in Nursing
  • More curricular time and integration of cultural
    diversity concepts and content need to be
  • For instance, the anthropological perspectives of
    both emic (insiders) and etic (outsiders)
    viewpoints in patient care should be integrated
    to nursing curriculum, theory, and practice.
  • Incorporating an emicetic approach in patient
    care allows nurses to adhere to a culturally
    diverse approach that puts them in a
    culture-brokering position.
  • (DeSantis, 1991).

The Future of Cultural Diversity in Nursing
  • Chalanda (1995) described culture brokering as
    the act of bridging, linking, or mediating
    between groups or persons through the process of
    reducing conflict or producing change (p. 19).
  • Through culture brokering, patients will be able
    to mediate between their beliefs and practices
    and the beliefs and practices promoted by Western
    biomedicine about how they should resolve their
    particular health or illness situation.
  • Chalanda (1995)
  • Nurses in clinical practice have been expected to
    use a recipe or formula approach to delivering
    culturally competent patient care.

The Future of Cultural Diversity in Nursing
  • Often, this approach does not adequately address
    cultural diversity because of preconceived and
    prescribed stereotypical notions and assumptions.
  • Patients must be viewed as individuals outside of
    stereotypical characteristics and categorized to
    a particular cultural group. In this way, it
    would become clear that there are views and
    practices that conceptualize diversity between
    and within cultures.
  • Nursing, from a cultural diversity approach and
    perspective, has been more descriptive in nature.
    Research approaches need to move from descriptive
    research to applied, programmatic, or biocultural
    in nature.

The Future of Cultural Diversity in Nursing
  • The dynamics of culture on patient responses to
    health and illness and on physiological factors,
    cost of care, length of stay, and rates of
    compliance/adherence need to be studied.
  • To enhance cultural diversity, nursing needs to
    study the effects of using culture on
    physiological, psychological, spiritual, and
    social factors.
  • Nursing care could then be based upon a
    culturally informed nursing science. Outcome
    measures of the effects of culture on health
    seeking behavior and the response to illness
    could be developed.

  • It is because we are different that each of us is

Tutorial Activities.
  • Part 1 Answer the following questions with
  • 1- How culturally competent are you? Assess the
    extent do you think you are culturally sensitive?
    What areas need further development?
  • 2- Is there racism in nursing? To what extent do
    you think nurses are transracial in their
    practice setting?
  • 3- What do you see as the biggest danger in the
    use of alternative and complementary medicine?
  • Part 2 Read the following two articles and
    discuss your impressions
    Carol Bradley Julia Pennbridge Report to The
    California Endowment, March 2003.
  • 2- Canadian Nursing Association PROMOTING
    STATEMENT.October 2010

Extra Readings
  • Branch, W.T. 2000. The Ethics of Caring and
    Medical Education. Academic Medicine 75127-132.
  • Carrillo, J.E., A.R. Green, and J.R. Betancourt.
    1999. Cross-Cultural Primary Care A
    Patient-Based Approach. Annals of Internal
    Medicine 130829-34.
  • Carrese J.A., and L.A. Rhodes. 2000. Bridging
    Cultural Differences in Medical Practice. The
    Case of Discussing Negative Information with
    Navajo Patients. Journal of General Internal
    Medicine 15(2) 92-96.
  • https//

  • Putsch III RW. Cross-cultural communication The
    special case of interpreters in health care. JAMA
  • Fawcett, J.(2005). Contemporary Nursing Knowledge
    analysis and evaluation of Nursing Models and
    Theories. 2nd edition. F.A.Davis company.
  • Cronin, P. Anderson,K.(2004). Knowledge for
    contemporary Nursing Practice. Mosby.
  • Tappan, Weiss, Whitehead (2007), Essentials of
    Nursing Leadership and Management, 4th edition,
    F. A. Davis Company, Philadelphia.
  • Marquis Hustom (2003), Leadership Roles and
    Management Functions in Nursing Theory
    Application, 4th edition, Lippincott,
  • John , L. Cynthia , A. (2009)Cultural Diversity
    The Intention of Nursing. Nursing Forum Volume
    44, No. 1.

  • American Association of Colleges of Nursing
    AACN. (2008). Establishing a Culturally
    Competent Masters and Doctorally Prepared
    Nursing Workforce. http//
  • Andrews, M., Boyle,J. ( 2008). Transcultural
    Concepts in Nursing Care. 5th edition, Wolters
    Kluwer, Lippincott Williams Wilkins.
  • Leininger, M., McFarland, M., (2002).
    Transcultural Nursing. Concepts, theories,
    research, practices. 3rd edition. McGraw Hill.
  • The Registered Nurses Association of Ontario.
    (2007). Embracing Cultural Diversity in Health
    Care Developing Cultural Competence
  • http//
  • The Emirates Center For Strategic Studies and
  • http//