CULTURAL DIVERSITY,

CARE & SAFETY

OBJECTIVES
After the completion of this chapter the student will be
able to:
 Identify the key concepts of cultural diversity.
 Define terminologies like culture, ethnicity, cultural
awareness, cultural competence, ethnocentrism,
stereotyping, etc.
 Describe the health practices in different cultures.
 Critically analyze the need for transcultural nursing
in contemporary society.
 Explain the different models of cultural assessment.
 Describe purposes & principles of cultural assessment
including nurse’s role.
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 Discuss cultural safety.
INTRODUCTION
 Humanity has inhabited every corner of the
world. As groups of people worked and lived
together, they developed distinctive cultures.
 The phrase 'Cultural Diversity' means a range of
different societies or people of different origins,
religions and traditions all living and interacting
together.
 Transcultural Nursing was developed because of
the need to work with people from widely
divergent cultural atmosphere.

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 TERMINOLOGIES
Culture
refers to knowledge, beliefs,
behaviors, ideas, attitudes,
values, habits, customs,
languages, symbols, rituals,
ceremonies, and practices that
are unique to a particular
group of people.
CHARACTERISTICS OF CULTURE
• Culture is learned and taught. Cultural knowledge is
transmitted from one generation to another. A person
is not born with cultural concepts but instead learns them
through socialization.
• Culture is shared. The sharing of common practices
provides a group with part of its cultural identity.
• Culture is social in nature. Culture develops in and is
communicated by groups of people.
• Culture is dynamic, adaptive, and ever-changing.
Adaptation allows cultural groups to adjust to meet
environmental changes. Cultural change occurs slowly
and in response to the needs of the group. This dynamic and
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adaptable nature allows a culture to survive.
TERMINOLOGIES
 Cultural Awareness is a cognitive process in which the nurse becomes
aware of and sensitive to the client’s cultural values, beliefs, and practices
 Cultural sensitivity is experienced when neutral language–both verbal
and nonverbal–is used in a way that reflects sensitivity and appreciation
for the diversity of the other
 Acculturation is the process of incorporating some of the cultural
attributes of the larger society by diverse groups, individuals, or peoples
 Cultural competence is defined as the attitudes, knowledge, and skills
necessary for providing quality care to diverse populations. It is a
dimension of our:
•own personal understandings
•training programs training programs
•workplace/institutions •social environments
•legislation (e.g., Indian Act, Jordan’s Principle) •government / political will

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TERMINOLOGIES
Cultural Imposition intrusively applies the majority cultural view to
individual and families. E.g., Prescribing a special diet without regard to
the client’s culture, and limiting visitors to immediate family borders is
cultural imposition
 Discrimination occurs when a person acts on prejudice and denies
another person one or more of his or her fundamental rights.
 Diversity as an all-inclusive concept, and includes differences in race,
colour, ethnicity, national origin, and immigration status (refugee,
immigrant, or undocumented), religion, age, gender, sexual orientation,
ability/disability, political beliefs, social and economic status, education,
occupation, spirituality, marital and parental status, urban versus rural
residence, enclave identity, and other attributes of groups of people in
society.
 Healthcare disparity is defined as a difference in treatment provided to
members of different racial (or ethnic) groups that is not justified by the
underlying health conditions or treatment preferences of patients
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TERMINOLOGIES
 Stereotyping is an expectation that all
people within the same racial, ethnic, or
cultural group act alike and share the same
beliefs and attitudes.
 Ethnicity is term that relates to races or large
groups of people classified according to common traits
or customs.
 Ethnocentrism is the belief that one’s own
culture is superior to all others.
 Race is related to biology, since members of
the same group share distinguishing physical
features such as skin colour, bone structure, 7
and blood group
TERMINOLOGIES
o Culture shock is disorder that occurs in response to
transition from one cultural setting to another. E.g., a
North American who goes to live in Japan may experience
culture shock through not fully understanding the
difference between the USA and Japan culture.
o Cultural blindness refers to the inability of an individual
to recognize or see one's own lifestyle, values, and modes of
acting as those based largely on ethnocentric and biased
tendencies. E.g., The nurse was "blind" to recognize and
accept what the client did and had told her. She did not
accommodate the Arab-Muslim's prayer time.
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 WAYS IN WHICH PEOPLE DIFFER

• Age, gender & educational level

• Language
• Occupation
• Residence (rural, urban, suburban)
• Socioeconomic status
• Religion
• Functional abilities
• Cognitive abilities
• Racial composition
• Nationality
• Family structure and ties
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HEALTH PRACTICES IN DIFFERENT
CULTURES
 Use of Protective Objects: Protective objects can be worn
or carried or hung in the home- charms worn on a string or
chain around the neck, wrist, or waist to protect the wearer
from the evil eye or evil spirits.
 Use of Substances: It is believed that certain food
substances can be ingested to prevent illness. E.g. eating
raw garlic or onion to prevent illness or wear them on the
body or hang them in the home.
 Religious Practices : Burning of candles, rituals of
redemption etc..
 Traditional Remedies: The use of folk or traditional
medicine is seen among people from all walks of life and
cultural ethnic back ground.
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HEALTH PRACTICES IN DIFFERENT
CULTURES
 Healers: Within a given community, specific people are
known to have the power to heal.
 Immigration: Immigrant groups have their own cultural
attitudes ranging beliefs and practices regarding these areas.
 Gender Roles: In many cultures, the male is dominant figure
and often they take decisions related to health practices and
treatment. In some other cultures females are dominant. In
some cultures, women are discriminated in providing proper
treatment for illness.
 Beliefs about mental health: Mental illnesses are caused by
a lack of harmony of emotions or by evil spirits. Problems in
this life are related to transgressions committed in a past life.
 Economic Factors : Factors such as unemployment,
underemployment, homelessness, lack of health insurance 11
poverty prevent people from entering the health care system.
 TRANSCULTURAL NURSING
 Definition: Transcultural nursing is an area of study or practice that takes
into account the specific values, beliefs, and ways of life of people of diverse or
similar cultures, with the goal of using this knowledge in creative ways to
provide culturally congruent care.

 Transcultural nursing is a comparative study of cultures to understand

similarities (culture universal) and difference (culture-specific) across human
groups (Leininger, 1991).

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THE GOALS OF TRANSCULTURAL NURSING

 Nursing has been to prepare a new generation of nurses

who would be knowledgeable, sensitive, competent and safe
to care for people with different or similar life ways, values,
beliefs, and practices in meaningful explicit, and beneficial
ways.

 To develop a scientific and humanistic body of knowledge in

order to provide culture-specific and culture-universal
nursing care practices to individuals, families, groups, and
communities from diverse backgrounds.
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 THE IMPORTANCE OF TRANSCULTURAL
NURSING
Leininger (1995) cites eight factors that influenced her to establish trans
cultural nursing:
 There was a marked increase in the migration of people within and
between countries worldwide. Transcultural nursing is needed
because of the growing diversity that characterizes our national and
global populations In its broadest sense.
 There has been a rise in multicultural identities (with people
expecting their cultural beliefs) values and lifeway's to be understood
and respected by nurses and other health care providers.
 The increased use of health care technology sometimes conflicts with
cultural values of clients such as Amish prohibitions against using
certain apnea monitors and other such health care technologic devices
in the home.
 Worldwide there are cultural conflicts clashes and violence that have14
an impact health care as more cultures interact with one another.
 THE IMPORTANCE OF TRANSCULTURAL
NURSING
Leininger (1995) cites eight factors that influenced her to establish trans
cultural nursing:
 There was an increase in the number of people traveling and working
in many different parts of the world.
 There was an increase in legal suits resulting from cultural conflict,
negligence, ignorance and imposition of health care practices.
 There has been a rise in feminism and gender issues with new
demands on health care systems to meet the needs of women and
children.
 There has been an increased demand for community and culturally
based health care services in diverse environmental contexts.

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THEORTICAL BASED FOR TRANSCULTURAL
NURSIN CARE: MODEL LEININGER
TRANSCULTURAL NURSING MODEL
 Madeleine Leininger is considered as the founder of the
theory of transcultural nursing which is now developed as a
discipline in nursing.
 Her theory first appeared in her theory book Culture Care
Diversity and Universality (1991) but originated in the
1950s.
 The theory was further expanded in her book Transcultural
Nursing (1995)
 In the third edition of her book Transcultural Nursing
(2002) explains the theory-based research and practice
applying the concepts of the transcultural theory.
 Transcultural nursing theory is also known as Culture 16
Care theory.
MAJOR CONCEPTS IN
LEININGER THEORY (1991)
 Illness and wellness are shaped by a various factors
including perception and coping skills, as well as the social
level of the patient.
 Cultural competence is an important component of nursing.
 Culture influences all spheres of human life. It defines
health, illness, and the search for relief from disease or
distress.
 Religious and Cultural knowledge is an important
ingredient in health care.
 The health concepts held by many cultural groups may
result in people choosing not to seek modern medical
treatment procedures.
 Health care provider need to be flexible in the design of
programs, policies, and services to meet the needs and 17
concerns of the culturally diverse population, groups that
are likely to be encountered.
MAJOR CONCEPTS IN LEININGER
THEORY (1991)
 Most cases of lay illness have multiple causalities and may
require several different approaches to diagnosis,
treatment, and cure including folk and Western medical
interventions..
 The use of traditional or alternate models of health care
delivery is widely varied and may come into conflict with
Western models of health care practice.
 Culture guides behavior into acceptable ways for the people
in a specific group as such culture originates and develops
within the social structure through inter personal
interactions.
 For a nurse to successfully provide care for a client of a
different cultural or ethnic to background, effective
intercultural communication must take place. 18
NURSING PROCESS AND THE
ROLE OF THE NURSE
 First, determine the client's cultural heritage and language
skills.
 Determine if any of his health beliefs relate to the cause of
the illness or to the problem.
 Collect information that any home remedies the person is
taking to treat the symptoms.
 Nurses should evaluate their attitudes toward ethnic
nursing care.
 Self-evaluation helps the nurse to become more comfortable
when providing care to clients from diverse backgrounds
 Understand the influence of culture, race & ethnicity on
the development of social emotional relationship, child
rearing practices & attitude toward health. 19
 Collect information about the socioeconomic status of the
family and its influence on their health promotion and
wellness
 Identify the religious practices of the family and their
influence on health promotion belief in families.
 Understanding of the general characteristics of the major
ethnic groups, but always individualize care.
 The nursing diagnosis for clients should include potential
problems in their interaction with the health care system
and problems involving the effects of culture.
 The planning and implementation of nursing interventions
should be adapted as much as possible to the client's
cultural background.
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 Evaluation should include the nurse's self-
evaluation of attitudes and emotions toward
providing nursing care to clients from diverse
sociocultural backgrounds.
 Self-evaluation by the nurse is crucial as he or
she increases skills for interaction. .

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GIGER AND DAVIDHIZERS
TRANSCULTURAL ASSESSMENT MODEL

METAPARADIGM FOR THE GIGER AND

DAVIDHIZAR MODEL includes:
 Transcultural nursing / culturally diverse
nursing.
 Culturally unique individuals.
 Culturally sensitive environments.
 Health and health states based on culturally
specific illness and wellness behaviors. 22
THE GIGER AND DAVIDHIZAR TRANSCULTURAL ASSESSMENT
MODEL

Assessment NURSING

Cultural
unique Communication
individual

Space

Biological Environment Social

Time 23
variations Control organization
 FIG.1 Application of cultural phenoma to nursing care and nursing practice.
COMMUNICAITON
 Communication is the means by which culture is
transmitted and preserved
 Both verbal and nonverbal communications are learned in
one’s culture
 Verbal and nonverbal patterns of communication vary
across cultures
 If nurses do not understand the client’s cultural rules in
communication, the client’s acceptance of a treatment
regimen may be jeopardized
 Accurate diagnosis and treatment is impossible if the
health-care professional cannot understand the patient
 When the provider is not understood, he or she often avoids
verbal communication and does not realize the effect of
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nonverbal communication, which is all too often the painful
isolation of patients who do not speak the dominant language
and who are in an unfamiliar environment
 Consequently, the patient experiences cultural shock and
may react by withdrawing, becoming hostile or
argumentative, or being uncooperative
 Thus, an assessment of communication should consider

 Dialect
 Style
 Volume, including silence
 Touch
 Context of speech or emotional tone
 Kinesics (including gestures, posture, and eye
behaviour) 25
 EXAMPLES (COMMUNICATION)

 Afghans can be expressive, warm, orientated to others,

shy and modest. Male-to-male communication is
permissive whereas female-to-male communication is
contraindicated unless with the husband, son, or father
of the women involved
 Asians consider it disrespectful to look someone directly
in the eye, especially if that person is a nurse, not
because of disinterest or dishonesty. An Asian patient
may avoid eye contact out of respect for the superior
status of the nurse
 Many Middle Easterners see direct eye contact between
a man and a woman as an invitation for love or
emotional involvement
 Knowing what the norm within the culture is will facilitate 26
understanding and lessen miscommunication
SPACE
 Space refers to the distance between individuals when they
interact
 All communication occurs in the context of space
 There are four distinct zones of interpersonal space:
 Inmate zone (extends up to 1 ½ feet)
 Personal distance (extends from 1 ½ to 4 feet)
 Social distance (extends from 4 to 12 feet)
 Public distance (extends 12 feet or more)
 Rules concerning personal distance vary from culture to
culture
 The extreme modesty practiced by members of some
cultural groups may prevent members from seeking
preventive health care 27
SPACE
 For instance, some Afghans prefer closeness in
space with others and particularly with the same
sex. When comfortable with others, these
individuals prefer to be in close proximity to
build trusting relationships
 Particularly the comfort level is related to
personal space - comfort in conversation,
proximity to others, body movement, perception
of space
 Eye contact, space, and touch practices may be
very different from one’s sphere of reference
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 SOCIAL ORGANIZATION
 The social environment in which people grow up and live
plays an essential role in their cultural development and
identification
 Children learn their culture’s responses to life events from
the family and its ethno-religious group
 Social organization refers to the social group organizations
with which clients and families may identify
 Family structure and organization, religious values and
beliefs and role assignments may all relate to ethnicity and
culture
 Many social barriers, such as unemployment,
underemployment, homelessness, lack of health insurance,
and poverty can also prevent people from entering the
health-care system 29
 SOCIAL ORGANIZATION
 For example, in the African-American culture,
family may include individuals who are unrelated
or remotely related
 Members of families depend on the extended
family and kinship networks for emotional and
financial support in times of crises
 Mothers and grandmothers play significant roles
in African-American households and should be
included in health care decisions

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 TIME ORIENTATION

 Time is an important aspect of interpersonal

communication
 Some cultures are considered future oriented, others
present oriented, and still others past oriented
 People who are future-oriented are concerned with long-
range goals and with health-care measures in the present
to prevent the occurrence of illness in the future
 They prefer to plan in making schedules, setting
appointments, and organizing activities
 Others are oriented more to the present than the future
and may be late for appointments because they are less
concerned about planning to be on time
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 TIME ORIENTATION

 These differences in time orientation may become

important in health-care measures such as long-term
planning and explanations of medication schedules
 For instance, most Afghans are more past and present than
future time oriented, but generally they tend to follow two
different time concepts
 Another example is that Latin Americans, Native
Americans, and Middle Easterners are present oriented
cultures and may neglect preventive health care measures
hey may show-up late or not at all for appointments
 United States and Canada tend to be future oriented

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 Environmental control
 Biological variations

 Body structure
 Skin colour
 Other visible physical characteristics
 Enzymatic and genetic variations
 Susceptibility to disease
 Nutritional preferences and deficiencies

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 CULTURAL SAFETY
 Cultural safety addresses quality in health care through issues of
communication and 'access to the health service. Nurses may be the first
health professional people meet, hence the attitude a nurse portrays, if it
is one of the criticism, blame or assumption, whether expressed knowingly
or unknowingly, may make a person feel demeaned and engender feelings
of reluctance either to seek health care or to return to a particular health
service.

 The focus of cultural safety teaching is to educate student nurses:

 To examine their own realities and the attitudes they bring to each new
person they encounter in their practice;
 To be open minded and flexible in their attitudes toward people who are
different from themselves, to whom they offer or deliver service
 Not to blame the victims of historical and social processes for their current
plight;
 To product a workforce of well educated, self-aware registered nurses who
are culturally safe to practice.
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CONCLUSION
 Nurses need to be aware of and sensitive to the
cultural needs of clients.
 The practice of nursing today demands that the nurse
identify and meet the cultural needs of diverse groups,
understand the social and cultural reality of the
client, family, and community, develop expertise to
implement culturally acceptable strategies to provide
nursing care, and identify and use resources
acceptable to the client

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