DECENT WORK EMPLOYMENT AND

TRANSCULTURAL NURSING
NCM 120
WMSU
MA. ESPERANZA E. REAVON, RN,
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REMINDERS:
• Students should be online 5-10 minutes before the scheduled meeting
• Attendances (google classroom attendance check)
• If the student/s cannot attend the said meeting, they should inform the
clinical instructor and present evidences of the said valid explanation
• Appear presentable during online classes
• Assertiveness is key during recitations
• Environment for learning should be conducive

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Week 5: DESIRED LEARNING OUTCOMES/ COMPETENCIES
At the end of each topic and semester, the student can:

• Integrate relevant principles of social, physical, natural, and health sciences and
humanities in the care of group of clients with diverse culture
• Apply ethico-legal considerations when providing safe, quality, and professional
nursing care
• Ensure intra-agency, inter-agency, multidisciplinary and sectoral collaboration in the
delivery of care
• Maintain a harmonious and collegial relationship among members of the health team
for effective, efficient, and safe client care

Week 5: COURSE CONTENT (3 hours)

• Culturally Competent Health Care

• Cultural Diversity in the Health Care Workforce

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Week 5: TOPICS

• Culturally Competent Health Care

A. Cultural Competence
B. Cultural Diversity in Health Care
C. Influences/ Barriers to Nursing Care
D. Assessment of Different Cultures
E. Ethical Considerations in Transcultural Nursing
• Cultural Diversity in the Health Care Workforce
A. Racial/ Ethnic Diversity in the Health Care Workforce
B. Diversity of Values and Beliefs in the Health Care Service Delivery
C. Quality of Care through Cultural and Linguistic Competencies
D. Continuing Education Programs for Culturally-Diverse Health Care
Workforce
TOPIC 4
I. Culturally Competent Health Care
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CULTURAL COMPETENCE
• Cultural competence in health care is having the knowledge, abilities, and
skills to deliver care more congruent with the patient’s cultural beliefs and
practices. Increasing one’s consciousness of cultural diversity improves the
possibilities for health-care practitioners to provide culturally competent care.
• Cultural competence should be a part of health-care provider basic training
and based on cultural knowledge and experiential learning methods as well
as having the opportunity to be exposed to different cultures (Khatib and
Hadid 2019).

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RATIONALE FOR CULTURALLY COMPETENT CARE
• Multiple factors are converging at this time in history to heighten societal awareness of
cultural similarities and differences among people. In many parts of the world, there is
growing awareness of social injustice for people from diverse backgrounds and the moral
imperative to safeguard the civil and health care rights of vulnerable populations.
• Vulnerable populations are groups that are poorly integrated into the health care system
because of ethnic, cultural, economic, geographic (rural and urban settings), or health
characteristics, such as disabilities or multiple chronic conditions (Office of Minority Health &
Equity, 2013).
• Immigration and migration result in growing numbers of immigrants, people who move
from one country or region to another for economic, political, religious, social, and personal
reasons. The verb emigrate means to leave one country or region to settle in another;
immigrate means to enter another country or region for the purpose of living there. People
emigrate from one country or region and immigrate to a different nation or region.

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RATIONALE FOR CULTURALLY COMPETENT CARE
• Nurses respond to global health care needs such as infectious disease epidemics and the
growing trends in health tourism, in which patients travel to other countries for medical and
surgical health care needs. By traveling to another nation, clients often obtain more
affordable care services or receive specialized care that is unavailable in their own country.
• Nurses also respond to natural and human-made disasters around the world and
provide care for refugees (people who flee their country of origin for fear of persecution
based on ethnicity, race, religion, political opinion, or related reasons) and other casualties of
civil unrest or war in politically unstable parts of the world.
• In all of these situations, nurses are expected to demonstrate effective cross-cultural
communication and deliver culturally congruent and culturally competent nursing care
to people from diverse countries and cultures.

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RATIONALE FOR CULTURALLY COMPETENT CARE
• Interprofessional collaborative practice refers to multiple health providers from different
professional backgrounds working together with patients, families, caregivers, and
communities to deliver the highest quality care (World Health Organization [WHO], 2010).
• Interprofessional teams have a collective identity and shared responsibility for a client or
group of clients. Culturally competent care is an extension of interprofessional collaborative
practice (Institute of Medicine, 2011; Interprofessional Education Collaborative Expert Panel,
2011; Oelke, Thurston, & Arthur, 2013), involving clients and their families; credentialed or
licensed health professionals; folk or traditional healers from various philosophical
perspectives, such as herbalists, medicine men or women, and others; and religious and
spiritual leaders, such as rabbis, imams, priests, elders, monks, and other religious
representatives or clergy, all of whom are integral members of the interprofessional team.
• The religious and spiritual healers are especially helpful when the client is discerning which
decision or action in health-related matters is best, especially when there are moral, ethical,
or spiritual considerations involved.

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DEFINITIONS AND CATEGORIES OF CULTURAL
COMPETENCE
Individual Cultural Competence Organizational Cultural Competence
• Refers to the care provided for an • Focuses on the collective
individual client by one or more competencies of the members of an
nurses, physicians, social workers, organization and their effectiveness
and/or other health care, education, in meeting the diverse needs of
or social services professionals.
their clients, patients, staff, and
community.
Before nurses can provide culturally competent care for individual clients or contribute to organizational cultural
competence, they need to engage in a cultural self-assessment to identify their cultural baggage.
Cultural baggage refers to the tendency for a person’s own culture to be foremost in his/her assumptions, thoughts,
words, and behavior. People are seldom consciously aware that culture influences their world view and interactions
with others.
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INDIVIDUAL CULTURAL COMPETENCE
• Individual cultural competence is a complex integration of knowledge, attitudes, values,
beliefs, behaviors, skills, practices, and cross-cultural nurse–client interactions that include
effective communication and the provision of safe, affordable, accessible, research, evidence-
based, and best practices, acceptable, quality, and efficacious nursing care for clients from
diverse backgrounds.
• The term diverse or diversity refers to the client’s uniqueness in the dimensions of race;
ethnicity; national origin; socioeconomic background; age; gender; sexual orientation;
philosophical and religious ideology; lifestyle; level of education; literacy; marital status;
physical, emotional, and psychological ability; political ideology; size; and other
characteristics used to compare or categorize people.
• Although the connotation of diversity is generally positive, Talabere (1996) argues that it is
itself an ethnocentric term because it focuses on “how different the other person is from me”
rather than “how different I am from the other.”

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INDIVIDUAL CULTURAL COMPETENCE
• Cultural competence is not an end point, but a dynamic, ongoing, lifelong, developmental
process that requires self-reflection, intrinsic motivation, and commitment by the nurse to value,
respect, and refrain from judging the beliefs, language, interpersonal styles, behaviors, and
culturally based, health-related practices of individuals and families receiving services as well as
the professional and auxiliary staff who are providing such services.
• Culturally competent nursing care requires effective cross-cultural communication, a diverse
workforce, and is provided in a variety of social, cultural, economic, environmental, and other
contexts across the life span (Roberts, Warda, Garbutt, & Curry, 2014).
• Given the large number of cultures and subcultures in the world, it’s impossible for nurses to
know everything about them all; however, it is possible for nurses to develop excellent
cultural assessment and cross-cultural communication skills and to follow a systematic,
orderly process for the delivery of culturally competent care. Nurses are encouraged to study
in-depth the top two or three cultural groups that they encounter most frequently in their clinical
practice and develop the affective (feelings or emotions), cognitive (conscious mental activities
such as thinking), and psychomotor (combined thinking and motor) skills necessary to deliver
culturally competent nursing care.

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INDIVIDUAL CULTURAL COMPETENCE

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ORGANIZATIONAL CULTURAL COMPETENCE
• According to the National Center for Cultural Competence (National Center for Cultural
Competence, n.d.), cultural competence requires that organizations have the following
characteristics:
– A defined set of values and principles and demonstration of behaviors, attitudes, policies,
and structures that enable them to work effectively cross-culturally
– The capacity to (1) value diversity, (2) conduct self-assessments, (3) manage the dynamics
of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity
and the cultural contexts of the communities they serve.
– Incorporation of the previously mentioned items in all aspects of policy making,
administration, practice, and service delivery and systematic involvement of consumers,
key stakeholders, and communities (National Center for Cultural Competence, n.d.c;
Marrone, 2014; Ray, 2010a, 2010b)

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CULTURAL DIVERSITY IN HEALTH CARE
• The term “cultural diversity” was being used as popular culture by faculty, but seldom linked to care,
health, or well-being with few exceptions. Accordingly, some schools labeled their courses “Cultural
Diversity,” “Culture and Health,” or “Culture and Nursing” by early 1990s.
• Recently, cultural diversity and universality are of great popular and professional interest but often with
limited knowledge of the terms.
• Cultural diversity refers to the variations and differences among and between cultural groups resulting
from differences in lifeways, language, values, norms, and other cultural aspects.
• Cultural diversity was one of the first concepts emphasized in transcultural nursing. This was because
nurses seemed to ignore cultural differences and treated “all clients alike” as if from the same culture in
the pre-1960 era, and some still do today.
• By identifying cultural differences among and between cultures, nurses gradually began to value such
differences and to provide culture-specific care.
• Cultural diversity also helps nurses to value differences and provide culture-specific care practices.
• Cultural universals refer to the commonalities among human beings or humanity that reveal the
similarities or dominant features of humans.

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CULTURAL DIVERSITY IN HEALTH CARE
• Universality refers to the nature of a being or an object that is held as common or universally found in
the world as part of humanity.
• Cultural universals are the opposite of cultural diversity. With universals one seeks to discover and
understand commonalities but not absolute universals as this may never be found to exist in statistical
or precise quantitative ways.
• The theory of Culture Care Diversity and Universality is focused on what is universal and diverse about
human caring and within cultural perspectives. The purpose of the theory is to discover similarities and
differences about care and culture and to explain the relationship and reasons for the findings.
Discovering commonalties and differences in lifeways, values, and rules among cultures is essential for
nurses in our multicultural world. For it is both the commonalties and differences among cultures that
keep nurses alert to humanistic care practices. With research findings on many cultures this would be of
great significance and help to nurses in caring and healing practices.

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CULTURAL DIVERSITY IN HEALTH CARE
What is Diversity in Healthcare?
• Diversity in any workplace means having a workforce comprised of multiple races, ages, genders, ethnicities, and
orientations. In other words, it refers to when the medical and administrative staff of a healthcare facility represents a
wide range of experiences and background. In modern society, healthcare diversity can refer to a number of qualities,
including but not limited to the following characteristics:
• Race • Age • Political beliefs • Socioeconomic
• Ethnicity • Sexual orientation • Education background
• Gender • Religion • Physical abilities and • Language
disabilities • Culture
Diversity is Vital to Patient Care
• Creating diversity in healthcare isn’t just important, it’s vital. Language, culture, and ethnicity can easily
create barriers, and in an industry where lives hang in the balance and every second could mean the
difference between life and death, delays and obstacles can quickly become deadly.
• But diversity isn’t something that can be created overnight. It requires a leadership dedicated to
increasing cultural awareness and inclusion. It requires co-workers who are willing to take the time to
learn about each other. It means being willing to identify and address personal biases. And it means
boldly opening ourselves up to discomfort for the greater good of our patients. 17
CULTURAL DIVERSITY IN HEALTH CARE
Diversity in the workplace carries a host of benefits for healthcare employers, their staff, and their patients.
Those benefits include:
• Higher Employee Morale - Diversity creates a stronger feeling of inclusion and community for
healthcare workers, which makes the workplace feel safer and more enjoyable.
• Better Care for Diverse Populations - A healthcare staff should be as diverse, if not more diverse, than
the patient base they are treating. This helps ensure that no matter who walks through the door, there is
someone on staff who can identify with them, communicate with them, and better serve their individual
needs.
• Higher Employee Retention - This goes hand-in-hand with improved morale. The happier and safer
healthcare workers feel in the workplace, the longer they will stay.
• Better Recruitment - A commitment to diversity helps when recruiting new healthcare workers and
administrative staff. It allows you to cast a wider net to attracted new talent and it offers a stronger
hiring proposition for candidates who may consider working at your hospital or clinic.

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CULTURAL DIVERSITY IN HEALTH CARE
• Stronger Individual Motivation - When there is a lack of diversity, minority healthcare workers may
feel stifled or unable to express their unique talents and personality traits. This is a natural inclination for
people when they are more concerned with fitting in as opposed to “being themselves.” That added
pressure can lead to increased stress, reduced morale, and it may even inhibit them from speaking up
when their perspective is needed most. A diverse work environment sends the message that a worker’s
cultural and ethnic background is an advantage that should be respected, if not celebrated.
• Better Problem Solving - A wide range of perspectives can lead to more creative solutions when
solving problems during an emergency or even during routine patient-care. Allowing for new ideas and
diverse perspectives can also lead to greater innovation and operational excellence.
• Better Results -Diverse healthcare teams get better results, period. The data show us that medical
teams who embrace diversity provide better healthcare.
• Final note on the benefits of healthcare diversity—It’s worth mentioning that while diversity is
important, diversity without inclusion is ineffective. Not only do healthcare teams need to represent a
variety of backgrounds, but each member needs to be given a voice.

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CULTURAL DIVERSITY IN HEALTH CARE
What are the Risks of Lacking Healthcare Diversity?
Just as healthcare diversity has its advantages, there are major risks that can be attributed to the lack of diversity.
• Communication Breakdown - Be it the result of a language barrier, differences in philosophy, differences in cultural norms
(& expectations), or even cultural bias, lack of diversity can lead to communication breakdown with patients. And when
patients cannot fully communicate or express their needs, dangerous mistakes can occur.
• Limited Perspectives - Lack of healthcare diversity can lead to limited perspective when providing patients with medical
care, psychological treatment, and social support. It can stunt innovation and creative thinking, but more importantly, it
could impede critical observations surrounding a patient’s diagnosis, medical history, or other socio-economic factors that
may affect their health and well-being.
• Lack of Role Models - Mentorship plays a critical role in our medical system. Doctors, nurses, medical assistants, and
administrative personnel will always need the support of a mentor to guide them in their respective professions. It’s
important for healthcare workers to have role models they can look up to and emulate throughout their careers. A lack of
diversity can make it difficult for minority healthcare workers to find mentors with whom they identify and learn from. In
turn, this can thwart their professional growth and their ability to provide the best patient care.
• Lack of Future Diversity - Albeit an obvious consequence, it is an important one to the future success of any healthcare
organization. The less diverse your medical staff is today, the harder it will be to foster it within your team tomorrow.
• Bias - Bias does not always have to be explicitly expressed within a healthcare setting for it to become a problem. Bias can
still impact decisions made for patients when it is embedded in the policies and procedures of a healthcare organization.
This is referred to implicit bias within a system. Greater diversity can stymie the destructive effects of implicit bias in patient
care.

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CULTURAL DIVERSITY IN HEALTH CARE
How to Promote Diversity in Healthcare
• It may be true that a greater burden of the responsibility for establishing healthcare diversity falls on hospital
administration and HR. After all, those departments control much of the hiring, advertising, and recruitment within
their respective institutions. However, healthcare workers (doctors, nurses, medical assistants, etc.) can also play an
important role. Here of some of the ways members of a healthcare staff can promote diversity in the workplace.
1. Create a Welcome Environment - Foster an environment of inclusiveness in every area possible. Make sure that
all voices are heard, and that all coworkers feel safe to share their perspectives.
2. Address Issues of Bias Quickly and Openly - Often the victims of bias or discrimination are reluctant to come
forward themselves for fear of repercussion or other forms of retaliation. Supporting co-workers in these times and
reporting cases quickly and transparently are vital to creating a safe working environment for everyone.
3. Encourage Diverse Applicants - Do you know someone who would be a wonderful fit in the healthcare
community? Encourage them to pursue their dreams!
4. Diversity for More Than Diversity’s Sake - Always remember, the point of encouraging diversity in your hospital
or clinic isn’t to have a diverse hospital or clinic… it’s to have a better hospital or clinic. As explained above, a diverse
workforce can provide a rich array of experiences and understanding that can only enhance the patient-care
experience and draw more success to your hospital or clinic.
5. Listen - Sometimes the best action you can take to promote diversity and creating an open work environment is
by simply listening. Listening (without interjecting or suggesting fixes) helps each of us understand new
perspectives, opens our minds to unseen needs, and shows co-workers or patients that their opinion matters.

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CULTURAL DIVERSITY IN HEALTH CARE
RACE CATEGORY DESCRIPTION (Based on US Census for Population)
1. White refers to people having origins in any of the original peoples of Europe and includes Middle
Easterners, Irish, German, Italian, Lebanese, Turkish, Arab, and Polish.
2. Black, or African refers to people having origins in any of the black racial groups of Africa and includes
American Nigerians and Haitians or any person who self-designates this category
regardless of origin.
3. American Indian and refer to people having origins in any of the original peoples of North, South, or Central
Alaskan Native America and who maintain tribal affiliation or community attachment.
4. Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent. This category includes the terms Asian Indian, Chinese, Filipino,
Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, and Thai.
5. Native Hawaiian and refer to people having origins in any of the original peoples of Hawaii, Guam, Samoa, Tahiti,
other Pacific Islander the Mariana Islands, and Chuuk.
6. Some other race was included for people who are unable to identify with the other categories.

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CULTURAL INFLUENCES AFFECTING NURSING CARE
Health is a cultural concept because culture frames and shapes how we perceive the world and our
experiences. Along with other determinants of health and disease, culture helps to define:
• How patients and health care providers view health and illness.
• What patients and health care providers believe about the causes of disease. For example, some
patients are unaware of germ theory and may instead believe in fatalism, a djinn (in rural Afghanistan,
an evil spirit that seizes infants and is responsible for tetanus-like illness), the 'evil eye', or a demon.
They may not accept a diagnosis and may even believe they cannot change the course of events.
Instead, they can only accept circumstances as they unfold.
• Which diseases or conditions are stigmatized and why. In many cultures, depression is a common
stigma and seeing a psychiatrist means a person is “crazy”.
• What types of health promotion activities are practiced, recommended or insured. In some cultures
being “strong” (or what Canadians would consider “overweight”) means having a store of energy
against famine, and “strong” women are desirable and healthy.

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CULTURAL INFLUENCES AFFECTING NURSING CARE
• How illness and pain are experienced and expressed. In some cultures, stoicism is the norm, even in the
face of severe pain. In other cultures, people openly express moderately painful feelings. The degree to
which pain should be investigated or treated may differ.
• Where patients seek help, how they ask for help and, perhaps, when they make their first approach.
Some cultures tend to consult allied health care providers first, saving a visit to the doctor for when a
problem becomes severe.
• Patient interaction with health care providers. For example, not making direct eye contact is a sign of
respect in many cultures, but a care provider may wonder if the same behavior means her patient is
depressed.
• The degree of understanding and compliance with treatment options recommended by health care
providers who do not share their cultural beliefs. Some patients believe that a physician who doesn’t
give an injection may not be taking their symptoms seriously.
• How patients and providers perceive chronic disease and various treatment options.

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CULTURAL INFLUENCES AFFECTING NURSING CARE
Culture also affects health in other ways, such as:
• Acceptance of a diagnosis, including who should be told, when and how.
• Acceptance of preventive or health promotion measures (e.g., vaccines, prenatal care, birth control,
screening tests, etc.).
• Perception of the amount of control individuals have in preventing and controlling disease.
• Perceptions of death, dying and who should be involved.
• Use of direct versus indirect communication. Making or avoiding eye contact can be viewed as rude or
polite, depending on culture.
• Willingness to discuss symptoms with a health care provider, or with an interpreter being present.
• Influence of family dynamics, including traditional gender roles, filial responsibilities, and patterns of
support among family members.
• Perceptions of youth and aging.
• How accessible the health system is, as well as how well it functions.

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CULTURAL INFLUENCES AFFECTING NURSING CARE

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CULTURAL INFLUENCES AFFECTING NURSING CARE

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BARRIERS TO NURSING CARE
DEMOGRAPHIC
• Age
• Gender
• Ethnicity
• Primary language
• Religion
• Educational level and
literacy level
• Occupation, income, and
health insurance
• Area of residence
• Transportation
• Time and/or generation
CULTURAL
• Age
• Gender, class and family
dynamics
• Worldview/ perceptions
of life
• Time orientation
• Primary language spoken
• Religious beliefs and
practices
• Social customs, values
and norms
• Traditional health beliefs
and practices
• Dietary preferences and
practices
• Communication patterns
and customs
HEALTH SYSTEMS
• Differential access to high quality care
• Insurance and other financial resources
• Orientation to preventive health services
• Perception of need of health care services
• Lack of knowledge and/or distrust of Western medical
practices and procedures
• Cultural insensitivity and incompetence in providers,
including bis, stereotyping and prejudice
• Lack of diversity in providers
• Western versus folk health beliefs and practices
• Poor provider-client communication
• Lack of bilingual and bicultural staff
• Unfriendly and cold environment
• Fragmentation of care
• Physical barriers (such as excessive distances)
• Information barriers
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WHAT HEALTH PROFESSIONALS CAN DO
The following suggestions may help you care for and communicate with patients:
• Consider how your own cultural beliefs, values and behaviors may affect interactions with patients. If
you suspect an interaction has been adversely affected by cultural bias – your own or your patient’s –
consider seeking help.
• Respect, understand and work with differing cultural perceptions of effective or appropriate treatment.
Ask about and record how your patients like to receive health care and treatment information.
• Where needed, arrange for an appropriate interpreter.
• Listen carefully to your patients and confirm that you have understood their messages.
• Make sure you understand how the patient understands his or her own health or illness.
• Recognize that families may use complementary and alternative therapies. For appropriate, specific
conditions, remind them that complementary and alternative medicine use can delay biomedical testing
or treatment and potentially cause harm.
• Try to ‘locate’ the patient. Assess their support system. What are their language skills?
• Negotiate a treatment plan based on shared understanding and agreement.
• Find out whether a patient or family would benefit from spoken or visual messaging for reasons of
culture or limited literacy.

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ASSESSMENT OF DIFFERENT CULTURES
• A cultural assessment is the process used by nurses to assess cultural needs of individual clients (Leininger,
1991, 1995).
• Cultural assessment, or culturologic assessment, refers to a systematic, comprehensive examination of
individuals, families, groups, and communities regarding their health-related cultural beliefs, values, and
practices.
• The cultural assessment consists of both process and content.
• Process refers to how to approach to the client, consideration of verbal and nonverbal communication, and
the sequence and order in which data are gathered.
• The content of the cultural assessment consists of the actual data categories in which information about
clients is gathered.
• Nurses are required to complete assessments before and/or at the time of admission to health care facilities,
when opening home health care cases, and prior to many types of medical and surgical procedures.
Depending on the circumstances, assessments may be very brief, or they may be detailed and in-depth.
Ideally, the cultural assessment is integrated into the overall assessment of the client, family, and significant
others. It is usually impractical to expect that nurses will have the time to conduct a separate cultural
assessment, so questions aimed at gathering cultural data should be integrated into the overall assessment
using the format provided by health care facilities, agencies, or organization for their admissions or intake
assessment.

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ASSESSMENT OF DIFFERENT CULTURES
• In general, the purpose of all successful cultural assessments is to collect information that helps health
professionals better understand and address the specific health needs and interests of their target
populations.
• Individual cultural assessments are accomplished through the use of a systematic process. In
community health nursing, the community is considered the client, and several models have been
proposed to help nurses assess the community (Stanhope & Lancaster, 2012), including the
Andrews/Boyle Transcultural Nursing Assessment Guide for Groups and Communities. A community
nursing assessment requires gathering relevant data, interpreting the data (including problem analysis
and prioritization), and identifying and implementing intervention activities for community health
(Stanhope & Lancaster, 2012).
• The community nursing assessment often focuses on a broad goal, such as improvement in the health
status of a group of people. It is often the characteristics of people that give each community its
uniqueness, and these common characteristics, which influence norms, values, religious practices,
educational aspirations, and health and illness behaviors, are frequently determined by shared cultural
experiences. Thus, including the cultural component to a community nursing assessment strengthens
the assessment base.
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BASIC PRINCIPLES OF CULTURAL ASSESSMENTS
1. All cultures must be viewed in the context in which they have developed. Cultural practices develop as a
“logical” or understandable response to a particular human problem, and the setting as well as the
problem must be considered. This is one reason why environmental and/or contextual data are so
important.
2. The meaning and purpose of the behavior must be interpreted within the context of the specific culture.
For example, the Hispanic client’s refusal to take a “hot” medication with a cold liquid is understandable
if the nurse is aware that many Hispanic patients adhere to hot/cold theories of illness causation. There
is often a range or spectrum of illness beliefs, with one end encompassing illnesses defined within the
biomedical model and the other end firmly anchored within the individual culture (Huff & Kline, 2007).
The more widely disparate the differences between the biomedical model and the beliefs within the
cultural group, the greater the potential for encountering resistance to biomedical interventions.
3. There is such a phenomenon as intracultural variation. Not every member of a cultural group displays all
the behaviors that are associated with that group. For instance, not every Hispanic client will adhere to
hot/cold theories of illness, and not every Hispanic mother will have a close personal relationship with
her son. It is only by careful appraisal of the assessment data, and validation of the nurse’s assessment
with the client and family, that culturally competent care can be provided.
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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
Ethical Diversity
• Ethical relativism holds that morality is relative to the norms of a particular culture; hence,
there are no universal truths in ethics. It emphasizes the need to examine the context of the
decision because sociocultural differences influence whether an act is moral. Ethical
relativism is unlike universalistic moral philosophies such as deontology (a theory that
suggests actions are good or bad according to a clear set of rules), which upholds the existence
of universal truths and unbreakable moral rules applicable to all situations (Butts & Rich,
2008), and teleology (explanation by reference to some purpose, end, goal, or function), which
judges the morality of an act based on its consequence or outcome. Ethical relativism
states that what is right for one group may not be right for another (Wong, 2006).

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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
• Ethics is concerned with human actions” (MacIntyre, 1996, p. 85).
• Ethics thus is concerned with human character or virtue (Rachels, 2003).
• “Ethics is defined as a code of conduct developed and reinforced in terms of what is good and right (or moral)
in character and behavior” (Ray, 1998, p. 72).
• Ethics and morality deal with questions of how people ought to live in society. The terms translate to mean
rules or norms, suggesting dignity for human persons and right action in human communities (Ahlquist 2003;
Lange, 2005; Roach, 2002).
• Ethics demands serving the good and being responsible for others, known as the ethical demand (Logstrup,
1997).
• Ethics as inquiry about the nature of good and evil (beneficence and maleficence respectively) in society
studies ways of being (character and virtue), rules, and action about people as they relate together (Rachels,
2003).
• Overall, ethics encourages the virtue of personal fidelity and commitment to a truth, such as, “Fear God and
keep his commandments; for this is the whole duty of man” (Ecclesiastes, 12:13, The New American Bible,
1987); the absolute moral law is followed by everyone without exception in all circumstances for all time (the
“categorical ought”), such as: “reason requires that we never lie” (Kant, 1959); or selfless devotion to a cause,
“first the Good (the affirmation of truth), then the risk of Evil (as perversion of the Good)” (Badiou, 2001, p.
xiii). Consequently, moral behavior is an exercise in virtue that “manifests human excellence” (MacIntyre, 1996,
p. 80).
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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Biomedical Ethics Biomedical ethics exemplifies a number of ethical principles: beneficence,
nonmaleficence, autonomy, veracity, confidentiality, justice, and fidelity (Edge &
Groves, 1994; Beauchamp & Childress, 2001; Veatch, 1977). “Ethical principles are
basic moral truths that guide deliberation and action” in medicine and nursing and
are grounded in ethical theories (Burkhardt & Nathaniel, 2008, p. 53).

Beneficence is to do good and requires nurses to act in ways that benefit or are
good for patients. Nurses are obligated to act beneficently—what is morally and
legally demanded by nursing’s professional role (Burkhardt & Nathaniel, 2008).
Nonmaleficence is a principle that requires nurses to act in such a way that no
deliberate harm, risk of harm, and harm that relates to doing no harm in the wake of
doing good. The first principle of the Hippocratic oath of medicine is to do no harm
(Burkhardt & Nathaniel, 2008, pp. 60–62).

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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Biomedical Ethics Autonomy means to facilitate the freedom for self-governance or self-organization
in patients with the assistance of family members or significant others. Often there is
a critique of the principle of autonomy or self-governance in cultures, such as in
Native American culture, where decisions are more communally based (Smith-Morris,
2007). Allowing choice, working with the patient, family, and community to cocreate
what is needed for health and well-being is a primary nursing role. Nurses are to be
advocates of the patient through knowledgeable caring, which means that within the
principle of autonomy, there should be no coercion, paternalism, thoughtlessness,
and deception.
Veracity is an ethical principle that relates to telling the truth. “Truthfulness is widely
accepted as a universal human virtue. . . .[t]ruth-telling engenders trust” (Burkhardt &
Nathaniel, 2008, p. 65). In terms of relational caring, trust is one of the most
important ways of being (Hilsenbeck, 2006; Ray, Turkel, & Marino, 2002).

36
ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Biomedical Ethics Justice is “the ethical principle that relates to fair, equitable, and appropriate
treatment in light of what is due or owed to persons, recognizing that giving to some
will deny receipt to others who might otherwise have received these things”
(Burkhardt & Nathaniel, 2008, p. 73). Justice issues relate to the distribution of the
greatest good to the greatest number. In health care and public health care in
particular, the principle focuses on distribution of goods, money, and services
(distributive justice).
Fidelity is an ethical principle that relates to faithfulness and keeping promises. In
nursing, the principle of fidelity means loyalty to the patient within the nurse-patient
relationship (Burkhardt & Nathaniel, 2008). Nurses make promises to their patients
by means of the social contract of a nursing license or certificate of competence and
as they care for the patients. Nurses must do everything in their power to be a
patient advocate

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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Transcultural Ethics Transcultural ethics is very complex and dynamic. The immediate purpose of
transcultural ethics is to “hear the other” and “learn from the other” with mutual
respect. This validates the idea that all people are cultural beings and have diverse
values, beliefs, and attitudes. As cultural beings relate, transcultural ethics offers a
framework within which to interact. The conscience in which this ethics illuminates
strives to mitigate disrespect or elements of misconduct and to propagate the good,
purpose, truth, and beauty within the interactions of all people and in nursing, nurses
and patients, families or community groups.

38
ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Transcultural Ethics In today’s challenging global culture, transcultural ethics seeks to understand
differences in people in interaction with others. Transcultural ethics validates the idea
of increasing and learning compassion and reaching out to alleviate suffering—to
help human beings by meeting needs and trying to secure human rights (individual
or communal), and do what is just for others (Dalai Lama 1999; Hirsch, 1976;
Leininger, 1991; Rachels, 2003; Ray, 1989a, 1994a; Singer, 1993; Watson, 2005;
Wielenberg, 2005). Transcultural ethics is consistent with transcultural caring and thus
transcultural caring and transcultural caring ethics are defined as follows: the
relationship between charity and right action, between love as compassion and
response to suffering and need, and justice or fairness in terms of doing what ought
to be done within [the dynamics of] a culture or society (Ray, 1989a, p. 19). Culture,
made up of beliefs, attitudes, values, principles, codes, standards, and rules of
behavior varies even within a given cultural community. Every individual experiences
life differently and conscience forms not only because of cultural orientation, but also
from life experience.
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ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING
ETHICAL THEORY DESCRIPTION
Transcultural Ethics Transcultural ethics illuminates the following:
• Respect the dignity of all people.
• Promote the good of all people.
• Honor all people through compassion and justice.
• Value language differences.
• Acknowledge complexity of religious, spiritual, and humanistic values.
• Seek understanding of dynamic relationships related to ethnohistorical evolution of people in world
cultures.
• Seek understanding of the transmission of diverse values (purposes of existence) and learned behaviors
and rules of law in cultures.
• Promote communitarianism (listening to and learning from the other; encouraging all people to have a
voice at the “table”).
• Negotiate and facilitate the alleviation of conflict and strife in culture.
• Develop covenants and rules of law, human rights, and cultural rights that promote rights to liberty and
equality regardless of race, color, sex, language, religion, national, or social origins, property, and birth
status. (Excerpted in part from The United Nations Universal
• Declaration of Human Rights, 1948; and the Transcultural Nursing Society Position Statement on Human
Rights, 2008).
• Protect the rights of nature (the environment).
• Promote individual and public health and well-being of all people.
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TOPIC 4
II. Cultural Diversity in the Health Care Workforce
41
DIVERSITY IN THE NURSING WORKFORCE
• Workplace diversity refers to differences between individuals in the work setting in any attribute that
may evoke the perception that another person is different from oneself (Dijk & van Engan, 2013;
Guillaume, Dawson, Woods, Sacramento, & West, 2013).
• One person may differ from another on a number of different attributes including demographic
characteristics such as race, ethnicity, national origin, age, gender, and marital status.
• People also may differ on the basis of sexual orientation, religion, education, expertise, skills, work
experience, profession, job title, socioeconomic background, political affiliation, ability/disability, tenure
or length of service to an organization, and other characteristics (American Academy of Nursing, 2012;
American Association of Colleges of Nursing, 2014a).
• Workplace diversity is the collective, all-inclusive mixture of human differences and similarities that
provides an organization with a large pool of people with knowledge, skills, and abilities required for
the accomplishment of organizational goals and objectives (Ewoh, 2013; Sabharwal, 2014).

42
DIVERSITY IN THE NURSING WORKFORCE
Advantages
• Diversity in the workplace is important because it contributes to the organization’s collective decision
making, effectiveness, and responsiveness to societal health care needs.
• Diversity enhances the organization’s ability to evaluate the intended and unintended consequences of
decisions by examining them through the lens of multiple perspectives.
• Diversity also enhances rational decision making and organizational efficiency and effectiveness (Ewoh,
2013; Singh, Winkel, & Selvarajan, 2013).
• There is evidence that creating a more diverse health care workforce has value for the people being
served and the health care organization
• Concordance, matching the demographics of employees to the community served, is tied to better
patient outcomes (Flores & Combs, 2013; Georges, 2012; Mittman & Sullivan, 2012; Sabharwal, 2014).
People tend to seek care from professionals with ethnic, racial, and linguistic backgrounds that are
similar to their own. from the perspective of its employees and leaders (Flores & Combs, 2013).
• Increased diversity of the health care workforce can lead to improved satisfaction for racial and ethnic
minority patients. Patients who are treated by physicians of their own racial or ethnic background are
more likely to report receiving higher quality care.

43
DIVERSITY OF VALUES AND BELIEFS IN THE HEALTHCARE
SERVICE DELIVERY
• Culturally competent health-care delivery organizations provide consumers with effective,
understandable, and respectful care provided in ways that fit with their cultural values and beliefs and in
the consumer’s preferred language. To achieve this goal, organizations develop, implement, and
promote a written strategic plan that outlines clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
Consequently, to ensure the design of an evidence-based strategic plan, the organization conducts
initial and ongoing organizational self-assessments of diversity-related activities.
• To establish rapport, health-care practitioners working with patients suffering from chronic disease must
avoid assumptions regarding health beliefs and provide rehabilitative health interventions within the
scope of cultural customs and beliefs. Failure to respect and accept patients’ values and beliefs can lead
to misdiagnosis, lack of cooperation, and alienation of patients from the health-care system.

44
DIVERSITY OF VALUES AND BELIEFS IN THE HEALTHCARE
SERVICE DELIVERY
• Critically analyzing our own values and beliefs in terms of how we see differences enables us to be less
fearful of others whose values and beliefs are different from our own (Calvillo et al. 2009).
• Culturally competent health-care delivery organizations provide consumers with effective,
understandable, and respectful care provided in ways that fit with their cultural values and beliefs and in
the consumer’s preferred language. To achieve this goal, organizations develop, implement, and
promote a written strategic plan that outlines clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
Consequently, to ensure the design of an evidence-based strategic plan, the organization conducts
initial and ongoing organizational self-assessments of diversity-related activities.

45
QUALITY OF CARE THROUGH CULTURAL AND LINGUISTIC
COMPETENCIES
• Linguistic Competence: Providing readily available, culturally appropriate oral and written language
services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff,
trained medical interpreters, and qualified translators.
• Cultural Competence: A set of congruent behaviors, attitudes, and policies that come together in a
system or agency or among professionals that enables effective interactions in a cross-cultural
framework.
• Cultural and Linguistic Competence: The ability of health care providers and health care organizations
to understand and respond effectively to the cultural and linguistic needs brought by the patient to the
health care encounter.

46
QUALITY OF CARE THROUGH CULTURAL AND LINGUISTIC
COMPETENCIES
• The professional must recognize that differences do not imply deficiencies or disorders. Culture and
language may influence the behaviors of individuals who are seeking health, habilitative, or
rehabilitative care and their attitudes toward speech, language, and hearing services and providers.
Similarly, the delivery of services is impacted by the values and experiences of the provider. Providing
competent care is providing service that is respectful of, and responsive to, an individual's values,
preferences, and language. Care should not vary in quality based on ethnicity, age, socioeconomic
status, or other factors.
• Nurses need to participate in conducting health literacy and cultural and linguistic competence audits
at a unit and organizational level, examine written and spoken communication and examine difficulties
in navigating facilities and complex systems in order to contribute to changes needed to become a
health literate organization.

47
QUALITY OF CARE THROUGH CULTURAL AND LINGUISTIC
COMPETENCIES
What are culturally competent and linguistically appropriate services?
• The task of identifying appropriate tools in order to deliver culturally competent and linguistically
appropriate services is difficult and time-consuming. As previously mentioned, there is no universally
accepted definition of the term, nor are there clear guidelines as to what criteria makes an individual
health professional or health organization culturally competent.
• Second, although there is a plethora of information relating to cultural competency at the individual
and organizational level, it is impossible to determine the effectiveness of any approach simply because
there has been little or no validating research to demonstrate the effectiveness of one approach over
another. As a result, individual health care professionals and organizations seeking to overcome cultural
and linguistic barriers to care have adopted a wide variety and/or combination of approaches including:
– Provision of staff training, sometimes referred to as cultural sensitivity or diversity training
– Utilization of bilingual providers
– Utilization of bilingual family members and support staff
– Utilization of professional medical interpreters
– Utilization of telephonic interpretation services
48
QUALITY OF
CARE
THROUGH
CULTURAL AND
LINGUISTIC
COMPETENCIES

49
STANDARDS OF PRACTICE FOR CULTURALLY COMPETENT
NURSING CARE
STANDARDS
1. Social Justice Professional nurses shall promote social justice for all. The applied principles of
social justice guide decisions of nurses related to the patient, family, community,
and other health-care professionals. Nurses will develop leadership skills to
advocate for socially just policies.
2. Critical Reflection Nurses shall engage in critical reflection of their own values, beliefs, and cultural
heritage in order to have an awareness of how these qualities and issues can impact
culturally congruent nursing care.
3. Knowledge of Nurses shall gain an understanding of the perspectives, traditions, values, practices,
Cultures and family systems of culturally diverse individuals, families, communities, and
populations for whom they care, as well as knowledge of the complex variables that
affect the achievement of health and well-being.
4. Culturally Nurses shall use cross-cultural knowledge and culturally sensitive skills in
Competent Practice implementing culturally congruent nursing care.

50
STANDARDS OF PRACTICE FOR CULTURALLY COMPETENT
NURSING CARE
STANDARDS
5. Cultural Healthcare organizations should provide the structure and resources necessary to
Competence in evaluate and meet the cultural and language needs of their diverse patients.
Healthcare Systems
and Organizations
6. Advocacy and Nurses shall recognize the effect of healthcare policies, delivery systems, and
Empowerment resources on their patient populations, and shall empower and advocate for their
patients as indicated. Nurses shall advocate for the inclusion of their patients’
cultural beliefs and practices in all dimensions of their health care when possible.
7. Multicultural Nurses shall actively engage in the effort to ensure a multicultural workforce in
Workforce health-care settings. One measure to achieve a multicultural workforce is through
strengthening of recruitment and retention effort in the hospital and academic
setting.

51
STANDARDS OF PRACTICE FOR CULTURALLY COMPETENT
NURSING CARE
STANDARDS
8. Education and Nurses shall be educationally prepared to promote and provide culturally congruent health
Training care. Knowledge and skills necessary for ensuring that nursing care is culturally congruent
in Culturally shall be included in global health-care agendas that mandate formal education and clinical
Competent Care training, as well as required ongoing, continuing education for all practicing nurses.
9. Cross-Cultural Nurses shall use culturally competent verbal and nonverbal communication skills to identify
Communication patient’s values, beliefs, practices, perceptions, and unique health-care
needs.
10. Cross-Cultural Nurses shall have the ability to influence individuals, groups, and systems to achieve positive
Leadership outcomes of culturally competent care for diverse populations.
11. Policy Nurses shall have the knowledge and skills to work with public and private organizations,
Development professional associations, and communities to establish policies and standards for
comprehensive implementation and evaluation of culturally competent care.
12. Evidence-Based Nurses shall base their practice on interventions that have been systematically tested and
Practice and Research shown to be the most effective for the culturally diverse populations that they serve. In areas
where there is a lack of evidence of efficacy, nurse researchers shall investigate and test
interventions that may be the most effective in reducing the disparities in health outcomes.
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CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Knowledge and Skill Acquisition
• Health-care organizations should ensure that staff at all levels and across all disciplines
receive ongoing education related to culturally and linguistically appropriate service delivery.
• To ensure the successful acquisition and maintenance of culturally and linguistically
appropriate knowledge and skills, organizations must allocate fiscal resources to educate
staff at all levels in order to develop the requisite role-specific competencies for the
provision of culturally congruent care.
• In addition, if bilingual staff express an interest in, and are able to provide the service,
internal and/or external funding sources should be made available to support the training of
staff as medical interpreters and translators.

53
CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Knowledge and Skill Acquisition
• Educational programming and learning outcomes related to cultural competence need to include,
principally, the cognitive and affective domains of learning, with, to a lesser degree, the
psychomotor domain. The curriculum should follow the educational design principle of simple-
to- complex and general-to-specific.
• The learning objectives and educational content should be evidence-based and address
definitions of cultural competence; discrimination, prejudice, and stereotyping; role-specific
performance criteria for the provision of culturally congruent care; and the completion of a
cultural health assessment, in general, and specific culture care needs of the most commonly
encountered demographics of the service area in particular.
• Moreover, the education should also include self-reflection, critical thinking, and cross-cultural
communication, including the appropriate use of medical interpreters and translators.
• Generational diversity and the diversity that exists among the health-care team should also be
addressed.

54
CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Knowledge and Skill Acquisition
• Diversity-related education must start in orientation and continue through
unit/department-based, population-specific orientation programs.
• Additionally, diversity education should be woven into annual educational initiatives and
performance appraisals using evidence-based assessment instruments to ensure the initial
and ongoing maintenance of competency, including the proficiency of trained medical
interpreters and translators.
• To accommodate the variety of learning styles that exist within the health-care team, a variety
of educational venues, such as face-to-face classroom interaction, online, Web-based
programs, and online and/or hard-copy resources at the point of care should be available.
Informal venues such as lunch-and-learn, and including diversity-related topics on staff
meeting agenda has been helpful to keep cultural competency visible in daily operations.

55
CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Knowledge and Skill Acquisition
• Transdisciplinary, interprofessional team learning approaches have demonstrated improved
communication within the health-care team. Onsite consultation and conferences and
workshops conducted by experts in the fields of transcultural nursing, cultural competency,
and organizational culture have been reported to help sustain diversity initiatives in fast-
paced health-care delivery systems (IOM 2002; Marrone 2008).
• Other successful strategic initiatives within culturally competent organizations that support
staff knowledge and skill acquisition include providing staff with incentives such as reward
and recognition ceremonies, pins, acknowledgment in organizational newsletters or Web
sites, preference to attend external conferences and workshops for staff who have completed
initial and ongoing cultural competency education and competency requirements, and
incentives for staff to volunteer in the community to learn about community members and
the cultures represented within the service area, including health fairs where specific
populations of the catchment area are present.

56
CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Cultural Competency Training
• Too often, diversity trainings, also referred to as sensitivity trainings, focus primarily on simply
acknowledging the differences that make each of us unique. The trainings advocate that cultural
differences be valued.
• Cultural competency trainings are designed to build awareness, knowledge, and skills related to cultural
difference through a variety of teaching methods including direct instruction, role playing, case studies,
facilitated group discussions, and technology/media. Through these approaches, staff learn the skills
need adapt to cultural difference.
• Using a 5-step approach, clients develop proficiency in:
1. Understanding their personal levels of cultural proficiency,
2. Understanding cultural variations in communication patterns that lead to misunderstanding
3. Understanding cultural differences in patterns of behaviors across cultures that impact intercultural
relationships,
4. Gaining skills necessary to manage the dynamics of cultural differences, and
5. Developing a data based action plan design to support the organizations goals for cultural
competency 57
CONTINUING EDUCATION PROGRAMS FOR CULTURALLY-
DIVERSE HEALTHCARE WORKFORCE
Cultural Competency Training
• Cultural competence mandates that organizations, programs and individuals must have the ability to:
– value diversity and similarities among all peoples;
– understand and effectively respond to cultural differences;
– engage in cultural self-assessment at the individual and organizational levels;
– make adaptations to the delivery of services and enabling supports; and
– institutionalize cultural knowledge.

58