Cultural Diversity in Nursing

How does cultural diversity affect nursing care? Increasing medical staff diversity through improved hiring practices, as well as improving cultural competencies in existing staff via training and exposure to other cultural groups are urgently needed revisions in the field of nursing and other facets of healthcare as well. 

Diversity in Nursing 

When we talk about diversity in the field of nursing, we're really talking about the diversity of our population as a whole. Nursing staff needs to reflect the demographic of its patients if the profession desires to fully understand them and be able to provide equitable healthcare.  

The American Association of Colleges of Nursing (AACN) states that "diversity references a broad range of individual, population, and social characteristics, including but not limited to age; sex; race; ethnicity; sexual orientation; gender identity; family structures; geographic locations; national origin; immigrants and refugees; language; physical, functional, and learning abilities; religious beliefs; and socioeconomic status." 

Why is Cultural Diversity Important in Nursing? 

When diverse individuals and families feel represented in their healthcare workers, they often feel more comfortable seeking care and expressing their concerns. “In the healthcare profession, it is important for the patient to see representation of their ethnicity and culture in the healthcare worker," said Dr. Maude McGill, PhD, MSN, RN-BC, CNE, graduate clinical faculty in Southern New Hampshire University's online nursing programs. "This representation builds trust and has been linked to compliance. In our current representation ratio, the healthcare profession is mismatched and understaffed of minority clinicians and minority educators.” 

Like all aspects of society, representation is important. “Diversity in nursing is multifaceted. A sprinkle of diversity here and there is not truly representative of cultural inclusion and assimilation. Healthcare leaders have to be intentional in their actions to employ competent and caring minority workers,” McGill said.  

She noted that representation does not end in the clinical setting. "In order to create the diverse workforce suggested by the National Academy of Medicine (formerly known as the Institute of Medicine), the learning environment must also illustrate diversity and inclusion to all learners with all cultural backgrounds," McGill said. "Unfortunately, our learning and workforce environments are not equivocal, and it leads to discrepancies in caring behaviors and experiences with both patient and student populations. There are some things that you cannot understand unless you have authentically experienced it.” 

New considerations for inclusivity continue to arise. For example, certain cultures may not stigmatize obesity as much as others. An individual may be more likely to seek care from someone who understands that, which may increase their likelihood to seek related medical guidance or comply with suggestions. 

Cultural Competencies for Nurses 

What is culturally competent nursing care? It means having staff with the knowledge, training or, ideally, firsthand experience of their patients' cultural aspects. This can include understanding the impacts, requirements and limitations of what the patient is willing or able to do while under care, based on their ethnic or religious background, beliefs and customs, body autonomy and willingness to accept medical intervention.  

Language barriers, socioeconomic disparity and lack of health insurance, education opportunities and more, can all influence the decisions patients make about medical care for themselves and their families. Cultural competency is a critical factor in nursing, and throughout the healthcare system, to best serve the needs of all patients. 

Lack of Diversity, Lack of Patient Trust 

Cultural competency can also entail grasping that some cultures may be resistant to care based on experiences and negative connotations they have had with the field.  

McGill confirms this is true in the people of color (POC) community.  

“There is such a horrible misconception for how you should care for people of color," she said. "50% of students (recently queried) actually believed our skin was thicker and that we didn’t experience pain like our white counterparts. A lot of Black communities refuse to go to the doctor because they believe they won’t be treated equally. We realize these discrepancies exist and fuel the social determinants of health that plague our patient populations.”  

These misconceptions are why it is important to have Black representation to help combat the misconceptions or skewed responses to the plight of the patient of color, she added. 

Reasons not to seek out care due to cultural differences or lack of diversity in the medical field are many. McGill gave an example of her personal experience. “I don’t have time to prove I’m in pain. I’ve driven for hours to see a Black doctor instead of someone 15 minutes away who doesn’t understand or believe me,” she said. “That’s a barrier to service right there."  

McGill recommends finding your allies and people who understand your humanity beyond a skin color — she said, "Those are the people you work with; those are the people who you build a trusting relationship with. Someone who does not dismiss your complaint or your issue due to their bias." 

Perception is a person's reality, McGill said, and “as healthcare professionals, we have to note a patient’s perception in order to address the pressing issue of their reality – that’s who you work with; there’s often the fear of not being understood, or being dismissed or minimized.” 

Problems of Perception 

In addition to the inherent biases medical staff may have about their POC or different-culture patients, there are also preconceived notions in the other direction as well. In order to reach a patient population of which they may not be a member, medical workers must be aware of embedded perceptions or negative past experiences that may prevent patients from trusting or reaching out for help.  

There can be long-standing historical events that have impacted certain populations seeking medical treatment as well. McGill explained the hesitation of the Black community getting vaccinated for COVID-19. Initial marketing attempts failed to entice POC to take advantage of the vaccine; it was only after they reached out to leaders of local Black communities to recommend the vaccine, that the level of trust and compliance increased. 

“Take the pandemic. Black people remember the Tuskegee Study, and that is a real problem with the vaccine and in the community. I have relatives that feel that way,” she said. “They show Black doctors and people taking it. But it wasn’t a real person that they knew. Then they reached out to Black leaders in communities, and that’s what worked. Then it was seen as, okay, someone who represents me got the vaccine.” 

Valuing Differences: The Key to Cultural Diversity in Nursing 

Is the nursing field diverse? It’s getting there, but there will always be more to learn and more ways to increase inclusivity. The key takeaway, McGill said, is that nurses and medical staff needs to be open to hearing about the values and experiences of their patients and respecting the fact that there is a lot to learn.  

Medical staff have to be willing to listen and be receptive, McGill said, citing both facets as important. “A lot of times, we won’t listen. Some medical professionals already have the answer or plan of care from hearing the symptoms or reading the chart rather than truly listening to the patient’s situation," McGill said. "Care is individualized and encouraged to be patient-centered. My headache might require a different regimen than your headache. Same symptom, different etiology and, therefore, different treatment options." 

As a medical professional, you should also be aware when a need arises for an intervening ally, especially if a patient feels misunderstood or unrepresented. “If you are working in a team and notice a disregard for the voice of a person of color, advocate and speak up. Call attention to it. Please understand that this person is speaking and wants to be heard,” McGill said.  

This can include finding staff that are familiar with – or ideally part of – the patient’s cultural background or sexual identity. It can also be as simple as providing a translator, to ensure important medical information is clearly transmitted to and from patient and doctor without a language barrier causing potentially hazardous results.  

McGill gave as an example a Hispanic patient of hers. Insulin was given by another medical professional, without fully understanding the patient’s blood sugar levels, which required different doses in the morning vs. evening. "The language barrier, and lack of interpretation, had serious consequences on the patient’s diabetic control," McGill said. "It was only until the patient was heard that the regimen was corrected and quality of life improved." 

What is Diversity in Nursing Care, and How Can We Increase It? 

According to the U.S. Census Bureau, “by 2044, more than half of all Americans are projected to belong to a minority group (any group other than non-Hispanic White alone)” (U.S. Census Bureau PDF Source). It also states the number of foreign-born U.S. citizens leaps to one in five by the year 2060. This richly diverse future patient population will need to be truly and widely represented if diversity in nursing is to be achieved. 

Achieving diversity in nursing will take a multi-pronged effort: 

Representation 

First, the nursing staff must reflect the population it serves. “Representation needs to be first, and that leads to conversation,” McGill said. While she appreciates white allies, their advocacy can only open the door to the conversation. "Representation brings an authentic truth to the conversation and reveals polymorphic needs of our diverse patient population. One of the white allies (at work) said you have to put yourself in those shoes. The problem is you really can't put yourself in their shoes. You can sympathize, but never really understand.”  

McGill also noted that in order to attract diversity into nursing programs, universities themselves need to address their own lack of diversity in educators and staff. Potential students desire to see the realistic outcome of “a person like me” succeeding in this field, she said.  

Conversation 

A large component of fixing the diversity disparity is a willingness on the part of non-minority staff to become educated on issues and concerns of their minority counterparts and patients. McGill said that we need people to be open and receptive to having the conversation; not afraid to talk and ask questions. 

"Increased exposure to diversity leads to an understanding of inclusivity which leads to responses that break barriers and biases; it leads to responses that are effective, inclusive, and equitable; responses that are indeed patient-centered, student-centered, person-centered," she said. "Three centimeters. As a nation, we have allowed three centimeters to create barriers, bias and boundaries to the nature of humanity. My skin, your skin, his skin, her skin, their skin only ranges three centimeters deep. There are more things that connect us than what separates us.” 

Kathleen Palmer is an award-winning journalist and writer.