1.6 Diversity and Culture

Culture

Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. The word “culture” may at times be interchanged with terms such as ethnicity or nationality. Cultural beliefs and practices bind group or community members together and help form a cohesive identity.^[1],^[2] Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures. Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals.^[4] Culture provides an important source of values and comfort for patients, families, and communities. Think of culture as a thread that is woven through a person’s world and impacts one’s choices, perspectives, and way of life. It plays a role in all of a person’s life events and threads its way through the development of one’s self-concept, sexuality, and spirituality. It affects everything from lifelong nutritional habits to death and dying. Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. Individuals can be members in more than one culture or subculture, in which a person expresses their cultural identities as closely intertwined, referred to as Intersectionality. For example, a person may identify themselves as a member of a minority, a student, and a member of the LGBTQ+ community.

Culture influences how a patient interprets “good” health, as well as their perspectives on illness and the causes of illness. The manner in which pain is expressed is also shaped by a person’s culture. In the case of mental health, it can impact whether or not the individual seeks help, the type of help sought, what recovery looks like, and the support available. For example, uncontrollable crying and headaches are symptoms of panic attacks in some cultures, whereas difficulty breathing may be the primary symptom in another culture. Understanding such distinctions will help nurses effectively treat them.^[3] Nurses and other health care team members are also impacted by their own personal cultural beliefs. For example, a commonly held belief in U.S. health care is the importance of timeliness; medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial. The first step in developing cultural competence as a nurse is to become aware of your own cultural beliefs, attitudes, and practices.

Assimilation

Assimilation is the process of adopting or conforming to the practices, habits, and norms of a cultural group. As a result, the person gradually takes on a new cultural identity and may lose their original identity in the process.^[5] An example of assimilation is a student from a country outside the United States, who after several months, exhibits the habits, learning styles, and eating habits of his classmates.

Assimilation is not always voluntary or easy and may become a source of distress. Refugees may not have had an active role in choosing a new home country. They may feel unwelcome in their communities. Some have experienced war, food shortages, or torture, and may never be able to return to their home countries. There are historic examples of involuntary assimilation in the United States. For example, in the past, authorities in the United States and Canadian governments required indigenous children to attend boarding schools, separated them from their families, and punished them for speaking their native language.^[6],^[7]

Culture and Well-Being

Four ways that culture can impact mental well-being are the following^[4]:

• Cultural stigma. Every culture has a different perspective on mental health, and most cultures have a stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help.
• Describing symptoms. Culture can influence how people describe or feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. For example, members of the Amish community are typically stoic and endure physical and emotional pain without complaining.
• Community support. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Because of existing stigma, it can be challenging for individuals to find mental health treatment and support.
• Resources. When looking for mental health treatment, it can be difficult to find resources and treatment options that take into account a specific culture’s concerns and needs.

See Table 1.6a for additional examples of how a person’s culture impacts common values and beliefs regarding family patterns, communication patterns, space orientation, time orientation, and nutritional patterns.

Table 1.6a Cultural Concepts

Cultural Concepts	Examples of Culturally Influenced Values and Beliefs
Family Patterns	Family size Views on contraception Roles of family members Naming customs Value placed on elders and children Discipline/upbringing of children Rites of passage End-of-life care
Communication Patterns	Eye contact Touch Use of silence or humor Intonation, vocabulary, grammatical structure Topics considered personal (i.e., difficult to discuss) Greeting customs (handshakes, hugs)
Space Orientation	Personal distance and intimate space
Time Orientation	Focus on the past, present, or future Importance of following a routine or schedule Arrival on time for appointments
Nutritional Patterns	Common meal choices Foods to avoid Foods to heal or treat disease Religious practices (e.g., fasting, dietary restrictions) Foods to celebrate life events and holidays

A person’s culture can also affect encounters with health care providers in other ways, such as the following:

• Level of family involvement in care
• Timing for seeking care
• Acceptance of treatment (as preventative measure or for an actual health problem)
• The accepted decision-maker (the patient, family member, significant other)
• Use of home or folk remedies
• Seeking advice or treatment from nontraditional providers
• Acceptance of a caregiver of the opposite gender

Cultural Diversity and Cultural Humility

Cultural diversity is a term used to describe cultural differences among people. While it is useful to be aware of specific traits of a culture or subculture, it is just as important to understand that each individual is unique and there are always variations in beliefs among individuals within a culture. Nurses should, therefore, refrain from making assumptions about the values and beliefs of members of specific cultural groups.^[9] Instead, a better approach is recognizing that culture is not a static, uniform characteristic but instead realizing there is diversity within every culture and in every person. The American Nurses Association (ANA) defines cultural humility as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.”^[10]

Current demographics in the United States reveal that the population is predominantly White. People who were born in another country, but now live in the United States, comprise approximately 14% of the nation’s total population. However, these demographics are rapidly changing. The United States Census Bureau projects that more than 50 percent of Americans will belong to a minority group by 2060. With an increasingly diverse population to care for, it is imperative for nurses to integrate culturally responsive care into their nursing practice.^[11],^[12]

Justice, a principle and moral obligation to act on the basis of equality and equity, is a standard linked to fairness for all in society.^[22] The ANA states this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety) but also fairness in all operations of societal structures. This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence.^[23]

Social justice is related to respect, equity, and inclusion. The ANA defines social justice as equal rights, equal treatment, and equitable opportunities for all.^[24] The ANA further states, “Nurses need to model the profession’s commitment to social justice and health through actions and advocacy to address the social determinants of health and promote well-being in all settings within society.”^[25]

At the center of patient-centered care is practicing with cultural humility and inclusiveness. In the 2021 edition of Nursing: Scope and Standards of Practice, the American Nurses Association (ANA) established a Standard of Professional Performance called Respectful and Equitable Practice. This standard is defined as, “The registered nurse practices with cultural humility and inclusiveness.” Cultural humility is “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process.”^[5] Inclusiveness is defined as “the practice of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those having physical or mental disabilities or belonging to other minority groups.”^[6] Providing care to marginalized individuals is discussed in the section on Vulnerable Populations.

It is worth noting that the DSM-5-TR includes information on the impacts of one’s culture on the presentation of a mental health condition ^[7]

The registered nurse:

• Demonstrates respect, equity, and empathy in actions and interactions with all health care consumers.
• Respects consumer decisions without bias.
• Participates in life-long learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers.
• Reflects upon personal and cultural values, beliefs, biases, and heritage.
• Applies knowledge of differences in health beliefs, practices, and communication patterns without assigning values to the differences.
• Addresses the effects and impact of discrimination and oppression on practice within and among diverse groups.
• Uses appropriate skills and tools for the culture, literacy, and language of the individuals and population served.
• Communicates with appropriate language and behaviors, including the use of qualified health care interpreters and translators in accordance with consumer needs and preferences.
• Serves as a role model and educator for the cultural humility and the recognition and appreciation of diversity and inclusivity.
• Identifies the cultural-specific meaning of interactions, terms, and content.
• Advocates for policies that promote health and prevent harm among diverse health care consumers and groups.
• Promotes equity in all aspects of health and health care.
• Advances organizational policies, programs, services, and practices that reflect respect, equity, and values for diversity and inclusion.