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Clinical Nursing Skills

5.2 Ethical Practice in Culture and Diversity

Clinical Nursing Skills5.2 Ethical Practice in Culture and Diversity

Learning Objectives

By the end of this section, you will be able to:

  • Identify ways to accommodate different cultural practices
  • Explain ethical ways to engage in cultural diversity practices
  • Define how nurses can be responsive to diversity and inclusion

As discussed in 5.1 Understanding Cultural Differences, the concept of culturally responsive care, which involves integrating an individual’s cultural beliefs into their health care, is an important foundation of cultural competence. Providing culturally competent care requires attention to diversity and inclusion and a willingness to understand and accommodate the cultural differences of others. According to the American Psychological Association (APA) (n.d.), cultural diversity is “the existence of societies, communities, or subcultures that differ substantially from one another.” And, inclusion is “the practice of creating an environment in which individuals of all backgrounds feel respected, valued, and supported.”

According to the Centers for Disease Control and Prevention (CDC) (2021), there are eight principles of cultural competence:

  1. Define culture broadly.
  2. Value patients’ cultural beliefs.
  3. Recognize complexity in language interpretation.
  4. Facilitate learning between providers and communities.
  5. Involve the community in defining and addressing service needs.
  6. Collaborate with other agencies.
  7. Professionalize staff hiring and training.
  8. Institutionalize cultural competence.

Note that it is the responsibility of the healthcare professional to seek out, understand, and integrate the patient’s beliefs into their care. Ultimately, the goal is to build cultural competence into the permanent framework of health care.

Accommodating Cultural Practices

According to the American Nurses Association (ANA) Code of Ethics (2015), nurses must practice with cultural humility and inclusiveness. Culture is constantly evolving, so true cultural competence requires a lifetime of learning with these changes. The 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 know everything about other cultures, and approach learning about other cultures as a life-long goal and process.”

There are both intrapersonal and interpersonal components to cultural humility (Table 5.3) (Hughes et al., 2020). The intrapersonal component consists of a personal awareness of one’s own limited knowledge of the patient’s culture. The interpersonal component involves respect for the patient’s culture and openness to their beliefs and experiences. By focusing on developing partnerships with patients, the nurse can create a space that encourages learning and appreciation for diverse cultures. It is a patient-centered way of providing culturally sensitive care.

Interpersonal Skills Intrapersonal Skills
Involves relations between people Occurs within the individual mind or self
Two or more parties involved No external parties involved
Feedback comes from the parties involved Feedback comes in the form of self-analysis
Important to building and maintaining relationships; must develop self-awareness Continuous flow of thought; ones’ own thoughts, views, opinions, and attitudes are developed
Table 5.3 Interpersonal versus Intrapersonal Skills

Avoid Forcing Change

Cultural humility involves inclusion. Inclusion means considering the patient’s own cultural preferences and involving the patient and caregivers in the process as much as possible. Forcing a patient to accept a treatment plan that conflicts with their cultural practices and beliefs is rarely effective and can damage the relationship of trust between the nurse and the patient. A cultural negotiation is a process by which the patient and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the patient’s cultural needs. Cultural negotiation is reciprocal and collaborative. When the patient’s cultural needs do not significantly or adversely affect their treatment plan, the cultural needs can and should be accommodated.

Seek Cultural Assistance

Having respectful, curious, in-depth conversations with patients is the best way to learn about their individual cultural practices. When seeking ways to accommodate diverse cultural practices, approach patients with cultural humility to learn how best to care for the patient. Cultural guides from various local communities may also be available for cultural dialogue (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Collaboration between patients from diverse cultures and nurses is an excellent way to produce culturally sensitive, patient-centered care plans (Hughes et al., 2020). Examples of seeking cultural assistance include exploring programs and initiatives that may be offered by various organizations, discovering available resources, or developing initiatives for unit-based councils.

Engagement in Cultural Diversity

As a nurse, it is necessary to actively engage with the patient and their culture to foster cultural competence, build trust, and tailor healthcare services to individual needs. This approach ensures a patient-centered, inclusive, and holistic approach to health care. Cultural negotiation is mutual; the nurse and the patient must gain an understanding of each other’s perspective. There are many ways a nurse can actively participate in learning about various cultures to best serve diverse patient populations. Some examples include encouraging the patient to bring food from home and involving the family in medical decision-making.

Active Learning

One of the first steps in engaging in cultural diversity is to get to know your community—what ethnic groups are most prevalent, what languages are most widely spoken, what religions are most popular? Use sources such as newspapers, journal or book articles, and cultural training seminars or courses to research cultural issues that are relevant to your area. However, it is important to remember not to stereotype or generalize patients. Make sure to ask each patient about their personal preferences when it comes to their cultural background and beliefs (Stubbe, 2020).

Learning about cultural diversity also includes becoming aware of your own practices and implicit biases. There are various implicit bias tests available to help you identify unconsciously held beliefs. Journaling is another way to help identify and reflect on personal thoughts and feelings toward working with diverse groups.

Awareness of your own practices can help identify and address issues with practices observed in the workplace. For example, your area may have a large Arabic-speaking population, but your clinic does not have consent forms in Arabic. You decide to advocate for your patients and ask the clinic to provide consent forms in Arabic. Another example would be your clinic hosts educational workshops so employees can actively learn about the populations they serve. Learning about the culture of your patient population leads to better patient outcomes and often greater job satisfaction.


Immersing yourself in diverse cultural communities can be an engaging and fun way to learn more about cultural diversity. Attending local cultural events such as festivals and dances, exploring art and music scenes, and even joining religious ceremonies (special permission may be needed) are all ways to experience cultural practices firsthand (Figure 5.4).

A groups of Louisiana Mardi Gras Indians dressed in bright orange feathered Mardi Gras Indian outfits.
Figure 5.4 Attending cultural festivals, like the annual Carnival celebration of Mardi Gras in Louisiana, is an excellent way to gain firsthand exposure to diverse cultural practices. (credit: “Fat Tuesday_Mardi Gras Indians_4,” by Derek Bridges/Flickr, CC BY 2.0)

Responsiveness to Cultural Diversity

Learning about diverse cultures is only one step toward providing culturally competent care. How one responds to cultural diversity is what directly affects the nurse-patient relationship and outcomes. According to the U.S. Department of Health and Human Services (HHS, n.d.), “being culturally responsive requires having the ability to understand cultural differences, recognize potential biases, and look beyond differences to work productively with children, families, and communities whose cultural contexts are different from one’s own.” Being responsive to cultural diversity involves taking what you have learned about other cultures from conversations, experiences, and research and integrating the knowledge into your practice. It also involves advocating for diversity and inclusion at a structural and institutional level.

Willingness to Change

Approach the process of learning about diverse cultures with cultural humility. To understand various cultures, one must engage in self-reflection and remain open to new ideas, beliefs, and behaviors. It is normal to encounter beliefs and practices that are different from your own. They may be in direct conflict with your own cultural background and may even make you uncomfortable, sad, angry, or confused. It is not expected that you will completely change all your thoughts and feelings, but a willingness to change is key to accepting others and putting cultural competence into action.

Real RN Stories

Recognition of Cultural Biases

Nurse: Jenny, RN
Clinical setting: Medical-surgical unit
Years in practice: 2
Facility location: Southern California

At 28 years old, I relocated from Florida to southern California. I am White, and until this point, I had spent my entire life living in Florida. I had been practicing nursing for two years and had just started a new job on a medical-surgical floor at a local hospital. The hospital was located in a community that was known for its large Vietnamese population. Most of the nurses, providers, and patients at the hospital were either Vietnamese immigrants or of Vietnamese descent.

One day I took report on a new patient, a 53-year-old Vietnamese female with a diagnosis of terminal brain cancer. The patient was not expected to survive; however she remained a full code, and the family was refusing hospice. I wondered why the patient and family would refuse hospice care.

As I went to assess the patient, I found her lying in bed and moaning while clutching her head in her hands. She was nonverbal and nonresponsive to my stimuli. I noticed she had an order for pain medication, so I administered it as ordered.

Upon reassessing her, I noticed the medication did not seem to make much difference in the observable behaviors. The patient was still clutching her head in her hands and moaning. The doctor refused to increase the dose at my suggestion and seemed to brush me off when I recommended talking to the family again about hospice or comfort measures. I found myself growing increasingly frustrated on behalf of my patient, and I felt she might be suffering unnecessarily at the end of her life.

At lunch, I called the patient’s daughter, Viv, and requested she come to the hospital to visit her mother. Upon the daughter’s arrival, I had just given the patient some IV pain medication, but the patient was not responding or showing signs of relief. Viv stated, “The pain medication does not seem to be making much of a difference the last couple of days.” I asked her if she had considered hospice for her mother and explained that I had found hospice very helpful when my own grandmother was at the end of her life. Viv told me that she had discussed hospice with the physicians but decided against it. “Hospice is not an option for us. In our culture, we believe in fighting with everything we have down to the last minute,” she stated. She explained that she and her family viewed the use of medication at end-of-life in hospice care as hastening death.

After having this conversation with Viv, I had a new understanding of why the family was refusing hospice and comfort measures. I now understood how important it was to the patient and the patient’s family that their own views on end-of-life care be respected. This conversation allowed me to reexamine my own cultural biases and be more culturally respectful of the patients I was now serving.


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