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Population Health for Nurses

23.3 Factors Affecting Culturally Responsive Care

Population Health for Nurses23.3 Factors Affecting Culturally Responsive Care

Learning Outcomes

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

  • 23.3.1 Discuss the impact of personal factors on culturally responsive care.
  • 23.3.2 Describe systemic barriers to providing culturally responsive care.
  • 23.3.3 Identify strategies to overcome barriers to providing culturally responsive care.

Numerous factors can affect the process of providing culturally responsive care. These include both personal and systemic factors that may act as barriers. This section addresses both.

Personal Factors

Personal factors including value system, beliefs, customs, and cultural identity, as well as knowledge and attitudes about other cultures, play a role in nurses’ interactions with clients. Cultural factors such as language and communication barriers, gendered roles, and health care practices can impact these interactions. Nurses who have limited experience interacting with clients from different backgrounds may lack cultural humility. These nurses may exhibit biases, othering, stereotyping, and ethnocentrism in their approach to care.

A nurse’s age and educational preparation can also affect their provision of culturally responsive care. Younger generations are increasingly more diverse (Fry & Parker, 2018), and older individuals may be less familiar with changing cultural dynamics. Education can provide the knowledge, skills, and critical thinking tools to effectively interact with a wide range of people. Individuals educated in a diverse environment who have some cross-cultural knowledge may be more adept at interacting with people outside their own culture (Sharifi et al., 2019). Socialization, personality, and prior experiences also play a role. For instance, people who were raised in diverse communities or who have traveled outside their own culture may feel more comfortable interacting with people from different cultures in a variety of settings, such as in the workplace, in social situations, and in their community.

Biases, Stereotyping, and Othering

Biases are prejudicial attitudes that filter the way people perceive, interpret, and react to the world. These opinions or beliefs (involving gender, race, age, or other categories) affect decision-making in ways that can be subtle or overt. When nurses focus only on certain information while ignoring other relevant data, their biases can lead to incorrect assumptions, judgments, and actions. In health care, biases can cause health care workers to draw false conclusions. They can lead to disparities in diagnoses and treatments, unequal access to services and resources, and slower response times. For example, due to bias, a nurse may view one group as lower priority and less deserving of care than other groups and, as a result, may not give clients from that group the same level of attention, fully explain procedures or medications, or advocate for them as strongly.

Bias can be both explicit and implicit. Explicit bias refers to clear and intentional feelings, attitudes, and behaviors; it exists at a conscious level and is often expressed verbally. When it reaches an extreme, explicit bias can manifest overtly as negative behaviors, such as physical or verbal harassment, or through more subtle forms, such as exclusion. Implicit bias is a type of prejudice that unconsciously affects a person’s behavior, decisions, and attitudes, even if it contradicts their expressed beliefs and values. Because it operates at an unconscious level, the individual is not fully aware of their behaviors. Implicit bias undermines clinical assessments, the establishment of therapeutic relationships, and decision-making, all of which negatively affect health outcomes.

Bias among health care providers can have a substantial impact on an individual’s or group’s health. For example, evidence increasingly demonstrates that individuals who identify as LGBTQ+ experience significant disparities in their physical and mental health because of implicit biases (Lick et al., 2013). In a 2020 study, 24 percent of LBGTQ people of color reported some form of negative or discriminatory behavior from a health care provider in the previous year, and 19 percent stated they were cared for by a provider who was visibly uncomfortable with their sexual orientation (Mahowald, 2021).

The Roots of Health Inequities

Implicit Bias

Implicit biases among nurses and other health professionals contribute to the persistence of health inequities. In this Institute for Healthcare Improvement video, Dr. Anurag Gupta discusses how different forms of implicit racial bias may negatively impact three areas of health care.

Watch the video, and then respond to the following questions.

  1. What are the three manifestations of implicit racial bias Dr. Gupta describes?
  2. How does implicit racial bias affect the care some clients receive?
  3. What are some strategies nurses can use to identify implicit racial bias?

Stereotyping is the act of ascribing certain characteristics or behaviors to someone based on their membership, or perceived membership, in a particular group. Stereotyping can lead to assumptions about people based on race, ethnicity, religion, gender identity, age, socioeconomic status, ability, or sexual orientation that may not be accurate or fair. In health care, stereotyping can have a negative impact if it leads to unequal, inadequate, or inappropriate care of clients. Stereotyping can also create a barrier to effective communication between nurses and their clients, negatively impacting the quality of care. For example, a nurse working with an older adult may assume, based on the client’s age, that they are not computer literate and therefore neglect to provide helpful online resources. Nurses must gather and use accurate information about their clients as individuals rather than relying on learned, and potentially damaging, assumptions.

Othering is the process of excluding, marginalizing, or differentiating individuals or groups based on their perceived differences from the dominant group in a society. Othering is used to separate individuals who do not fit social norms or expectations, and it often implies that a person or group is inferior. This can involve ascribing negative characteristics or traits, which can lead to feelings of isolation, discrimination, and social inequality. Othering can have harmful effects on individuals and communities because it can create barriers to social inclusion, equal opportunities, and fair treatment. It can also reinforce negative stereotypes and prejudices and prevent individuals and groups from being treated with dignity and respect. For example, a community health nurse is teaching a group of adults about the importance of smoking cessation. One of the clients who has been quiet throughout the session finally asks a question, speaking in a heavy accent. Rather than responding to the client the same way they answered questions from others in the group, the nurse speaks loudly and slowly, using very simplistic words and assuming that the client does not understand English. This behavior, while potentially meant to be helpful, can stigmatize, exclude, and isolate the client, ultimately having a negative impact on their health and well-being.


Ethnocentrism, as previously mentioned, is the belief that one’s own culture is superior to other cultures (Beser et al., 2021). Ethnocentrism involves judging others by the standards of one’s own culture, assuming that one’s own culture is the norm against which all others should be measured. Ethnocentrism can result in discrimination, bias, and suboptimal care. For example, a client newly diagnosed with heart failure has been prescribed a diuretic. The nurse is reviewing the medication with the client and asks if they have any questions. The client, feeling apprehensive, expresses a wish to consult with a traditional healer from their cultural group. Rather than encouraging collaboration, the nurse perceives the traditional cultural practices as inferior to their own cultural orientation to biomedicine. Assuming that non-Western medicine is ineffective or irrational while Western biomedicine is superior is an example of ethnocentrism. Nurses need to be aware of their own ethnocentric tendencies, striving to be more culturally aware and culturally sensitive. Practicing cultural humility (see Attitudes, Skills, and Knowledge) allows nurses to recognize the biases created by ethnocentrism and to emphasize the client’s values, rather than those of the nurse or the dominant culture (Foronda et al., 2022).

Systemic Barriers to Providing Culturally Responsive Care

Some of the policies, practices, and procedures in U.S. health care present systemic barriers to providing culturally responsive nursing care. These systemic barriers may be organizational or structural. Organizational barriers are related to a particular clinic, hospital, or other health care institution, whereas structural barriers result from factors in the broader health care environment—for example, the composition of the health care workforce, the workings of the U.S. health insurance industry, and state and federal laws governing the provision of health care.

Organizational Barriers

Barriers to cultural competence may exist within organizations. These barriers can be far-reaching in scope because they extend well beyond the individual. Organizational barriers include lack of diversity in the workforce, lack of education in cultural competence, inadequate or absent translation or interpretive services, policies and procedures that fail to consider a diverse clientele, and lack of support from leadership. Leadership in particular plays a key role in creating a culture of inclusion and respect for diversity, as well as in designing, implementing, and enforcing policies to support an inclusive workplace and provide culturally and linguistically responsive services (Office of Minority Health, n.d.). For example, a lack of support from organizational leaders who do not prioritize or value cultural competence makes it more difficult for nurses to provide culturally responsive care. Furthermore, because culture is ever changing, providing culturally responsive care requires a commitment to updating and maintaining programs and policies that support it.

Structural Inequities

Structural inequities in health care are the systemic barriers and disparities in the health care system that prevent certain individuals or groups from receiving optimal care. These inequities can be caused by a range of factors, including unequal access to health care resources, discriminatory policies and practices, and inadequate representation in the health care workforce. In the United States, lack of health insurance coverage and the cost of health care are structural inequities that greatly affect health outcomes. Specifically, among rural adults, 24.5 percent of Black and 23.1 percent of Hispanic individuals report not seeing a health care provider because of the cost, compared with 15 percent of White individuals (James et al., 2017). Although Black, Hispanic, and Native American individuals bear a greater burden of chronic diseases than White individuals do, more of them lack a consistent source of medical care, health insurance coverage, and the ability to afford care (James et al., 2017).

Another example of structural inequity is the unequal distribution of health care resources, such as diagnostic and treatment facilities, across different communities. For example, individuals in rural areas or those living in communities of lower socioeconomic status may have limited access to specialized medical care. This lack of access can have a significant impact on population health because it can result in individuals’ not receiving the care they need, leading to an increase in preventable illnesses and chronic conditions.

A lack of representation of certain groups in the health care workforce is also a structural inequity. For instance, Black and Latina/Latino individuals are underrepresented in the health professions, including nursing, which can diminish efforts to provide culturally responsive care for clients from these backgrounds and reduce the quality of care provided. Evidence shows that the majority of Black (61.1 percent) and Hispanic (61.3 percent) adults prefer a health care provider who either shares or understands their culture. However, of those with this preference, 13.4 percent of Black and 14.7 percent of Hispanic individuals were never able to meet with such a provider, compared with 4 percent of White individuals (Terlizzi et al., 2019).


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