Learning Outcomes
By the end of this section, you should be able to:
- 25.2.1 Explore various techniques to assess cultural and social identity.
- 25.2.2 Distinguish between the factors that create and reinforce stereotypes and biases.
- 25.2.3 Recognize the principles of decolonization in nursing.
- 25.2.4 Define privilege.
- 25.2.5 Explain how privilege can affect health care interactions.
- 25.2.6 Examine how nurses can utilize privilege to promote health equity and address health care disparities.
- 25.2.7 Identify areas for growth and development.
The process of developing cultural humility involves addressing bias and stereotypes and managing conflicts. On this journey, nurses shift from being unaware of their biases and cultural stereotypes (unconscious impermeability) to heightened awareness of their biases and active commitment to self-reflection and learning (active engagement). To accomplish these goals, nurses must understand where their stereotypes and biases come from.
Assessing One’s Own Cultural and Social Identity
Cultural and social identity are related but distinct concepts that refer to different aspects of a person’s sense of self and belonging. An individual’s cultural and social identities combine to form their cultural background. The ANA Code of Ethics (2021) emphasizes the need for nurses to be aware of their cultural background to avoid letting personal biases affect the therapeutic relationship. This requires introspection into one’s cultural beliefs, perceptions, and assumptions. Nurses should recognize and understand the effects of oppression, racism, discrimination, and stereotyping personally and professionally (ANA, 2015).
As discussed in Cultural Influences on Health Beliefs and Practices, cultural identity refers to a sense of belonging and identification with a particular cultural group. Cultural identity provides a foundation of cultural values, beliefs, and practices that contribute to how individuals engage with their community and express themselves culturally. On the other hand, social identity encompasses the various aspects of an individual’s identity that are shaped by their membership in different social groups beyond just culture.
Assessing one’s cultural identity is a process of self-reflection and exploration that helps individuals better understand their cultural background, beliefs, values, and experiences. While there is no definitive tool to fully capture an individual’s cultural identity, various methods and exercises can aid in this process; examples include:
- Cultural genogram: A cultural genogram depicts family members’ cultural identities, traditions, and migration histories. Creating a cultural genogram helps individuals understand the interplay of cultural influences within their family and how it has shaped their cultural identity (Haber et al., 2022).
- Cultural autobiography: This written account of an individual’s cultural experiences, upbringing, and identity development allows individuals to reflect on significant cultural events, interactions, and how they have shaped their sense of self and cultural identity. Telling one’s life story can promote self-reflection on power dynamics, but it can also reinforce harmful biases (Bruewer et al., 2021).
Social identity refers to an individual’s self-concept derived from social groups. Cultural Influences on Health Beliefs and Practices discusses how individuals define themselves according to the social groups to which they belong. The Social Identity Wheel can aid nurses in exploring and comprehending their social identity (Figure 25.3). The Social Identity Wheel visually represents the different social identity categories that a person may hold by dividing a circle into sections or categories. These categories can include but are not limited to (University of Michigan LSA Inclusive Teaching, 2021):
- Race and Ethnicity
- Gender
- Sexual Orientation
- Religion
- Socioeconomic Status
- Age
- Nationality
- Disability Status
- Language
- Education
- Occupation
- Geographic Location
The Social Identity Wheel helps individuals reflect on their many intersecting identities and understand how they impact their experiences and interactions with others. It can foster empathy when it helps an individual to acknowledge the privileges and disadvantages of their different identities. This awareness is crucial in promoting a more inclusive and equitable environment, as it helps individuals recognize their biases and become more sensitive to the experiences of others. By utilizing this tool, nurses can gain insights into their identities and develop a deeper appreciation for the diversity within themselves and others (University of Michigan LSA Inclusive Teaching, 2021).
Social Identity Wheel
The non-profit organization Facing History and Ourselves provides a template for creating your own Social Identity Wheel. Visit the site, create your own wheel, and then respond to the following questions.
- Which identities most substantially impact how you perceive or define yourself?
- Which identities strongly impact how you think other people perceive or label you?
- Which identities most substantially impact how you perceive or define others?
- How do factors of your identity inform your decision making in nursing practice?
- How does your identity align with or differ from (conflict with) the identities of others?
- What privileges and advantages are associated with your identity?
- Describe how your social identity may inform your unconscious biases.
- What have you learned about yourself from the process of creating your Social Identity Wheel?
Let’s return to the scenario from the beginning of the chapter. For a few weeks, Sarah kept a journal and listened mindfully during client interactions. She realized that her viewpoints differed significantly from those of her clients and worried that she might have unconscious biases that could hinder her ability to show cultural humility and responsiveness. To overcome this challenge, Sarah decided to explore her own social identity by completing a Social Identity Wheel and assessing how her identity influences client care.
By recognizing the filters through which she views the world, Sarah became aware of potential biases and assumptions that may unconsciously influence her client interactions. This first step enabled Sarah to approach client interactions more openly, free from preconceived notions. Recognizing the impact of personal biases on client interactions prompted Sarah to question her assumptions to ensure she doesn’t impose her values on clients and remains receptive to diverse perspectives. Sarah’s decision to explore her social identity reflects a commitment to continuous learning. She understands that cultivating cultural humility is an ongoing process, and humility comes from a willingness to learn and adapt. This translates into more effective and empathetic care.
The insights Sarah gains from self-reflection directly inform her approach to client care. She becomes more attuned to each client’s unique needs and values, ensuring that her care is culturally sensitive and respectful and increasing the likelihood that her clients feel seen, heard, and understood, fostering a therapeutic relationship built on trust.
Nurses can better understand their biases and stereotypes by acknowledging their cultural backgrounds and social identities. This helps nurses avoid making inaccurate assumptions about clients and mitigates their impact on client care. The next section explores the impact of cultural and social identity on biases and stereotypes.
Factors That Inform Stereotypes and Biases
As discussed in Cultural Influences on Health Beliefs and Practices, values and beliefs can shape how individuals perceive the world and others. When these values and beliefs are based on limited information about others, they can lead to stereotypes and biases.
Cultural values and beliefs can shape biases that affect interpersonal interactions and decision-making processes. Ingrained through upbringing and societal influences, these values and beliefs can lead to the development of unconscious biases that impact how people interact with individuals from different cultural backgrounds, and these biases can influence judgments, attitudes, and behaviors toward others.
Social identity plays a role in shaping how individuals perceive themselves in relation to different social groups, and it can contribute to the development of biases and stereotypes toward others. The nested-levels framework developed by Skinner-Dorkenoo et al. (2021) depicts how different systemic levels influence individual attitudes and how individual attitudes also impact systems (Figure 25.4). For example, personal and interpersonal encounters, which are nested within communities and institutions that set the local context for interpersonal experiences, are the most immediate influences on racial bias. Communities are situated within broader cultural contexts that shape society’s norms, values, and beliefs. At the outermost level, temporal influences capture how past manifestations of these systems continue to influence members of society (Skinner-Dorkenoo et al., 2021).
Skinner-Dorkenoo et al. (2021) contend that each level influences racial bias bidirectionally across the nested levels of the framework. At the innermost level, personal and interpersonal experiences, such as socialization from caregivers and interracial friendships, have the most proximal influence on individual-level racial bias, nested within communities and institutions that set the local context for interpersonal experiences. Communities are situated within a broader cultural context that shapes the norms, values, and beliefs that structure society. At the outermost level, temporal influences capture how past interpersonal, institutional or community, and societal influences continue to affect individuals throughout their lives.
While this model’s primary focus is on how each level of influence affects individual-level attitudes, the levels also influence one another. For instance, culture can shape organizations and interpersonal experiences within that culture, as well as individual-level biases. Likewise, individual-level racial biases can mold interpersonal experiences, which can shape factors at the organizational and community level.
In-group favoritism, or in-group bias, is a psychological phenomenon referring to people’s tendency to favor members of their own social or cultural in-group. This bias can manifest in various ways, including positive judgments, greater willingness to cooperate, and allocation of resources in a more favorable manner toward members of the in-group compared to individuals from other groups—out-groups. In 1979, both Tajfel & Turner and Brewer published research establishing the foundation for understanding in-group favoritism and its implications for intergroup relations. This knowledge is essential for comprehending theories on social identity, categorization, and cognitive biases that contribute to forming and maintaining in-group favoritism. Table 25.2 outlines various factors that shape and influence stereotype and bias development.
| Action | Description |
|---|---|
| In-Group Favoritism | People tend to show a preference for members of their social identity groups. This bias can lead to a more positive evaluation of individuals within one’s group and a tendency to perceive them more favorably than those from different groups (Brewer, 1979; Tajfel & Turner, 1979). |
| Out-Group Homogeneity | Individuals may perceive members of other social identity groups as more similar than they are. This bias can result in oversimplified and generalized views of others from different groups and may influence social judgments and behaviors (Andreychik et al., 2020). |
| Confirmation Bias | Individuals may be more likely to notice and remember information confirming their biases or stereotypes about certain social identity groups. This confirmation bias reinforces and strengthens these biases over time (Velez et al., 2021). |
| Media and Cultural Influences | The portrayal of certain social identity groups in media can reinforce or perpetuate stereotypes or create new biases based on intersections of race, gender, and other social categories (Mastro, 2020). |
| Limited Interactions | Limited or negative interactions with individuals from certain social identity groups can contribute to forming biases and stereotypes. Lack of exposure to diverse perspectives may perpetuate inaccurate beliefs about these groups and contribute to developing and reinforcing negative stereotypes and biases (Craig et al., 2018). |
| Cognitive Efficiency | When information is presented in a format that is easy to understand, individuals tend to be more easily persuaded by that information, which can lead to biased perceptions and decision making (Critcher & Gilovich, 2021). |
Nurses need to understand how these factors shape their beliefs and values to comprehend their influence on nursing decision making. Here are some effective techniques to create an inventory of personal values and beliefs:
- Performing Self-Reflection: Using introspection and thinking critically about personal values, beliefs, and cultural heritage can provide insight into how these factors influence perceptions, decisions, and interactions. This process also helps nurses recognize unconscious biases that might impact client care, encouraging them to question their assumptions and consider alternative perspectives (Richardson & Storr, 2020).
- Writing Down Values and Beliefs: Documenting personal values and beliefs, including those related to nursing practice, allows for clarity and deeper exploration. Consider how personal values align or conflict with professional standards and ethical guidelines. Writing down specific values related to respect, empathy, and client-centered care can be a foundation for ethical decision making (Gallagher, 2020).
- Evaluating Influence on Decision Making: After identifying values and beliefs, evaluate how they shape one’s nursing practice. For example, how do they impact interactions with clients, colleagues, and health care team members? Reflect on instances where values might have influenced decisions and consider whether these decisions were aligned with client needs and cultural considerations (Epstein & Hundert, 2002).
- Identifying Areas for Improvement: Recognize areas where values and beliefs may differ from those of clients, colleagues, or the broader health care environment. Identifying potential conflicts helps one proactively address them. Consider situations where values might unintentionally affect one’s ability to provide unbiased and culturally sensitive care (Haas & Greiner, 2020).
Your identity is your superpower
In this video, actor, director, and activist America Ferrera discusses her experiences with cultural stereotypes in the entertainment industry.
Watch the video, and then respond to the following questions.
- In the presentation, America Ferrera describes the challenges she faced based in the entertainment industry based on cultural stereotypes. How did these challenges impact her personally and professionally?
- America Ferrera mentions a casting director asking her to “sound more Latina.” What does this request reveal about the stereotypes and expectations placed on individuals based on their cultural background, and how does it connect to the broader issue of representation in the media?
- America Ferrera received messages throughout her life that her identity was an obstacle. How did these messages affect her perception of herself, and what steps did she take to overcome these obstacles?
- How can America Ferrera’s emphasis on the importance of questioning our own fundamental values and beliefs for change to occur be applied to the nursing field? Why is it essential for nurses to understand and reflect on their beliefs about others in the context of decision making?
- America Ferrera states, “My identity is not my obstacle. My identity is my superpower.” How can this shift in perspective contribute to a more inclusive and diverse health care environment, and what lessons can nurses draw from this statement in their interactions with clients?
Privilege
The nursing profession has been shaped by Western perspectives and beliefs, representing a Eurocentric viewpoint, and by colonial ideologies which that been imposed on other cultures and societies. The ANA (2022) has urged the decolonization of nursing by addressing the lasting effects of colonialism on practice, education, and research. Decolonization in nursing is a process of critically examining and deconstructing the Eurocentric and colonial ideologies that have influenced nursing. It also promotes practices that center on decolonization and cultural humility. To promote decolonization in nursing, it is necessary to challenge these influences and create a health care system that is culturally sensitive and inclusive. This process requires challenging and dismantling historical and ongoing systems of oppression, including the privilege of specific knowledge systems and cultural perspectives over others (Zappas et al., 2021). This involves recognizing and valuing diverse cultural knowledge, traditional healing practices, and worldviews. A decolonization approach prioritizes culturally competent care that recognizes and respects clients’ unique cultural backgrounds and experiences (Fedje & Bissonette, 2019).
Decolonizing nursing requires acknowledging past injustices, establishing meaningful partnerships with diverse communities, integrating cultural humility into nursing practice, and advocating for policies that address health disparities and promote social justice. By doing so, nurses can contribute to providing equitable and respectful health care services that meet the unique needs and preferences of all individuals and communities, regardless of their cultural background. By adopting a decolonizing approach, nurses can help to eliminate health disparities and promote health equity for marginalized communities (Fedje & Bissonette, 2019).
The decolonization of nursing practice is closely related to the concept of privilege. Privilege refers to the advantages and benefits that specific individuals or groups enjoy due to their social identities, such as race, gender, sexual orientation, socioeconomic status, or other factors. Privilege can influence access to quality care, treatment decisions, and health outcomes. According to the ANA (2022), nursing students should develop a solid moral character and undergo professional formation to promote fair and respectful care while advocating effectively. To accomplish this, ANA (2022) contends that students must acknowledge their social privileges and ethically take responsibility to address unjust systems and structures. This requires critically analyzing beliefs, biases, and social structures contributing to health disparities.
The concept of privilege significantly impacts the provision of health care services, affecting both nurses and clients. Those who are privileged often have better access to health care resources, including insurance coverage, transportation, and medical facilities, which gives them an advantage over others (Togioka et al., 2023). The impact of privilege on health care encounters is explained in the following:
- Privilege can consciously or unconsciously lead to biases and stereotypes among health care providers. For example, providers with privilege may make assumptions or have preconceived notions about clients from marginalized groups, potentially leading to unequal treatment, discrimination, or neglect of certain clients’ needs (Hobbs, 2018).
- Privilege can influence the dynamics of communication and trust between clients and health care providers (Togioka et al., 2023). For example, clients who belong to marginalized groups may be more skeptical or wary of providers who hold privileged identities, leading to challenges in establishing trust and effective communication.
- Privilege often results in a lack of diversity and representation in the nursing workforce (Togioka et al., 2023). Although the nursing population is becoming more diverse, minority nurses remain underrepresented. For example, the most common ethnicity of nurses in 2022 was White: 73.6 percent; Black or African American: 14.5 percent; Asian: 8.9 percent; and Hispanic or Latino: 8.1 percent (U.S. Bureau of Labor Statistics, 2023). This lack of representation can result in a deficiency of cultural understanding and sensitivity among nurses, causing cultural gaps. In addition, clients from marginalized groups may feel more comfortable and understood when they have health care providers with similar backgrounds or experiences.
- Privilege is intertwined with social determinants of health (SDOH) and health disparities. For example, clients who belong to marginalized groups often face higher rates of disease, limited access to health care, and poorer health outcomes than privileged individuals (Brown & White, 2020). Nurses need to be aware of these disparities and work toward mitigating them through advocacy, culturally competent care, and addressing SDOH. Social Determinants Affecting Health Outcomes provides a more in-depth discussion of SDOH.
To grasp the concept of privilege, it is crucial to differentiate between the agent and target groups. The agent group refers to those who hold a dominant social status either by birth or acquisition and may knowingly or unknowingly take advantage of their position over the target group. The target group, on the other hand, includes individuals belonging to social identity groups who experience discrimination, marginalization, oppression, or exploitation at the hands of the agent and the institutionalized system that they represent (Garran et al., 2020).
Systemic oppression has distinct features, one of which is the dominant group’s ability to impose their version of reality and dictate what is considered normal, authentic, and right. The target group’s culture, history, and language are often misrepresented or dismissed, while the dominant cultures are enforced. This type of oppression takes many forms, such as racism, sexism, ableism, and ageism, and is present at all levels of society, contributing to systemic injustices and unequal power dynamics. These forms of oppression can be deeply ingrained in cultural norms, institutions, policies, and practices, resulting in marginalization, discrimination, and disadvantage for certain groups of people (Garran et al., 2020). See Structural Racism and Systemic Inequities for more information.
Discrimination and unequal treatment can arise from stereotypes and prejudice based on characteristics such as race, gender, disability, age, and more. Additionally, societal norms can perpetuate oppressive systems like gender roles or hierarchical power structures that limit opportunities for marginalized groups. Institutional biases also exist in policies, procedures, hiring practices, and decision-making processes, leading to unequal outcomes for individuals and communities who face discrimination. Table 25.3 depicts target groups that experience discrimination, marginalization, oppression, or exploitation by the agent by types of oppression (Garren et al., 2020).
| Type of Oppression | Target Group | Agent |
|---|---|---|
| Racial | BIPOC (Black, Indigenous, and People of Color) | White People |
| Religion | Non-Christian | Christian |
| Class | Working Class | Middle and Upper Class |
| Gender | Women, Transgender People | Men, Anti-Transgender |
| Sexual Orientation | Lesbian, Gay, Bisexual, Queer, Pansexual People | Heterosexual People |
| Ability | People with Disabilities | People without Disabilities |
| Age | People over Age 65 | Young People |
| Immigrant Status | Immigrant | U.S. Born |
| Language | Non-English Speaking | English Speaking |
Privilege exists within and perpetuates the framework of systemic inequalities and historical injustices. It can vary in type and degree depending on an individual’s identity and life circumstances. Acknowledging and comprehending privilege is crucial for addressing disparities and promoting social equity (Johnson, 2020).
Nurses have access to various assessment tools that can help them better understand their privilege and how it affects their interactions with others. For example, the Privilege Checklist lists different privileges associated with various social identities. By reflecting on these statements, individuals can recognize the privileges they may possess based on their social identities. In addition, the Privilege and Responsibility Curricular Exercise (PRCE) offers a hands-on learning experience that encourages participants to reflect on their own privileges, consider the responsibilities that come with those privileges, and develop a deeper awareness of the impact of privilege on individuals and communities. This tool guides participants through a process that promotes critical thinking, self-reflection, and open dialogue (Matthews et al., 2020).
Acknowledging one’s privilege and being mindful of its influence are critical to fostering empathy, understanding, and promoting social justice. Recognizing privilege does not diminish an individual’s struggles or challenges but addresses systemic inequities and creates a more equitable and inclusive society. When discussing privilege, it is essential to ask questions that prompt self-reflection, foster awareness, and promote a deeper understanding of how privilege operates in society.
Nurses can use their professional status to promote health equity and address health care disparities by advocating for policies and practices. They can collaborate with community organizations and policymakers to address social determinants of health, improve access to health care services in underserved areas, and support community health initiatives. Nurses can also advocate for language access services, like interpreter services and translated health care materials, to enable clients with limited English proficiency to understand and participate in care.
One way for nurses to tackle privilege-based issues is to focus on improving health literacy. As discussed in Culturally and Linguistically Responsive Nursing Care, health literacy refers to an individual’s ability to obtain, comprehend, assess, and apply health-related information to make informed decisions about their well-being and health care. It encompasses various skills related to health information and activities, such as reading, writing, numeracy, communication, and critical thinking (Institute of Medicine (US) Committee on Health Literacy, 2021). By tailoring health education materials and resources to the client’s health literacy level, nurses can ensure that everyone can access relevant and easily comprehensible information, regardless of socioeconomic status or educational background. Addressing health literacy empowers clients to take charge of their health and make informed choices about their health care (Frosch, 2020; Trachtenberg et al., 2021).
As a nurse, it is essential to reflect on one’s privileges, comprehend how they contribute to health care disparities, and actively strive to provide fair and equitable care to all clients.
Identifying Areas for Growth and Development
Self-assessment improves a nurse’s ability to provide culturally and linguistically competent care by identifying areas of growth and strengths.
As a nurse, it is essential to possess the knowledge and awareness of different cultures to provide appropriate care. This includes understanding customs, traditions, languages, family structures, religious practices, and health care beliefs. While one cannot be an expert on every cultural nuance, learning about the cultural groups in the community or client population being served is a crucial aspect of providing culturally responsive care.
When interacting with individuals from different cultures, it can be useful to categorize them based on their cultural traits. Cultural Influences on Health Beliefs and Practices discusses how cultural generalizations can provide a foundation for understanding and anticipating what to expect when interacting with individuals from a specific culture. These generalizations play a role in intercultural communication, helping nurses comprehend new experiences and information. However, generalizations should not be applied to every person within a cultural group and should not be confused with cultural stereotypes. Unlike stereotypes, which are fixed and often negative, generalizations are flexible and can change as new information is integrated. Generalizing about cultural groups can help nurses determine which questions to ask and provide a starting point to understand the extent to which the client adheres to cultural characteristics. To manage cultural differences effectively, nurses must cultivate skills in differentiating between generalizations and stereotypes (Figure 25.5).
To become culturally aware, one must also recognize and acknowledge their culture, experiences, feelings, thoughts, and surroundings without imposing them on others from different backgrounds. As defined by Purnell (2005), cultural self-awareness involves a deliberate and conscious process of understanding oneself, including personality, values, beliefs, professional knowledge standards, and ethics, and how these factors impact interactions with individuals from diverse backgrounds. Suggestions within this chapter that focus on promoting cultural self-awareness include practicing mindfulness, cultivating cultural humility, evaluating one’s cultural identity, and creating an inventory of one’s cultural background. Cultural Influences on Health Beliefs and Practices provides additional information on the utilization of assessment tools to measure cultural competence.
Remember Sarah? She was initially confident in her ability to provide culturally appropriate care when she joined the public health department. However, during the first few weeks, she had several encounters with clients who had views and health practices that differed from her own, making her realize she needed to become more aware of the cultural groups her agency served.
After assessing her cultural knowledge and skills, Sarah recognized she was unfamiliar with Vietnamese culture and expressed a desire to learn more about its customs and traditions. As a result, Sarah set goals to understand cultural norms concerning health beliefs, family involvement, and communication styles. She participated in cultural competency workshops and welcomed feedback from her colleagues to improve her understanding of the diverse cultures in the public health service region. Additionally, Sarah engaged in self-reflection to identify and challenge her own biases and stereotypes about Vietnamese culture. She consciously tried to suspend judgment and assumptions based on cultural differences, recognizing that cultural humility requires a willingness to confront and overcome personal biases.
Sarah Demonstrates Providing Client-Centered Care
One day, Sarah attends to Mrs. Nguyen, an older client who appears hesitant and reserved. Sarah recognizes the importance of cultural humility in providing client-focused care and takes the necessary steps to demonstrate it.
Respectful and open communication:
Sarah approaches Mrs. Nguyen with a warm smile and greets her using a respectful greeting in Vietnamese, such as “Xin chào.” Sarah learns that Mrs. Nguyen is fluent in English and will not require the services of a medical interpreter. Nevertheless, she uses simple, straightforward language to communicate with Mrs. Nguyen, avoiding medical jargon and ensuring that Mrs. Nguyen understands the information she shares.
Active listening and valuing the client’s perspective:
Sarah takes the time to actively listen to Mrs. Nguyen’s concerns and preferences and any cultural practices that may be important to her. She respects and values Mrs. Nguyen’s perspective, allowing her to express her feelings and thoughts without interruption.
Collaborative decision making:
Sarah involves Mrs. Nguyen and her family in the decision-making process. She seeks their input and respects their autonomy and preferences. Sarah recognizes that the Nguyens are the experts in their own cultural practices and integrates their input into the client’s care plan.
Adapting care practices:
Sarah modifies her care practices to align with Mrs. Nguyen’s cultural preferences and needs. For example, she works with Mrs. Nguyen to create a diet plan to include traditional Vietnamese dishes that are familiar and acceptable to Mrs. Nguyen.
By becoming culturally knowledgeable and demonstrating cultural humility in her interactions with Mrs. Nguyen, Sarah ensures that she provides client-centered care that is respectful, inclusive, and responsive to Mrs. Nguyen’s cultural background and needs. Sarah’s actions foster trust, promote effective communication, and contribute to a positive health care experience for her client.