Learning Outcomes
By the end of this section, you should be able to:
- 25.3.1 Recognize the many forms that biases and stereotypes can take.
- 25.3.2 Analyze factors contributing to conflicts arising from differences in values, beliefs, communication styles, and expectations.
- 25.3.3 Apply strategies and methodologies to effectively confront biases resulting from one’s cultural and social identity.
- 25.3.4 Differentiate between emotional intelligence (EI) and cultural intelligence (CQ).
- 25.3.5 Explain how emotional intelligence (EI) and cultural intelligence (CQ) contribute to conflict resolution in diverse health care environments.
- 25.3.6 Describe the effects of power imbalances on nurse-client relationships in health care while distinguishing between different power dynamics.
- 25.3.7 Identify client-centered strategies to mitigate power imbalances and promote equitable and client-centered care.
- 25.3.8 Apply mindful practices to enhance cultural competence in health care interactions.
In nursing practice, cultural diversity can sometimes cause conflict between health care providers and clients who come from different cultural backgrounds. This is often due to differences in values, beliefs, communication styles, and expectations. Such conflicts can have a negative impact on client care and communication, as well as overall health care outcomes. Effective communication, empathy, cultural understanding, and a commitment to respectful resolution are necessary to manage conflicts that arise from cultural diversity. It is essential to address both conscious and unconscious biases, which can help to reduce stereotypes and assumptions. By continuously striving to be culturally responsive, health care providers can achieve better client outcomes, higher levels of client satisfaction, and improved overall health care quality.
Confronting Biases
As discussed in Culturally and Linguistically Responsive Nursing Care, implicit biases can lead individuals to unknowingly treat people from certain groups differently based on their race, gender, sexual orientation, or other characteristics. Implicit biases can affect health care outcomes, resulting in disparities in treatment and client experiences (Belton et al., 2018). Providers’ implicit biases may also play a role in causing racial health disparities (FitzGerald & Hurst, 2017), and clinical decision making can be influenced by these biases (Hoffman et al., 2016).
Health care professionals, including nurses, have demonstrated unconscious biases toward clients based on irrelevant characteristics such as weight, mental health, clients with AIDS, clients with brain injuries who may have contributed to their injury, clients who are intravenous drug users, and clients with disabilities, in addition to race, ethnicity, gender, socioeconomic status, and age. These biases can affect the care provided to these individuals and contribute to health disparities (FitzGerald & Hurst, 2017). Unconscious processes may affect judgments, negatively impacting the nurse-client relationship and compromising client care (Greenwald et al., 2022). Table 25.4 presents examples of common forms of bias that may be either implicit or explicit.
| Type of Bias | Definition | Implications in Health Care |
|---|---|---|
| Gender | The differential treatment, attitudes, and expectations toward individuals based on their gender, leading to unequal opportunities and outcomes | Can manifest in various ways, affecting client care, medical research, and career opportunities for health care professionals (Piercy & Fletcher, 2020). For example, studies have shown that women are often undertreated for their pain, wait longer to receive a diagnosis or treatment, and are less likely to be the subjects of research studies. Gender bias also affects women’s reproductive health, and the stigma associated with sexual assault may lead women to avoid seeking care following an attack (Concern Worldwide US, 2022). |
| Age (ageism) | Discrimination or stereotyping of individuals based on age, either old or young | Older individuals may face challenges accessing appropriate health care due to age-related stereotypes and assumptions. Health care providers might attribute specific symptoms to aging rather than considering underlying medical conditions, leading to delayed diagnoses, inadequate care, and a lack of attention to the unique health care needs of older clients (Levy & Macdonald, 2020). |
| Weight | Involves negative attitudes and stereotypes toward individuals based on their weight or size | Health care providers may hold prejudiced beliefs about clients with obesity, leading to substandard care, misdiagnoses, or stigmatization. Clients with obesity may receive incomplete assessments, and their health concerns may be attributed solely to their weight rather than addressing underlying medical issues (Puhl & Suh, 2020). |
| Socioeconomic | Differential treatment based on an individual’s economic status or social class | Clients from lower socioeconomic backgrounds may face barriers to accessing health care services and may receive less personalized care than those with higher socioeconomic status. Socioeconomic bias can also result in disparities in health care quality and health outcomes (Hohl et al., 2020). |
| Disability | Prejudices and discrimination against individuals with disabilities | Health care providers and settings may not fully accommodate the needs of clients with disabilities. Inadequate communication, inaccessible facilities, and a lack of consideration for the specific challenges this population faces in seeking and receiving health care services lead to disparities in health care access and outcomes (McMahon et al., 2020). |
| Sexual orientation, also known as LGBTQ+ (lesbian, gay, bisexual, transgender, and queer/questioning) bias | Discrimination or prejudices against individuals based on their sexual orientation or gender identity | This bias can affect access to health care services, health insurance, quality of care, and nurse-provider communication for LGBTQ+ individuals (National LGBTQIA+ Health Education Center, 2020; MAP, 2023a). Bias also includes heteronormative assumptions that clients are cisgender or heterosexual. |
Addressing biases is a critical aspect of providing client-centered care for nurses. Negative impacts such as unequal treatment, misdiagnosis, and reduced client trust can be avoided by addressing biases. Nurses can achieve this by increasing their self-awareness, being culturally responsive, and adopting humility through education. By doing so, they can provide equitable care that respects clients’ diverse backgrounds and needs.
Becoming Self-Aware of Unconscious Bias
As described in Culturally and Linguistically Responsive Nursing Care, the Implicit Association Test (IAT) can help the nurse become more self-aware and reflect on any implicit biases they may have related to gender, race, age, or other social categories.
Select an Implicit Association Test (IAT) from a list of possible topics. Complete the assessment. Reflect on the findings, and then respond to the following questions.
- Are there any discrepancies between your explicit beliefs and the implicit biases indicated by the test?
- What actions could you take to address biases?
Maintaining a balance between personal and professional obligations is crucial for nurses to avoid client misunderstandings. Self-awareness plays a vital role in reducing biases. Having cultural sensitivity is important in reducing biases and promoting inclusivity. As a nurse, it is important to appreciate diversity in all forms and recognize that cultural differences enrich society and provide opportunities for learning and growth. Respectfully celebrating cultural practices, holidays, and traditions without appropriating or trivializing them is essential to fostering inclusivity, mutual respect, and understanding among diverse cultural groups.
To recognize and mitigate the impact of implicit biases, nurses must make a conscious effort to challenge them. Nurses must redirect their responses and counteract implicit biases when dealing with individual interactions. Recognizing one’s implicit biases requires self-reflection, observation, and a willingness to confront and examine one’s thoughts and beliefs. Nurses can prevent conflicts, promote effective communication, and prioritize client well-being by addressing personal biases.
Strategies to mitigate unconscious biases typically include training programs that increase awareness of personal beliefs, implicit attitudes, and stereotypes (Schmader et al., 2022). Identifying contexts that may lead to bias expression and creating plans to regulate behavior actively are also essential. Similarly, interventions to reduce unintentional biases involve effectively training individuals to regulate their beliefs, implicit attitudes, and stereotypes. Examples of strategies to reduce biases are presented in Table 25.5.
| Strategy | Description |
|---|---|
| Stereotype replacement |
|
| Counter-stereotypic imaging |
|
| Evaluative conditioning |
|
| Individuation |
|
| Perspective taking |
|
| Identifying self with the outgroup |
|
| Cultural immersion and engagement |
|
Recall that Sarah, a home health nurse, has been assigned to conduct a home visit for a new client, Mr. Ramirez, who recently relocated to the community from a Latin American country. Arriving at Mr. Ramirez’s residence, Sarah observes the neighborhood and senses a subtle discomfort within herself. Unbeknownst to her, this discomfort is driven by implicit biases that influence her perceptions and attitudes. During the visit, Sarah unintentionally makes assumptions about Mr. Ramirez’s health practices, family dynamics, and overall lifestyle based on her own cultural background and preconceived notions. These biases may manifest subtly, such as in nonverbal cues or unintentional microaggressions, impacting the quality of care and communication.
Sarah’s Steps to Reduce the Impact of Her Implicit Biases
Sarah reflects on her interactions with Mr. Ramirez and becomes aware of the implicit biases that may have influenced her perceptions. Recognizing the need to address these biases to provide culturally congruent care, Sarah undergoes training and education to increase her cultural awareness and seeks guidance from her supervisor on strategies to overcome implicit biases.
Self-awareness and reflection:
- Sarah acknowledges her reaction to her client’s neighborhood and reflects on her biases and assumptions.
- She recognizes that her biases can influence her interactions and decisions and commits to addressing them.
Cultural sensitivity:
- Sarah engages in ongoing education and training to enhance her cultural responsiveness and sensitivity.
- She seeks to understand the experiences, values, and beliefs of the diverse population she serves. This includes learning about the cultural practices, health care beliefs, and community resources relevant to the Latin American community.
Building rapport and trust:
- Sarah focuses on building rapport and trust with Mr. Ramirez and other community members.
- She recognizes that establishing a respectful and trusting relationship is essential for effective communication and engagement. She actively listens to their concerns, values their perspectives, and involves them in their health care decisions.
Challenging stereotypes and assumptions:
- Sarah consciously challenges stereotypes and assumptions she may have about individuals from different cultures or backgrounds. She reminds herself that each person is unique, with their own strengths, challenges, and aspirations.
- She avoids making assumptions based on external factors, such as neighborhood appearance or socioeconomic status.
Seeking diverse perspectives:
- Sarah actively seeks opportunities to engage with members of the Latin American community and learn from their experiences.
- She attends community events, participates in cultural celebrations, and seeks input from community leaders to better understand their needs, values, and concerns.
Reflective practice and continuous learning:
- Sarah regularly reflects on her experiences and interactions with the community to identify any moments where implicit biases may have influenced her actions or decisions.
- She self-reflects, accepts feedback, and commits to continuous learning and improvement.
Sarah’s actions reflect her commitment to providing equitable and culturally sensitive care to the community. She acknowledges the potential impact of her implicit biases on health care delivery and tries to overcome them. Sarah prioritizes self-awareness, cultural competence, collaboration, and reflection to provide unbiased care that respects her client’s needs and values.
Emotional and Cultural Intelligence
Emotional and cultural intelligence are essential in managing cultural conflicts in nursing practice. Understanding emotional intelligence (EI) and cultural intelligence (CQ) is crucial for effectively navigating interactions and relationships, particularly in diverse and multicultural environments. Although they have some similarities, they are separate concepts that deal with different aspects of human behavior and interpersonal abilities.
Emotional intelligence (EI) refers to the ability to recognize, understand, and manage one’s emotions and the emotions of others effectively. Daniel Goleman coined the term in his 1995 book Emotional Intelligence: Why It Can Matter More Than IQ, where he introduced EI’s significance in personal and professional success. Goleman argues that traditional measures of intelligence, such as IQ (intelligence quotient), do not fully predict a person’s success in life. EI involves several key components (Goleman, 1995):
- Self-awareness: The ability to recognize and understand one’s emotions, strengths, weaknesses, and values
- Self-management: The capacity to manage and regulate one’s emotions, impulses, and behaviors
- Motivation: Harnessing emotions to drive and sustain motivation, set, and achieve goals
- Empathy: The ability to understand and share the feelings and perspectives of others, demonstrating sensitivity and compassion
- Social skills: Proficiency in building and maintaining positive relationships, effective communication, conflict resolution, and teamwork
Emotional Intelligence (EI) Test
This Emotional Intelligence Test from the Global Leadership Foundation consists of 40 questions derived from the Global EI Capability Assessment instrument and is based on Goleman’s four-quadrant Emotional Intelligence Competency Model (2002). You may use your test results as a guide to assess areas where you are doing well and others you may need to develop further. The test generally takes 10 minutes.
- Take the Emotional Intelligence Test.
- Click on the Score Test button, and wait for the computer to generate an EI profile of your scores.
- Reflect on the capability level within each of the EI quadrants.
- Discuss how EI can contribute positively to promoting cultural humility.
Emotional intelligence (EI) aids individuals in managing stress, navigating social interactions, and making sound decisions. In various fields, such as leadership, management, and health care, emotional intelligence is vital in establishing solid relationships, motivating others, and resolving conflicts.
Developing cultural intelligence (CQ) is another means for addressing cultural conflicts in nursing practice. In Cultural Intelligence: Individual Interactions Across Cultures, Earley and Ang (2003) define cultural intelligence as the ability to adapt and interact effectively with people from different cultural backgrounds. It involves having knowledge, awareness, and skills related to cultural diversity. The components of cultural intelligence include:
- Cultural knowledge: Understanding of norms, values, beliefs, and practices of different cultural groups
- Cultural understanding: Unbiased recognition and appreciation of cultural differences and similarities
- Cultural skills: Interpersonal and communication skills to effectively interact and communicate across cultures
- Cultural adaptability: Willingness and ability to adjust one’s behaviors, attitudes, and beliefs to fit into different cultural contexts
Cultural intelligence enables individuals to navigate diverse settings, foster inclusive relationships, and avoid misunderstandings or conflicts stemming from cultural differences. As health care professionals, nurses must regularly reflect on their emotional and cultural intelligence to identify their strengths and areas for growth in providing culturally competent care.
To assess their emotional and cultural intelligence, nurses can use the following techniques:
- Consider taking an emotional intelligence assessment to identify personal strengths and areas for growth.
- Reflect on emotional reactions in various social situations, including the workplace, mainly when dealing with colleagues and clients. Analyze how emotions may impact decision making and interactions with others.
- Seek feedback to gain insight into how one is perceived regarding emotional and cultural intelligence. This can help nurses identify their blind spots, or unconscious or implicit biases they are unaware of (Banaji & Greenwald, 2016). Blind spots can influence a person’s perceptions, judgments, and decision making without their conscious knowledge or intention. They are often formed and reinforced by societal norms, cultural influences, personal experiences, and media portrayals.
- Observe interactions with others to identify how one responds to situations that involve cultural differences. Consider how interactions may reflect one’s level of cultural intelligence.
- Engage in continuous education to improve emotional and cultural intelligence. This can include reading books or articles, attending cultural competency workshops, or seeking mentorship from colleagues skilled in providing culturally responsive care.
- Use self-reflection to identify personal cultural biases and beliefs. Then, consider how one’s cultural background may influence interactions with clients and colleagues from different cultural backgrounds.
Emotional and cultural intelligence enable empathy and comprehension and promote effective communication when interacting with people from cultures that are different from one’s own. With these skills, nurses can foster inclusive and harmonious interactions in personal and professional settings. EI equips nurses to manage conflicts constructively, while CI enhances their capacity to navigate disputes arising from cultural differences. EI and CI enable nurses to manage misunderstandings, bridge cultural gaps, and establish positive relationships across cultures. Conflict resolution and relationship building are essential to cultural competency, as they foster collaboration, trust, and mutual respect in culturally diverse environments.
Addressing Power Imbalances
In nursing, power imbalances can create conflicts and hinder effective communication between health care providers and between providers and clients. Imbalances can arise in the nurse-client relationship due to differing roles, knowledge, and authority (Foronda, 2019; Foronda et al., 2016). For example, nurses may perceive themselves as having more power than their clients due to their professional knowledge and authority, while clients often feel a sense of vulnerability and dependence on the health care system (Karim, 2023). Addressing these imbalances is essential for promoting client autonomy and improving outcomes.
In health care organizations, nurses hold varying levels of authority and responsibility compared to clients. This hierarchical structure can impact communication patterns and make clients feel subordinate. Nurses often have decision-making authority in health care settings, which can limit client autonomy and control over their own health care decisions. How power is distributed affects how nurses and clients communicate and make decisions. For example, clients may feel uncomfortable sharing their concerns or preferences because they worry about upsetting or questioning the nurse’s authority. Meanwhile, nurses may find it challenging to balance empowering clients and maintaining control over the care process (Karim, 2023). When power is used in an authoritarian manner, clients may feel disempowered and less trusting of the health care system (Karim, 2023). Cultural context can also play a role in shaping power dynamics within nurse-client interactions. In some cultures, clients may defer to the authority of health care professionals, leading to a more pronounced power imbalance (Karim, 2023).
To provide client-centered care, nurses should engage clients in shared decision making, honor their preferences and values, and offer the information they need to make informed choices about their care (Figure 25.6). When nurses advocate for client involvement in decision making and respect their autonomy, it increases client trust and satisfaction (Ringdal et al., 2017). Advocacy and autonomy are principles in the Nursing Code of Ethics (ANA, 2015). Advocacy ensures that clients’ voices are heard, their rights are respected, and their needs are met. Autonomy empowers clients to actively participate in their health care decisions, giving them a sense of ownership and control over their well-being. These principles are the foundation of client-centered care and ethical nursing practice.
To create a safe and respectful environment, nurses should promote open and respectful communication, actively listen to clients, and encourage them to voice their concerns and preferences without fear of judgment or retribution. To empower clients and promote participation in their care, nurses should strive to create a trusting and supportive environment where clients feel comfortable expressing their needs and preferences (Ringdal et al., 2017). Addressing power imbalances requires nurses to adopt a client-centered approach, promoting partnership and collaboration rather than paternalistic attitudes. Here are some strategies nurses can implement:
- Practice cultural humility and respect clients’ unique perspectives and values (Foronda, 2019).
- Foster open and honest communication, ensuring clients feel comfortable asking questions and expressing their concerns (Ringdal et al., 2017).
- Allow clients to have a voice and actively involve them in shared decision-making processes (Molina-Mula et al., 2020), providing them with information and options to make informed choices about their care (Ringdal et al., 2017).
- Engage in relationships that support clients’ health care preferences (Pelletier & Stichler, 2014).
- Advocate for client rights and autonomy within the health care system (Molina-Mula et al., 2020).
- Continuously reflect on one’s power and privilege and work toward mitigating the impact of power imbalances in the nurse-client relationship.
Cases where power and resources are unevenly distributed can result in health inequalities (National Academies of Sciences, Engineering, and Medicine, 2017). Nurses can tackle power imbalances and encourage care by prioritizing the client, leading to more autonomy and a fairer and more empowering health care setting.
Engaging in Mindful Awareness
Understanding the connection between mindful awareness and cultural humility is essential for creating culturally sensitive interactions in different situations, especially in health care settings. These concepts can help nurses better appreciate cultural diversity and provide client-centered care. Mindful awareness means being present in the moment and observing thoughts, emotions, and sensations without judgment. Being consciously or mindfully aware and receptive in the context of cultural responsiveness means actively and intentionally seeking to understand, respect, and appreciate the diverse cultural backgrounds, perspectives, and practices of individuals and communities. It involves recognizing the influence of culture on people’s behaviors, values, beliefs, and norms, consciously bridging cultural gaps, and fostering inclusive interactions.
To cultivate mindful awareness, nurses can actively engage in several practices:
- Mindful Listening: Practice active listening by entirely focusing on the speaker. Seek to understand the speaker’s perspective without interrupting or judging prematurely.
- Suspension of Judgment: Be aware of automatic judgments and biases that arise and consciously set them aside. Instead, aim to understand the reasoning behind different viewpoints before forming an opinion.
- Empathy and Perspective Taking: To gain a better understanding of someone’s experiences, emotions, and motivations, try to adopt their perspective. Cultivate empathy by imagining oneself in the same circumstances.
- Continuous Learning: Foster a growth mindset, and embrace a lifelong learning attitude. Seek new information, engage in diverse experiences, and be open to changing personal beliefs based on new evidence or insights.
- Reflection and Self-Awareness: Regularly reflecting on thoughts, biases, and reactions helps develop self-awareness of times when one may resist new information.
Practicing mindfulness can benefit everyone involved, including clients, professionals, and personal well-being. ANA’s Scope and Standards of Practice acknowledges the significance of mindfulness in nursing practice, emphasizing the need for nurses to “practice with presence, intention, and focused attention” to enhance client-centered care and promote a culture of safety (ANA, 2020, p. 10). This requires nurses to possess a heightened self-awareness to cultivate an authentic presence. This means being attuned to their own thoughts, emotions, and reactions as they engage with clients, colleagues, and various clinical situations. Being fully present involves acknowledging and managing distractions that might hinder effective communication or decision making. This concept goes beyond the nurse’s physical presence—it requires being mentally present, actively listening, and responding empathetically to clients’ needs and concerns. This requires the nurse to have the skill set to adapt their behavior according to their self-awareness and situational awareness. Nurses can employ practical tools to cultivate compassionate habits that support well-being, communication, resilience, and success. These mindfulness practices are not just quick fixes for stress; they can serve as a solid foundation for developing more empathetic nursing practice. Mindfulness practice can enhance engagement, a sense of purpose, and the ability to manage difficult client conversations while fostering empathy (Bertin, 2020; Mindful Communications, n.d.).
Mindful Breathing: Practicing Self-Care
Mindful breathing, or intentionally focusing on each inhalation and exhalation, can help increase muscle relaxation and improve sleep and overall mental health and well-being. This video guides the viewer through a short exercise in this technique.
Play the video, complete the exercise, and then respond to the following questions.
- How can the practice of taking seven mindful breaths, following the rhythm of inhaling, and exhaling on one, help individuals improve their overall health and well-being?
- How might incorporating the practice of taking seven mindful breaths in moments of crisis or before challenging situations contribute to building stronger interpersonal relationships and fostering a more compassionate society?
- How does grounding oneself through mindful breathing practice align with the goal of mindful communications to promote healthier and more mindful ways of interacting with oneself and others?
Mindfulness in nursing practice can equip nurses to better manage the challenges of caring for clients from diverse cultural backgrounds. Mindfulness practices can enhance emotional intelligence and empathy (Brewer et al., 2019). Integrating mindfulness into cultural care delivery can help health care providers better comprehend and address the psychological aspects of clients’ experiences related to their cultural background (Zandbelt et al., 2017).
By practicing mindfulness, nurses can gain a deeper understanding of their own biases and assumptions. This promotes the nurse’s ability to approach client interactions with openness and sensitivity to cultural differences. Nurses can adapt their care strategies and communication styles to meet the unique needs of clients from diverse backgrounds by heightening awareness of cultural variations.
For example, Sarah, the newly hired nurse from the previous examples, is passionate about delivering quality care to her clients. She is keenly aware of the importance of cultural humility but feels overwhelmed by her clients’ diverse cultural backgrounds. Struggling to bridge cultural gaps and foster inclusivity, Sarah embarks on a journey to integrate mindfulness principles into her nursing practice.
Sarah started practicing mindful awareness during client interactions. She observes her thoughts, emotions, and assumptions without judgment, allowing her to gain insight into her biases. Utilizing mindfulness practices, Sarah focuses on cultivating emotional intelligence. This involves understanding her emotions and those of her clients, fostering a deeper connection. Sarah extends mindfulness to comprehend the psychological aspects of clients’ experiences related to their cultural background. This helps her address the unique emotional needs of each client. As Sarah integrates mindfulness into her nursing practice, she experiences transformative outcomes. Mindfulness allows Sarah to gain a deeper understanding of her biases and assumptions. This self-awareness becomes the foundation for her approach to client interactions. Sarah’s mindfulness practices promote openness and sensitivity to cultural differences. She learns to approach each client nonjudgmentally, fostering trust and mutual respect. Heightened awareness of cultural variations empowers Sarah to adapt her care strategies and communication styles. She tailors interventions to meet the unique needs of clients from diverse backgrounds. Sarah’s case illustrates the transformative power of integrating mindfulness into nursing practice, particularly in cultural humility and competency, through mindful awareness, emotional intelligence, and a commitment to ongoing learning.
Mindfulness is a practice that teaches personal growth as a never-ending journey. Sarah understands that becoming culturally responsive is a continuous process that requires constant learning and adaptation and encourages humility in approaching different cultures. Being present in the moment allows nurses to engage with their clients fully. This is crucial in understanding subtle cues, nonverbal communication, and nuances that may carry cultural significance, resulting in increased cultural sensitivity. Mindfulness helps to cultivate an open-minded approach to every client interaction, enabling nurses to approach situations with curiosity instead of preconceived notions and creating an environment that values and respects diverse perspectives.