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Psychiatric-Mental Health Nursing

8.2 Ethical Practice in Culture and Diversity

Psychiatric-Mental Health Nursing8.2 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 8.1 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 accommodate the cultural differences of others. According to the American Psychological Association (APA, n.d.), cultural diversity means a variety of communities that are very different from one another. Nurturing a community that acknowledges, respects, and has regard for people from all different cultures is called inclusion.

According to the Centers for Disease Control and Prevention (2024), there are eight principles of cultural competence:

  1. Define culture broadly.
  2. Value clients’ 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 health-care professional to seek out, understand, and integrate the client’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 (2018), nurses must practice with cultural humility and inclusiveness. Culture is constantly changing and evolving, so true cultural competence requires a lifetime of learning with these changes. Respecting and learning about the cultures of others while exploring one’s own cultural biases is considered cultural humility.

There are both intrapersonal and interpersonal components to cultural humility (Table 8.2) (Hughes et al., 2020). The intrapersonal component consists of a personal awareness of one’s own limited knowledge of the client’s culture. The interpersonal component involves a respect for the client’s culture and openness to their beliefs and experiences. By focusing on developing partnerships with clients, the nurse can create a space that encourages learning and appreciation for other cultures. It is a client-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; one’s own thoughts, views, opinions, and attitudes are developed
Table 8.2 Interpersonal versus Intrapersonal Skills

Avoid Forcing Change

Cultural humility involves inclusion. Inclusion means taking into account the client’s own cultural preferences and involving them in the process as much as possible. Forcing a client 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 client. The process where the client and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the client’s cultural needs is called cultural negotiation. It is reciprocal and collaborative. When the client’s cultural needs do not significantly or adversely affect their treatment plan, the cultural needs can and should factor into the plan.

Seek Cultural Assistance

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

Ethical Engagement in Cultural Diversity

As a nurse, it is necessary to actively engage with the client and their culture. Cultural negotiation is mutual; the nurse and the client must gain an understanding of each other’s perspective. There are many ways a nurse can actively take part in learning about different cultures to best serve diverse client populations. Some examples include encouraging the client to bring traditional or culturally important food from home that is compatible with dietary orders and needs or 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. At the same time, do not stereotype or generalize clients. Make sure to ask clients’ 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 inventories available to help you identify unconsciously held beliefs. Journaling or reflective practice is another way to help identify and reflect upon 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 clients 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 client population leads to better client outcomes.


Immersing yourself in different cultural communities can be an engaging and fun way to learn more about your clients. Attending local cultural events, such as festivals and dances, exploring art and music scenes, and even joining religious ceremonies (may require special permission) are all ways to experience cultural practices firsthand (Figure 8.3).

An individual dressed in a colorful traditional costume, celebrating Traditional Mardi Gras Indians in Louisiana.
Figure 8.3 Attending cultural festivals, like celebrations of Traditional Mardi Gras Indians in Louisiana, is an excellent way to gain firsthand exposure to diverse cultural practices. (credit: “Mardi Gras Indians at Algiers Riverfest New Orleans 2009” by Mark Gstohl/Flickr, CC BY 2.0)

Responsiveness to Cultural Diversity

Learning about different cultures is only one step toward providing culturally competent care. How one responds to cultural diversity is what directly affects the nurse-client relationship and outcomes. Being responsive to cultural diversity involves taking lessons learned about other cultures from conversations, experiences, and research and integrating the knowledge into practice. It also involves advocating for diversity and inclusion at a structural and institutional level.

Steps to Change

EveryNurse (2023) defines the cultural differences encountered by nurses that may pose barriers to quality nursing care. For example, language differences can impact communication and complicate the nurse-client relationship; cultural traditions may influence the client’s acceptance of certain medications or interventions and may be misinterpreted by health-care providers; health literacy can create differences in understanding, accessing, and being able to use health-care information and can impact client education and discharge planning; cultural assumptions can lead to knowledge deficit and interfere with the nurse-client relationship.

Cultural sensitivity in nursing practice, and in health care in general, is essential (EveryNurse, 2023). Table 8.3 outlines strategies to meet these challenges.

Challenge Strategy
Awareness Share with your peers that you are working toward stronger cultural sensitivity; engage them in the process. Be open about this change, appreciate the effort, and state the goal of excellence in client care.
Assumptions Build validation and inquiry into your interactions with clients and families.
Keep your own nonverbal cues appropriate when clients clarify and answer.
Knowledge Visit an area where a culture is dominant and read about the culture from reputable books and online sources. Reflect upon your own assumptions and strive to become informed.
Trust and rapport If working with a translator, remain focused on the client for nonverbal cues and speak to the client. The translator will interpret the messages.
Language barriers Explore translation technology, and use appropriate pictures or gestures to communicate if needed. Keep in mind that the process may be frustrating and allow sufficient time.
Client education “Teach back” is an effective method to ensure messages have been received. Use translation assistance if necessary; seek to preserve the client’s dignity. Your own awareness may be enhanced when you experience how you are received by others.
Active listening Active listening is an effective technique in all nurse-client interactions. Use eye contact, touch, and proximity as appropriate. Repeat what you have heard them say and give them time to explain.
Table 8.3 Steps to Overcome Cultural Barriers to Optimal Nursing Care (EveryNurse, 2023)

Willingness to Change

Approach the process of learning about other cultures with cultural humility. Learning about other cultures requires self-examination and openness to new ideas, beliefs, and behaviors. It is normal to encounter beliefs and practices that are extremely different from one’s own. They may be in direct conflict with the nurse’s own cultural background, and may even make them uncomfortable, sad, angry, or confused. It is not expected that nurses will completely change all their 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
Years in Practice: 2 years
Clinical Setting: Med-Surg Unit
Geographic Location: Southern California

I was a twenty-eight-year-old registered nurse from Florida who recently resettled in an area of Southern California. I am White and prior to this had lived in Florida all of my life. I had been practicing for two years and had just started a new job on a med-surg 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 clients at the hospital were either Vietnamese immigrants or of Vietnamese descent.

One day I took report on a new client. The client was a fifty-three-year-old Vietnamese female with a diagnosis of terminal brain cancer. The client had no expected chance of survival, but she remained a full code and the family was refusing hospice. I wondered why the client and family would refuse hospice care.

As I went to assess the client, 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 pain medication, so I administered as ordered.

Upon reassessing her, I noticed the medication didn’t seem to make much difference. The client 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 client, and I felt she might be suffering unnecessarily at the end of her life.

At lunch, I called the client’s daughter, Viv, and requested she come to the hospital to visit her mother. Upon the daughter’s arrival, I administered the client some IV pain medication, but the client 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 for why the family was refusing hospice and comfort measures. I now understood how important it was to the client and the client’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 clients I was now serving.


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