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Psychiatric-Mental Health Nursing

8.4 Diversity, Equity, and Inclusion

Psychiatric-Mental Health Nursing8.4 Diversity, Equity, and Inclusion

Learning Objectives

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

  • Define important considerations related to providing equal, diverse, and inclusive nursing care
  • Identify factors that can prevent diversity, equity, and inclusion
  • Explain how barriers to communication affect diversity, equity, and inclusion

Diversity, equity, and inclusion (DEI) create an environment that encourages different ideas, cultures, backgrounds, and experiences. This type of environment allows nurses to provide more comprehensive and effective care to their clients. Diversity, equity, and inclusion foster a culture of mutual respect, understanding, and support, which can lead to improved client outcomes. DEI is at the organizational level and higher, while cultural competency works on an individual level. Additionally, diversity and inclusion can help to reduce health disparities, which can improve health-care access and quality for communities that are traditionally underserved. Ultimately, diversity and inclusion are critical components of successful nursing practice that can help to ensure that all clients receive the best possible care.

Health Equity through Diversity and Inclusion

In nursing, health equality means that nurses treat all clients as individuals, show respect for their personal choices and differences, and recognize their dignity and human rights. It assumes equal treatment and support. In contrast, health equity speaks to social justice and is when everyone has a fair opportunity to obtain optimal health (Centers for Disease Control and Prevention [CDC], 2022a). Both equity and equality are important considerations when providing inclusive nursing care Figure 8.6.

Graphic showing equality represented by four people of varying heights standing on boxes of the same height vs. equity represented by four people of varying heights standing on boxes of different heights that make them all the same height.
Figure 8.6 Health equality implies that everyone gets the same treatment, and health equity gives everyone a fair opportunity to obtain optimal health. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The ethical principle and moral obligation to act on the basis of equality and equity, or justice, is a standard linked to fairness for all in society. The ANA states that this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety), but also fairness in all operations of societal structures (2021). This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence.

The Centers for Disease Control and Prevention discuss diversity and inclusion as important factors in health equity considerations. Diversity refers to the existence of societies, communities, or subcultures that differ substantially from one another. Inclusion is the practice of creating an environment in which individuals of all backgrounds feel respected, valued, and supported (CDC, 2022b). There are numerous factors that can prevent diversity, inclusion, and justice. These can, in turn, create health disparities that limit access to care and worsen health outcomes for certain groups.

Race/Ethnic Heritage

Race and ethnicity are both socially constructed ideas. There are no true scientifically or genetically distinct races or ethnicities (Mersha & Beck, 2020). Nonetheless, race and ethnicity have an undeniable effect on health-care access and outcomes. The belief that races are distinct from one another, and that there is a hierarchy to race, implying that races are unequal is the concept of racism. As health-care providers, nurses have an obligation to recognize the impact of racism on their clients and the communities they serve. In the United States, race and ethnic background have long played a role in health disparities among different populations.

Most racial and ethnic minorities experience higher rates of chronic disease and premature death compared with White populations; some underrepresented groups, such as Asian and Hispanic immigrants, experience lower rates (Weinstein et al., 2017). American Indian, Alaska Native, and Black populations experience the highest infant mortality rates, while Asian and Pacific Islanders experience the lowest (Figure 8.7). Black individuals are more likely than White individuals to die prematurely from heart disease, and Black males are twice as likely as White males to die prematurely from stroke.

A chart from the CDC showing infant mortality rates by race and ethnicity in the U.S. Rates are as follows: Non-Hispanic Black: 10.6 per 1,000 live births; Non-Hispanic Native Hawaiian or other Pacific Islander, 8.2 per 1,000 live births; Non-Hispanic American Indian or Alaska Native, 7.9 per 1,000 live births; Hispanic: 5 per 1,000 live births; non-Hispanic White: 4.5 per 1,000 live births; and non-Hispanic Asian: 3.4 per 1,000 live births.
Figure 8.7 This chart from the Centers for Disease Control and Prevention shows infant mortality rates by race and ethnicity for the United States and illustrates discrepancies between groups. (credit: "Infant Mortality Rates by Race and Ethnicity, 2019" by Centers for Disease Control and Prevention, Public Domain)

Implicit bias related to race and ethnicity has been repeatedly shown in research to negatively affect client care and outcomes. Nurses should also be sensitive to the fact that individuals from certain ethnicities may be distrusting of health-care professionals due to cultural history and other factors.

Spirituality and Religion

Throughout human history, spirituality, religion, and health have often gone hand in hand. In many healing traditions, healers also serve as religious leaders (Figure 8.8). A person’s religious beliefs may affect their diet, what medications they will take, their views on physical and mental illness, and their approaches to death and dying. Many people consult and rely on their religious and spiritual beliefs when making medical decisions. For instance, Jehovah’s Witnesses do not accept whole blood, plasma, and platelets because they believe that this might interfere with eternal salvation. A person’s religious beliefs can affect their views on mental health care as well. For example, members of the Church of Scientology believe that modern psychology and psychiatric medicine are inhumane, cruel, and unscientific (McCall, 2006). They believe that modern mental health care robs an individual of their freedom and can even damage the brain, and that following certain practices within the Church are the only ways to improve one’s mental well-being.

A man wearing a mask and holding his hands over a female patient, praying over her.
Figure 8.8 Religion and health are closely intertwined for many people. (credit: "Guatemalan Clergymen Lead Sunday Mass Aboard USNS Comfort" by Mass Communication Specialist 2nd Class Ethan J. Soto/Flickr, Public Domain)

Nurses must be prepared to take clients’ religious and spiritual preferences into account as an important part of the treatment plan (Swihart et al., 2022). A thorough cultural assessment should include information on a client’s religious or spiritual beliefs that might affect their health behaviors and their care. Nurses must be aware of implicit biases and personal beliefs and be culturally aware to provide equitable and competent care. One tool that can assist in a thorough spiritual assessment is FICA. FICA is an acronym that stands for faith or beliefs, the importance of beliefs, the community supporting the individual and beliefs, and the way in which we can address care issues related to spirituality.


Older adults struggle with some limitations in their care related to their age. Studies have shown that health-care providers are more likely to assume that older clients’ conditions, such as cognitive decline, are due to their age and to deny them certain treatments as compared with younger clients (Hughes et al., 2020). Older clients also tend to be undertreated for pain and depression (Hughes et al., 2020).

Gender Identity and Sexual Orientation

An individual’s deeply held sense of their gender, which may or may not align with the sex assigned to them at birth is called gender identity. The term used to describe a person whose gender identity matches their sex assigned at birth is cisgender. To the extent that a person’s gender identity does not conform with the sex assigned to them at birth, they may identify as Transgender or as gender nonbinary. Someone whose gender identity or expression differs from traditional cultural gender roles for one’s sex assigned at birth is called Transgender. Transgender people, like cisgender people, may be sexually oriented toward males, females, both sexes, or neither sex. Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms. Sharing pronouns as part of a basic introduction to a client can assist a Transgender client to feel secure sharing their pronouns in a health-care setting. Asking a client for their pronoun (he, she, they, ze, etc.) is considered part of a nursing assessment.

There is a strong body of research showing a history of gender bias in health care (Hughes et al., 2020). Providers are more likely to believe that the health complaints of women result from emotional instead of physical causes compared with men. There is also a demonstrated history of underdiagnosis and undertreatment of cardiovascular disease in women when compared with men. Moreover, studies reveal that “Transgender people already experience health inequities at a disparate rate compared to their cisgender peers, including increased rates of mental health disorders, substance use disorders, sexual and physical violence, and sexually transmitted infections” (Walter-McCabe & Chen, 2022, para 2).

A person’s physical and emotional interest or desire for others is their sexual orientation. It exists on a continuum and is manifested in one’s self-identity and behaviors. The acronym LGBTQIA stands for lesbian, gay, bisexual, Transgender, Queer or Questioning, Intersex, or Asexual in reference to sexual orientation. Historically, individuals within the LGBTQIA+ community have experienced discrimination and prejudice from health-care providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this group of people in recent years, members of the LGBTQIA+ community continue to experience significant health disparities (Walter-McCabe & Chen, 2022).


Disabilities can be present from birth or acquired later in life. They can be physical, cognitive, or mental health related. Adults with disabilities are more likely than adults with no disabilities to report poor health, including higher rates of obesity, diabetes, smoking, lack of physical activity, and cardiovascular disease. Adults with disabilities are also more likely to live in poverty, and even those with health insurance are less likely than adults without disabilities to seek care. Adults with disabilities also cite common stereotypes, bias, and beliefs among providers as barriers to care (VanPuymbrouck et al., 2020). Examples include lack of appropriate equipment to transfer clients with disabilities in doctor’s offices, or a health-care provider’s assumption that the client is unhealthy or fragile simply because they are disabled.

Education Level

Differences in educational levels can affect how people access health-care services and understand health information in order to make informed decisions. The higher a person’s level of education, the higher their life expectancy and the more likely they are to access preventative and screening services (Viinikainen et al., 2022).

Raghupathi and Raghupathi (2020) analyzed data from twenty-six countries over ten years and identified connections between education and health. Their research proposed investments in education as investments in population health. Raghupathi and Raghupathi found that parental education at the tertiary level (beyond high school) was especially significant for infant and child health and overall life expectancy (2020). Heightened awareness of individual health could result from focused promotional campaigns. These efforts could increase school completion rates and employment skills and serve to reduce health disparities by promoting health maintenance and illness prevention (Raghupathi & Raghupathi, 2020).

Physical Characteristics

Certain physical characteristics have the potential to create barriers to care. For example, clients who are deaf or blind may need accommodations to ensure that communication is clear and accurate. To supplement spoken and printed communication, American Sign Language interpreters can be sought for deaf clients. Educational materials and consent forms printed in Braille can assist blind populations. Health equity and inclusion provides care for everyone assuming basic equal support and resources, no matter what their physical characteristics are.

Socioeconomic Status

In the United States, socioeconomic status is a major determinant of health status. People who belong to low socioeconomic groups—such as people who are homeless or people living in poverty—are more likely to report higher rates of disease, such as heart disease, diabetes, stroke, and obesity (National Academies of Sciences, 2017). This is because they have fewer opportunities to seek early prevention. They also are lacking the resources to follow through with standard treatment plans. For instance, someone who is homeless is unable to perform clean dressing changes daily without adequate access to water. Socioeconomically disadvantaged individuals also have higher rates of infant mortality, substance misuse, and shorter life expectancies. Additionally, they may report avoiding care because they feel discrimination from health-care workers (Hughes et al., 2020).

In 2021, the majority of Americans relied on privately purchased insurance for their health care. Most of this insurance is made available through employers. Individuals are also able to purchase health insurance through the federal Marketplace. The Marketplace mandates that all of their available plans cover both inpatient and outpatient mental health and substance use disorder treatment (, n.d.). About 35 percent of the population holds a public form of insurance in the form of Medicaid or Medicare. Medicare is for those who have been determined to need special care, such as older people or those who have disabilities. Medicare covers both inpatient and outpatient mental health services, although clients may still be responsible for deductibles, copays, or coinsurance. Medicaid is for those who need aid in receiving care, such as people who meet certain lower income guidelines. It is the top payer of mental health services in the United States (, n.d.).

Veteran Status

Military veterans often have complex needs due to physical and psychological trauma sustained during military service and socioeconomic issues that arise after discharge (Figure 8.9). Many veterans are eligible for health-care benefits through the Veterans Administration if they meet certain criteria, such as age or level of disability (Veterans Affairs, n.d.). The Veterans Administration also offers free health care to veterans who meet certain low-income guidelines. The Veterans Administration covers community-based care in non-VA facilities for individuals who meet certain criteria, including those who live in a place where no VA facilities are available. That said, many veterans still struggle with a lack of access to health-care benefits, sometimes based on residing in rural locations that do not have veteran-specific health-care facilities.

A veteran receiving care from a nurse in a hospital room.
Figure 8.9 Veterans are an especially vulnerable population and often have complex needs. (credit: U.S. Air Force photo by Tech. Sgt. Bennie J. Davis III, Public Domain)

Factors Preventing Sensitivity to Diversity

Several factors related to a person’s experiences, attitudes, and knowledge hinder sensitivity to diversity. One significant factor is a lack of exposure to diverse individuals and cultures. Limited exposure can lead to a lack of understanding and appreciation for diversity. Stereotyping and prejudice can also contribute to insensitivity; preconceived notions or stereotypes about certain groups can lead to discrimination and bias. Personal biases can influence perceptions and attitudes toward different groups, leading to insensitivity. Additionally, a lack of education or awareness about different cultures and backgrounds can lead to misunderstandings. Overcoming these barriers requires ongoing education, open-mindedness, and a willingness to learn about and appreciate different cultures and backgrounds. It also requires actively challenging one’s biases and seeking out opportunities for exposure to diversity.


The assumption that a person has the attributes, traits, beliefs, and values of a cultural group simply because they are a member of that group is called stereotyping. Engaging in stereotyping prevents the ability to identify people’s needs on an individual level. One common stereotype is the assumption that all older clients are forgetful or have memory problems. This stereotype can lead to medical professionals overlooking or dismissing legitimate concerns or symptoms of older clients, attributing them solely to age-related memory decline, which can, in turn, lead to misdiagnosis or delayed treatment. Culturally equitable care extends beyond general knowledge of a cultural group to knowledge of the individual themselves.

Cultural Imposition

The imposition of one’s own values, beliefs, and practices upon another person or group is called cultural imposition. It runs counter to cultural humility and can manifest in various ways. Examples include disregarding a client’s cultural practices, beliefs, and values when making medical decisions, or imposing Western medical practices on non-Western cultures without consideration for their unique cultural beliefs and practices. For instance, health-care providers may fail to consider a client’s traditional healing practices or the role of family members in health-care decisions, which can lead to a breakdown in communication and a lack of trust between clients and health-care providers.

Cultural Blindness

The belief that all cultural groups are the same and share identical experiences is called cultural blindness (Bhattacharya et al., 2019). Different cultural groups can have vastly different experiences just within the health-care system. Cultural blindness might lead a nurse to conclude that all treatment services are adequate for all clients, contributing to the continuation of policies that prevent diversity and inclusion. For example, a hospital may carry copies of all of its consent forms in English and Spanish, but there is a large local Vietnamese population as well, and the nurse can never find a Vietnamese consent form for these clients. This is a result of system-wide cultural blindness. Once the nurse identifies the issue, they can escalate it and have the issue addressed by having adequate Vietnamese-language consent forms available for the client population.

Culture Conflict

Tension or opposition between different cultures can result in culture conflict. Often, the dominant culture weakens the cultural practices of the underrepresented group as a result (APA, n.d.). Culture conflict can arise in many ways, such as when a client’s cultural beliefs around illness and healing differ from those of the health-care provider, or when a client’s cultural practices conflict with medical protocols. For example, a client who refuses to receive a blood transfusion due to religious beliefs may have conflict with the nurse who sees this treatment as medically necessary.

Culture conflict can also arise when health-care providers make assumptions or judgments about clients based on their cultural background, leading to biases and discrimination. This can result in disparities in health-care access and outcomes for clients from diverse backgrounds. Nurses should approach such conflicts with cultural humility to ensure they are resolved without damage to the nurse-client relationship.

Barriers to Communication Affecting Diversity and Inclusion

It is necessary to overcome communication barriers in order to maximize the clients’ opportunities for best care. According to the Agency for Healthcare Research and Quality (2020), for instance, about three out of one hundred people in the United States have a hearing disability, and two out of one hundred have a visual disability to the extent that they are blind or have trouble seeing even with corrective vision wear. Various strategies can help improve the communication process for these clients.

For clients with hearing barriers, offer print materials, text telephones (TTYs), or videos with captioning. Sign language interpreters use American Sign Language or Signed English; there are also oral and cued-speech interpreters who use articulation and gestures. When having conversations, make sure the television or other sources of background noise are silenced and the surrounding environment is free of distracting noise.

For clients with sight barriers, make sure that the lighting is at their comfort level. Whenever possible, provide assistance in the form of audio recordings, large-print materials, and screen magnifiers. Text-to-speech or Braille output screen reading software is also available.

According to recent data, 8 percent of the U.S. population has limited English proficiency (Haldar et al., 2023). Linguistically competent care aims to help these people understand their treatment. The Agency for Healthcare Research and Quality defines linguistic competence as “providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators” (Agency for Healthcare Research and Quality, 2019, para 2).

All educational materials, instructions, and consent forms should be offered in the client’s preferred language. When caring for a client whose primary language is not English and they have a limited ability to speak, read, write, or understand the English language, seek the services of a trained medical interpreter. Health-care facilities are mandated by the Joint Commission to provide qualified medical interpreters. Use of a trained medical interpreter is linked to fewer communication errors, shorter hospital stays, reduced thirty-day readmission rates, and improved client satisfaction (Fidler, 2023).

Refrain from asking a family member to act as an interpreter. The client may withhold sensitive information from them, or family members may possibly edit or change the information provided. Unfamiliarity with medical terminology can also cause misunderstanding and errors.

Medical interpreters may be on-site or available by videoconferencing or telephone. When possible, obtain a medical interpreter of the same gender as the client to prevent potential embarrassment if a sensitive matter is being discussed. Some additional guidelines for working with a medical interpreter are to:

  • Allow extra time for the interview or conversation with the client.
  • Whenever possible, meet with the interpreter beforehand to provide background.
  • Document the name of the medical interpreter in the progress note.
  • Always face and address the client directly, using a normal tone of voice. Do not direct questions or conversation to the interpreter.
  • Speak in the first person (using “I”).
  • Avoid using idioms, such as “Are you feeling under the weather today?” Avoid abbreviations, slang, jokes, and jargon.
  • Speak in short paragraphs or sentences. Ask only one question at a time. Allow sufficient time for the interpreter to finish interpreting before beginning another statement or topic.
  • Ask the client to repeat any instructions and explanations given to verify that they understood.

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