RACES

Nursing Study Notes: Cultural Diversity and Culturally Competent Care

Chapter 12 • Organized by your learning objectives • Cram-friendly, with key definitions, examples, and nursing applications

These notes use only the chapter you provided and are organized around your learning objectives. I’ve kept the explanations concise while including the important details you may need for nursing exams.

1. Diversity vs. multiculturalism

Diversity: Differences among people, including race, ethnicity, gender, religion, socioeconomic status, sexual orientation, and culture.
Multiculturalism: Accommodating diversity through inclusion, acceptance, and respect for individual differences.

Key difference: Diversity describes the differences that exist; multiculturalism promotes inclusion and respect for those differences.

2. Why cultural competence is important for nurses

Patients have different cultural beliefs, values, health practices, and expectations.
Care appropriate for one cultural group may be ineffective or inappropriate for another.
Cultural competence improves communication, trust, patient participation, treatment adherence, and health outcomes.
It helps reduce healthcare disparities and supports equitable, safe, patient-centered care.
Nurses must respect patients' cultural preferences while protecting their health and safety.

Exam tip: Culturally competent care is individualized care that respects cultural differences rather than treating every patient the same way.

3. Culture and acculturation

Culture: The learned, shared, and transmitted beliefs, values, customs, behaviors, and ways of living that influence how people think, make decisions, and act.

Characteristics of culture

Learned: Acquired through family, education, and life experiences.
Shared: Members often share beliefs, traditions, and practices.
Transmitted: Passed from generation to generation.
Dynamic: Changes over time through interactions and new experiences.
Universal: Everyone has a culture.
Multilevel: Includes material elements (clothing, art, artifacts) and nonmaterial elements (beliefs, customs, language).
Sometimes unconscious: People may not recognize their own cultural assumptions.
Diverse: Individuals within the same culture may differ considerably.

Acculturation vs. assimilation vs. socialization

Term	Definition	Example
Acculturation	Learning and adopting elements of a new culture while retaining elements of one's original culture.	An immigrant learns English while continuing to celebrate traditional holidays.
Assimilation	Gradually adopting the dominant culture's essential values, beliefs, and behaviors.	A newcomer increasingly adopts the dominant language and customs.
Socialization	Learning the rules, roles, norms, and behaviors of a society or group.	A nursing student learns professional nursing expectations.

Remember: Acculturation combines elements of cultures; assimilation involves merging into the dominant culture.

4. Concepts pertaining to cultural diversity in nursing

Concept	Definition
Ethnicity	Shared social and cultural heritage passed down through generations. Example: Puerto Rican or Hmong heritage.
Race	A social classification historically associated with perceived physical or phenotypic characteristics. It cannot be reliably determined from appearance alone.
Religion	An organized system of beliefs concerning the nature and purpose of existence, often involving worship of a God or gods.
Bicultural	Identifying with and integrating elements of two cultures.
Multicultural	Describes a group, workplace, or community containing people from many cultures.
Dominant culture	The group with the greatest power or authority to influence societal values and behaviors.
Subculture	A group within a larger culture with distinct characteristics, experiences, values, or lifestyles. Examples: nurses, older adults, or rural communities.
Underrepresented/minority group	A group that may have fewer members or experience inequitable treatment and marginalization.
Ethnocentrism	Believing one's own cultural or social group is superior and viewing other groups' practices as wrong or strange.

Important distinctions:

Race, ethnicity, and religion are not interchangeable.
A person's ethnicity does not determine their race or religion.
Individuals may belong to several overlapping cultures and subcultures.
Ask patients how they identify and what terms they prefer; never assume based on appearance.

5. Vulnerable populations in the United States

Vulnerable populations are groups more likely to develop health problems or experience poor outcomes because of limited access to care, high-risk behaviors, or multiple and cumulative stressors.

Examples include:

People experiencing homelessness.
People experiencing poverty or economic instability.
People with mental illness.
People with physical disabilities.
Infants, children, and older adults.
People without health insurance or with limited access to healthcare.
Some racial and ethnic minority groups.
People living in rural areas with limited services.

Why nurses must recognize vulnerability

Vulnerable populations may face barriers to healthcare, preventive services, and treatment.
Health disparities may result in higher rates of illness, complications, or death.
Older adults may experience physical, financial, sexual, or psychological abuse, or neglect.

Nursing priority: Focus on the patient's strengths, resources, needs, and barriers—not exclusively on risks or limitations. Advocate for equitable care and access to services.

6. Culture universals vs. culture specifics

Culture universals: Beliefs, values, or practices shared by people across all cultures.
- Example: All cultures have ways of celebrating the birth of a baby.
Culture specifics: Beliefs, values, or practices unique to a particular culture.
- Example: The specific rituals, clothing, or ceremonies used to celebrate a birth.

Exam tip: The event may be universal, but how people observe it may be culture specific.

7. Cultural archetypes vs. cultural stereotypes

Archetype	Stereotype
A general cultural symbol or pattern that helps people remember cultural characteristics.	An unsupported assumption that all members of a racial or ethnic group are alike.
Not necessarily negative.	May be positive or negative, but can lead to inaccurate judgments.
Does not establish an individual's actual behavior.	Can lead to biased assessments and inappropriate care.

Example: Knowing that a cultural group may have a particular traditional healing practice is an archetypal generalization. Assuming every member of that group uses the practice is stereotyping.

Nursing rule: Treat each patient as a unique individual who may be influenced by culture but is not defined by it.

8. The culture of the U.S. healthcare system

The conventional U.S. healthcare system is largely based on Western biomedical medicine, which emphasizes scientific explanations of illness, diagnosis, treatment, and disease prevention. It also reflects values associated with the dominant U.S. culture.

Common norms of U.S. healthcare

Category	Examples
Beliefs and values	Health means absence or minimization of disease; reliance on biomedical science and technology; desire to conquer disease.
Practices	Immunizations, preventive examinations, diagnostic tests, and stress reduction.
Habits	Handwashing, documentation, use of medical jargon, and systematic problem-solving.
Preferences	Punctuality, cleanliness, organization, and adherence to treatment plans.
Customs	Procedures surrounding birth and death; respect for professional hierarchy and ethical codes.
Rituals	Annual physical examinations and surgical procedures.

Professional subcultures

A professional subculture is a group within the healthcare system with its own learned values, norms, and practices.

Examples include nurses, physicians, therapists, and other healthcare professionals.

Nursing subculture values include:

Autonomy and caring.
Critical thinking and clinical judgment.
Objective reporting and documentation.
Systematic assessment and decision-making.
Professional responsibility and patient safety.

Why this matters

Healthcare professionals may assume their own methods and values are universally appropriate. For example, a nurse who values emotional restraint may misinterpret a patient who expresses pain loudly as exaggerating.

Nursing application: Recognize how professional beliefs influence your judgments. Avoid allowing nursing norms to override the patient's experience, preferences, or cultural understanding of illness.

9. Cultural phenomena that affect nursing care

Culture influences health beliefs, communication, pain expression, family relationships, treatment choices, and responses to illness.

Six major culture specifics

A useful framework: Giger's six cultural phenomena

1. Communication

Includes language, gestures, eye contact, touch, facial expressions, and silence. Cultural differences can cause misunderstandings even when people speak the same language.

Nursing: Use clear language, observe nonverbal cues, and ask how the patient prefers to communicate.

2. Space

Personal space is the physical distance a person prefers between themselves and others. Territoriality refers to space a person considers their own.

Nursing: Respect personal boundaries, explain procedures before touching, and preserve privacy.

3. Time orientation

Past-oriented: Decisions and actions are influenced by tradition and past experiences.
Present-oriented: Focuses on immediate needs and current circumstances.
Future-oriented: Emphasizes planning, prevention, and future outcomes.

Nursing: Adapt health teaching to the patient's priorities and circumstances. Offer reminders and practical plans when useful.

4. Social organization

Includes family structure, kinship, community relationships, religious affiliations, and decision-making roles.

Nursing: Ask who the patient wants involved in care and who should participate in decisions. Do not assume a particular family member has authority.

5. Environmental control

Refers to a person's perception of their ability to influence health, illness, nature, and life circumstances.

Nursing: Explore beliefs about control over illness, pain, treatment, and recovery. Do not assume that accepting illness means a patient does not care.

6. Biological variations

Differences in physiology and genetics, including body structure, skin characteristics, vital signs, disease susceptibility, and medication metabolism.

Nursing: Assess each patient individually. Consider biological variation when interpreting findings and evaluating treatment responses.

Other influences on health

Values: Principles or standards that matter to a person. Example: independence.
Beliefs: Things a person accepts as true. Example: germs cause disease.
Practices: Behaviors followed by a person. Example: washing hands before preparing food.
Religion and philosophy: May influence treatment acceptance, dietary practices, or decisions about blood transfusions.
Education: Influences understanding of health, illness, and available treatments.
Technology: Availability of equipment and supplies shapes healthcare expectations.
Politics, law, and economy: Affect healthcare funding, eligibility, affordability, and access.

Exam application: A patient's refusal of pain medication does not mean they have no pain. Assess pain using a validated scale, ask about acceptable ways to manage it, and explore concerns without stereotyping.

10. Differing views of health and illness

People may use several health belief systems, sometimes simultaneously.

System	Main belief	Example
Biomedical/scientific	Illness results from identifiable physiological or pathological processes.	Antibiotics to treat a bacterial infection.
Holistic	Health involves harmony and balance among physical, emotional, spiritual, social, and environmental aspects of life.	Combining appropriate medical treatment with rest, nutrition, meditation, or other supportive practices.
Magico-religious	Health and illness are understood through supernatural or mystical forces.	Prayer, charms, or religious rituals intended to promote healing.
Folk medicine	Traditional health beliefs and practices passed down within families or communities.	Chicken soup for a cold or traditional herbal remedies.

Conventional vs. indigenous healthcare

Conventional healthcare: Formal healthcare delivered by trained professionals, usually using biomedical methods.
Indigenous healthcare: Traditional healing systems, folk medicine, home remedies, and traditional healers.

Patients may use both systems. Dismissing traditional practices can damage trust and prevent patients from disclosing what they use.

Complementary, alternative, and integrative healthcare

Complementary medicine: Used alongside conventional treatment.
Alternative medicine: Used instead of conventional treatment.
Integrative healthcare: Coordinates conventional care and other health practices the patient uses, considering their potential interactions and the patient's overall well-being.

Examples of traditional or alternative approaches described in the chapter include Ayurveda and traditional Chinese medicine, which emphasize balance, harmony, and individualized practices.

Evaluating cultural health practices

Effect	Meaning	Nursing response
Efficacious	Helpful or beneficial.	Encourage when appropriate and safe.
Neutral	Neither helpful nor harmful.	Allow if it does not interfere with care.
Uncertain	Effects are unknown.	Investigate before recommending or discouraging.
Dysfunctional	Harmful or potentially dangerous.	Explain risks and negotiate safer alternatives.

Key nursing principle: Respect the patient's beliefs without automatically accepting every practice as safe. Assess potential interactions, harm, and interference with necessary treatment.

11. Transcultural assessment: guidelines and models

Transcultural nursing involves understanding cultural differences and similarities to provide care that fits the patient's beliefs, values, and needs.

Guidelines for conducting a cultural assessment

Establish rapport: Build trust before collecting sensitive information.
Ask open-ended questions: Encourage the patient to describe their beliefs, background, and health practices.
Assess cultural identity: Ask about preferred identity terms, language, religion, and cultural traditions.
Assess family and social organization: Identify important relationships and whom the patient wants involved in decisions.
Explore health beliefs: Ask what the patient believes caused the illness and what treatments they consider helpful.
Assess folk remedies and alternative treatments: Identify herbs, supplements, home remedies, and traditional healers.
Assess communication preferences: Determine preferred language, interpreter needs, and comfort with eye contact or touch.
Assess biological variations: Consider skin assessment, physiological differences, and individual treatment responses.
Assess pain beliefs and practices: Ask how pain is understood, expressed, and managed.
Document and individualize care: Incorporate relevant findings into the care plan and reassess as needed.

Important: Obtain cultural information directly from the patient whenever possible. Family may provide additional information when appropriate, but should not replace a qualified medical interpreter.

Cultural assessment models

Model/tool	Main focus
Giger and Davidhizar's Transcultural Assessment Model	Six phenomena: communication, space, time orientation, social organization, environmental control, and biological variations.
Leininger's Sunrise Model	Cultural care diversity and universality; identifies cultural factors that influence care.
Transcultural Nursing Assessment Guide	Helps nurses collect information about cultural influences on health and care.
Spector's Heritage Assessment Tool	Assesses heritage consistency—how strongly a person's lifestyle reflects their traditional cultural origins.

Cultural assessment questions to remember

“What do you think caused your illness?”
“What is most important to you during treatment?”
“Are there any cultural or religious practices you would like us to accommodate?”
“Do you use any herbs, supplements, home remedies, or traditional healers?”
“Who would you like involved in healthcare decisions?”
“What language do you prefer for discussing your care?”
“How do you usually manage pain or discomfort?”

Exam tip: Ask, don't assume. Cultural knowledge guides assessment, but the patient's individual answers guide care.

12. Cultural implications in nursing diagnoses

Cultural differences can affect how a nurse interprets a patient's symptoms, behavior, beliefs, and treatment choices.

Examples of culturally influenced nursing diagnoses

Nursing diagnosis or problem	Possible cultural influence
Nutrition alteration	Hospital food does not accommodate the patient's traditional diet.
Parenting alteration	Traditional disciplinary practices conflict with accepted safety standards or expectations.
Powerlessness	The patient feels unable to communicate the importance of cultural rituals or preferences.
Verbal impairment	Language differences interfere with communication. A language difference alone should not be mistaken for a speech or language disorder.
Health maintenance alteration	A treatment plan conflicts with the patient's beliefs, resources, or traditional practices.
Acute pain	Cultural expectations influence how pain is expressed or whether medication is accepted.
Anxiety or coping impairment	The patient's distress may be interpreted differently across cultural contexts.
Decisional conflict	Family expectations, religious beliefs, or differing health beliefs complicate treatment decisions.
Noncompliance	Apparent failure to follow treatment may reflect cost, misunderstanding, beliefs, or limited access.

Preventing culturally biased diagnoses

Collect objective assessment data rather than relying on assumptions.
Ask why a patient is refusing medication or not following a plan.
Explore financial, language, educational, religious, and cultural barriers.
Validate the diagnosis with the patient.
Make sure the diagnosis reflects the patient's actual health needs rather than the nurse's personal expectations.

Example: A patient does not take prescribed blood pressure medication. Instead of immediately labeling the patient noncompliant, assess whether the medication is affordable, understood, available, and acceptable within the patient's health beliefs.

13. Nursing strategies that promote culturally competent care

The nursing process

Assessment — Recognize cues

Collect cultural, social, spiritual, communication, health-belief, and biological information. Establish trust and identify barriers.

Diagnosis — Analyze cues

Identify actual patient problems and validate diagnoses. Avoid interpreting cultural differences as pathology or nonadherence without further assessment.

Planning — Prioritize and generate solutions

Set measurable, culturally appropriate goals with the patient. Consider personal preferences, family involvement, religious practices, resources, and treatment safety.

Implementation — Take action

Adapt teaching and interventions, accommodate safe cultural practices, negotiate treatment conflicts, use interpreters, and advocate for equitable care.

Evaluation — Evaluate outcomes

Determine whether goals were met, treatments were understood and acceptable, and the patient's cultural needs were respected. Revise the plan when necessary.

Leininger's three culturally congruent care actions

These are particularly important for nursing exams.

Culture care preservation/maintenance: Support beneficial cultural practices and help patients continue them.
- Example: Accommodating a safe religious ritual during hospitalization.
Culture care accommodation/negotiation: Work with patients to adapt or negotiate care so cultural preferences and health needs can both be addressed.
- Example: Arranging blood pressure checks while allowing the patient to continue seeing a traditional healer.
Culture care repatterning/restructuring: Help patients modify harmful practices while respecting their cultural values.
- Example: Working with a patient to replace a dangerous remedy with a safer approach.

Other nursing interventions

Mutual goal setting: Collaborate with the patient to develop realistic goals.
Self-responsibility facilitation: Support informed participation in healthcare decisions.
Culture brokerage: Bridge the patient's cultural beliefs and the biomedical healthcare system through culturally appropriate strategies.
Advocate for patients who experience discrimination or limited access to care.
Collaborate with family members and traditional healers when appropriate and acceptable to the patient.
Provide culturally appropriate educational materials, diagrams, referrals, and dietary accommodations.
Protect patient autonomy and avoid coercion.

Five practical strategies for cultural competence

Self-reflection: Examine your own values, assumptions, and biases.
Continued learning: Learn about cultures represented in your community and workplace.
Accommodation and negotiation: Incorporate safe cultural practices and negotiate conflicts.
Collaboration: Work with patients, families, interpreters, and other care providers.
Respect: Recognize each patient as an individual and preserve dignity.

Memory aid: BALI

B — Be aware of your own cultural heritage.
A — Appreciate that the client is unique.
L — Learn about the client's cultural group.
I — Incorporate the client's cultural values and behaviors into the care plan.

Cultural competence vs. cultural humility

Cultural awareness: Recognizing external signs of cultural diversity.
Cultural sensitivity: Understanding and appreciating cultural similarities and differences.
Cultural competence: Applying cultural understanding to provide appropriate, respectful care.
Cultural humility: Lifelong self-reflection, learning, and openness to the patient's perspective.

Cultural competence is a developmental process, not something achieved simply by memorizing facts about different groups. Cultural humility emphasizes continuing to learn from each patient.

14. Techniques for communicating with clients who face language barriers

Best practices

Use a qualified medical interpreter. This is especially important for informed consent, explaining treatment, and obtaining accurate health information.
Use trained bilingual staff when available and appropriate, following facility policy.
Use face-to-face or telephone interpretation when needed.
Speak directly to the patient, not to the interpreter, and maintain the patient's dignity.
Use simple, clear language. Avoid medical jargon, slang, idioms, and complicated explanations.
Speak slowly and pause frequently to allow accurate interpretation; do not shout.
Use pictures, diagrams, and translated written materials to reinforce verbal teaching.
Verify understanding, such as by asking the patient to explain the plan in their own words through the interpreter.
Observe nonverbal communication, while remembering that gestures, eye contact, and silence can have different cultural meanings.
Follow facility policies if the patient speaks a dialect the interpreter cannot understand or if additional language assistance is required.

Interpreter vs. translator

Interpreter	Translator
Conveys the meaning of spoken communication between languages.	Converts written information from one language into another.
Can help clarify culturally influenced meanings and communication.	Helps patients understand written materials in their preferred language.

Important: Do not rely on family members as interpreters when a qualified interpreter is needed, particularly for sensitive information and informed consent. Family members may omit, misunderstand, or filter information.

CLAS standards

Culturally and Linguistically Appropriate Services (CLAS) standards promote healthcare that respects and responds to patients' cultural and language needs.

The chapter identifies language assistance through bilingual staff, trained face-to-face interpreters, or telephone interpreters, as appropriate under the applicable standards and facility policies.

Exam tip: When a patient cannot understand the language used for informed consent, arrange qualified interpretation rather than relying on gestures or a family member to obtain consent.

15. Barriers to culturally competent care

Know these terms and how they affect patient care.

Barrier	Definition	Nursing example
Bias	Lack of impartiality; a one-sided viewpoint that may be positive or negative.	Assuming a patient will refuse treatment because of their background.
Ethnocentrism	Believing one's own culture is superior to others.	Calling a patient's traditional healing practices strange or wrong without assessment.
Stereotyping	Assuming all members of a group share the same characteristics.	Assuming a patient will not want pain medication because of their ethnicity.
Prejudice	A negative attitude toward someone based on a generalized belief or stereotype.	Believing a patient is irresponsible because of their socioeconomic status.
Discrimination	Actions that unfairly deny people services, opportunities, or equitable treatment.	Providing less attentive care because of a patient's race or religion.
Racism	Racist ideas and policies that produce or normalize racial inequities.	Racial bias affecting the quality or timeliness of healthcare.
Language barriers	Difficulty communicating because of language, dialect, slang, or jargon differences.	A patient misunderstands medication instructions.
Lack of cultural knowledge	Insufficient understanding of another person's beliefs or practices.	Mistaking a culturally appropriate behavior for a symptom.
Fear and distrust	Emotional responses that interfere with communication and relationships.	A patient with previous experiences of discrimination hesitates to disclose concerns.

Nursing responsibilities related to racism and discrimination

Provide fair, respectful care to all patients.
Recognize personal biases and challenge discriminatory assumptions.
Speak up when observing racism or injustice.
Advocate for equitable treatment and access to services.
Address barriers that delay care or worsen health disparities.

Final cram sheet: High-yield definitions

Use this as a quick review before your exam.

Self-test: 0 of 24 definitions revealed

Reveal all

Diversity

Multiculturalism

Culture

Acculturation

Assimilation

Socialization

Ethnocentrism

Culture universal

Culture specific

Archetype

Stereotype

Vulnerable population

Biomedical system

Holistic care

Folk medicine

Complementary medicine

Alternative medicine

Integrative healthcare

Cultural competence

Cultural humility

Culture brokerage

Cultural preservation

Cultural accommodation

Cultural repatterning

Five principles to remember for nursing exams

Ask, don't assume: Cultural identity does not predict every patient's beliefs or behavior.
Assess before intervening: Understand the patient's beliefs, preferences, resources, and barriers.
Respect while protecting safety: Support helpful and neutral practices, investigate uncertain practices, and address harmful ones.
Individualize the nursing process: Cultural factors can affect assessment, diagnosis, goals, interventions, and evaluation.
Communicate effectively: Use qualified interpreters when needed, clear language, and patient-centered teaching.

The single most useful question to remember from this chapter is: “What matters most to you in your illness and treatment?” The answer can guide culturally appropriate care, improve trust, and help you develop a plan the patient can understand and participate in.