by Dawn M. Bowker, PhD, ARNP-BC, CNE
America is changing and we are experiencing more diversity than ever before. With this diversity, we are creating mosaic of cultures that add a richness to our communities however; it can also create challenges in providing culturally appropriate care to patients. To achieve the best outcomes, we must respect the fact that our patient’s culture shapes their concept of health, illness, and health practices. To be an effective partner in their health journey, we need employ cultural humility and be cognizant of our own ethnocentrism.
As nurses care for patients and families with diverse backgrounds, preferences, and cultures, we experience cross-cultural experiences. Culture influences people’s health status and it shapes our concept of health, illness, and health practices. Impact of and meaning ascribed to an illness by a patient could be in conflict with the meaning ascribed to the illness by the nurse. This difference can result in a cultural misunderstanding that can negatively impact the health outcome for the patient.
Nurses need to develop cultural humility so they can bridge the gap between the patient and the health care system. Cultural humility is recognizing and being cognizant of ethnocentrism so we do not make false assumptions. A nurse who possesses cultural humility recognizes the limitations of their cultural perspective and works towards overcoming their perspective in order to provide better nursing care to all patients. Cultural humility addresses the power imbalance between the nurse and the patient. A nurse who recognizes their own unconscious bias is more likely to maintain an open mind and be respectful of all people and not act as if their way was the only way or the best way to proceed. Cultural humility entails working collaboratively with clients and embracing difference. Cultural humility comes from a position not as experts but from a perspective of learning and understanding. It forces us to step back and realize this person is an expert on their culture, background, and experiences.
The American Nurses Associations (ANA) Code of Ethics states that nurses must practice “with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (ANA, 2015).”
Cultural humility is a lifelong journey of self-reflection and works in apposition with cultural competence to improve health outcomes and decrease disparities. Cultural humility, along with an understanding of the impact of social determinants of health (SDOH) improve health outcomes and reduce health inequities. SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH can be grouped into five domains: economic stability, education access and quality, health care access and quality, neighborhood- built environment, and social and community context (Healthy People 2030). One of Healthy People 2030 overarching goals specifically related to SDOH is to “Create social, physical, and economic environments that promote attaining the full potential for health and well Being for all.” Reducing health inequity is a clear social mandate for nursing in the 21st century, and will require nursing care that is more acutely focused on the SDOH (Thorton & Persaud, 2018).
SDOH require knowledge of and include, but not limited to, the concepts of advocacy, ethics, clinical judgement, communication, compassionate care, diversity, equity, inclusion, evidenced based practice, quality and safety, and professionalism. It is important to specifically address the concepts of diversity, inclusion, and equity. The definitions of these concepts vary in the literature.
Diversity addresses potential differences in individuals and groups. Diversity encompasses differences in race, age, gender identity, religion, culture, language, sexual orientation, and socioeconomic class of individual persons. Inclusion is creating, fostering, and sustaining practices and conditions that encourage and allow each of us to be fully ourselves—with our differences from and similarities to those around us—as we work together (Jagoo, 2021). Inclusion refers to the act or practice of including and accommodating people who have historically been excluded because of their race, gender, sexuality or ability (Jagoo, 2021). Diversity focuses on representation, whereas inclusivity focuses on how to help the group feel like they belong.
Equity examines the fairness by which persons of diverse backgrounds are able to access information, health care, higher education, and other resources that help them to advance and fully contribute to society. A common image differentiating equality and equity is three different persons with different physical characteristics. Equality is providing all three people with three identical bicycles. Equity is providing each individual with a bicycle that is appropriate for their use. In this analogy, a young child would receive a smaller bicycle than a person who is six feet tall or a person with physical limitations. With equity, each would receive a bicycle to accommodate their physical structure, strengths, and limitations.
Similarly, the definitions of race and ethnicity are often used synonymously. Race represents the physical characteristics. Race is biological, describing physical traits inherited from your parents. A person may identify as belonging to one or more race such as White, Black or African American, Asian, American Indian or Alaska Native, or Native Hawaiian or Pacific Islander. Ethnicity reflects cultural identification. Cultural identity, chosen or learned from your culture and family. Commonalities such as national origin, tribal heritage, religion, language, and culture can describe someone’s ethnicity.
As nurses, we cannot overemphasize the significant impact cultural humility, SDOH, diversity, equity and inclusion have on the health outcomes of our patients. When we understand and employ these concepts, we can bridge the gap between the patient and the health care system and provide the best possible care for our patients.
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