Chapter 2 Culturally competent care

Written by Cory Shaw Retherford, Margaret M. Andrews

Adapted by Frances Hughes, Lesley Seaton

1. Define the terms culture, subculture, ethnicity, acculturation, assimilation, stereotyping, ethnocentrism, cultural imposition, values, cultural safety, transcultural nursing and cultural competency.

2. Describe factors that contribute to health disparities among different cultural and ethnic groups.

3. Describe the potential effects of migration on people’s health.

4. Describe strategies for successful cross-cultural communication.

5. Identify social and spiritual aspects of culture and ethnicity to consider when providing nursing care.

6. Identify ways that the nurse’s own cultural background may influence nursing care when working with patients from different cultural and ethnic groups.

7. Identify strategies for planning and documenting culturally appropriate nursing care.

8. Describe the role of the nurse in reducing health disparities.

In today’s increasingly multicultural environment, nurses will come into contact with individuals from many different cultures during their professional careers. They will find themselves in patient care situations that require an understanding of the patient’s cultural beliefs if they are to participate in planning and providing effective culturally safe care. The worldwide recognition of the needs of Indigenous peoples, and the changing demographic and cultural composition of Australia, New Zealand (or Aotearoa, the Māori name for New Zealand) and other developed countries, make it imperative for nurses to be aware of cultural differences in healthcare needs and healthcare practices, and the potential differences in expectations between patients and healthcare providers. The nurse needs to acknowledge and accept the influence of a patient’s cultural beliefs to prevent conflict from occurring between the goals of nursing and the patient’s own healthcare practices based in their cultural background.

The nurses providing care for Australia’s and New Zealand’s diverse populations are registered nurses, enrolled nurses and assistants in nursing, who make up the largest portion of healthcare providers. Nurses today are finding it increasingly challenging to provide care for the growing number of patients who will inevitably be from cultural backgrounds other than their own. Even when nurses provide care for patients from their own cultural background (see Fig 2-1), the nurse may be from a different subculture than the patient. It is important that all nursing care provided in healthcare situations should be carried out with full consideration of the unique cultural needs of individual patients and their families. In some cultures (e.g. Indigenous Australian or Māori), relationships may be managed in a different way. It may depend on their ‘skin relationship’ as to whether an Indigenous nurse can care for another Indigenous person. Some communities have strict taboos as to who can speak to whom and who can care for whom. Indigenous nurses and patients will know if this occurs and changes in patient allocation should be facilitated.

Figure 2-1 A special Māori Health Nursing Scheme was established early last century to allow Māori nurses to train and minister to the health needs of their people.

Source: Archives New Zealand/Te Rua Mahara o te Kawanatanga, Wellington Office.

Culture

There are many definitions of culture. In general, culture encompasses the knowledge, values, beliefs, art, morals, law, customs and habits of the members of a society. Culture also includes the systems of technology and political practices. Cultural patterns of behaviour develop over time and are shared by members of the same cultural group.¹ Culture affects ways of perceiving, behaving and evaluating the world, and serves as a guide for people’s values, beliefs and practices, including those related to health and illness.²

Values are the sets of rules by which individuals, families, groups and communities live. They are the principles and standards that serve as the basis for beliefs, attitudes and behaviours. Although all cultures have values, the types and expressions of those values differ from one culture to another. These cultural values develop over time, guide decision making and actions, and may affect a person’s self-esteem. Cultural values are often unconsciously developed as a child is assimilated into the culture and learns what becomes for them acceptable and unacceptable behaviour. The extent to which a person’s cultural values are internalised influences that person’s tendency towards judging other cultures, while using their own culture as the accepted standard.^1,³^–⁵ For example, homosexuality is acceptable to some people and not to others. Homosexuals who live within a gay or lesbian community are seen as ‘normal’ and accepted by their peers. If they move outside their own community, others such as those from the heterosexual community may have a more negative reaction to them. Likewise, homosexuals may not necessarily trust someone whom they consider ‘straight’—that is, non-homosexual. This is something of a generalisation, but it does illustrate how we often see things only through our own eyes and use our views to judge others whom we may not have even met or associated with.

Although individuals within a cultural group will have many similarities through their shared values, beliefs and practices, there is also much diversity within groups. Each person is culturally unique.⁴ Diversity is a phenomenon that occurs as a result of the different perspectives and interpretations used to interpret everyday situations. These differences may be based on age, gender, marital status, family structure, income, education level, religious views and life experiences.

Within any cultural group there are smaller subcultures, which may not hold all of the values of the dominant culture. These subcultures, including ethnic groups, have experiences that differ from those of the dominant group. These differences may be related to ethnic background, residence, religion, occupation, health-related characteristics, age, gender, sexual preference, education or other factors that unite the group. Members of a subculture share certain aspects of culture that are different from those of the overall cultural group. Religious subcultures include Catholics, Jews, Muslims and other members of any of the 1200 recognised religions worldwide. Ethnic subcultures include groups who share common traits, such as ancestry, language or physical characteristics; for example, Australian Aboriginal and Torres Strait Islander people, and Māori and members of the many Pacific Island communities. Throughout this textbook, the term Indigenous Australian will be used generally to refer to Australian Aboriginal and Torres Strait Islander peoples, except where these peoples are discussed specifically.

It is important to understand certain aspects of culture if the nurse is to understand the impact of culture and how cultural practices may affect the way people take care of their health or treat illnesses. The four basic characteristics of culture (learned, shared, adapted, dynamic) are described in Box 2-1.

Cultural practices change over time through active or passive processes, including acculturation and assimilation. Acculturation occurs when people modify their own culture as a result of contact with another culture.⁵ This process may be a gradual change that results in increased similarities between the two cultures. Assimilation involves a generally one-way process whereby people lose their own cultural identity as they gradually adopt and incorporate characteristics of the prevailing culture.⁵ Both acculturation and assimilation may be voluntary or, in some instances, involuntary (e.g. as a result of war, colonisation or involuntary relocation).

The meaning of the terms ethnicity and race continues to evolve and be debated. Ethnicity refers to groups whose members share a common social and cultural heritage and history. This heritage is passed on through the generations and enables identification with that particular group (see Fig 2-2). Members of an ethnic group may share a common language, history, education, lifestyle and religion. They share a sense of identity, loyalty and social belonging.^3,⁶ However, ethnic groups do not exist in isolation. In the modern world, where people have become so geographically mobile, we are increasingly aware of differences that separate one ethnic group from another. The term race is used less often today; historically, it was used to label people who shared a common ancestry or physical characteristics such as inherited skin colour or bone structure. Ethnicity is considered to be a more global and less discriminating term than race and is used in this textbook.

Figure 2-2 Cultural and social heritage are passed on through the generations.

Stereotyping involves viewing members of a specific culture or ethnic group as all being alike and sharing the same values and beliefs—it is an oversimplified concept, opinion or belief about some aspect of an individual or a group of people.⁶ This oversimplified approach does not take into account the individual differences that exist within a culture. For example, the Pacific is inclusive of cultural groups from Tonga, Samoa, the Cook Islands, Tokelau, Niue, Nauru, Fiji, Kiribati and Vanuatu. Within each of these cultures there are many subcultures based on variations including geographic region, religion, language, socioeconomic level, gender, family structure, parenthood status, educational level and degree of adherence to traditional medicines and practices.⁶ In healthcare (as well as in most other) settings, being a member of a particular ethnic group should not be considered to make that person an expert on other members of that same group. Such stereotyping can lead to false assumptions being made, which can negatively affect a patient’s care. For example, it would be inappropriate to assume that just because a nurse is English-speaking, the nurse would know how an English-speaking patient’s beliefs may affect the patient’s healthcare practices. The nurse may have been born and raised in a large city, such as Melbourne or Auckland, and assimilated a different culture from an older patient who was born and raised in a rural area of Victoria or New Zealand’s rural far north.

Ethnocentrism is the tendency to subconsciously view others using one’s own understanding and customs as the standard.² When considering one’s own ways of thinking, acting and believing to be the only right and natural ways, there is a danger of seeing others’ beliefs as unusual or strange, and therefore wrong.⁵ Comparing others’ ways of living to one’s own can lead to seeing others as different or inferior. To avoid ethnocentrism, it is necessary to maintain an objective and non-judgemental view of the values, beliefs and practices of others. Failure to do this can result in ethnic stereotyping or cultural imposition.

Cultural imposition results when one’s own cultural beliefs and practices are imposed on another person or group of people. In healthcare it can result in disregarding or trivialising a patient’s healthcare beliefs or practices. Cultural imposition may result when a healthcare provider is not aware of a patient’s cultural beliefs and moves forwards with planning and providing care without taking these beliefs into account.

Nursing as a discipline has developed and used different scholarly opinions and theories to enable nurses to deepen their understanding of culture and enable them to care appropriately for patients from different cultural backgrounds.² Several of the more commonly used theories, ideas and terms are explained here; however, knowledge is constantly evolving in this new field of understanding. So while these views and explanations serve to offer some insight, nurses must remain open to further developments on the subject of cross-cultural care.

Cultural competence

The term transcultural nursing was developed by Madeleine Leininger, a North American nursing theorist, in the 1950s. Transcultural nursing has today developed into a specialty that focuses on the comparative study and analysis of cultures and subcultures. The goal of transcultural nursing is the discovery of culturally relevant facts that can guide the nurse in providing culturally appropriate and competent care.^3,⁷^–⁹

In Australia and New Zealand the term cultural competence is more often used than transcultural nursing. Cultural competence involves the complex integration of knowledge, attitudes and skills that enable the nurse to provide culturally appropriate healthcare.^2,⁴ Developing cultural competence requires: (1) cultural awareness; (2) cultural knowledge; (3) cultural skills; and (4) cultural encounter and cultural desire (see Box 2-2).

BOX 2-2 Processes involved in developing cultural competence

Cultural awareness

• Identify one’s own cultural background, values and beliefs, especially as related to health and healthcare.

• Examine one’s own cultural biases towards people whose cultures differ from one’s own culture.

Cultural desire

• Be motivated to engage in the process of becoming culturally aware, knowledgeable and skilful and to seek cultural encounters as opposed to being required to seek such encounters.

• Develop a genuine passion to be open to others, accept and respect differences, and be willing to learn from others as cultural informants.

CULTURAL AWARENESS

Cultural awareness is a conscious learning process in which individuals become appreciative of and sensitive to the cultures of other people. Every person is a cultural being. Therefore, any nurse–patient interaction will be affected by the culture of both the nurse and the patient. Nurses are influenced not only by their own cultural background but also by the nursing profession and the culture of the healthcare setting in which the interaction occurs.² One of the first steps in developing cultural awareness is for nurses to examine their own cultural biases towards people from different cultures. A nurse’s biases may interfere with providing culturally appropriate healthcare.

Developing knowledge and awareness of some of the ideas held by different cultural groups can be challenging and sometimes even personally distressing or confronting for nurses. Being faced with lifestyles, personal habits or choices that differ significantly from one’s own can be very difficult to understand or even to think about in an impartial way. One situation encountered in Australia that has become surrounded by controversy is that of female circumcision (often referred to as female genital mutilation). Even in its naming the controversy becomes evident as those who take part in or support such a practice would prefer to use the more impartial terms ritual female cutting or women’s marks, not female genital mutilation.

With nursing today having a deeper awareness of ethical codes and standards, there is the added responsibility to consider ethical and often legal requirements and obligations. These require nurses to consider and accommodate all the cultural, religious and social practices of patients when providing care. This ethical mandate refers not only to those practices that nurses might be comfortable with but also to those that may be contrary to the nurse’s belief system or that are different from broader social norms. One familiar example is that of the right of some patients, such as Jehovah’s Witnesses, to refuse blood products on religious grounds. This right to be different is supported ethically and legally. It is also commonplace to accommodate a range of dietary habits through providing halal or kosher meals. Any number of religious practices and observances are either accommodated for or provided to patients. Most nurses today incorporate a variety of different cultural and social practices into their care-giving behaviour. It could be argued that practices such as female circumcision are a choice made by patients as individuals and should be accepted less critically by nurses to respect the right to individual choice for that particular patient or social community.

Developing cultural awareness is an important step towards providing culturally appropriate care and avoiding ethnocentrism and cultural imposition.

CULTURAL KNOWLEDGE

Cultural knowledge involves understanding the key aspects of a group’s culture, especially as it relates to health and healthcare practices. Different cultural groups have different beliefs about the causes of illnesses and the appropriateness of various treatments. It is important for the nurse to try to determine the patient’s explanatory model (what causes the disease or illness and the potential methods the patient believes would best treat the condition). It is also important to determine how patients’ different experiences and beliefs might affect their health and healthcare. Patients may be using culturally appropriate remedies that may affect the treatment prescribed by the healthcare provider. In addition to asking patients about prescribed medications they may be taking, nurses also need to ask about ‘natural’ or herbal substances or over-the-counter medications used to prevent or treat their condition. For example, an Indigenous Australian patient may be taking bush remedies for diabetes, or a woman of Eastern European descent may take a traditional medicine from her home country for treating an illness. Either of these substances could interact with prescription medications and cause untoward effects. Members of cultural groups such as Māori and Pacific Islanders may use traditional healing methods, either in place of, or in addition to, orthodox Western medicine.^10,¹¹

Lack of cultural awareness can lead to misdiagnosis and mistreatment of a patient because the patient’s natural expression of pain or emotions or use of traditional healthcare practices is misinterpreted. The consequences of this can range from minor to serious. For example, the traditional South-East Asian treatment of cupping uses glass cups that are heated to create a vacuum when placed on a patient’s skin. This treatment is used for many illnesses, especially for increasing local circulation and treating lung congestion. Another treatment is coining, which involves placing a menthol oil or ointment on the skin and then rubbing or scraping the area with a coin. This treatment is used for pain, colds, heat exhaustion, vomiting or headache and leaves marks that can look like a strap mark. If either of these treatments has been used and the healthcare provider does not know about it, the results may appear to be from physical abuse.^2,¹²

CULTURAL SKILLS

The term cultural skills refers to the nurse’s ability to develop a rapport with the patient that will enable the nurse to collect relevant cultural data regarding health histories and perform culturally appropriate assessments. Gaining and understanding shared cultural knowledge can be beneficial to creating a safe environment so that patients feel able to share information about their health-related cultural practices. Specific information is presented throughout this textbook to assist with developing an awareness of cultural differences and learning assessment skills for different cultural groups. Box 2-3 presents a cultural assessment instrument.

BOX 2-3 Cultural assessment

Health-related beliefs and practices

• To what cause(s) does the person attribute illness and disease (e.g. divine wrath, imbalance in hot/cold or Yin/Yang, punishment for moral transgressions, hex, soul loss)?

• What does the person believe promotes health (eating certain foods, wearing amulets to bring good luck, exercise, prayer, rituals to ancestors, saints or intermediate deities)?

• What is the person’s religious affiliation (e.g. Judaism, Islam, Pentecostalism, Seventh-Day Adventism, Catholicism, Mormonism)?

• Does the person rely on cultural healers (e.g. curandero, shaman, spiritualist, priest, minister, monk)?

• Who determines when the person is sick and when he or she is healthy? Who determines the type of healer and treatment that should be sought?

• In what types of cultural healing practices does the person engage (use of herbal remedies, potions, massage, wearing of talismans or charms to discourage evil spirits, healing rituals, incantations, prayers)?

• How are biomedical/scientific healthcare providers perceived? How do the person and family perceive nurses or doctors? What are the expectations of nurses and nursing care?

• What is appropriate ‘sick role’ behaviour? Who determines what symptoms constitute disease/illness? Who decides when the person is no longer sick? Who cares for the person at home?

• How does the person’s cultural group view mental disorders? Are there differences in acceptable behaviours for physical versus psychological illnesses?

Nutrition

• What is the meaning of food and eating to the person? With whom does the person usually eat? What types of food are eaten? What does the person define as food? What does the person believe composes a ‘healthy’ versus an ‘unhealthy’ diet?

• How are foods prepared at home (type of food preparation, cooking oil(s) used, length of time foods are cooked, especially vegetables, amount and type of seasoning added to various foods during preparation)?

• Do religious beliefs and practices influence the person’s diet (e.g. amount, type, preparation or delineation of acceptable food combinations, such as kosher diets)? Does the person abstain from certain foods at regular intervals, on specific dates determined by the religious calendar or at other times?

• If the person’s religion mandates or encourages fasting, what does the term ‘fast’ mean (e.g. refraining from certain types or quantities of foods, eating only during certain times of the day)? For what period of time is the person expected to fast?

• During fasting, does the person refrain from liquids/beverages? Does the religion allow exemption from fasting during illness? If so, does the person believe that an exemption applies to them?

Socioeconomic considerations

• Who composes the person’s social network (family, peers and cultural healers)? How do they influence the person’s health or illness status?

• How do members of the person’s social support network define caring (e.g. being continuously present, doing things for the person, looking after the person’s family)? What are the roles of various family members during health and illness?

• How does the person’s family participate in the nursing care (e.g. bathing, feeding, touching, being present)?

• Does the cultural family structure influence the person’s response to health or illness (e.g. beliefs, strengths, weaknesses and social class)? Is there a key family member whose role is significant in health-related decisions (e.g. eldest adult son in Asian families)?

• Who is the principal wage earner in the person’s family? What is the total annual income? (Note: This is a potentially sensitive question that should be asked only if necessary.) Is there more than one wage earner? Are there other sources of financial support (extended family, investments)?

• What impact does economic status have on lifestyle, place of residence, living conditions, ability to obtain healthcare, discharge planning?

Organisations providing cultural support

• What influence do ethnic/cultural organisations have on the person receiving healthcare (e.g. churches, schools, community-based healthcare programs and clinics)?

Spiritual considerations

• Does the person have religious objects in the environment?

• Does the person wear outer- or undergarments having religious significance?

• Are get-well greeting cards religious in nature or from a religious representative?

• Does the person appear to pray at certain times of the day or before meals?

• Does the person make special dietary requests (e.g. kosher diet; vegetarian diet; diet free from caffeine, pork, shellfish or other specific food items)?

• Does the person read religious magazines or books?

• Does the person mention God (Allah, Buddha, Yahweh or a synonym), prayer, faith or other religious topics?

• Is a request made for a visit by a member of the clergy or other religious representative?

• Is there an expression of anxiety or fear about pain, suffering, death?

• Does the person prefer to interact with others or to remain alone?

Source: Adapted from Andrews MM, Boyle JS. Transcultural concepts in nursing care. 5th edn. Philadelphia: Lippincott Williams & Wilkins; 2007. Jarvis C. Physical examination and health assessment. 6th edn. Philadelphia: WB Saunders; 2011.

Delivery of culturally appropriate care can prevent unnecessary conflict between the nurse and patients who are from different cultural backgrounds. Providing culturally appropriate care also increases patient satisfaction and may assist the patient to follow through on the regimen that has been agreed upon. This in turn has the potential to enhance the patient’s progression towards wellness, decrease the length of hospital stay, and enable health teaching and health promotion activities.

CULTURAL ENCOUNTER AND CULTURAL DESIRE

Cultural encounter is the process that encourages individuals to engage directly in cross-cultural interactions with people from culturally diverse backgrounds (see Fig 2-3). Developing cultural competence requires that the nurse works positively within the experience of interacting with persons from different cultures and learning how their cultural beliefs and practices affect their health and healthcare practices. Through developing expertise in interacting with members of other cultures, the nurse can become more culturally competent in caring for them. However, there are times when a cultural encounter can feel more like a member of one culture ‘bumping’ against another, unfamiliar and different culture. Experiencing such a ‘bump’ should lead the individual to reflect on the encounter, which can promote cross-cultural understanding.¹³ If not, the ‘bumpy’ obstacle remains until renegotiated through personal reflection and openness. Understanding of other cultures is encouraged through spending time with others. This must always be seen as an ongoing process of cross-cultural learning and understanding that never comes to an end.

Figure 2-3 The cultural encounter process encourages individuals to engage in cross-cultural interactions with people from culturally diverse backgrounds.

The nurse also needs to be motivated to become culturally aware, knowledgeable and skilful and to seek cultural encounters. This cultural desire is in contrast to being required to seek such experiences and encounters. The nurse needs to genuinely desire to be open to others, accepting and respecting differences, and willing to learn from others as cultural informants.

CULTURAL VITALITY

Cultural vitality has been described as ‘the emotional strength, the spirit, the essence of people who strive and struggle to maintain strong identity and adapt to new and challenging environments, while they value and pass on distinctive cultural beliefs, practices and life ways’.¹³ Understanding cultural vitality assists healthcare professionals to move beyond stereotyping cross-cultural practices and behaviours to where they are able to fully engage with and support another’s right to live their culture in whatever contemporary way they deem appropriate. Migrants who choose to live in another country with a totally different culture maintain cultural vitality through defining a strong personal identity while still adapting to their new environment. Similarly, Indigenous Australians, Māori and Pacific Islander peoples may not overtly express traditional cultural practices while living in urban areas and cities, but their cultural integrity will be vital and enduring for their descendants, provided they can effectively problem solve the process of adaptation.

CULTURAL SAFETY

The concept of cultural safety was introduced to New Zealand nursing by the late Dr Irihapeti Ramsden. Closely linked to the Treaty of Waitangi, and to Māori health and the need for more Māori nurses, cultural safety is now embedded in the educational practices of all New Zealand nursing schools. The term has become more broadly used and understood over time. Ramsden believed that all recipients of nursing care should experience cultural safety—that is, they should be protected from the imposition of an individual nurse’s culture and understanding and from the culture of health professionals—‘our attitudes, our power and how we manage these things whether unintentionally or otherwise’.¹⁴

The idea that nursing itself (like all the healthcare professions) has a culture, and that we may harm patients and/or their families through the way we relate to them, even unintentionally, can be a difficult one to accept. Ramsden’s argument, which has been continued by nurse leaders in New Zealand, is that until we truly understand the effects of our interactions on others, and the way these may inadvertently hurt others, we cannot act safely as health professionals. Of course, the concept is one we all need to continue to work towards, not one that we can ever say is finally achieved, just as the general concept of safety to practise is always under scrutiny in the life of a professional nurse. Safety is something nurses need to consider in every interaction with every patient.

It is for this reason that cultural safety is embraced by the Nursing Council of New Zealand. The Nursing Council of New Zealand defines cultural safety as: ‘The effective nursing practice of a person or family from another culture, and is determined by the person or family.’¹⁵ For nurses to deliver the nursing service in a culturally safe manner, they have to undertake a process of reflection on their own cultural identity and recognise the impact that their own personal culture has on their professional practice. An unsafe cultural practice is defined as any action that ‘diminishes, demeans or disempowers the cultural identity and well-being of an individual’.¹⁵

The Nursing and Midwifery Board of Australia requires nurses to adhere to Competency Standards, a Code of Ethics and a Code of Professional Conduct. The Competency Standards require nurses to practise in a way that acknowledges the dignity, culture, values, beliefs and rights of individuals/groups. The Code of Ethics states that nurses should value quality nursing care for all people, respect and kindness for self and others, the diversity of people, and access to quality nursing and healthcare for all people. The Code of Professional Conduct states that nurses should respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues.¹⁶

More information about cultural safety can be found in the Resources on p 35.

Health disparities and the social determinants of health

Differences in the occurrence of diseases in different racial and ethnic populations exist globally. For example, the Australian Bureau of Statistics and the Australian Institute of Health & Welfare have published data that indicate that Indigenous Australians are disadvantaged across a number of indicators, all of which impact on their health and wellbeing. For the period 2005–2007, life expectancy at birth was estimated to be 67 years for Indigenous males and 73 for Indigenous females, compared with 79 years for non-Indigenous males and 83 years for non-Indigenous females—a difference of 12 years and 10 years for males and females, respectively.¹⁷ Generally, diseases such as diabetes mellitus and cardiac and renal conditions are overrepresented in the Australian Indigenous population. An overview of Australian Indigenous health is provided by Australian Indigenous HealthInfoNet (see Resources on p 35). Similarly, in New Zealand, the US and Canada, the Indigenous populations have higher incidences of diabetes mellitus and other chronic illnesses than the general population.^18,¹⁹ Differences among ethnic groups represent both a challenge to understand the reasons and an opportunity to reduce illness and death and to improve survival rates.

Information concerning disparities in health among ethnic and Indigenous Australian groups in Australia is available on the Australian Institute of Health & Welfare website (see Resources on p 35). Similarly, information about the health of Māori and non-Māori in New Zealand is available on the Statistics New Zealand website (see Resources on p 35). In addition, individual chapters in this textbook discuss specific ethnic and cultural variations in disease and responses to treatment.

Social and economic factors are known to have a fundamental impact on health, as are the consequences of racism and other forms of discrimination.²⁰ Key social and economic determinants that influence health status include income, education, employment and housing. The health of Indigenous peoples is argued to have been significantly affected by colonisation within the South Pacific and Australasia and the consequent impact on lifestyle and life chances associated with loss of land, loss of self-determination and governance, as well as the introduction of new diseases.¹³ In New Zealand, the efforts to recognise the Treaty of Waitangi are an attempt to rectify some of these problems. In Australia, however, reconciliation is more complex, as no such treaty was made and colonisation took effect within a perception of terra nullius (‘no man owns this land’). Self-determination in health issues remains a problem for Indigenous Australian communities, which are often still trapped in a reliance on federal governance and money.²¹

MIGRATION

Migrants may be at risk of developing health problems for many reasons. They may be at risk because of pre-existing conditions they have when migrating, in the case of humanitarian arrivals, or they may be at increased risk after arriving in a new area. Relocation is associated with many losses and can cause stress and mental distress (see Fig 2-4).²²

Figure 2-4 Migration can be a daunting experience for the young and the elderly.

Health problems faced by humanitarian migrants include not just the psychosocial sequelae of moving country but also the potential to bring with them the typical illnesses of their homeland. It is recognised that resettled refugees and asylum seekers have high-level healthcare needs.²³ Those who care for such migrant populations need special skills in counselling and in dealing with a range of diseases that are less common in Australia and New Zealand. Examples include, but are not limited to: tuberculosis, malaria and human immunodeficiency virus (HIV) infection.

The majority of migrants coming into Australia and New Zealand, however, are from skilled migration streams and they are invariably healthy on arrival as they must meet strict selection criteria and undergo health screening assessments prior to arrival in their new country. So, on arrival, compared to the local population, there is an apparent ‘healthy’ migrant effect. This is because entry is permitted only for those migrants who are healthy. Epidemiological measures such as mortality, hospitalisation rates and the prevalence of lifestyle-related health risks support this.²⁴ However, this relative advantage tends to diminish as length of stay increases and former migrants become integrated into their new community. Evidence is beginning to emerge that morbidity and mortality from certain diseases are increased in certain ethnic minority groups. One major reason for this has been identified as the avoidance of healthcare services that are perceived as culturally incongruent.²⁵ A range of social, economic and environmental determinants also impact on ethnic minority groups. For example, language barriers, financial difficulties, housing problems and unemployment can pose problems, making it very difficult for migrants, in both the short and long term, to settle into their new country. Eventually, this increases their risk in terms of health burden across a range of categories. In spite of the settlement services available to new migrants and refugees, they often remain at a disadvantage with a very negative correlation to good health.²⁶

Cultural and ethnic differences in illness and treatment

Many culture-related factors affect the patient’s health and healthcare. Several potential factors are presented in Box 2-4. These factors should be considered when providing nursing care.

BOX 2-4 Cultural factors affecting health and healthcare

Time orientation

• For some cultures it is more important to attend to a social role than to arrive on time for an appointment with a healthcare provider.

• Some cultures are future oriented; others are past or present oriented.

Language and communication

• Patients may not speak English and may not be able to communicate with the healthcare provider.

• Even with interpreters, there may be difficulties with communication.

Healthcare system

• Patients may not make or keep appointments because of the time lag between the onset of an illness and an available appointment.

• Hours of operation of healthcare facilities may not accommodate patients’ needs to work or use public transportation.

• Cumbersome requirements to access some types of care may discourage some patients from taking the steps to qualify for healthcare or healthcare payment assistance.

• Some patients have a general distrust of healthcare professionals and health systems.

• There may be a lack of ethnic-specific healthcare programs.

• Transportation may be a problem for patients who have to travel long distances for healthcare.

• Patients may not have a general practitioner and may use emergency departments or urgent care centres for healthcare.

• Shortages of healthcare providers from specific ethnic groups may deter some people from seeking healthcare.

• Patients may have a lack of knowledge about the availability of existing healthcare resources.

• Facility policies may not be culturally sensitive (e.g. hospital policy may limit the number of visitors, which is problematic for cultures that value having many family members present).

Beliefs and practices

• Care provided in established healthcare programs may not be perceived as culturally relevant.

• Religious reasons, beliefs or practices may affect a person’s decision to seek (or not seek) healthcare.

• Patients may delay seeking care because of fear or dependence on folk medicine and herbal remedies.

• Patients may stop treatment or discontinue visits for healthcare because the symptoms are no longer present and there is the perception that further care is not required.

• Some patients associate hospitals and extended care facilities with death.

• Patient may have had a previous negative experience with culturally insensitive healthcare providers or discriminatory practices.

• Some people mistrust the majority population and institutions dominated by them.

• Some patients may feel apprehensive about unfamiliar diagnostic processes and treatment options.

Symptoms are interpreted through a person’s cultural norms and may vary from the recognised allopathic (conventional) interpretations of Western medicine. All patient symptoms have meaning for patients as individuals, but the meanings may vary from one culture to another. People experience symptoms based on their own explanatory models.

Culture-bound syndromes are illnesses or afflictions that are recognised in a particular way within a certain cultural group (see Table 2-1). The syndromes have their origins in the psychosocial characteristics of a particular culture. Anorexia nervosa and bulimia have been described as Western culture-bound syndromes because they are predominantly found in Western cultures.² Many Indigenous Australians believe that hospital is where you go to die, so they can be quite fearful of hospitals. Also, many believe that if they do die in hospital, rather than at home, their spirit will be unable to find its way back home. Similarly, some older Māori who have had extended family members die in hospital may be fearful of hospitals and doctors.²⁷

TABLE 2-1 Culture-bound syndromes

Syndrome	Description
Bilis or colera	Caused by strongly experienced anger or rage. Many Latino groups believe that anger affects the body balance of hot and cold. Symptoms include acute nervous tension, headache, trembling, screaming, stomach disturbances and, in severe cases, loss of consciousness.
Brain fag	West African term describing brain ‘fatigue’ caused by the challenges of school. Symptoms include difficulties in concentrating, remembering and thinking.
Falling out	Characterised by a sudden collapse, which may sometimes be preceded by dizziness or ‘swimming’ in the head. The person can hear but is unable to move. Occurs primarily in southern US and Caribbean groups.
Ghost sickness	Among native Americans this condition is sometimes associated with witchcraft and a preoccupation with death. Symptoms include bad dreams, weakness, feelings of fear, danger, futility, dizziness and a sense of suffocation.
Nervios	Many cultures have conditions involving ‘nerves’. In the Latino population nervios may be brought on by difficult life experiences. Symptoms may include headaches or ‘brain aches’, irritability, stomach and sleep disturbances, and an inability to concentrate.
Shenjing shuairuo	In China this condition is characterised by physical and mental fatigue, headaches and other pains, dizziness, sleep disturbances and concentration difficulties.
Sung	Many Indigenous Australians believe that hospital is a place where you go to die and that if they do die in hospital their spirit will not be able to find its way home. As sorcery practices are still present in some Indigenous Australian communities, if a person believes they have been ‘sung’, they may just fade away and die. At such times a traditional healer needs to be called.

DERMATOLOGICAL VARIATIONS

Differences in skin colour require the nurse to be astute in assessment skills. In addition to differences in assessing dark and light skin for signs of jaundice or cyanosis, the nurse should be aware of conditions that are specific to different ethnic groups. For instance, keloids (an overgrowth of scar tissue) may be present in dark-skinned people. The Mongolian spot is a common hyperpigmentation among Asians, southern Europeans, Native Americans, Native Africans and Hispanic newborns.⁴ Specific information related to skin assessment for different populations is discussed in Chapter 22.

PAIN

Each culture has its own beliefs and ways of defining, expressing and managing pain. All patients may experience pain associated with their illness or disease. Some patients may not ask for pain medications. They may perceive the healthcare providers to be busy and do not want to add to their work by asking for medications. Individuals from other groups may believe that pain is something to be controlled and expect immediate relief. Yet others could be accepting of pain, but expect that after a pain assessment has been carried out, appropriate interventions will occur to address the pain. It is important that a range of responses be considered as acceptable by the nurse.²⁷

Some patients from minority ethnic groups may describe their pain in terms that are different from those used by Anglo Australians. These descriptions may be more diffuse and unfamiliar to the nurse if they do not share the same culture. Alternative therapies are increasingly being used by many people and some specific remedies or measures may be more commonly used by particular ethnic groups. Patients may also choose to treat pain externally using oils or massage.

The nurse must not forget that responses to pain will differ within defined cultural groups: pain is a subjective and unique experience for each person.²⁷

MEDICATIONS

Particular ethnic groups may also respond differently to some medications (see Table 2-2). The growing field of pharmacogenetics is devoted to the study of differences in genetic susceptibility to drugs. For example, compared with Caucasians, in general Chinese people are more sensitive to the effects of β-adrenergic blockers (e.g. propranolol), and African Americans are less responsive to β-adrenergic blockers, especially propanolol and atenolol. In addition, Chinese people may have sensitivity to atropine and have shown increased responses to antidepressants and anticonvulsant drugs.²

TABLE 2-2 Ethnic differences in response to medications/drugs that affect the central nervous system

Comparison groups	Drug class example	Clinical response
Chinese/Caucasian	Benzodiazepines (diazepam, alprazolam)	Chinese require lower doses; more sensitive to sedative effects
Chinese/Caucasian	Antidepressants (imipramine, amitriptyline)	Chinese require lower doses
Asians/Caucasian	Neuroleptics (e.g. haloperidol)	Asians require lower doses
Asian Indians/Caucasian	Analgesics (e.g. codeine)	Asian Indians have greater clearance rates
Chinese/Caucasian	Analgesics (e.g. codeine)	Chinese less able to metabolise and require increased doses to achieve therapeutic effects
Chinese/Caucasian	Analgesics (e.g. morphine)	Chinese less sensitive to cardiovascular and respiratory effects and more sensitive to gastrointestinal effects
Asians/Caucasian	Alcohol	Asians more sensitive to side effects
Native Americans/Caucasians	Alcohol	Native Americans have faster metabolism and less tolerance

Source: Adapted from Chaudhry I, neelam k, Duddu V et al. Ethnicity and psychopharmacology. J Psychopharmacol 2008; 22:673.

People from different cultural groups may experience variations in their response to mydriatic medications. A person with light-coloured eyes may experience wider dilation when given mydriatic drugs than a person with dark eyes. Such variations in physiological responses require astute assessment and evaluation.

Regardless of their cultural origins, many people use both culturally derived remedies and prescription medications to treat their illnesses. The new science that is examining the use of traditional medicines is called ethnopharmacology. Problems can result from interactions of the active substances in traditional and prescription medicines. For example, if a person takes ginseng as a tonic stimulant and is placed on an anti-hypertensive drug, they may be at risk of overmedicating themselves.¹ Many people self-treat their depression with St John’s wort, but this can result in an overdose if prescription antidepressants are also taken.

Indigenous Australians and some Māori and Pacific Islander peoples may seek care from their own traditional healers. They may avoid standard Western medicine until herbal and other remedies are ineffective or the illness becomes more acute. The challenge for nurses is to try to accommodate the patient’s need for traditional aspects of care while also using scientific approaches as appropriate and as acceptable to the patient. Evaluating the safety of traditional healing therapies is an important part of this process.

Social and spiritual elements of health and illness care

SPIRITUALITY/RELIGION

Spirituality and religion are aspects of culture that may affect a person’s beliefs about health and illness. They may also play a role in nutrition and the decisions made by an individual as related to health and the ways that the person responds to or treats an illness.

Spirituality refers to a person’s effort to find purpose and meaning in life. It is influenced by an individual’s unique life experiences and reflects one’s personal understanding of life’s mysteries. Spirituality relates to the soul or spirit more than to the body, and it may provide hope and strength for an individual during an illness.²⁸

Religion is a more formal and organised system of beliefs, including belief in or worship of a God or gods. Religious beliefs include the cause, nature and purpose of the universe, and involve prayer and ritual(s). Religion is based on beliefs about life, death, good and evil, and pain and suffering.⁴

Nurses can expect to encounter many ways that patients meet their own spiritual needs. These may include prayer, scripture, healing ceremonies, listening and referral. Many patients find that such rituals help them during times of illness.²⁸ Rituals help people to make sense of their life experiences and may take the form of prayer, meditation or other practices that the patient may choose. The nurse needs to include spiritual assessment in the complete assessment of the patient and plan nursing care based on that assessment. Australia and New Zealand are both multicultural and pluralist societies. This must be considered when addressing the application of rituals in any care context.

COMMUNICATION

Communication style is influenced by culture, which can impact on both verbal and non-verbal interactions. Verbal communication includes not only the language or dialect but also the voice tone, volume, timing and one’s willingness to share particular types of thoughts and feelings.⁵ Non-verbal communication may take the form of writing, gestures, body movements, posture and facial expressions. Non-verbal communication also includes eye contact, use of touch, body language, style of greeting and spatial distancing. Culture influences the ways that feelings are expressed, as well as what verbal and non-verbal expressions are appropriate in given situations.³

Silence is also interpreted according to cultural experiences. Some people are comfortable with silence, whereas others become uncomfortable and may speak to fill the silence. Many Indigenous Australians are comfortable with silence and interpret it as essential for thinking and when carefully considering their response—silence shows respect for the other person and demonstrates the importance of the remarks. In traditional Japanese and Chinese cultures, the speaker may stop talking and leave a period of silence for the listener to think about what has been said before continuing. In such cultures silence may be intended to show respect for the speaker’s privacy, whereas in other cultures (e.g. Anglo-European cultures such as French, Spanish and Russian) the speaker may interpret silence as meaning agreement.

Eye contact varies greatly among cultures. Although an Anglo-European nurse may have been taught to maintain direct eye contact with patients, some patients (e.g. Indigenous Australians) may avoid direct eye contact and consider it disrespectful or aggressive. Other variables to consider include the role of gender, age, status or position on what is considered to be appropriate eye contact. For example, Muslim–Arab women exhibit modesty by avoiding eye contact with men (other than their husbands), especially when in public situations.

FAMILY AND KINSHIP TIES, ROLES AND RELATIONSHIPS

Family roles differ from one culture to another (see Fig 2-5). For this reason, it is important for nurses to determine who should be involved in communication and decision making related to healthcare. For instance, in the healthcare systems of Anglo-Australia, New Zealand, the UK and the US, there are strong beliefs related to autonomy. In these countries an individual is expected to sign a consent form as an autonomous individual when receiving healthcare. In other cultural groups there may be an emphasis on interdependence rather than independence. It may be another family member, not the patient, who is expected to make healthcare decisions. Yet others may value affiliation rather than confrontation, and cooperation rather than competition. In many New Zealand hospitals, provision is made (e.g. extended waiting room space) to accommodate whānau (extended family) who need to be with a Māori or Pacific Islander patient. When the nurse encounters a family that values collectivity over individualism, there may be conflicts as to how decisions are made. There may be a delay in treatment while the patient waits for significant family members to arrive before giving consent for a procedure or treatment. In other instances, the patient may make a decision that is best for the family but that may be perceived by healthcare professionals as having negative or adverse consequences for the patient. Being aware of such values will better prepare the nurse to advocate for the patient.

Figure 2-5 Family roles and relationships differ from one culture to another.

Another factor that is important in family roles is the expectation of who provides care. In some cultures (e.g. throughout South-East Asia), family members commonly provide the majority of personal care for a hospitalised relative, whereas other cultural groups expect all care to be provided by the nurse or other healthcare professional. The predominant Western expectation that the patient will assume self-care as quickly as possible may therefore not be universally understood. Clearly, these expectations and assumptions need to be assessed, explained and negotiated between families and healthcare professionals.

The nurse also needs to understand about culturally relevant male–female relationships for particular groups by observing and becoming aware of behaviours within different social groups. This is preferable to violating a cultural norm and perhaps ultimately undermining the therapeutic relationship. For example, in some Muslim and Middle Eastern cultures it is not appropriate for a man to be alone with a woman other than his wife, and so same-gender caregivers are preferred. This needs to be taken into account when providing care to these patients.

PERSONAL SPACE

Personal space zones are very important. Generally, intimate distance ranges from 0 to 45 cm and personal distance ranges from 45 to 120 cm. Personal distance is the one experienced with friends. Social distance ranges from 1.2 to 3.6 m and public distance is 3.6 m or more. Nurses often interact with their patients in the intimate or personal zones, which may be uncomfortable for some patients.

There is wide variation in the perception of appropriate distances when considering various cultural groups. Personal space distance varies within cultures. Australians, New Zealanders, Americans, Canadians and the British require more personal space than Latin Americans, Japanese and Arabic groups.² The distance the nurse maintains between self and the patient may cause the patient to feel that the nurse is unfriendly or it may offend the person.

TOUCH

Physical contact with patients conveys various and different meanings depending on the culture. To complete a comprehensive assessment of a patient, touching the patient is necessary. In cultures such as Muslim, Arabic and traditional Indigenous Australian cultures, male healthcare providers may be prohibited from touching a female patient. Touch is an important aspect of cross-cultural practice and nurses need to be sensitive to this aspect of culture. It is important to ask permission before touching a patient.

A further aspect of touch is that in most cultures it is considered important to keep ‘clean’ and ‘dirty’ items separate (the concepts vary between language and cultural groups). For example, in some cultures pillows used for the head should not be used for sitting on, or for supporting the body.²⁹ The ways in which these cultural norms are expressed varies considerably. In some groups there are expectations about which hand is used for particular purposes. In most cultures it is important to keep items related to food and food preparation well away from those relating to bodily hygiene.

NUTRITION

Food is an important part of all cultural practices, in terms of both the types of foods that are eaten and the rituals and practices associated with food. When individuals and families migrate to an area that is very different from their country of origin, they may be faced with unfamiliar foods, food-storage systems and food-buying habits. Patients may be asked to make major changes in their diets because of health problems or the food offered in a hospital may be very different to that which they are accustomed to eating. It is important that nurses take into account ethnic and cultural practices and habits when helping patients to plan their food/fluid intake or to make any necessary dietary changes. This means taking into account the individual’s food preferences, while still indicating healthy nutritional practices.

NURSING ASSESSMENT: PROVIDING SAFE, CULTURALLY COMPETENT CARE

Planning nursing care involves the assessment of all aspects of the patient’s and family’s needs. This chapter has highlighted the importance of undertaking a good-quality assessment of the patient’s and family’s cultural needs and understanding the implications of these needs. These factors should be incorporated into the care plan for each patient and family group (or community). Later chapters discuss the assessment and planning for the specific needs of patients with a variety of health problems or conditions. Whatever their presenting problem, all patients have a right to culturally competent, culturally safe care.

Nurse’s self-assessment

The first step in providing culturally safe or competent care is for nurses to understand their own cultural background and their own values and beliefs, especially those related to health and healthcare. Many tools are available to assist in this process. Box 2-2 suggests some ways nurses can work towards improving their capacity to offer culturally competent and culturally safe care. This information can help nurses to understand patients better and to provide more culturally competent and relevant care.

Patient assessment

Understanding the impact of culture and seeing this as significant for individual patients and their families is an important element of any nursing assessment. In some institutions, this assessment may involve a specific cultural assessment guide; in others, it will be up to the nurse to ensure that this is taken into account. An example of a cultural assessment guide is provided in Box 2-3. It is important to determine: (1) the patient’s health beliefs and healthcare practices; and (2) the patient’s perspective of the meaning, cause and preferred treatment of illness. When this is done, it will increase the likelihood of successful outcomes for both the nurse and the patient.

How is the nurse to be aware of the differences among ethnic groups? Various guides to cultural assessment can help nurses to develop greater understanding of working with patients, families or groups from different cultures. Textbooks and guidelines can be used to explore the degree to which patients share commonalities with the cultural information generally attributed to their cultural group, but it is important to make certain that these are not used to typecast people.³⁰ Ultimately, however, it is most important to identify potential similarities and differences through robust assessment/observation and interaction with individuals to assist the nurse to deliver culturally appropriate nursing and healthcare.

It is important to avoid cultural stereotyping while conducting any assessment or when interacting with patients and their families. Learning to feel comfortable in cross-cultural situations can take many years and, as the cultural safety movement teaches us, we must also take regard of patients’ experiences of cross-cultural encounters with nurses and healthcare professionals.

Nursing care is always dependent on good communication. When meeting a patient or their family members, it is appropriate for nurses to introduce themselves and indicate how the patient should address them. Inquiring whether the patient prefers to be called by their first name or something else such as Mr, Ms or Mrs or another title shows respect, individualises the encounter and will assist the nurse to begin the relationship in a culturally appropriate manner.

Effective communication is most likely to occur when meaning is mutually created and understood—whether that communication is through language, spoken words, gestures or voice tone. To show respect for the patient, any communication should take into account the patient’s usual communication style. For example, a health history should start out in an unhurried manner and should include acceptable social and cultural aspects appropriate for the culture. In some cultures it is best to get to the point and not waste time; in others, it is most effective to engage in ‘small talk’, with the discussion including answers that may seem unrelated to the questions. If the nurse appears to be too busy or fails to notice what is needed for patients to share information comfortably in an open and honest manner, then communication will be impaired.

Interpreters play a pivotal role when interacting with non-English speaking patients as part of nursing practice. Nurses’ skills working with interpreters, and interpreter availability, engagement and accuracy can enhance or impede effective care.³¹ Each state in Australia and the District Health Board in New Zealand has access to an interpreter service, which can provide assistance in many languages. Sometimes family members may need to act as interpreters, but the nurse should be mindful that anyone who interprets needs to fully understand the message they are conveying, so checking mutual understanding between the nurse, interpreter and patient is critical. Box 2-5 provides guidelines about using interpreters and Box 2-6 provides guidelines for when no interpreter is available.

BOX 2-5 Using a medical interpreter

Choosing an interpreter

• Use an interpreter employed by or recommended by your healthcare facility, if possible.

• The interpreter should be a trained medical interpreter who knows how to interpret, has a healthcare background, understands patients’ rights and can help with advice about the cultural relevance or appropriateness of the healthcare plan and instructions.

• Use a family member if necessary. Be aware that there may be limitations if the family member does not understand medical terms, is younger than or of a different gender from the patient, or is not aware of the healthcare procedures or medical ethics.

• The interpreter should be able to do the following:

– Translate the non-verbal as well as the literal translation.

– Translate the message into understandable terms.

– Act as a patient advocate to represent the patient’s needs to the nurse.

– Be culturally sensitive and understand how to provide teaching instructions.

BOX 2-6 Guidelines for communicating when no interpreter is available

1. Be polite and formal.

2. Pronounce the person’s name correctly. Use proper titles of respect, such as ‘Mr’, ‘Mrs’, ‘Ms’, ‘Dr’. Greet the person using the last or complete name. Gesture to yourself and say your name. Offer a handshake or nod. Smile.

3. Proceed in an unhurried manner. Pay attention to any effort by the patient or family to communicate.

4. Speak in a low, moderate voice. Avoid talking loudly. Remember that there is a tendency to raise the volume and pitch of your voice when the listener appears not to understand. The listener may perceive that you are shouting and/or angry.

5. Use any words that you know in the person’s language. This indicates that you are aware of and respect their culture.

6. Use simple words, such as ‘pain’ instead of ‘discomfort’. Avoid medical jargon, idioms and slang. Avoid using contractions (e.g. don’t, can’t, won’t). Use nouns repeatedly instead of pronouns.

Example:

Do not say: ‘He has been taking his medicine, hasn’t he?’

Do say: ‘Does Juan take medicine?’

7. Pantomime words and simple actions while you verbalise them.

8. Give instructions in the proper sequence.

Example:

Do not say: ‘Before you rinse the bottle, sterilise it.’

Do say: ‘First wash the bottle. Second, rinse the bottle.’

9. Discuss one topic at a time. Avoid using conjunctions.

Example:

Do not say: ‘Are you cold and in pain?’

Do say: ‘Are you cold (while pantomiming)? Are you in pain?’

10. Validate whether the person understands by having them repeat instructions, demonstrate the procedure or act out the meaning.

11. Write out several short sentences in English and determine the person’s ability to read them.

12. Try a third language. Many Indochinese speak French. Europeans often know two or more languages. Try Latin words or phrases.

13. Ask who among the person’s family and friends could serve as an interpreter.

14. Obtain phrase books from a library or bookstore, make or purchase flash cards, contact hospitals for a list of interpreters, and use both a formal and an informal network to locate a suitable interpreter.

Source: Jarvis C. Physical examination and health assessment. 6th edn. Philadelphia: WB Saunders; 2011.

The role of the nurse in reducing health disparities

In addition to the cultural considerations the nurse will make in relation to the direct care of patients and families, other factors also impact on health; for example, the social and economic circumstances people find themselves in, and the need for housing, employment and a life free of discrimination. In their professional roles (and, for those who choose, in their personal lives outside work) nurses can take action to assist people in overcoming some of the barriers they face in these areas of their lives.

Throughout the history of nursing, a number of nurses have contributed to the better health of whole communities. Nurses who are interested and have a goal of this kind may want to participate in relevant activities. Some suggestions are listed below, although this list is not exhaustive.

• Get to know people from a wide range of cultural backgrounds. Ask them about the things that are important for their health and the health of their families.

• Learn about the lives of the nurses who changed history (past and present). Understand what they did and how they accomplished their work.

• Pay attention to the policies of political parties and how they will influence the health of society’s most needy. Vote mindfully.

• Speak up against racism and other forms of discrimination whenever you hear it or see it.

• Volunteer in a community group of some kind.

• Take the opportunity to educate others about healthy living as you understand it (and learn from them too).

• Initiate change in your workplace when you think something could be done better. (Find out the channels to go through and seek support first.)

• Join a professional or community group that supports equity and social justice.

• Make a difference one moment at a time.

Many nurses may already recognise the significance of a diverse workforce in addressing culturally competent, culturally safe patient, family and community care needs.³² Populations are becoming increasingly diverse and, as a result, the workforce needs to change to mirror these demographic groups. ‘While matching workforce to client populations we serve and students we teach can be an effective strategy for bridging cultural differences between nurse and client, it cannot be the only strategy.’³² Nurses also need to be able to care for patients who are different from themselves.