Fact #1: Registered nurses comprise the largest portion of the health care work force in the United States.1 Fact #2: Of the nearly 2.7 million licensed RNs in this country, only 13% come from racial or ethnic minority backgrounds.2 Fact #3: Twenty-five percent of the total U.S. population—i.e., one out of four Americans—is non-Caucasian.3 Fact #4: Within the next 25 years, the ethnic and racial minority population of the U.S. is projected to increase at a faster rate than the nation’s Caucasian population.1,4

These statistics dramatically illustrate America’s urgent need to develop a more diverse nursing work force that is able to provide culturally and linguistically competent care to our increasingly multicultural population. This means not only increasing the number of minority nurses but also ensuring that nurses of all races and ethnicities are thoroughly prepared to care for patients from widely diverse backgrounds and cultures.

One place to start is by making sure that our nursing schools’ curricula truly reflect the cultural differences of our country’s wide spectrum of racial and ethnic populations. Although curricula may contain accurate cultural terminology, they often lack the qualities that enable students to understand different cultures and their health care needs. When revising curricula to incorporate a multicultural perspective, it is crucial to include in-depth information on cultural factors,6, 7 such as:

• environmental control (e.g., the practice of folk medicine or use of traditional healers) 8
• biological (physical and genetic) differences among cultural groups, which can include not only body build, skin color and hair texture, but also healing responses, susceptibility to disease and nutritional variations8
• social organizations, such as families, that shape an individual’s cultural development, beliefs and responses to major life events
• space and time orientation (e.g., some cultures are future-oriented and concerned with long-range planning while others focus on the present).

In addition, communication is an integral part of nursing practice. To communicate effectively with patients from diverse cultures, nurses must have knowledge of different languages, verbal and nonverbal behaviors, use of silence and attitudes about eye contact. They must understand not only what is communicated but also how it is communicated.

Evening Up the Score

While much has been written about incorporating cultural competency into nursing school curricula, one area that has received little attention is faculty-generated classroom testing. Because test scores play a significant role in student evaluations, it is important to utilize test questions that are as culturally unbiased as possible.

Educators must keep in mind that nursing students come from a diverse range of cultural backgrounds and may lack the necessary experience to perform well on tests if these cultural differences are not taken into account. In fact, a faculty’s failure to recognize the potential for bias in classroom testing can adversely affect minority students’ ability to succeed in the nursing program.

This inability to do well on tests is not due to lack of intelligence, but instead may result from a lack of necessary learned behaviors, or from differences in thinking patterns between cultures.9 For example, the Native American student has learned by stories, legends and role modeling.9 This nonlinear way of learning allows for more than one right answer,9 as opposed to the multiple-choice testing format customarily used in nursing schools. As a result, Indian students may have difficulty not only in learning but also in expressing their knowledge and understanding test questions.

Fortunately, most students are capable of learning test-taking skills if they are given the opportunity. It is the faculty’s responsibility to provide this opportunity—for example, by making tutoring available, within or outside of the nursing department, to help students identify and strengthen areas that need further development, such as writing, studying and time management. Providing these options for minority students does not mean lowering standards; rather, it means that mechanisms should be in place to enable faculty to refer students for additional help if it is needed.

A Culturally Sensitive Approach to Testing

What can nursing schools do to ensure that faculty-generated tests are not inadvertently biased against minority students? One solution is to use culturally sensitive standardized test questions. While these may be hard to find, one helpful resource is the National League for Nursing (www.nln.org), which is striving to make standardized tests culturally sensitive by reviewing them for potential bias. Another recommendation is to have culturally diverse groups of students and faculty evaluate potential test questions.

Within the larger context of providing a culturally sensitive learning experience for all nursing students, it is important to use clinically focused scenarios and class exercises that relate to multicultural issues, and to select textbooks, journal articles and reference materials that reflect cultural diversity. The following texts are recommended for their culturally diverse content:

• Spector, R.E. (1996). Cultural Diversity in Health and Illness (4th edition). Stamford, Conn.: Appleton & Lange.
• Kelly, M.L. & Fitzsimons, V.M. (2000). Understanding Cultural Diversity: Culture, Curriculum, and Community in Nursing. Sudbury, Mass.: Jones & Bartlett.
• Bennett, C.I. (1999). Multicultural Education: Theory and Practice (4th edition). Boston: Allyn & Bacon.

Finally, inviting culturally diverse guest speakers to discuss culture-specific behaviors and customs can be excellent way to help both students and faculty broaden their understanding of cultural differences.


1. Moses, E.B. (1992, March). Nursing Facts: From the American Nurses Association.

2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing (2000, March). Preliminary Findings, National Sample Survey of Registered Nurses.

3. U.S. Census Bureau (2001, March). Census 2000 Brief: Overview of Race and Hispanic Origin.

4. U.S. Census Bureau (1995, August). Selected Social and Economic Characteristics for the 25 Largest American Indian Tribes: 1990.

5. U.S. Census Bureau (1997, October 31). Facts for Native American Month (November 1-30).

6. McCarthy, M. (1996). “Travelers From Many Lands: The Impact of Culture.” In Carson, V.B. & Arnold, E.N. (Eds.), Mental Health Nursing: The Nurse-Patient Journey (1st edition). Philadelphia: W.B. Saunders.

7. Strasser, J., Maurer, F.A., & Kavanagh, K.H. (1995). “The Relevance of Culture and Values for Community Health Nursing” (ibid.)

8. Spector, R.E. (1996). Cultural Diversity in Health and Illness (4th edition). Stamford, CT: Appleton & Lang.

9. Crow, K. (1993). “Multiculturalism and Pluralistic Thought in Nursing Education: Native American Worldview and the Nursing Academic Worldviews.” Journal of Nursing Education.

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