Resolving Differences Within Diversity

It’s common knowledge that nurses of color play a critical role in bridging cultural gaps between racial/ethnic minority patients and America’s traditionally “white majority” health care system. When minority patients seek treatment, it’s only natural that they feel more comfortable when nurses or doctors share their cultural heritage.

But just because patients and their health care providers are members of the same ethnic minority group doesn’t mean that cultural conflicts don’t arise. Many intra-ethnic differences still exist—from language fluency and recency of immigration to educational level. Nurses must be able to deal sensitively with these differences to prevent misunderstandings and barriers to care.

“Even if [patients and providers] are from the same country or the same town, they still may view things differently,” says Julia Puebla Fortier, director of Resources for Cross Cultural Health Care in Silver Spring, Md., a national network that provides technical assistance and information on cultural competence in the health professions.

Common ethnicity may add initial comfort to the relationship between a nurse or doctor and a patient, adds Ira SenGupta, cultural competency training manager for the Cross Cultural Health Care Program in Seattle. “But we can’t make assumptions that this is the only thing that’s important,” she says.

A shared ethnic heritage does not guarantee cultural competence, SenGupta stresses. She recalls a recent-immigrant patient who was staying at a battered women’s shelter and was in need of prenatal care. SenGupta’s program matched her with a doctor who was from the same country as the patient. After the appointment, however, the woman returned to the program upset. “I don’t want to ever see her again,” she said of the doctor. Apparently, the physician had assumed that the patient only wanted an ultrasound to determine the sex of the baby. She accused the patient of planning an abortion if the baby was a girl.

“This doctor made a huge generalization,” SenGupta says. “Misunderstandings can happen when people make assumptions about others, and these assumptions can become a barrier to care.”

Like and Yet Unlike

The American Heritage Dictionary defines “culture” as “the arts, beliefs, customs, institutions and all other products of human work and thought created by a people or group at a particular time.” Thus, any culture by definition is intricately complex. Even within the same cultural minority group, differing education and literacy levels, socioeconomic status, length of residency in the United States, degree of acculturation and region of origin all have the potential to create conflict if those differences aren’t respected.

Part of the problem is that society tends to put people in categories and assume that everyone within a particular category is virtually the same. Hispanics, for instance, are often wrongly considered one homogeneous group, says Guadalupe Pacheco, special assistant to the director of the U.S. Department of Health and Human Services Office of Minority Health in Washington, D.C. But within that group are people from Mexico, Puerto Rico, Cuba and other countries. Even though Spanish is officially spoken in all of these countries, slight but significant language differences can arise. And even within the same country, colloquial terms can vary from one region to another.

Moreover, lifestyles and attitudes may vary dramatically among Hispanics who recently immigrated to the United States versus those whose families have lived here for several generations. For instance, recent arrivals to this country may be more likely to use folk medicine to treat health problems.

Among African Americans, cultural beliefs and attitudes can be vastly different for those who grew up abroad, such as in Haiti or Ethiopia, and those who were born here. “They are all of African descent, but they have different attitudes about health,” Pacheco says.

Many Haitian immigrants, for example, speak only Creole and are poorly educated. Some believe in voodoo. Haitians may use herbal teas and massage to treat health problems in the early stages, and may rely on spiritual practices to prevent illness. Yet Haitians who have recently immigrated to this country and African Americans whose families have lived here for many generations would both be categorized as “black” in the United States.

Intra-ethnic differences are also a major issue for Asian American/Pacific Islander patients. “Medical providers need to understand that we are not a monolithic group, but are very diverse in language, customs, beliefs, values and national origins,” says Kem Louie, president of the Asian American/Pacific Islander Nurses Association. “I have been asked many times to translate for Asian patients without being given information as to their national origin. Just because we are both Asian doesn’t automatically mean we speak the same language.”


Meanwhile, in India, SenGupta notes, there are 18 official languages, 1,000 unofficial languages and more than 5,000 dialects.

As for Native Americans, different traditions and practices among tribes can impact attitudes about health care. “When I care for a Native American patient, there is a common connection that happens between us,” says Sandra Littlejohn, RN, BSN, secretary of the National Alaska Native American Indian Nurses Association and administrative director of inpatient neural muscular services at Gunderson Lutheran Medical Center in La Crosse, Wis. “We are part of the same cultural group. But when it comes to certain habits or traditions, there might be different belief systems.”

Clan structures may vary, for instance. In a patrilineal tribe, a wife would go to live with her husband’s family. In a matrilineal tribe, the community link would be through the wife’s family. Health traditions also differ from tribe to tribe, including the use of herbs and the practices used for cleansing.

Taking the Time

How can minority nurses recognize and prevent potential intra-ethnic conflicts with patients before they can arise? The first step is to simply be aware that differences exist and should be respected, SenGupta believes.

Nurses also should examine the stereotypes they may have about others, Fortier says. “We all find it comfortable to think, ‘These people are like that,’ or ‘They’re just like me,’ when it comes to education and social class. It’s very easy to give in to those stereotypes.”

She agrees that being a member of the same ethnic group gives a nurse an advantage in establishing rapport with a patient. But, she warns, “If you talk down to patients, you’re going to lose that advantage.”

Cultural competency training can help nurses examine their own attitudes, Fortier continues. She recommends periodic training and re-training because people can change over time with new experiences. “I don’t think cultural competency training is a one-shot deal,” she says.

When working with clients, even those from their same cultural group, nurses must make no assumptions, believes Nilda Peragallo, DrPH, RN, FAAN, president-elect of the National Association of Hispanic Nurses and associate professor at the University of Maryland School of Nursing. “Nurses have an ethical duty to learn about clients and their needs so that they can deliver the best care,” she asserts.

This learning process can take time. “Getting to know the patient is more time-consuming than just marching in and starting to treat,” Fortier says. But the time spent figuring out who the patient really is and what he or she really needs can go a long way toward building rapport. She suggests asking patients questions such as, “When did you start thinking you had an illness?” and “Have you done anything to treat this at home?”

Littlejohn agrees that asking good open-ended questions can elicit the information nurses need to provide the right care for clients. She asks patients, “How would you normally care for that at home?” and “Are there any further needs you’d like to identify or suggest that we address in your care plan?”

Peragallo suggests asking clients where they were born and how long they have lived in the United States. Nurses should also know patients’ literacy levels so they don’t give them papers they can’t read. “You can ask these questions in a nice way,” she points out.

Because language differences can be one of the biggest barriers to quality health care, nurses should take special care when arranging for interpreters, SenGupta advises. To make patients feel more comfortable, the interpreter should be the same gender as the patient. In cases where the only interpreters available are the patient’s relatives or members of the community, they should be asked to translate everything the patient says and not to omit or add information.

“Sometimes untrained interpreters edit what patients say, especially when they think the information may not be what medical practitioners want to hear,” SenGupta explains. “But nurses need to know exactly what the patient says in order to understand and correctly meet his or her needs.”

Conflict Resolution

Despite your shared cultural heritage and your best efforts to understand the patient, an intra-ethnic conflict has arisen between the two of you. For whatever reason, the patient does not feel comfortable working with you. Now what?

“As nurses, we have to take a moment to step back and reassess what’s happening in the situation,” says Littlejohn. “With Native American patients, that may involve sitting with them quietly.” Nurses may also get assistance by talking to the patient’s family members to learn what is the best way to proceed. Occasionally, resolving the conflict may even require stepping out of the situation and finding another staff member to help.

On the other hand, minority nurses can play a major role in mediating cultural conflicts between patients and doctors. “It’s important for nurses to step in at any time,” Littlejohn maintains. But, she adds, openness to discussions about cultural competency can vary widely among different workplaces. In some situations, where there is little dialogue about cultural competency, nurses must work covertly to serve their patients in a culturally sensitive way. As Littlejohn puts it, “You know what needs to be done for the patient, and you get it done.”

Meanwhile, health care organizations and providers can receive guidance from new federal standards developed by the Office of Minority Health for culturally and linguistically appropriate services (CLAS). While cultural competence has become a growing issue in the national health care agenda, until now no comprehensive standards for cultural or linguistic competence in patient care had been developed by any national group. Instead, federal health agencies, state policy-makers and national groups have addressed only pieces of the big picture. The new CLAS standards are designed to serve as guidelines to help health care professionals respond effectively to the cultural and linguistic needs of patients in today’s multiracial, multiethnic and multicultural America. 

But even with federal “gold standards” and cultural competency training, there is still no easy answer for how to resolve conflicts between health care clients and providers that stem from cultural differences, or even intra-cultural differences, Peragallo believes. “For me, the most important thing is being open-minded and accepting people for who they are and where they come from,” she says.

In other words, it all comes down to treating the patient with respect and sensitivity—the very basics of nursing.