The Role of Cultural Sensitivity in Building Patient Relationships

The Role of Cultural Sensitivity in Building Patient Relationships

Culture is everywhere—and it defines almost every aspect of our lives in one way or another. That can be true across a variety of dynamics, including how someone functions within a family, relates to others, or responds to stress. Nurses encounter patients and families with myriad cultural influences every day. That’s why understanding and practicing cultural sensitivity is so important for building relationships and providing excellence in patient care.

The Importance of Building Relationships

In any setting, trusting relationships are important. However, some patients may hesitate to trust health care providers because of several factors—such as a history of discrimination, disparity in representations of diverse people as care providers, and lack of recognition of the particular challenges that some patients face.

According to a report from the American Psychological Association (APA), individuals with low incomes or those from racial or ethnic minority groups are more likely to experience severe stress than others, a dynamic that can lead to poorer mental and physical health outcomes. Unfortunately, such individuals may be less likely to pursue medical care because of financial concerns or fear of discrimination from a provider. However, if clinicians learn to build trusting relationships, then those who need care may feel more comfortable in accessing it.

The Role of Cultural Sensitivity

Previously referred to as “cultural competency,” cultural sensitivity requires that nurses possess the needed skills to affirm diversity and embrace the values of people from different social or cultural backgrounds. Practicing cultural sensitivity is essential to building relationships, since it helps nurses step outside of their own perspectives to better understand the unique needs of the patients and families for whom they provide care.

The shift in language from “competency” to “sensitivity” underscores the role of culture across an individual’s life and care continuum, and the need for clinicians to recognize the importance of this dynamic. Thus, when nurses become educated about different cultures, they are better equipped for building relationships with patients and families, which can help to improve outcomes of care.

Strategies for Building Trust

In addition to learning about different cultures, nurses can make use of empowering strategies to help patients and families feel understood and accepted; such strategies are included in The National Education Association’s Diversity Toolkit:

  • Use inclusive language in written and verbal discussions.
  • Ask each client for their preferred pronouns, even when you feel sure of their gender.
  • Take time to learn proper pronunciation of each person’s name.
  • Ask for permission before touching or hugging each person.
  • Learn cultural customs for any community or group with whom you are working closely.
  • Encourage patients to have a family member accompany them if privacy is needed.
  • Offer to translate information or rewrite it in more understandable terms if someone is having difficulty reading or understanding complex medical information.
  • Know the cultural or diversity-related resources in your community.

To learn more about the role of cultural sensitivity in building relationships, see “How To Be Culturally Sensitive Working with Clients with a Range of Identities.”

Nursing Students Gain Valuable Skills in Remote Areas

Nursing Students Gain Valuable Skills in Remote Areas

In hopes of gaining a breadth of experience, many nursing students immediately look for a job in a hospital setting upon graduation. But Judy Liesveld, associate professor at the University of New Mexico’s College of Nursing, encourages students to look past the typical offerings.

Working on a “Nurse Education, Practice, Quality and Retention-Bachelor of Science in Nursing Practicum” grant from the U.S. Department of Health and Human Services, Liesveld runs a program in which selected nursing students from the University of New Mexico and San Juan College in Farmington, New Mexico, work twice a year (once in fall and once in early spring) in the Chinle Indian Health Service Unit on very rural Navajo Nation Reservation located in Arizona, three hours outside of Albuquerque.

In their two-week stay on the reservation, the students are immersed in an unfamiliar culture and with medically underserved people who need healthcare that runs the gamut from minor to serious. Students who want to return are able to complete a senior capstone in the following term.

When they are in this setting, they are in a very rural setting where it’s a totally different culture with a vulnerable population,” she says. “This totally helps to expand their world view. This is a robust, rich experience for them.”

And the experience the nursing students get in a short time rivals intense clinical experience in a larger healthcare setting, she says. Liesveld should know—her first job out of nursing school was working in Chinle Health Services.

The Chinle clinicals, as they are called, bring students through things like the emergency department, obstetrics, urgent care, and pediatrics. There are primary care clinics that the students participate in as well as home visits where many residents live without running water or heat in extremely remote areas where dirt roads are common. Even in living conditions that aren’t what they are used to, students see the human bonds that make the community what it is, Liesveld says. They see an incredibly close family structure and a culture that is powerful and strong.

The nursing students give presentations on health topics to different populations increasing both their presentation capabilities and their understanding of the different needs throughout a community.

They presented at a senior center on smokeless tobacco and at a middle school on self esteem,” she says. Through the presentations, the nursing students interacted with people and felt like they were making a difference.

The hope is students will love the experience and will work in rural settings,” says Liesveld. But if they never work in a rural setting again, she says the experience they gain on the reservation is one they will never forget and one that will offer them skills they will use throughout their careers.

They learn they have to be resourceful and they learn how to think on their feet,” says Liesveld. Students quickly develop authentic rapport with the residents and they use nursing skills they might not have a chance to use in other places. “It changes their world,” she says.

If they stay in the region, they are likely to work with a Native American population, so the exposure to their culture will give them a cultural competency that can only be gained by such an immersive experience.

And the ripple effect of what they have learned can lead to advocacy as well. Students begin to think about health policy on a national level and what that means for the country as a whole and these rural pockets of communities that exist across the nation.

When there is that kind of meshing of skills, understanding, and cultural exposure, nursing students, wherever they land after graduation, will have a broad view that will benefit them and their patients.


3 Tips for Hosting a Successful Vision Board Party

3 Tips for Hosting a Successful Vision Board Party

Get Your Supplies Together
Vision boards are an excellent way to visualize your best life, goals, and dreams. Vision boards are a creative way to generate a visual of the things that you want to see manifested in your life, and a way to provide yourself a daily reminder of why you work so hard, and what your outcome will be. Creating a vision board does not have to be a tedious process. This can be a fun opportunity for a girls night, wine, and some creativity
Here is what you need to host your vision board party:
-Poster boards/Paper or Cork Board
-Most Importantly Some Good Wine/Vino
Have a Method to Your Board
There is no right or wrong way to do this. I tend to divide my poster board into sections by category. Divide you vision board into 9 different sections.  The top three sections of the board (from left to right) should be prosperity, reputation, partnerships/love.  The second row should be family, health, and unity.  The third row should be self-improvement, career, and travel.  You can see a visual example of several options on Pinterest.
It is important to remember that you can change or update your vision board as much as you deem it necessary. I typically opt for the cork board version of the vision board because it is easier to modify. If you are hosting the vision board party and would like to utilize the cork board, it may be more cost-effective to collect those funds from your guests in advance, or request that they bring their own if they would like to use that.
Get Digital
Don’t have the time or resources to buy supplies for everyone? Get digital with your vision boards. There are several different ways that you can complete a vision board digitally by downloading simple apps from App Store from Apple or the Android Market. I particularly like the Success Vision Board Application by Jack Canfield, the creator for chicken soup for the soul. You can also create one online at
Remember the law of attraction! Hang your vision board somewhere you will see it daily. Use it to inspire you and generate positive energy at the beginning of your day. Live and work towards your dreams every day.

Photo by keepitsurreal

Resolving Differences Within Diversity

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.

Putting Culturally Competent Communication into Hospital Accreditation

Putting Culturally Competent Communication into Hospital Accreditation

Last summer, The Joint Commission’s culturally and linguistically competent patient-centered communication standards became part of the hospital accreditation process. One year later, what difference are they making?

In 2009, Minority Nurse published a Vital Signs story that asked: “Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care?” What prompted that question was The Joint Commission’s announcement that it was developing a set of standards that would incorporate the provision of culturally competent patient-centered care into the national requirements for hospital accreditation.

They’ve been a long time coming, but on July 1, 2012, these new and revised standards for patient-centered communication officially became part of the overall accreditation decision. The standards—which are published in a free downloadable implementation guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals—require health care organizations to, among other things:

  • Identify and effectively meet the oral and written communication needs of all patients, including those with limited English proficiency, hearing or visual impairments, and low health literacy;
  • Use highly qualified interpreters and translators, rather than untrained individuals, family members, or bilingual staff;
  • Document patients’ language and communication needs in their medical records.

Plus, the standards include two provisions designed to create a more equitable environment for lesbian, gay, bisexual, and transgender (LGBT) patients and their loved ones. One requires hospitals to prohibit discrimination based on sexual orientation and expression of gender identity. The other provides equal hospital visitation rights for same-sex domestic partners by allowing “a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.”

As all nurses know, Joint Commission accreditation reviews are something hospitals take seriously. One year later (or two years in the case of the LGBT standards, which took effect in July 2011 to align with the Centers for Medicare & Medicaid Services’ 2011 visitation rights regulations1), what effect have the patient-centered communication standards had? Are they helping hospitals do a better job of serving culturally diverse patients’ needs? And more importantly, are they starting to make any difference in improving minority health outcomes?

Too Soon to Know

The answer is: It’s still too early to tell.

“We’ve been trying to do some analysis of the scoring data and the requirements for improvement that we’ve seen since last July,” says Christina Cordero, PhD, MPH, associate project director, Department of Standards and Survey Methods, at The Joint Commission. “These data have been somewhat limited because of the time frame. But we’re planning to [look at] that information to see how frequently these issues are being scored, what kinds of situations and comments are coming up on survey, and what our surveyors are seeing on-site.”

In the meantime, anecdotal evidence suggests that most hospitals are at least trying to make sure they’re implementing the standards correctly. For instance, says Cordero, who helped develop the patient-centered communication standards and the Roadmap for Hospitals, The Joint Commission has been fielding many questions about how to implement standard RC.02.01.01, EP 28, which requires hospitals to include patients’ race and ethnicity in their medical records.

“Most of these inquiries have focused on what categories and question formats hospitals should use to collect that information from patients,” she explains. “For example, should they ask about race and ethnicity together in one question or in two separate questions? We responded by publishing FAQ documents on our website to help hospitals implement a data collection system that works for them.”

As for identifying areas where improvement may be needed, The Joint Commission’s initial analysis of data from surveyor site visits seems to indicate that hospitals are finding some of the standards harder to comply with than others.

“The one standard that has been coming up most frequently on-site over the last few months is PC.02.01.21, identification of patients’ language and communication needs during the provision of care, treatment, and services,” Cordero reports. “This may mean that hospitals are struggling more with that issue. Our surveyors are looking at not just the documentation of communication needs but what hospitals are doing to identify and address those needs.”

Is It Enough?

Minority health advocates are also keeping an eye on what The Joint Commission’s evaluation of the standards’ early years will reveal.

“I hope there will be a systematic examination of the outcomes and the impact on the quality of patient care,” says Cora Muñoz, PhD, RN, co-author of the book Transcultural Communication in Nursing. “But the fact that there are now two external bodies that require this—the Office of Minority Health [which developed the Culturally and Linguistically Appropriate Services (CLAS) standards in 20002] and now The Joint Commission—is a step in the right direction.”

Hector Vargas, JD, Executive Director of GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay & Lesbian Medical Association) feels that the patient-centered communication standards are “just one piece of a larger picture of progress we’ve seen over the last few years. These standards, the CMS hospital visitation rules, the [2011] Institute of Medicine report [The Health of LGBT People: Building a Foundation for Better Understanding], Healthy People 2020—which for the first time includes specific LGBT health goals—and the Affordable Care Act have all made a difference in how hospitals are addressing the needs of LGBT patients.”

But some transcultural nursing leaders, such as Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CNS, CTN-A, FAAN, President and Founder of Transcultural C.A.R.E. Associates in Cincinnati, argue that simply having culturally sensitive accreditation standards—or even federal government mandates—in place is not enough. Unless these requirements are vigorously enforced, she believes, there’s no guarantee that hospitals will act on them.

Vargas agrees. “The policies are there at the macro level,” he says, “but we really have to rely on the professionals in the hospitals—nurses in particular, but all members of the health care team—to make sure those policies are enforced.”

Nurses as Communication Champions

What can nurses do to help ensure that their institutions are complying with the standards on an ongoing basis—not just when Joint Commission surveyors show up? Muñoz, who is professor emeritus and an adjunct professor at Capital University School of Nursing, asserts that nurses must be leaders in a constant dialogue about the crucial role culturally competent communication plays in planning and delivering the best possible care for every patient.

“When nurses have a patient who needs language assistance, they must demand that the patient gets those [interpretation] services,” Muñoz adds. “As patient advocates, they should not settle for just getting by, or using family members [as interpreters] when it is convenient. That is not acceptable.”

Laura Hein, PhD, RN, an assistant professor at the University of South Carolina College of Nursing and a member of GLMA’s board of directors, gives two reasons why it’s important for nurses to be involved in championing the standards’ LGBT-inclusive provisions. “One is patient protection and advocacy. The other is to protect the rights of their [LGBT] colleagues, whether they themselves are LGBT-identified or not.” However, she cautions, “If they’re working in a state, or a hospital, that is not accepting of LGBT people, it’s a little trickier for them to be an advocate without endangering their own employment.”

            Even though the impact of the patient-centered communication standards is still a work in progress, Muñoz emphasizes that progress is the key word. “At least we have the standards now; we didn’t have them before,” she says. “We’re moving forward. I wish we could move faster. But we’re moving.”



  1. U.S. Department of Health and Human Services, “Medicare Finalizes New Rules to Require Equal Visitation Rights for All Hospital Patients,” November 17, 2010,, accessed March 26, 2013.
  2. U.S. Department of Health and Human Services, Office of Minority Health, “National Standards on Culturally and Linguistically Appropriate Services (CLAS),”, accessed March 25, 2013.