Culture and Diversity; Spirituality
Learning Objectives
At the end of this chapter, the learner will:
1. Identify and acknowledge diverse cultural perspectives and spiritual values, beliefs and worldviews different from their own.
2. Apply evidence-based techniques for exploring assumptions when analyzing biased behavior related to cultural and spiritual practices.
3. Recognize the impact of cultural competence to patients’ health care decisions and patient outcomes.
4. Discuss the importance of cultural competence in assessing the patient’s culture, spirituality belief systems and health practices.
5. Develop a deeper understanding and appreciation of cultural self-awareness when caring for patients, families, and population.
Chapter Overview
This chapter includes information on providing nursing care to meet the cultural and spiritual needs of the patients. People may describe a spiritual experience as sacred or transcendent or simply feel a deep sense of aliveness and interconnectedness. Some people’s spiritual life is linked to a religious association with a church, temple, mosque, or synagogue, whereas others pray and find comfort in a personal relationship with God or a higher power and still others find meaning through their connections to nature or art.
The chapter will also review religious beliefs and practices of various world religions, and discuss therapeutic interventions that nurses can use to promote the spiritual well-being of their patients.
Introduction
No matter who we are or where we come from, every person belongs to a culture. The impact of culture on a person’s health is profound because it affects many health beliefs, such as perceived causes of illness, ways to prevent illness, and acceptance of medical treatments. Culturally responsive care integrates these cultural beliefs into an individual’s health care. Culturally responsive care is intentional and promotes trust and rapport with patients. At its heart, culturally responsive care is patient-centered care. The American Nurses Association (ANA) states, “The art of nursing is demonstrated by unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”
Nurses provide holistic care when incorporating their patients’ physical, mental, spiritual, cultural, and social needs into their health care (referred to as holism). As a nursing student, you are undertaking a journey of developing cultural competency with an attitude of cultural humility as you learn how to provide holistic care to your patients. Cultural competency is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.
Cultural humility is defined by the American Nurses Association (2021) as “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process.” You will improve the quality of your nursing care by understanding, respecting, and responding to a patient’s experiences, values, beliefs, and preferences.
Spirituality includes a sense of connection to something bigger than oneself and typically involves a search for meaning and purpose in life. People may describe a spiritual experience as sacred or transcendent or simply feel a deep sense of aliveness and interconnectedness. Some people’s spiritual life is linked to a religious association with a church, temple, mosque, or synagogue, whereas others pray and find comfort in a personal relationship with God or a higher power and still others find meaning through their connections to nature or art. A person’s definition of spirituality and sense of purpose often change throughout one’s lifetime as it evolves based on personal experiences and relationships. Therefore, spiritualty is an important part of health care.
Exercises: Multicultural Simulation
You are about to watch the multicultural simulation which shows how important culture is in nursing care. Focus on recognizing and understanding the cultural implications in the scenario.
I. Simulation Learning Objectives:
1. Students will recall and implement appropriate safety measures particularly related to informed
consent and preoperative preparation.
2. Students will identify the most important focused assessment.
3. Students will identify the cultural needs of the patient and family, and implement these needs as
appropriate in the care provided.
4. Students will communicate effectively with the patient, family members and the health care team
as required.
II. Watch the Simulation Video
III. Debriefing: Guided Reflection Questions for Multicultural Simulation
- How did you feel throughout viewing the simulation experience?
- Describe the objectives you were able to achieve by viewing the simulation?
- Which ones were you unable to achieve (if any)?
- Did you have the knowledge and skills to meet objectives?
- Were you satisfied with your ability to understand the simulation?
- Could the nurses have handled any aspects of the simulation differently?
- How would you handle the situation differently?
- What were the key assessments and interventions?
- Is there anything else you would like to discuss?
I. Basic concepts related to culture
A. Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. The word “culture” may at times be interchanged with terms such as ethnicity, nationality, or race. See Figure 9.1 for an illustration depicting culture by various nationalities. Cultural beliefs and practices bind group or community members together and help form a cohesive identity.
Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals. Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. For example, sushi is a traditional Asian dish that has become popular in America in recent years.
Nurses and other health care team members are impacted by their own personal cultural beliefs. For example, a commonly held belief in American health care is the importance of timeliness; medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial. Identifying and acknowledging cultural perspectives that are different from your own can decrease tension in the nurse-patient relationship and help to promote dialogue that will result in positive outcomes for patients.
Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures. The first step in developing cultural competence is to become aware of your own cultural beliefs, attitudes, and practices. Nurses should also be aware of subcultures. A subculture is a smaller group of people within a culture, often based on a person’s occupation, hobbies, interests, or place of origin. People belonging to a subculture may identify with some, but not all, aspects of their larger “parent” culture. Members of the subculture share beliefs and commonalities that set them apart and do not always conform with those of the larger culture.
Exercise
Query 1
B. Cultural Competency
As a college student, you are likely to find yourself in diverse classrooms, organizations, and eventually – workplaces. It is important to prepare yourself to be able to adapt to diverse environments. Cultural competency can be defined as the ability to recognize and adapt to cultural differences and similarities. It involves “(a) the cultivation of deep cultural self-awareness and understanding (i.e., how one’s own beliefs, values, perceptions, interpretations, judgments, and behaviors are influenced by one’s cultural community or communities) and (b) increased cultural understanding (i.e., comprehension of the different ways people from other cultural groups make sense of and respond to the presence of cultural differences).”1
Cultural competency requires you to be aware of your own cultural practices, values, and experiences, and to be able to read, interpret, and respond to those of others. Such awareness will help you successfully navigate the cultural differences you will encounter in diverse environments. Cultural competency is critical to working and building relationships with people from different cultures; it is so critical, in fact, that it is now one of the most highly desired skills in the modern workforce.2
In the following video, representatives from Rutgers University Behavioral Health Care elaborate on the concept of cultural competency:
We don’t automatically understand differences among people and celebrate the value of those differences. Cultural competency is a skill that you can learn and improve upon over time and with practice. What actions can you take to build your cultural competency skills?
Reflective Exercise: Developing Your Cultural Competency
Objective
- Define and apply principles of cultural competency
Instructions:
This activity will help you examine ways in which you can develop your awareness of and commitment to diversity on campus. Take some time to reflect and then answer the following questions:
- What are my plans for expanding myself personally and intellectually in college?
- What kind of community will help me expand most fully, with diversity as a factor in my expansion?
- What are my comfort zones, and how might I expand them to connect with more diverse groups?
- Do I want to be challenged by new viewpoints, or will I feel more comfortable connecting with people who are like me?
- What are my biggest questions about diversity?
Consider the following strategies to help you answer the questions:
- Examine extracurricular activities. Can you get involved with clubs or organizations that promote and expand diversity?
- Review your college’s curriculum. In what ways does it reflect diversity? Does it have departments and courses on historically unrepresented peoples, e.g., cultural and ethnic studies, and gender and sexuality studies. Look for study-abroad programs, as well.
- Read your college’s mission statement. Read the mission statement of other colleges. How do they match up with your values and beliefs? How do they align with the value of diversity?
- Be open about diversity. Discuss this concept with with family, friends, faculty, and/or colleagues. What does it mean to others? What positive effects has it had on them? Ask people about diversity.
Small Group Discussion: Putting It All Together
Patient Scenario
Mrs. Rosas is a 76-year-old patient admitted to the hospital after experiencing a stroke. The patient’s primary language is Spanish, and she has a limited understanding of English. The family is on a limited budget with no insurance and occasionaly visits the local clinic.
- The patient’s daughter reports that the patient has been experiencing headaches and dizziness over the last three weeks.
- She has not been taking the medication prescribed for high blood pressure regularly.
- During the admission assessment the nurse attempts to collect additional information related to current symptoms, diet, and activity.
- The patient nods in response to questions and converses quietly in Spanish with her daughter.
Applying the Nursing Process. Share your information with the class.
Assessment: Using the concepts of cultual competency, describe the assessment findings related to this patient encounter with the health care system.
Based on the assessment information that has been gathered, create a nursing care plan for Mrs. Rosas.
Overall Goal:
SMART Expected Outcome:
Planning and Implementing Nursing Interventions:
Evaluation:
Sample Documentation
Activity
1. Test yourself for implicit bias at the Learning for Justice website.
2. Consider the following scenario.
You are completing the admission assessment for Mr. Xiong, a 64-year-old patient admitted to the medical surgical floor with pneumonia. Mr. Xiong speaks Hmong and some English. What actions should be undertaken to ensure that you are providing culturally responsive care to Mr. Xiong?
Query 1
II. Spirituality
A. Provision 1 of the ANA Code of Ethics states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” and “optimal nursing care enables the patient to live with as much physical, emotional, social, and religious or spiritual well-being as possible and reflects the patient’s own values.”
is defined by the Interprofessional Spiritual Care Education Curriculum (ISPEC) as, “A dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence and experience relationship to self, family, others, community, society, nature, and the significant or sacred.” Spiritual needs and spirituality are often mistakenly equated with religion, but spirituality is a broader concept. Elements of spirituality include faith, meaning, love, belonging, forgiveness, and connectedness. Spirituality and spiritual values in the context of nursing are closely intertwined with the concept of caring.
Spirituality includes a sense of connection to something bigger than oneself and typically involves a search for meaning and purpose in life. People may describe a spiritual experience as sacred or transcendent or simply feel a deep sense of aliveness and interconnectedness. Some people’s spiritual life is linked to a religious association with a church, temple, mosque, or synagogue, whereas others pray and find comfort in a personal relationship with God or a higher power and still others find meaning through their connections to nature or art. A person’s definition of spirituality and sense of purpose often change throughout one’s lifetime as it evolves based on personal experiences and relationships.
B. Spiritual Distress
When patients are initially diagnosed with an illness or experience a serious injury, they often grapple with the existential question, “Why is this happening to me?” This question is often a sign of spiritual distress. is defined by NANDA-I as, “A state of suffering related to the inability to experience meaning in life through connections with self, others, the world, or a superior being.” Nurses can help relieve this suffering by therapeutically responding to patients’ signs of spiritual distress and advocating for their spiritual needs throughout their health care experience.
Over the past decade, research has demonstrated the importance of spirituality in health care. Spiritual distress is very common in patients and their family members experiencing serious illness, injury, or death, and nurses are on the front lines as they assist these individuals to cope. Addressing a patient’s spirituality and providing spiritual care have been shown to improve patients’ health and quality of life, including how they experience pain, cope with stress and suffering associated with serious illness, and approach end of life.
C. Spiritual Assessment
The Joint Commission requires that health care organizations provide a spiritual assessment when patients are admitted to a hospital. Spiritual assessment can include questions such as the following:
- Who or what provides you with strength or hope?
- How do you express your spirituality?
- What spiritual needs can we advocate for you during this health care experience?
In addition to performing a routine spiritual assessment on admission, nurses often notice other cues related to a patient’s spiritual distress or desire to enhance their spiritual well-being. When these cues are identified, spiritual care should be provided to relieve suffering and promote spiritual health. There are several nursing interventions that can be implemented, in addition to contacting the health care agency’s chaplain or the patient’s clergy member.
Agencies often provide a standardized spiritual assessment tool to complete when a patient is admitted. If a standardized assessment tool is not available, the FICA model can be used.
The FICA model contains open-ended questions to ask patients about their personal spiritual beliefs in a way that is open and nonjudgmental.
F–Faith or beliefs: What are your spiritual beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life?
I–Importance and influence: Is faith/spirituality important to you? How has your illness and/or hospitalization affected your personal practices /beliefs?
C–Community: Are you connected with a faith center in the community? Does it provide support/comfort for you during times of stress? Is there a person/group/leader who supports/assists you in your spirituality?
A–Address: What support can we provide to support your spiritual beliefs/practices?
The HOPE tool is also helpful for incorporating spiritual assessment questions into a medical interview. HOPE stands for:
H: Sources of hope, meaning, comfort, strength, peace, love and connection
O: Organized religion
P: Personal spirituality and practices
E: Effects of spirituality on medical care and end-of-life issues
The first part of the mnemonic, H, pertains to a patient’s basic spiritual resources, such as sources of hope, without immediately focusing on religion or spirituality. This approach allows for meaningful conversation with a variety of patients, including those whose spirituality lies outside the boundaries of traditional religion or those who have been alienated in some way from their religion. It also allows those for whom religion, God, or prayer is important to volunteer this information. The second and third letters, O and P, refer to areas of inquiry about the importance of organized religion in patients’ lives and the specific aspects of their personal spirituality and practices that are most helpful. A useful way to introduce these questions is a normalizing statement such as: “For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs. Is this true for you?
Many hospitals, nursing homes, assisted living facilities, and hospices employ professionally trained chaplains to assist with the spiritual, religious, and emotional needs of patients, family members, and staff. In these settings, support and encourage people of all religious faiths and cultures and customize their approach to each individual’s background, age, and medical condition. Chaplains can meet with any individual regardless of their belief, or lack of belief, in a higher power and can be very helpful in reducing anxiety and distress. A nurse can make a referral for a chaplain without a provider order.
A chaplain assists patients and their family members to develop a spiritual view of their serious illness, injury, or death, which promotes coping and healing. A spiritual view of life and death includes elements such as the following:
-
- Suffering occurs at physical, mental, emotional, and spiritual levels. Sociocultural factors, religious beliefs, family values and dynamics, and other environmental factors affect a person’s response to suffering.
- Hope is a desire or goal for a particular event or outcome. For example, some people may view dying as “hopeless” whereas a spiritual view can define hope as a “good death” when the patient dies peacefully according to the end-of-life preferences they previously expressed. Read more about the concept of a “good death” in the “Grief and Loss” chapter.
- Mystery is knowing there is truth beyond understanding and explanation.
- Peacemaking is the creation of a space for nurturing and healing.
- Forgiveness is an internal process releasing intense emotions attached to past incidents. Self-forgiveness is essential to spiritual growth and healing.
- Prayer is an expression of one’s spirituality through a personalized interaction or organized form of petitioning and worship
III. Application in Practice
Exercises:
1. Mr. Hernandez is a 73-year-old patient admitted with end stage kidney disease, pneumonia, and diabetes. He appears anxious and verbalizes “I think this is the end” when he is admitted to the medical surgical unit.
As you complete the admission assessment, the patient asks you if you believe in God?
Utilizing the FICA model, what questions might you ask to gain insight into the patient’s personal spiritual beliefs?
Exercises: PUTTING IT ALL TOGETHER
Patient Scenario
Mr. Yun is a 34-year-old man presenting to his physician’s office with complaints of difficulty concentrating, sadness, and anxiety. The patient recently experienced the loss of his wife in a motor vehicle accident and reports difficulty sleeping and weight loss of greater than 15 pounds in the previous month. He reports feeling “hopeless” and “angry at God” for the loss that he has experienced. He states he used to attend religious services with his wife, but “That was really more of ‘her’ thing. I really don’t know what to believe anymore.”
Applying the Nursing Process
Assessment: The nurse notes that the patient is experiencing difficulty concentrating, feelings of sadness and hopelessness, and reported anxiety. He self-reports feeling hopeless, feelings of anger toward God, and uncertainty in his belief system.
Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Yun:
Nursing Diagnosis: Spiritual Distress related to loss of challenged belief system as manifested by self-reported “hopelessness,” being “angry at God,” and general uncertainty in beliefs.
Overall Goal: The patient will demonstrate improved spirituality.
SMART Expected Outcome: By the end of the teaching session, Mr. Yun will describe a spiritual practice that provides him comfort.
Planning and Implementing Nursing Interventions:
The nurse will identify the factors that influence the patient’s personal belief system. The nurse will provide support to the patient and allow the patient to express emotions and anger. The nurse will observe and listen empathetically in the communication experience. The nurse will encourage the use of spiritual resources and ask the patient permission to contact a chaplain.
Sample Documentation
Mr. Yun exhibits signs of spiritual distress in relation to the loss of his personal belief system as the result of his wife’s recent death. He verbalizes anger, hopelessness, and uncertainty in his belief system. However, he does find comfort in spending time outdoors in nature. A chaplain has been contacted with the patient’s permission to address Mr. Yun’s spiritual needs.
Evaluation
At the end of the teaching session, the nurse explains that with his permission, a chaplain will call Mr. Yun at home to follow up. Mr. Yun grants permission for the referral. The nurse asks what other spiritual resources Mr. Yun plans to use at home. Mr. Yun explains that he will purposefully go for daily walks outdoors to spend time in nature. The SMART outcome was “met.”
Exercises: Watch
Exercises
IV. Reflections
Key Takeaways
- Diversity refers to a great variety of human characteristics and ways in which people differ.
- Surface-level diversity refers to characteristics you can easily observe, while deep-level diversity refers to attributes that are not visible and must be communicated in order to understand.
- Cultural competency is the ability to recognize and adapt to cultural differences and similarities.
- Diverse environments expose you to new perspectives and can help deepen your learning.
V. Recommended Resources
Cancer: Finding Peace in Spirituality : https://www.upmc.com/health-library/article?hwid=abp7300
View these supplementary videos regarding cultural diversity and cultural competence:
Haley Yeates | It’s Past Time to Appreciate
Enhancing Diversity in the Nursing Workforce:https://www.aacnnursing.org/news-data/fact-sheets/enhancing-diversity-in-the-nursing-workforce
COMMON RELIGIONS AND SPIRITUAL PRACTICES: https://wtcs.pressbooks.pub/nursingfundamentals/chapter/18-3-common-religions-and-religious-practices/
APPLYING THE NURSING PROCESS: https://wtcs.pressbooks.pub/nursingfundamentals/chapter/18-4-applying-the-nursing-process/
SPIRITUAL CARE OF SELF: https://wtcs.pressbooks.pub/nursingfundamentals/chapter/18-5-spiritual-care-of-self/
View these videos about spiritual care provided by chaplains:
- Spiritual Health and Chaplains
- A Day in the Life of a Chaplain
- Chaplains and the Role of Spiritual Care in Health Care
Read more information about using the HOPE tool.
https://www.youtube.com/watch?v=r62Zp99U67Y&ab_channel=Johnson%26JohnsonNursing
Cultural Competence: https://montgomerycollege.idm.oclc.org/login?url=https://fod-infobase-com.montgomerycollege.idm.oclc.org/PortalPlaylists.aspx?wID=16705&xtid=286917
References and Attributes
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association
- Delagran, L. (n.d.). What is spirituality? University of Minnesota. https://www.takingcharge.csh.umn.edu/what-spirituality ↵
- Pilger, C., Molzahn, A. E., de Oliveira, M. P., & Kusumota, L. (2016). The relationship of the spiritual and religious dimensions with quality of life and health of patients with chronic kidney disease: An integrative literature review. Nephrology Nursing Journal, 43(5), 411–426. https://pubmed.ncbi.nlm.nih.gov/30550069/ ↵
- Puchalski, C., Jafari, N., Buller, H., Haythorn, T., Jacobs, C., & Ferrell, B. (2020). Interprofessional spiritual care education curriculum: A milestone toward the provision of spiritual care. Journal of Palliative Medicine, 23(6), 777–784. https://doi.org/10.1089/jpm.2019.0375 ↵
- Pilger, C., Molzahn, A. E., de Oliveira, M. P., & Kusumota, L. (2016). The relationship of the spiritual and religious dimensions with quality of life and health of patients with chronic kidney disease: An integrative literature review. Nephrology Nursing Journal, 43(5), 411–426. https://pubmed.ncbi.nlm.nih.gov/30550069/ ↵
- Puchalski, C., Jafari, N., Buller, H., Haythorn, T., Jacobs, C., & Ferrell, B. (2020). Interprofessional spiritual care education curriculum: A milestone toward the provision of spiritual care. Journal of Palliative Medicine, 23(6), 777–784. https://doi.org/10.1089/jpm.2019.0375 ↵
- Erickson, H. (2007). Philosophy and theory of holism. The Nursing Clinics of North American, 42(2).https://doi.org/10.1016/j.cnur.2007.03.001 ↵
- Bennett, J. M. (2015). “Intercultural Competence Development.” The SAGE Encyclopedia of Intercultural Competence. Thousand Oaks, CA: SAGE Publications, Inc.
- Bennett, J. M. (2015). “Intercultural Competence Development.” The SAGE Encyclopedia of Intercultural Competence. Thousand Oaks, CA: SAGE Publications, Inc.
- “10 Reasons Why We Need Diversity on College Campuses.” Center for American Progress. 2016. Web. 2 Feb 2016.
- TED Institute. (2018, February 15). It’s (past) time to appreciate cultural diversity | Hayley Yeates | TED Institute. [Video]. YouTube. Video licensed under CC BY–NC–ND 4.0. ↵
- Johnson & Johnson Nursing. (2018, December 3). Becoming a culturally competent nurse. [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=r62Zp99U67Y&feature=emb_title↵
- Dameron, C. M. (2005). Spiritual assessment made easy… With acronyms! Journal of Christian Nursing, 22(1). https://www.nursingcenter.com/journalarticle?Article_ID=725343&Journal_ID=642167&Issue_ID=725337 ↵
