How do nurses meet the care needs of a diverse group

Diversity is an increasingly important factor in the provision of health care in the UK.  As racial and cultural diversity increases, it becomes more likely that nurses will encounter patients from backgrounds other than their own (Davidhizar & Giger, 2004).  This paper will present various definitions of diversity and its related terms.  Then, the health care needs of a diverse group will be explored, along with the impact of prejudice and some suggestions as to how the multi-professional team can respond the care needs of diverse populations.  Addressing diversity is likely to benefit not only patients, but also health care providers and organizations (Bullas, 2003).

Diversity, Culture, Race, and Ethnicity

Diversity usually means a good thing, as in “community” or “equality” (Alexis, 2005).  Diversity may include ethnicity, gender, disability, age, or sexuality and is related to social identity or membership in groups whose members share many common experiences and needs (Robb & Douglas, 2004).  Diversity also means any difference putting one in a minority (Bullas, 2003).  

The terms race, culture and ethnicity are often used interchangeably, but they define different characteristics of people (Watt & Norton, 2004).  Culture is the set of rules, meanings and ideas shared by a group that informs their world view and dictates behavior (Watt & Norton).  According to Davidhizar and Giger (2004), culture is “a patterned behavioural response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations” (pp. 48-49).  Culture is both innate and a product of environment, is shaped by values, customs, and beliefs of the shared group, and is significant in influencing behaviors and giving meaning to phenomena (Davidhizar & Giger, 2004).  

Ethnicity refers to cultural attitudes and practices characterizing a given group and distinguishing them from other groups based on a political and historical context (Watt & Norton, 2004).  Ethnicity does not imply a biological basis for differences, but is based upon similarities derived from group membership (Robb & Douglas, 2004).
Race refers to the assumed differences in biological backgrounds, and is considered by some to be a contentious term (Watt & Norton, 2004).  There are fewer genetic differences between racial groups than within them (Robb & Douglas, 2004).  Racial and biological differences are much narrower than cultural differences which include varied values, beliefs, and interpretations of things (Davidhizar & Giger, 2004).  For the purposes of this paper, diversity will refer to any difference putting one in a minority.
Factors affecting Health in Immigrants from Diverse Backgrounds

Health results from a complex combination of economic, political, biological, psychological spiritual and familial factors (Striepe & Coons, 2002).  Thus health care providers need to assess all the underlying factors for the presenting health concern, and to respond to the relational or environmental factors that may influence health (Striepe & Coons, 2002).  

People from distinct, special population groups are likely to have common cultural beliefs affecting their health including family values, reliance on alternative medicine, and religious or spiritual beliefs (Ramirez, 2003).  Health may be low on the priority list of recent immigrants due to numerous other pressing needs (Hepinstall, Kralj & Lee, 2004).  These individuals have often suffered trauma just getting to the UK, and then face major life changes once there—leaving them vulnerable to poor health (Hepinstall, Kralj & Lee, 2004).  Furthermore, immigrants often have little control over their lives, live in poverty, and receive hostile, abusive treatment by others.  Hepinstall and colleagues (2004) point out that the NHS may not be prepared to deal with the mental and physical sequelae of torture that many asylum seekers bring with them.  Refugees and those seeking asylum likely experience various deprivations that can have a severe impact upon their health (Bullas, 2003).  They may have certain illnesses based on country of origin, acquired during their flight to the UK, or acquired once they reach the UK (Hepinstall, Kralj & Lee, 2004).  Furthermore, many people from different cultures will not have a frame of reference for the western health system, and thus will not know how to even begin to access care (Hepinstall, Kralj & Lee, 2004).  

Honoring diversity means giving patients equal access to services, based on need, no matter what their differences (Bullas, 2003).  Bullas (2003) described several cultural factors which may impact access to care.  These include: rituals practiced around major life events; dietary habits; needs during times of cultural festivals or observances; presentation of symptoms and the response to assessment and treatment; language and communication; body language (e.g., eye contact and personal space); and the ability to access and use information (e.g., literacy, vision or hearing impairment, learning ability). 
Language barriers can negatively impact access to quality health care (Ramirez, 2003).  

Cultural competence is partially related to the use of language in communication.  Bullas (2003) reports that as many as 600,000 people are unable to communicate with health professionals because of inadequate English language skills.  Differences in communication styles may become problems when they prevent the patient from asking questions or understanding her care, or when the patient herself is misunderstood (Robb & Douglas, 2004).  Patient non-compliance with advised therapy may be an untoward consequence of discordance between health beliefs of the provider and the patient (Harmsen et al., 2003). 

Such discordance may affect the way in which problems are presented and the outcome of the clinical visit (Harmsen et al., 2003).  Research has shown that communication in consultation between GP’s and patients who do not speak the native language is less effective than in consultations with persons speaking the same language as the GP (Harmsen et al., 2003).  In fact, communication in those with like backgrounds may be insufficient in 25% of cases, while in those with dissimilar backgrounds, it may be as high as 50% (Harmsen et al., 2003).  

Better training of health care workers to communicate effectively with diverse individuals—both linguistically and culturally—is an important part of improving their care (Ramirez, 2003).  More research and research funding is necessary in order to improve patient-provider communication with diverse populations (Ramirez, 2003).  Interpreting services can be a valuable tool to use with non English speaking patients.  There is a free, nationally available telephone interpreting service through NHS Direct at every NHS site (Hepinstall, Kralj & Lee, 2004).  Use of family members (especially children) is to be avoided except for emergencies (Hepinstall, Kralj & Lee, 2004).  The gender of the interpreter may be important for women from some cultures.  In addition, one should keep in mind that two speakers of Arabic may be from rival cultures (Hepinstall, Kralj & Lee, 2004).  When interpreting services are not available, providers should use careful listening, pay attention to body language, and even use mime or drawings to communicate (Hepinstall, Kralj & Lee, 2004).  When caring for culturally diverse families, providers should use flexibility in verbal and non-verbal communication, should speak slowly and clearly, avoid the use of slang terms, and be patient yet observant for any misunderstandings created by a language or cultural barrier (Cioffi, 2002, p. 300). 

Health care providers may have to seek the services of a bi-lingual health care worker or interpreter (pp. 301-302).  In addition, it may be beneficial to learn some basic words in other languages.  For example, in the context of midwifery, one should learn words such as “push”, “don’t push”, “breathe”, etc. (p. 303).   
It is almost impossible to unravel the effects of social deprivation, racism and social isolation that are so much a part of society today (Hutchinson & Hickling, 1999, p. 165).  However, women immigrants have a dual burden of being both culturally diverse, and being female.  Power over socioeconomic determinants of health is differentially distributed in women than in men.  “Gender determines the differential power and control men and women have over the socioeconomic determinants of their…health and lives, their social position, status and treatment in society, and their susceptibility and exposure to specific mental health risks” (WHO, n.d., no pagination).  Many of women’s gender based risks are connected to discrimination, exposure to poverty, and socioeconomic disadvantage (WHO, n.d., p. 3), as well as income and insurance status (WHO, n.d., p. 4), gender-based violence, subordinate social status, and a high level of required care for others.  For example, there is a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental disorders in women.  

The traditional gender roles of women, stressing passivity, submission, and dependence, may increase susceptibility to mental illness (WHO, n.d., p. 3).   The female gender role suggests “unremitting care of others and unpaid domestic and agricultural labour” (WHO, n.d., p. 3).  Desirable feminine characteristics are similar to those of both depression and low social rank (WHO, n.d., p. 12).  There is a need for gendered health policy and gender-specific health risk-reduction strategies.  Also, there should be accessible, gender sensitive health services (WHO, n.d., p. 10).  Accessibility to health care services for women can be increased by having short waiting times, providing evening and weekend hours, and being near public transportation routes (WHO, n.d., p. 10).  

Some have argued that the conventional health system may neglect the values of patients who prefer a non-individualist lifestyle to a more conventional, self-reliance based lifestyle (Leighton, 2005).  Examples are those living in a pastoral-communal setting based on retreat, interdependence, and naturalism.  Further, it should not be assumed that immigrant women do not share western attitudes about such topics as contraception (Hepinstall, Kralj & Lee, 2004).  However, many women will be ambivalent about using contraception—not wanting to use it, but also not wanting to have more children.
Mental health is an especially important topic in immigrants—especially those seeking asylum.  Care should be taken not to pathologise normal responses to trauma such as grief (Hepinstall, Kralj & Lee, 2004).  “It is important to acknowledge the resilience of individuals and communities and not label people with diagnoses that may add to their stigma and powerlessness” (Hepinstall, Kralj & Lee, 2004, p. 51).  

Impact of Assumptions, Prejudices, and Stereotyping upon Health Care Delivery

When caring for patients from different cultures, nurses and other care providers may make assumptions about the perspective and needs of these patients (Komaromy, 2004).  When diversity is seen as “otherness” it can become seen as the other’s problem that the “non-diverse” individual does not have to deal with (Keys, 2005).  The language associated with immigrants is often negative—such as flooding, overrunning, illegal, burden (Hepinstall, Kralj & Lee, 2004).  Asylum seekers are often treated poorly and little consideration is given to their skills and potential to make positive contributions to the UK (Hepinstall, Kralj & Lee, 2004).  
Individuals often make generalizations based on characteristics such as ethnicity or gender, while ignoring differences within groups and similarities between groups.  This may lead to care provided based upon shared assumptions related to group membership (Robb & Douglas, 2004).  Such generalizations or stereotypes are usually negative as they are defined by the majority or the group in power (Robb & Douglas, 2004).  In addition, immigrants should not be seen as vectors of disease (Hepinstall, Kralj & Lee, 2004).  

Responding to Diverse Health Care Needs

In addition to the above, several suggestions can be given for nurses, the multi-professional team, and health care agencies to improve care for diverse groups including immigrants from abroad.  Some suggestions include: appreciation of variations in affective responses to illness; sensitivity to variations in communication styles and in the communication or lack of communication of negative signs and symptoms; having an understanding that the meaning if symptoms may vary between cultures; and having an understanding of common biological variations (Davidhizar & Giger, 2004).  Interdisciplinary care will be most effective when team members communicate and synchronize interventions to offer contextual, gender and culture-specific assessment and treatment to help diverse patients make informed decisions about their health (Striepe & Coons, 2002).  

Nurse managers in NHS Trusts should develop strategies emphasizing the importance of race and ethnic composition in relation to health in diverse populations (Chevannes, 1997).  Care given should be based on objective assessment, ethnically derived, and not based upon assumptions of the care giver (Chevannes, 1997).  Initiatives to improve communication with non-English speaking populations include providing interpreters and publishing literature in other languages (Robb & Douglas, 2004).  

Cultural differences need to be taken into account in nursing education, research and practice (Gerrish, 1998).  Some suggestions for how nurses and agencies may respond to diverse care needs include providing immigrants with opportunities to volunteer in health clinics and consulting with community leaders to identify ongoing problems (Gerrish, 1998).  According to Gerrish (1998), “For efficient and appropriate care,  practitioners need to understand the values and cultural prescriptions operating within the patient’s culture, particularly those that may impinge upon the patient’s conception of health and illness…” (p. 116). 


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