2 Diversity in Health Care Organizations
Sonia A. Udod and Louise Racine
In a multi-race society, no group can make it alone.
—Martin Luther King, Jr., March 31, 1968 (Phillips, 1999, p.136)
Workplace diversity is becoming increasingly important in Canadian health care settings. As the nursing workforce and demographic patterns change, it is important for nurse leaders to understand and influence staff with various values, beliefs, and expectations. In this chapter, we first review cultural diversity, ethnicity, race, cultural competency, and cultural safety. Second, we explore the differences between cultural competency and cultural safety. Third, we present theories that can be used to guide the implementation and delivery of culturally competent nursing care. We review the role of nurse managers in supporting the implementation of culturally competent care with clients and within health care organizations. Finally, we will discuss how diversity applies to new generations and see how intergenerational conflicts arise from different cultural beliefs. We conclude with strategies for managing workplace diversity.
- Understand the concepts of culture, cultural competence, and cultural safety in leading and managing nursing.
- Discuss cultural diversity and the ways in which people differ.
- Identify theoretical models that can facilitate culturally competent patient care.
- Articulate the generational differences among Veterans, Baby Boomers, Generation X, and Generation Y.
- Explore the issues of workplace diversity in health care organizations for nursing staff, nurse leaders, and patients and families.
- Describe how the nurse leader can manage workplace diversity.
In Canada, the general population is becoming increasingly diverse in colour, culture, religion, ethnicity, and origin (Statistics Canada, 2017). Data suggest that in 2011, 20 per cent of the Canadian population were immigrants, and projections are that the percentage of immigrants in Canada will continue to increase (Statistics Canada, 2017). The influx of immigrants to Canada has been characterized by sustained immigration and an increased diversification of immigrants, which has been designed to meet Canada’s economic needs and to provide a welcome refuge for vulnerable refugees.
The number of new immigrants and their geographical locations could affect the ethnocultural diversity of various regions in Canada. For example, the top ten countries from which immigrants come to Saskatchewan have been Philippines, India, China, Pakistan, Ukraine, United Kingdom, United States, Bangladesh, Iraq, and South Africa (The Canadian Magazine of Immigration, 2016). Such changes to the cultural reconfiguration of the prairie landscape will affect workplace diversity.
These changes have led to a growing challenge in nursing leadership related to the management of a culturally diverse work environment. Cultural and generational differences related to attitudes, beliefs, work habits, and expectations have proven to be challenging for nurse leaders (Kramer, 2010) and will continue to be a critical managerial and leadership priority. Demographics, language, education, cultural, gender, race, and generational differences are factors that have increased conflict within health care teams, which is associated with burnout and decreased job satisfaction (Almost, 2006; Mortell, 2013). When conflict and disharmony occur within a team, the nurse leader plays a significant role. Results of misunderstandings and misinterpretations related to cultural and generational differences can be costly to organizations as they can result in increased absenteeism, decreased staff satisfaction, and decreased quality patient care (Weingarten, 2009).
2.1 Cultural Diversity
Canada, the United States, and European nations are presently facing a migration crisis of a magnitude that has not been seen since the massive population displacements of the post–World War II era (Fleras, 2015). Due to the effects of globalization, economic policies, financial constraints, and forced migrations due to environmental or armed conflicts, nurses are providing health care to very diverse and sometimes vulnerable populations such as refugees and asylum seekers (Racine & Lu, 2015). On the other hand, globalization also brings increased ethnic and cultural diversity within health care organizations, which affects the way nurses deliver care and how they interact with nurses coming from other countries. More than ever, nurses must be culturally competent and culturally safe in their everyday practice regardless of the health settings in which they work. Similarly, nurse managers need to understand their roles in supporting cultural competency and safety at both the individual and the organizational level. Cultural competency and cultural safety are key skills for nurses to acquire and sustain. The Canadian Nurses Association, the Canadian Association of Schools of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the US Office of Minority Health are among the major regulatory nursing bodies and organizations that recognize the moral and ethical duty of nurses to advocate for and provide culturally competent care.
Cultural diversity refers to cultural differences and how individuals and groups vary based on certain ethnic, racial, and cultural attributes. However, the concept of cultural diversity is complex, as the recognition of this diversity does not mean that the differences of the “Other” are respected and accepted (Bhabha, 1994). Andrews and Boyle (2012) define diversity as “differences in race, ethnicity, national origins, religion, gender, sexual orientation, ability or disability, social and economic status or class, education, and related attributes of groups of people in society” (p. 5). Cultural diversity in our country requires that nurses become culturally knowledgeable and conscious of their attitudes toward people from other ethnocultural groups. Issues of race and ethnicity are often conflated and emerge as problematic issues arising from cultural conflicts or misunderstandings between individuals and groups. It is, therefore, important to understand the differences between ethnicity and race.
Ethnicity and Ethnocentrism
The context of race and ethnic relations represent a challenge of contemporary nursing practice as our world becomes more global and diversified. Cornell and Hartmann (2007) define an ethnic group as “a collectivity within a larger society having real or putative common ancestry, memories of a shared historical past, and a cultural focus on one or more symbolic elements defined as the epitome of their peoplehood” (p. 19). Ethnicity and race represent different concepts, yet they sometimes overlap. For example, Ericksen (2010) underlines that Croatians, Serbs, and Bosnians can be seen as caucasian, but they form various ethnic groups. The same reasoning applies to Asian peoples with ethnic differences that include Vietnamese, Chinese, Korean, and Cambodian peoples. Cornell and Hartmann (2007) reinforce the notion that ethnic groups are self-conscious of their distinct characteristics. Eriksen (2010) defines ethnicity as “the relationships between groups whose members consider themselves distinctive” (p. 10). Ethnicity and the values underlying the belonging to an ethnic group may be used to categorize individuals and groups based on some norms or values that can cause prejudice. This process is called ethnocentrism.
Ethnocentrism refers to the “universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways” (Purnell, 2013, p. 7). Ethnocentrism can lead to cultural impositions, which may create conflicts with clients and nurse colleagues because of different worldviews on health, illness, or nursing. Ethnocentrism not only affects interactions between nurses and clients or groups, but also creates or reinforces inequities in accessing health care. Ethnocentrism may affect health and clinical outcomes because underserved and underprivileged groups may refrain from consulting nurses or other health professionals if they feel these professionals do not respect their ethnocultural beliefs (Sampselle, 2007). Ethnocentrism violates nursing’s mandate of advocacy and social justice by bringing prejudices into the professional delivery of care (Boutain, 2016).
Race, Othering, and Racialization
Race remains controversial because it is rooted in colonialism, where differences constructed between European and non-European peoples led to marginalization (Driedger, 2003). From a colonialist perspective, race can be used to assign differences based on skin colour, yet the view of race as a strict biological construct is highly problematic because it paves the way to racism. Cornell and Hartmann (2007) argue that race is a social construct as race relates to meanings attributed to certain biological differences. They state that race refers to “a group of human beings socially defined by physical characteristics. Determining which characteristics constitute the race, the selection of markers and, therefore, the construction of the racial category itself, is a choice human beings make” (2007, p. 25).
In other words, race is socially constructed as people select the markers of racial differences based on biological or cultural attributes.
Purnell (2013) argues that “race has social meaning, assigns status, limits or increases opportunities, and influences interactions between patients and clinicians” (p. 8). Racism is a “negative concept, based on the belief that some races are inferior to others” (Driedger, 2003, p. 216). As a biological and social construct, race can be used as a means of social stratification also called othering. Canales (2010) argues that othering is both exclusionary and inclusionary. Othering represents a process of racialization (Ahmad & Atkin, 1996). Canales contends that othering “often uses the power within relationships for domination and subordination with the potential consequences being alienation, marginalization, decreased opportunities, internalized oppression, and exclusion. Othering correlates with the ‘visibility’ (e.g., skin color, presence of an accent, sexual orientation) of one’s otherness” (2010, p. 5). It is hard to reflect on one’s racial biases, but it is a necessary step toward developing and implementing cultural competency and safety.
Our discussion of race and ethnicity underlines that “cultures and cultural differences are not discovered, they are constructed” (Allen, 1999, p. 230). If stereotypes are socially constructed, it is safe to argue that cultural competency and safety are processes by which nurses will deconstruct race and ethnicity to avoid applying racial and cultural stereotypes in their interactions with individuals and groups from different racial and ethnocultural groups. Nurses have an ethical duty to respect other persons’ and groups’ cultural beliefs related to health and illness. This respect intersects with culture and cultural competency to help us move beyond the boundaries of race and ethnicity and to treat individuals who are culturally different from us in a humanistic and caring way (Andrews & Boyle, 2012).
Andrews and Boyle (2012) mention that transcultural nursing enables the development of a “scientific and a humanistic body of knowledge to provide culture-specific and culture-universal nursing care” (p. 4). To provide culture-specific and culture-universal nursing care, nurses have to strive to know those who come from different ethnocultural backgrounds. Nurses must endeavour to become culturally competent and culturally safe in their interactions not only with clients, but also with other nurses and health care providers.
2.3 Cultural Competency
Cultural competency is a concept that arises from the seminal work of Madeleine Leininger, who was trained as a nurse and an anthropologist. Leininger first saw the importance of culture in nursing care delivery. Leininger’s theory of cultural care diversity and universality (1995) is based on the fundamental assumption that culture affects people’s health and illness experiences as well as nursing care delivery. Leininger (1995) postulates that “culture is an integral and essential aspect of being human, and the culture care aspects cannot be overlooked or neglected” (p. 4). Culture represents “the learned, shared, and transmitted knowledge of values, beliefs, norms, and lifeways of a particular group that guides an individual or group in their thinking, decisions, and actions in patterned ways” (Leininger, 1995, p. 60). Religion, gender, and socialization influence cultural patterns and create a diversity of needs when applied to nursing and health care. Nurses need to possess cultural competency when navigating culturally diverse clienteles and multicultural workplaces.
Cultural competency is both an individual and an organizational process (Andrews & Boyle, 2012). Purnell (2013) defines cultural competence in health care as “having the knowledge, abilities, and skills to deliver care congruent with the patient’s cultural beliefs and practices” (p. 7). Jeffreys (2010) refers to cultural competence as “a multidimensional learning process that integrates transcultural nursing skills in all three dimensions (cognitive, practical, and affective), involves transcultural self-efficacy (confidence), and aims to achieve culturally competent nursing care” (p. 36). Campinha-Bacote (2002) defines cultural competency as an “ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client [individual, family, community]” (p. 181). Campinha-Bacote’s Process of Cultural Competency and Model of Care (2002) builds on the assumption that cultural competency is an ongoing process of being and becoming. Campinha-Bacote (2002) points out that to be effective, this model “requires health care providers to see themselves as becoming culturally competent rather than already being culturally competent” (p. 181). This ongoing process means that nurses are immersed in a continual process of education where there is no end point to learning about cultural differences.
In her article, Bourque Bearskin (2011) points out that “culture is everything about people: the way they live, the way they view things, the way they communicate” (p. 4). It is through encounters with peoples from different ethnocultural backgrounds that nurses start their journey of becoming culturally competent. Cultural competency cannot happen if there is no exposure to cultural diversity. Similarly, Campinha-Bacote underlines that encountering cultural diversity is a prerequisite or an antecedent for the development of cultural competency. In her model, Campinha-Bacote describes five interrelated concepts: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural encounters, and (5) cultural desire.
Cultural awareness involves assessing one’s cultural and racial biases as a means to identify how one’s cultural stereotypes may affect the delivery of nursing care to cultural or linguistic minority groups. Cultural knowledge refers to knowledge about cultural groups and how their cultural beliefs and norms may impact on perceptions and experiences of health and illness, and influence access to health care and relationships with nurses and other health care professionals. It is important to know how ethnicity and race may affect pharmacotherapeutics or how culture shapes lifestyle and other health-related behaviours.
Campinha-Bacote (2002) argues that the acknowledgement of culture implies that nurses must develop knowledge and cultural skills to conduct a cultural assessment of each client. A cultural assessment is defined as “a systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values, and practices to determine explicit needs and intervention practices” within the context of the health encounters (Leininger, 1995, p. 122). Other theories can be used to conduct cultural assessments using Giger and Davidhizar’s Transcultural Assessment Model (2002), Leininger’s Cultural Care Diversity and Universality Theory (2002), Purnell’s Model for Cultural Competence (2013), or Spector’s Model of Cultural Diversity in Health and Illness (2009). For instance, Giger and Davidhizar’s Transcultural Assessment Model (2002) explores six cultural phenomena, believed to be culturally unique among persons, that become the object of cultural assessment. These variables are: (1) communication, (2) space, (3) social organization, (4) time, (5) environmental control, and (6) biological variations (Giger & Davidhizar, 2002, p. 185). Similarly, Purnell’s Model for Cultural Competence (2013) assesses 12 domains of culture. The domains of culture are:
1) overview, inhabited localities, and topography, 2) communication, 3) family roles and organization, 4) workforce issues, 5) biocultural ecology, 6) high-risk behaviours, 7) nutrition, 8) pregnancy and childbearing practices, 9) death rituals, 10) spirituality, 11) health care practiced, and 12) health care provider. (Purnell, 2013, p. 18)
Cultural encounters focus on cross-cultural interactions. Cross-cultural interactions enable nurses to engage with culturally diverse clients or groups to change or challenge ethnic and racial biases. Communication and language are important factors to facilitate access to clients’ lived experiences of health and illness. In cases of a lack of linguistic fluency, nurses may use interpreters or cultural brokers to access clients’ knowledge of their illness or conditions.
Cultural skill represents the ability to perform the cultural assessment when meeting with clients or families. Cultural desire refers to the motivation and the genuine desire for cultural understanding, as opposed to the obligation of encountering cultural diversity. Campinha-Bacote suggests that caring is an antecedent of cultural desire in the fact that the nurse cares about those from different cultures. Cultural desire can be manifested through openness to cultural diversity and a willingness to learn from others. Campinha-Bacote explains that becoming culturally competent is an interactive and transformational endeavour.
Professional Nursing Guidelines for Culturally Competent Care
The delivery of culturally competent care is embodied in standards and codes of ethics set by international, national, and provincial nursing regulatory bodies, including the Canadian Nurses Association. The International Council of Nurses (2012) mentions that “in providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family, and community are respected” (p. 2). The Canadian Nurses Association supports the view of social justice that is inherent to the delivery of culturally competent nursing care. The Canadian Nurses Association (2010) defines cultural competency as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable them to work effectively in cross-cultural situations” (p. 1). In a document entitled “Cultural Competence and Cultural Safety in Nursing Education: A Framework for First Nations, Inuit and Métis Nursing,” the Aboriginal Nurses Association of Canada (now the Canadian Indigenous Nurses Association), the Canadian Association of Schools of Nursing, and the Canadian Nurses Association stipulate that Canadian nurses must know the impact of colonialism on Indigenous health issues to avoid the pitfalls of ethnocentrism and cultural imposition. Nurses need to learn how to communicate and respect Indigenous ways of knowing. While cultural competency encompasses attributes like cultural awareness, sensitivity, and humility, the ultimate goal of developing and applying core cultural competencies is to advocate and protect the dignity of individuals and groups (Douglas et al., 2014).
Similarly, in the United States, the Office of Minority Health (OMH), part of the US Department of Health and Human Services, requires that US citizens have access to “culturally and linguistically appropriate services, are respectful of and responsive to the health beliefs, practices and needs of multicultural and diverse patients” (OMH, 2017). Cultural competency is therefore not only a nurse’s individual and ethical duty, but also an organization’s responsibility—a responsibility to enable and facilitate the establishment of rules and policies that will promote cultural competency within work relations in nursing workplaces.
Finally, the Saskatchewan Registered Nurses’ Association (SRNA) stipulates that the development of cultural safety is a core competency that must be addressed in nursing curricula. Cultural competency is reflected in Standard II.2 (44): “Negotiates priorities of care and desired outcomes with clients while demonstrating an awareness of cultural safety and the influence of existing positional power relationships” (SRNA, 2013, p. 13). We now examine the characteristics of culturally competent organizations.
2.4 Cultural Competency within Organizations
Canada’s increased cultural diversity requires organizations to adapt their services to the demographic mosaic of our country. The delivery of culturally competent care cannot be effective without the implementation of culturally competent nursing values within health care organizations. Although social determinants of health affect people differently, health organizations must strive to adapt nursing and health care delivery to meet the needs of a culturally diverse population. Knowing that inequities affect health outcomes, both nurses and health organizations should strive to provide quality care that will take into account cultural diversity.
In the United States, issues of cultural competency among organizations represent a priority for the Office of Minority Health. The Office of Minority Health has contributed to the development of national standards for culturally and linguistically appropriate services (CLAS) in health and health care. There are 15 national CLAS standards directed at improving the quality of health care and advancing health equity within health organizations. The three main principles undergirding the standards are: (1) governance, leadership, and workforce, (2) communication and language assistance, and (3) engagement in continuous improvement and accountability.
Andrews and Boyle (2012) believe that organizational cultural competence involves characteristics shared within an organization. They assert that organizations must have principles and policies that will sustain nurses and other health care professionals to work effectively in diversity contexts. According to Andrews and Boyle (2012), these organizations will “value diversity, conduct self-assessment, manage dynamics of differences, acquire and institutionalize cultural knowledge, and adapt to diversity within hiring and staffing processes” (p. 18). While Douglas et al. (2014) state that a one-size-fits-all approach to cultural competency within an organization does not apply to all health settings and cultural groups, some general principles or guidelines may demonstrate organizational openness to cultural diversity. Douglas et al. (2012) define ten guidelines that support cultural competency at the instructional level: (1) knowledge of cultures, (2) education and training in culturally competent care, (3) critical reflection, (4) cross-cultural communication, (5) culturally competent practice, (6) cultural competence in health care systems and organizations, (7) patient advocacy and empowerment, (8) multicultural workforce, (9) cross-cultural leadership, and (10) evidence-based practice and research.
Although we refer you to the article by Douglas et al. (2014) for further details, the guidelines delineate the critical role played by nurse managers and administrators in creating a positive and open environment for managing cultural diversity. Also, health care organizations must provide the tools and context for nurse leaders to support cultural competency. Andrews and Boyle (2012) underscore the need for training and education in cross-cultural communication, as well as access to linguistically adapted tools and to interpreters who can also act as cultural brokers, enabling the understanding of behaviours, attitudes, and norms about experiences of health and illness. Cultural competency also implies that organizations will be mindful of cultural diversity within their organizations. The ongoing issue of nurse migration illustrates the need for health agencies to develop strategies to address cultural conflicts and support internationally educated nurses in their adaption to a new working environment (Douglas et al., 2014).
In summary, cultural competency is a core competency required from all nurses. Providing culturally competent nursing care is an ethical and respectful way to acknowledge that one’s clients, families, and communities see health and illness in ways that may differ from oneself. Cultural competency does not require nurses to know every detail about peoples’ ethnocultural backgrounds. Cultural competency is about demonstrating attitudes of openness and flexibility to enter into a meaningful dialogue with clients or families (Bourque Bearskin, 2011; Woods, 2010). Respect and ethical practice are the hallmarks of cultural competency. Cultural competence is closely aligned with the concept of caring (Leininger, 1995). Caring always involves the respect of cultural differences and cultural diversity (Racine, 2014). To achieve cultural competency, nurses must also be mindful of power relations. As such, nurses must examine their own cultural values and the attitudes they bring to their nursing practice with diverse ethnocultural groups.
2.5 Cultural Safety
Despite the remarkable growth in the literature in nursing on cultural competency, the delivery of culturally safe nursing care remains to be achieved (Racine, 2014). Cultural safety is a concept that originated from the pioneering work of Irihapeti Ramsden, a Maori nurse who described the persistent inequities affecting the Indigenous peoples of New Zealand (Nursing Council of New Zealand, 2011). Although cultural safety is a relatively new concept, it is critical to the understanding of the persistence of health inequities among Indigenous and minority populations in Canada. The continued existence of health inequities explains why cultural competency alone cannot address systemic and institutional barriers that affect health and health outcomes (Racine, 2014). Cultural competency helps us to understand other cultural norms and behaviours, but tends to overlook systemic barriers or those created by unequal access to the social determinants of health. The reason is that at the centre of race relations lies the concept of power, and race relations cannot be dissociated from issues of power that affect racial, gender, ethnic, and language discrimination (Racine, 2014). Cultural safety requires nurses to be aware of power relations in their interactions with clients or colleagues at work.
Cultural safety is defined as “nursing or midwifery action to protect from danger and/or reduce risk to patient/client/community from hazards to health and well-being” (Papps & Ramsden, 1996, p. 493). Contrary to cultural safety, transcultural nursing does not require nurses to examine their own cultural attitudes and behaviours and the impact these ethnocentric attitudes may have on patients (Ramsden, 1993). In cultural safety, the nurse becomes the centre of reflection whereas cultural competence focuses on knowing the ethnocultural backgrounds of clients, families, or communities. Cultural safety shifts the critical lens to the nurse, and the client judges the quality of culturally safe nursing care. As such, any nursing intervention that does not account for power relations may jeopardize individuals’ and groups’ health and integrity, and therefore can be seen as culturally unsafe. The presence of power relations within the nurse–client professional encounter requires nurses to reflect on their biases and racial or ethnic privileges when caring for culturally diverse individuals and groups. In other words, being culturally competent is not enough to provide nursing care that will be responsive to the health care beliefs and practices of diverse and vulnerable clienteles (Andrews & Boyle, 2012). Cultural safety theorists urge nurses to become cognizant of the location of health problems within historical and social processes. Cultural safety is about building trust to make clients, families, and communities feel accepted and welcomed in the health care system. Browne and Fiske (2001) underline that culturally unsafe practices jeopardize clients’ access to health care because of nurses’ and other health care providers’ negative stereotypes about cultural differences. Cultural safety represents a powerful analytic lens to explore issues of power and how power affects nursing care and delivery (Smye & Browne, 2002).
Cultural safety is about power relations and more specifically about the impact of colonialism and post-colonialism in creating health inequities among marginalized groups (Racine, 2008). As well, Bourque Bearskin reminds nurses that their responsibilities “for cultural safety must include paying attention to the disparities in health care” (2011, p. 6). Within the twenty-first–century context of globalization, nurse migration and the massive displacements of refugees from developing to developed countries compels Western nurses to apply both cultural competency and cultural safety in professional encounters with non-Western clients and families. This ever-changing context of cultural diversity requires that nurse managers become aware of their central role in creating opportunities for training and advocating for the professional, cultural, and social integration of non-Western nurses in nursing workplaces. Although many efforts to achieve culturally competent and safe managing practices have been defined (see, for example, American Organization of Nurse Executives, 2015; Canadian Indigenous Nurses of Canada, 2009; Canadian Nurses Association, 2010; International Council of Nurses, 2012; Nursing Council of New Zealand, 2011), much action still needs to be taken as health inequities persist and internationally educated nurses still face challenges within Western health care systems (Mortell, 2013).
Dauvrin, M., & Lorant, V. (2015). Leadership and cultural competence of healthcare professionals: A social network analysis. Nursing Research, 64(3), 200-210.
The purpose of this study was to describe the cultural competence of leaders and the health care staff, and to determine the association between leader cultural competence and staff cultural competence using a social network analysis.The first research question hypothesized that health care staff would likely be more culturally competent if their leaders were culturally competent. The second research question hypothesized that the leadership effect would depend on the characteristics of the leader, including the leader’s expertise in cultural competence.
Three geographical zones reflecting non-resident populations were selected in Belgium. The final sample consisted of 24 health services: five outpatient primary care services and 19 inpatient services recruited from four hospitals. The 19 inpatient health services included four geriatric units, four intensive care units, four oncology units, three psychiatry units, two communicable disease units, one palliative care unit, and one endocrinology unit. Participants included leaders (n=71) and health care professionals (n=436). The Cultural Competence Scale was adapted to the Belgian context for all health care providers. The scale consisted of five different culturally competent domains: (1) paradigm (ability to adapt to a different type of care), (2) communication (ability to provide information to patients in clear language), (3) specificity (ability to provide specific care for specific groups), (4) organization (ability of the organization to adapt to the needs of the patients), and (5) mediation (ability to negotiate with patients).
The cultural competence of the health care staff was associated with the leader’s cultural competence. This was especially significant in the cultural domains of mediation and paradigm, suggesting workplaces that encourage and role model different ways of providing care and that teach staff how to mediate cultural differences are better equipped to provide quality care to various migrant populations.
Application to practice
International migration is a global phenomenon challenging leaders and health care providers in the provision of culturally competent care. Leaders with formal positions have a greater positive impact on the diffusion of cultural competence among health care staff. Strategies such as role modelling may help to convey the value of empathy, respectful attitudes toward individuals of all cultures, and professionalism. Social relationships and leadership effects within health services should be considered when developing and implementing culturally competent strategies. Further research from a Canadian perspective is warranted.
2.6 Theories and Models of Cultural Competency
There are a number of conceptual models and theories that exist to guide the application of cultural competency in nursing education. One of the major critiques is that these theories or models of cultural competency remain patient or client-oriented rather than focused on organizations.
The lack of utilization of nursing cultural theories to guide research about organizational cultural competency may be associated with the fact that competency has been studied from an individual point of view rather than from an organizational perspective. It also means that nursing remains culturally homogenous. A substantial body of knowledge on internationally educated nurses has been developed over the years, but less research has been done on issues of managing cultural diversity in nursing management. In the context of mass migration and globalization, nurse leaders may need to review Leininger’s cultural care diversity and universality theory in applying best managerial practices to integrate migrant nurses and other forms of diversity (generational, demographic) (McFarland & Wehbe-Alamah, 2017).
The purpose of Leininger’s theory on cultural care diversity and universality is to “discover, document, know, and explain the interdependence of care and culture phenomena with differences and similarities between and among cultures” (McFarland & Wehbe-Alamah, 2017, p. 5). While care, caring, and culture represent central concepts of the theory, Leininger found the concepts of emic and etic knowledges, ethno-history, environment, worldview, and professional nursing care as profoundly influenced by culture (McFarland & Wehbe-Alamah, 2017). In using these latter concepts, it becomes possible to apply Leininger’s theory to explore organizational cultures. The emic knowledge represents the people’s, participants’, clients’, families’, or communities’ knowledge, whereas the etic knowledge describes professional (elitist) knowledge. Ethno-history refers to the “facts, events, instances, and experiences of human beings, groups, and institutions that occur over time in particular contexts that help explain past and current lifeways [practices]” (McFarland & Wehbe-Alamah, 2017, p. 15). The environmental context refers to the social, cultural, economic, and technological factors that influence corporations and organizations.
The use of cutting-edge technology influences nurse managers’ decisions, as well as their perceptions of complex health care problems. A worldview refers to an individual’s perception of issues of everyday life like health, illness, and the delivery of health services; this worldview reveals societal and organizational values. Also, worldviews can be seen as ideologies that influence health care organizations and define missions and strategic planning activities. Leininger’s theory can be applied to explore, discover, and understand an organizational culture and how it affects the vision, mission, and delivery of health care services. Leininger’s theory is a grand nursing theory, and due to its broad scope, one can more easily shift its focus from individual nurses to a health care organization.
Essential Learning Activity 2.6.1
Review four of the references provided below and select a key takeaway from each to discuss with your classmates.
For more information on diversity, see “Sustaining the Workforce by Embracing Diversity” on the Canadian Nurses Association’s website.
For more information on cultural competency, see Dr. Josepha Campinha-Bacote’s “Process of Cultural Competence in the Delivery of Healthcare Services.”
For more information on cultural competency and cultural safety, see “Cultural Competence and Cultural Safety in Nursing Education. A Framework for First Nations, Inuit and Métis Nursing” (2009) published by the Aboriginal Nurses Association of Canada (now the Canadian Indigenous Nurses Association).
For more information on cultural competency, see the Canadian Nurses Association’s “Position Statement on Promoting Cultural Competency in Nursing.” (2010)
For more information on cultural competencies, see the Saskatchewan Registered Nurses’ Association’s “Standards and Foundation Competencies for the Practice of Registered Nurses.” (2013)
For more information on cultural safety, see the Nursing Council of New Zealand’s “Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice.” (2011)
For more information on Dr. Madeleine Leininger’s theory of cultural care diversity and universality, visit the website of the Transcultural Nursing Society.
For information on cultural competence, see the website of the US Office of Minority Health.
For more information on competencies, see the American Organization of Nurse Executives’ “Nurse Manager Competencies.” (2015)
Essential Learning Activity 2.6.2
Divide yourselves into groups of four or five. Choose an ethnocultural group to study and discuss. (Your instructor will circulate a sign-up sheet with a list of groups that are present in your geographic area.) As a group, prepare a 10- to 15-minute presentation for the class (10 minutes for the presentation and 5 minutes for discussion and/or questions). In your presentation, you should:
- provide information about your chosen ethnocultural group;
- identify cultural factors that may influence health care services for individuals that belong to that group; and
- identify culturally sensitive strategies that may have a positive impact on the provision of care.
In your discussions, consider the following: How would an employee from each identified cultural group affect the workplace? When does nursing care become culturally unsafe? Why does cultural safety remain unachieved in nursing?
2.7 Generational Diversity
Generational diversity can be found in every health care organization. Each generation has its own set of values, views on authority, attitudes toward work, communication styles, and expectations of their leader and of their workplace (Stanley, 2010). Generational cohorts refer to groups of people who share birth years, history, and a collective personality as a result of their defining experiences (Kramer, 2010). Nurse leaders are challenged to embrace and respect a multigenerational staff while simultaneously developing and supporting a highly functioning and cohesive nursing team (Hahn, 2011). Familiarity with the characteristics and core values of each cohort can lead to better understandings of each other’s generational personality and enable individuals to work better as a team, increase productivity, and influence retention. Generational markers are events that affect members of a generation (Huber, 2014). There is a tendency among generational cohorts to view each other as having character flaws rather than to appreciate their cultural and generational differences (see Table 2.7.1 Generational Cohorts).
Generational Diversity Workforce
Four distinct generational cohorts make up the present nursing workforce: Veterans, Baby Boomers, Generation X, and Generation Y. Generation Z is the most recent generational cohort, yet less is known about them in the context of the workplace. The profiles of each generational cohort, set out below, allow us to understand their values, work ethics, attitudes toward authority, and professional aspirations (Kramer, 2010). Recognizing and respecting differences can promote a work environment that effectively meets the different needs, expectations, and behaviours of each generation, and leads to a cohesive work group.
Veterans (before 1946)
This cohort of nurses is quickly diminishing in the workforce, yet a few individuals remain. Veterans are experienced, loyal, dedicated, and reliable nurses who value consistency; for them change does not occur easily (Hahn, 2011). This generational cohort grew up in political and economic uncertainty with life experiences that include the Great Depression and World War II. Authority figures are to be obeyed and achievement comes from hard work and following the rules. Due to their loyalty, duty, respect for authority, and hard work, this group values command and control leadership styles. Face-to-face or written communication is typically more effective than electronic communication technologies. Evidence of the Veteran generation’s work ethic is still apparent in the bureaucracies, policies, and practices of health care organizations today.
Baby Boomers (1946–1963)
The Baby Boomer generation is typically defined as including individuals born between 1946 and 1963 (Duchscher & Cowin, 2004). Baby Boomers were born after World War II and did not face the same harsh expectations to respect authority or to conform (Blythe et al., 2008). Consequently, Baby Boomers grew up in an era characterized by optimism, team orientation, opportunity, and growth (Hart, 2006; Solaja & Ogunola, 2016; Stanley, 2010). This generation’s core values include a strong sense of duty, involvement, health and wellness, and a strong work ethic equated with self-worth and fulfillment (Duchscher & Cowin, 2004; Hart, 2006; Solaja & Ogunola, 2016; Stanley, 2010; Weingarten, 2009).
Baby Boomers are considered to be workaholics, driven by material rewards, and critical of those with differing opinions from their own (Blythe et al., 2008; Lavoie-Tremblay et al., 2010; Widger et al., 2007). Many Baby Boomers had secure jobs, material prosperity, and access to education (Stanley, 2010).
Currently, many Baby Boomers in the workforce have leadership roles in health care organizations (Solaja & Ogunola, 2016). However, these leaders are increasingly reaching or surpassing the age of retirement, and subsequently leaving the workforce.
Generation X (1964–1980)
Members of Generation X were born between 1964 and 1980 (Duchscher & Cowin, 2004). Central to Generation X is the focus on work to live. This group grew up in a time where double-income households were becoming more commonplace, divorce rates were on the rise, and family instability was experienced by many (Hart, 2006; Solaja & Ogunola, 2016). This group is dependent and self-directed (Hahn, 2011). At the same time, technological innovations, such as the introduction of the computer, began to play a transformative role in communications. Members of Generation X value diversity, balance, informality, global thought, the ability to multitask, and independence (Gursoy, Maier, & Chi, 2008; Hart, 2006; Solaja & Ogunola, 2016; Weingarten, 2009).
One of the largest contrasts between Generation X and the Baby Boomer generation is their viewpoints on work: Generation X feel their work is only one part of their identity (Jovic, Wallace, & Lemaire, 2006; Wendover, 2002). A focus on questioning the status quo and questioning authority figures is commonplace, and they recognize job security as a thing of the past (Stanley, 2010). As a cohort they value feedback, and tend to be self-reliant and resourceful individuals who prefer to work alone rather than as part of a team (Hahn, 2011).
Generation Y (1981–2000)
Individuals born between 1981 and 2000 are classified as members of Generation Y or the Millennials (Duchscher & Cowin, 2004). Their lives have been significantly impacted by the availability and accessibility of information and instant communication through the internet and smartphones. Born to older parents who were involved in coaching their children in multiple after school activities, their experiences shaped the values of this generation, which include confidence, civic duty, morality, achievement, and sociability (Calhoun & Strasser, 2005; Duchscher & Cowin, 2004; Hart, 2006; Solaja & Ogunola, 2016). Overall, this group is considered to be quite distinctive compared to preceding generations: they are the youngest and largest group in the workforce; they have a higher level of affluence and education; and their members are more ethnically diverse.
As Generation Y enters the workforce, they bring with them a distinct work ethic. This ethic emphasizes completing work at one’s own pace and in one’s own style. Consequently, members of Generation Y require upper management to clearly define work expectations and deliverables, provide feedback, communicate resource allocation, and set timelines. This cohort values a flexible work schedule to achieve work–life balance. Like Generation X, Generation Y places higher importance on skill development while job security is less important (Bova & Kroth, 2001; Loughlin & Barling, 2001). Members of Generation Y have been found to be highly productive in their work, especially when they believe in its outcomes and the larger organization’s values and goals (Erickson, 2009). They are optimistic and sociable, and they embrace teamwork and diversity (Hahn, 2011; Stanley, 2010).
Generation Z (2000–early 2010s)
There is still some debate as to the exact birth year range of Generation Z; however, it is agreed that this cohort constitutes one of the largest yet to be entering the workforce (Wiedmer, 2015). As the majority of individuals within this generation have not yet entered the workforce, little is known about how they will perform.
Overall, among Baby Boomer nurses, job satisfaction is generally high, and pay and promotional opportunities are of low concern (Blythe et al., 2008). This may be because the age of retirement is near, their seniority affords some level of protection during periods of organizational restructuring, and they likely hold full-time positions. Baby Boomers perceive their younger counterparts as less committed to the profession and arrogant (Blythe et al., 2008). Comparatively, Generation X nurses value education and skill development, which is indicative of a divergence from previous generations (Blythe et al., 2008). Among Generation Y nurses, more emphasis is placed on monetary compensation, prestige and recognition, and diverse career opportunities (McNeese-Smith & Crook, 2003). These younger nurses are less critical of their older counterparts and view themselves as self-reliant rather than arrogant (Blythe et al., 2008).
|• The Great Depression
• Pearl Harbor
• World War II
• Age of the Silver Screen
|• Hard work
• Respect for authority
• Peace and harmony (i.e., they are uncomfortable with conflict)
• Acceptance of delayed reward
|• Financial security||• Defined by the clock (time)
• Strong work ethic
|• Civil Rights movement
• President Kennedy, Robert Kennedy, & Dr. King assassinations
• First lunar landing
|• Strong sense of duty
• Peace and harmony (i.e., they are uncomfortable with conflict)
• Immediate gratification and reward
|• Self-fulfillment and meaning||• Visibility
• Enjoy face-to-face interaction
• Willing to work to get ahead (i.e., overtime)
|• Resignation of President Nixon
• Watergate scandal
• AIDS epidemic
• Three Mile Island disaster
• Work and play balance
• Action rather than words
• Individual positive feedback
|• Achievement of financial goals without sacrificing personal time||• Get the job done and move on
• Strive for work–life balance
|• Columbine shootings
• Oklahoma City bombing
• Gulf War
• Global War on Terrorism
• Can-do attitude
|• Fun and meaningful work||• Use technology to make work more efficient to free up time
• Want meaningful jobs and work–life balance
Essential Learning Activity 2.7.1
You are a new nurse on the neurology unit in a large teaching hospital. You have noticed there are a lot of “older nurses” working on the unit and that the nurse manager is “older” as well. Many of the nurses your age have graduated within the last five years and want to work more effectively with all members of the health care team.
Working in pairs, identify how a Baby Boomer nurse manager can successfully bridge generational divides between the “older nurses” and Generations X and Y. What leadership strategies can the manager use to create a more positive workplace environment?
2.8 Managing Workforce Diversity
Nurse leaders play a pivotal role in creating a supportive work environment where cultural and generational differences are valued and individual differences are supported and accommodated. The following are some key recommendations and strategies for nurse leaders in a diverse workforce:
- Set an example through your own behaviour by appreciating diversity in order to create and maintain a supportive work environment. Employees want to feel valued and involved regardless of their age or job title. Demonstrating respect for cultural and generational perspectives is a way to support and foster teamwork (Yukl, 2013). Withholding judgement, emphasizing the positive, and practising good communication techniques creates success.
- Hold all staff to the same employment expectations and organizational goals related to valuing workplace diversity. In doing so, you set ground rules for each individual’s professional conduct and professional practice.
- Seek to learn more about diversity and educate your staff about cultural and generational differences with respect to attitudes, behaviours, and values while simultaneously fostering a cohesive work group (Yukl, 2013).
- Match the diverse needs of workers with diverse patient needs. Embracing commonalities and maximizing diversity through individual talents is critical to lead positive change in the work environment. In turn, success with culturally diverse patients and families can foster the recruitment of a diverse workforce. The synergy of diverse viewpoints can improve nursing’s knowledge base and care strategies.
- Use a flexible, open, and approachable leadership style sensitive to creating equal opportunities and eliminating discrimination while acknowledging differences. Although this approach takes considerable effort and energy, it is vital for creating a supportive work environment.
- Be flexible in accommodating a variety of communication styles that align with cultural and generational preferences.
- Explain benefits of workplace of diversity (Yukl, 2013). An open forum with staff that engages new and different ways of thinking and approaches to problem solving and conflict resolution can improve care practices.
- Recognize that differences can be a source of stress and conflict (Hahn, 2011). The differences among the generations can have a direct impact on how problems, assessments, and intervention strategies are determined (Huber, 2014). Consider issues of communication style, interpersonal space, time sense, and other variations in beliefs and behaviours in order to promote effective teamwork.
- Create workplace autonomy and promote professional growth by coaching and mentoring staff in various stages of career development. Doing so can influence workplace culture and practices to enhance job satisfaction and retention. Providing opportunities for leader development, advancement of clinical skills, and participation in committee work can improve communication skills, motivational efforts, and problem solving. For example, supporting a staff member’s participation on a unit or hospital committee may increase group cohesion, innovation, and autonomy in the workplace (Kramer, 2010).
Understanding the motivations, perspectives, and drivers of each generation can facilitate the nurse leader’s ability to better understand generational differences. As global immigration continues to impact Canada, there is a greater need to understand cultural differences and minimize conflict that is detrimental to building effective teams.
Capitalizing on the best each individual has to offer can create a powerful network of nurses and maximize their contributions to working collaboratively in providing safe, quality patient care. Over the next ten years, we will see a large number of Baby Boomers retire and Generations X and Y will continue to actively engage in the workforce and assume leadership roles. Our collective understandings of workplace diversity can leverage staff cooperation and collaboration in a high-intensity health care workplace.
After completing this chapter, you should now be able to:
- Describe the concepts of culture, cultural competence, and cultural safety in leading and managing nursing.
- Discuss cultural diversity and the ways in which people differ.
- Apply theoretical models that facilitate culturally competent patient care.
- Describe the generational differences among Veterans, Baby Boomers, Generation X, and Generation Y.
- Identify and describe the issues of workplace diversity in health care organizations for nursing staff, nursing leaders, and patients and families.
- Describe how the nurse leader can manage workplace diversity.
- Why is understanding cultural and generational differences important in clinical practice?
- What can nurse leaders do to manage diversity in health care organizations?
- How can a registered nurse be an effective follower in supporting diversity in the workplace?
- Define cultural safety and cultural competency.
- Differentiate cultural safety from cultural competence.
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