ultural Diversity: A Nursi
Not Yet Reliablv Defined
Glenna Lee Habayeb,
RN,
BA, MS
The definitions for cultural diversity are
remarkably varied.
T
he United States always has
been a multicultural nation, and
cultural diversity is frequently identified
as a critical core concept relevant for
the nursing profession.‘” Although nursing is committed to addressing and sup
porting culturally competent education,
research, and clinical practice, major
problems continue to persist regarding
the definition of cultural concepts such
as diversity.
In the context of this article, concepts are those ideas, communicated
through words and labels, that serve as
the essential threads or unifying themes
of a profession. Concepts are used to
shape, organize, and implement theory,
practice, and research in a logical and
focused manner. Therefore, to facilitate
mutual understanding within a profession, it is essential that concepts found
in the professional literature reflect
standard and clearly accepted definitions of terminology. The purpose of
this article is to review recent nursing
literature about cultural diversity to
demonstrate the need for standardization in definition.
BACKGROUND
Although the term cultural diversity is
used frequently, it has many definitions,
as evidenced by the variety of meanings,
both negative and positive, found in the
nursing literature. When Brink’ asked
N URS OUTLOOK 1995;43:224-7.
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224 H a b a y e b
the rhetorical question, “How much
cultural diversity can nursing tolerateZ,”
her own reply was, “The answer depends
on the particular typeof cultural diversity that is being referred to.”
Discrepancies in definitions arise
when nursedo not visualize every person (themselves included) as having a
culture, as having a cultural heritage,
and as being culturally diverse.5 Attempts to define cultural diversity become problematic when this holistic
influence of culture is ignored. TyleP
defined culture as “that complex whole
which includes knowledge, belief, art,
morals, law, customs and any other capabilities and habits acquired by man as
a member of society.” Culture includes
the interrelationship of beliefs, values,
language, modes of dress, social relationships, rules or norms of behavior, economics, politics, law and social control,
artifacts, technology, dietary practices,
and health care.’ lnstead of a holistic
definition that considers all of these factors, however, color, religion, and geographic location are frequently the only
elements used to narrowly define culture and highlight cultural diversity.
GermairP concludes that cultural diversity is often discussed only in terms of
minority/ethnic clients.
Cultural diversity is not easy to define. Educatcr s sometimes find it easier
to note what cultural diversity is not,
than to note what it is. Kavanagh and
Kennedy9 broadly define diversity as a
lack of homcgenicity or sameness.
VOLUME 43
Curiously, despite the importance to
the profession 4 defining cultural divers i t y a review o f the nursing literature
shows chat only Soro+man;’ and Fitzpatrick and W h a offer explicit
(though brief) definitions of cultural
diversity. Sorofman equates cultural diversity with ethnicity and delineates
ethnic populations by race, nationality,
religion, and geography. Fitzpatrick and
Whall define cultural diversity as the
varied patterns and attributes of health
and care among diverse cultures that are
nonuniversal These themes are used by
man); authc~rs.!~.‘~
Although Sorofman’s and Fitzpatrick
and Whall’s definitions are the only explicit definitions that exist, the literature abounds with implicit interpretations. Brinkzz observes that studies of
Concepts are used to
shape, organize, and
implement theory,
practice, and research
in a logical and
focused manner,
cultural diversity often serve as a database from which to derive diagnosis; a
referent to content in basic nursing
education; an indication of racial, national, and ethnic diversity of a nursing school student body; and indication
of racial, national, and ethnic diversity
of faculty, or of staff and administration in clinical settings; or a reference
to men in nursing.
Indeed, implicit definitions of cultural diversity are confusingly dissimilar. In the nursing literature these defi-
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NURSING OUTLOOK
nitions include such divergent concepts
as immigrant staus, an increase in the
number of Asian and South American
immigrants, noncompliant client behavior, different susceptibility to disease,
differences among population groups,
demographic changes, urban and rural
To facilita te mutual
understanding within
a profession, it is
essential that
concepts found in the
professional
literature reflect
standard and clear/y
accepted definitions
of terminology
contexts, workforce diversity, complex
research issues, human diversity, social
class, and economic differences.
IMPLICIT THEMES RELATED TO
CULTURAL DIVERSITY
The nursing literature is filled with references to cultural diversity. This literature review specifically focuses on only
eight themes of cultural diversity as reflected in the nursing literature, though
as Brink noted, many more exist. These
eight themes were particularly chosen
to highlight the variability of meanings
applied to the concept of cultural diversity, as found in nursing literature. These
themes are immigrant status, noncompliant patient behavior, different
population susceptibility to disease, differences among population groups, demographic changes, urban and rural contexts, workforce diversity, and complex
research issues.
lmmigran t Status
According to Lipson and Meleis,” all of
North America is a continent of immigrants, with the exception of Native
Americans. Immigration, by its nature,
increases cultural diversity and individual-and group levels of stress.
NURSING OUTLOOK
Matt_son2’ concludes that cultural differences, norms, and biases lead to differences in expectations between old and
new iimmigrants, confuse patterns of
communication, and eventually affect
health status of people and health care
delivery.
Increase in Number of Asian and
South American immigrants
Henkle and KennerlF5 and Shadick19
also equate cultural diversity with increasing numbers of immigrants, specifically targeting new arrivals to the
United States from Asian and from
Spanish-speaking countries. They suggest that the cultural composition of the
United States is now becoming more
diverse and that this diversity challenges
the ability of nurses to respond with sensitivity to client needs.
the same time addressing the vitally
important individual and small group
variations that occur within any cultural
group despite color, religion, or geographic location. Shadick19 notes that
cultural diversity occurs with the mixing of people of different cultures and
may mean intracultural or intercultural
diversity. Culturally diverse populations
are seen as providing nurses with new
challenges and unique opportunities for
meeting health care needs in a pluralistic society.
Demographic Changes
To Koehm18 and Princeton29 cultural diversity means demographic change indicated by increases in single-parent
families, growing numbers of older
adults, and an increase in the indigent
population.
Noncompliant Patient Behavior
Urban and Rural Contexts
CharonkoL6 and Germain” suggest that
cultural diversity between health care
providers and patients is at the root of
noncompliant decision making and behavior. They suggest that the nursing
process inadvertently generates personal
and professional biases in the way health
care professionals are taught about the
following: what to look for, when to
look, and what procedures should be
used to obtain information. Nurses often forget that choices made about what
to comment on, and what to ignore,
encouragement or discouragement of a
behavior, are all part of personal and
professional biases. Charonko theorizes
that a lack of shared backgrounds between client and caregiver affects the
compliance of health care recipients.
Wenge?’ examined cultural diversity
aspects in rural and urban contexts.
Wenger states that, typically, urban and
rural comparisons and distinctions are
made on the basis of population density,
Different Popula tion Susceptibility
to Disease
Arnold and Bopps” state that cultural
diversity equals different susceptibility
to disease, primarily due to genetic and
lifestyle differences.
Color, religion, and
geographic location
are frequently the
only elements used
to narrowly define
culture and highlight
cultural diversity
while often patterns o f rural cultural diversity are ignored. Ignoring patterns of
rural cultural diversity has significant
implications affecting the formulation
and implementation of effective public
health policies that deal with rural
health needs.
Workforce Diversity
Differences Among Population
Groups
Nurse educators have struggled for years
with ways to present and discuss cultural
diversity without stereotyping, while at
SEPTEMBER/OCTOBER 1995
Burner et al.,” Thomas et al.,‘* Kerfoot,”
Lajokowicz,” and Williams and Roge&
all liken cultural diversity to workforce
diversity, which is viewed as a potentially disrupting factor in a work enviHabayeb 225
ronment that challenges managers to
extract the highest level of productivity from workers. According to these
authors, cultural diversity produces
workforce problems that include, but are
not limited to, miscommunication due
to language barriers, reluctance to admit to a lack of understanding of instructions, inadequate training in psychologic
skills, lack of staff awareness and appre-
Symptoms, emo tions,
and illness constitute
fundamentally
different forms of
social and cultural
reality
ciation of a family’s need for involvement in client care, failure of staff to
understand the impact that differing
cultural values have on their own way
of providing health care, and the difficulty nurses trained overseas experience
working in United States health care
systems where health care is viewed as a
business. Affirming diversity is viewed
as a competitive business strategy to
develop a sense of synergy and high
morale in workers. It is assumed that this
synergy will contribute to excellence in
patient care.
Complex Research Issues
Many nurse researchers have made the
observation that the study of cultural
diversity complicates already complex
research issues. The determination of
constructs is particularly critical to research because unclear definitions result
in confusing and often uninterpretable
results.
Cultural diversity issues, according to
Tripp-Reimer, may involve problems
and methodology found in accurately
translating questionnaires and the need
for subsequent field testing”; methods
to assess the accuracy of participant-
observation data using six criteria: time,
place, circumstance, language, intimacy,
and consensus3i; and the orientation of
226 H a b a y e b
future research to cumulative trends,
researc:h-based theory development, and
increased application of research to nursing practice.3E She finds that cultural
studies are not predictive at the individual level.
hnother concern of Tripp-Reimer is
with issues of reliability of crosscultural research observations and mea-
standardization of nursing care issues
across cultures. He notes that crosscultural research in health behavior
poses complications for research methodologies, instruments employed, and
questions asked. Specifically. symptoms,
emotions, and illness constitute fundamentally different forms of social and
cultural reality. Rios evaluated results of
sures, particularly those relating to their
stability and equivalence. Tripp-Reimer
feels that training of Interviewers in
audio and videotaping methods is essential to ensure inter-rater reliability
of interviewing styles and methods and
research findings.
Cohen and Tripp-Reime? consider
a University of Iowa research project
conducted with elderly diabetic patients
in Gurabo, Puerto Rico, and found that
researchers mistakenly assumed that biomedical practice is identical across cultures. He is especially concerned about
the variety of methodologies a qualitative researcher might use in crosscultural studies, specifically: ethnography, grounded theory, oral or life history,
ethnoscience, ethology, phenomenology, triangulation,‘@ philosophic inquiry,
and historical research. They conclude
that consideration of the nature of the
research question, prior work in the area,
and the qualifications of the investigators are essential determinants for judging the appropriateness of methodology
in cultural diversity research.
Sorofman4’ highlights the difficulties
of attempting to categorize ethnic groups
for the purpose of research using nationality, kinship, religious heritage, and language criteria to determine groups. He
also lists behavioral groupings used by
other researchers based on the following: participation in ethnically specific
organizations, self-identification with a
specific group, having friends from one
predominant ethnic group, choices of
music and literature, selection of clothing, residence patterns, and political
affiliations.
DeSantis et al.‘: developed an institute for the study of culture and nursing
at The University of Miami. Their work
focuses on promoting culturally focused
research, improving the art and science
of nursing, and preparing nurses to function from a multicultural perspective.
They believe that this type of research
is a resource with the potential to link
nursing and health care communities.
Rios*3 examined issues involving the
VOLUME 43
questions of validity that arise in attempts to attach cross-cultural meanings
to basic concepts such as insulin therapy.
urine testing, diet management, and
exercise.
Henderson et al.* find that, despite
the pluralistic nature of our society, most
research paradigms do not reflect diversity. According to them, valid research
that is generalizable must be undertaken
with a raised consciousness regarding the
impact of culture on the persons or phenomena being studied, on the research
process itself, and on the researcher.
Tripp-Reimer and J?Ix’~ contend that
a nursing definition of cultural diversity
should focus on human diversity so as
Rios found that
researchers
mistakenly assumed
that biomedical
practice is iden tical
across cultures.
not to categorize people inappropriately
and to avoid ethnic stereotyping. They
strive for a more creative and holistic
definition than is currently found in
nursing articles and textbooks.
CONCLUSION
The review clearly shows that the definitions used for cultural diversity are
remarkably varied and unrelated. Al-
though the difficulties in defining cultural diversity are recognized and only
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NURSING OUTLOOK
two explicit definitions are found in the
literature, the holistic influence of culture has been largely ignored in terms
of cultural diversity. The effect that culture, cultural heritage and cultural diversity have on all people, even those
from seemingly homogeneous population groups, is often ignored. Color, religion, and geographic locat ion are most
often used to narrowly define culture
and highlight cultural diversity, which
is often portrayed solely as a minority/
majority issue. This lack of standardization regarding the definition of cultural
diversity has implications for direction
and clarity in future nursing education,
practice, research, and public health
policies. Lack of standardization of a
definition affects how nurses understand
and promote cultural awareness in themselves and others; how nurses communicate and interpret behaviors; how
health agencies recognize and deal with
cultural variety; how organizational culture is transmitted; how conflict is mediated; and how problems, assessments,
interventions and strategies are formulated in nursing research. w
I thank Dr. Virginia Ruth and Dr. Judith
Strasser, professors in the University of
Maryland at Baltimore Intercultural Community Health Program, for their continued support.
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GLENNA LEE HABAYEB, MS, RN, is a
clinical nurse specialist in community
health for Options and Choices, a corporate health education company in
Rockville, Maryland, and an adjunct
instructor at the University of Maryland at Baltimore, the intercultural
Community Health Program.
Habayeb
227