CONCEPT OF

C U LTU RAL
DIVERSITY AND
S P IRITUALITY
P R E S E N T E D B Y: M S . K R I M A PAT E L
  Explain the concepts of cultural  Identify five that
diversity and respect. factors spirituality.
influence
 Describe influences that affect  Describe the influences
culturally respectful healthcare. spirituality
of on everyday
 Describe transcultural nursing. living, health and illness.
 Practice cultural respect when  Perform a nursing assessment of
assessing and providing nursing spiritual health.
care for patients from diverse  Develop nursing diagnoses that
LEARNING cultural groups. correctl identify
 Discuss factors in the health care y spiritual
OBJECTIVES
system and in nursing that distress. nursing strategies
facilitate or impede culturally  Describe to spiritual health
competent nursing care. cure spiritual
promote anddistress.
 Define spirituality and  Plan, implement and
its concepts. nursingevaluate
care related to nursing
diagnosis involving
spiritual
distress.
  Cultural Diversity  Spirituality
Cultural Concepts- Concepts-Faith, Hope,
Culture, Subculture, Religion, Spirituality,
Multicultural  Spiritual Wellbeing
Diversity, Race, Factors
Acculturation, Affecting
CHAPT Assimilation Spirituality
Transcultura Spiritual Problems in
ER l Nursing Acute, Chronic,
OUTLI  Cultural
Competence
Terminal Illnesses and
Near-death
NE Providing Culturally Experiences
Responsive Care Dealing with Spiritual
Distress/Problems
 INTRODUCTION

Culture is the total of all the material

and spiritual values formulated in the
process of social development and the
tools that are used to create and
transmit these values down to
upcoming generations and show the
extent of the man’s authority and
control over their natural and social
environment.
CULTURAL CONCEPTS
 1. CULTURE

DEFINITION ELEMENTS OF CULTURE

• The National Institute of Health
defines culture as the combination of a • Personal Identification
body of knowledge, a body of belief,
• Language
and a body of behavior.
• Communication
• Culture may also be defined as a • Thoughts
shared system of values, beliefs and • Actions
behavioral expectations that provide a • Customs
social structure for daily living. • Beliefs
• Values
 CHARACTERISTICS OF
• CULTURE
Culture shapes the acceptable behavior of people in a specific community.
• Culture provides an identity to the members of the same cultural group.
• Culture is learned by each new generation through both formal and informal life
experiences.
• Language is the primary means of transmitting culture.
• Cultural practices may remain constant as long as they satisfy a group’s needs.

• Because culture is made up of people, there are differences both within cultures
and among cultures.
• Culture influences the way people of a group view themselves, have expectations
and behave in response to certain situations.
 2. CULTURAL DIVERSITY
•Cultural diversity can simply refer to having different cultures and
respecting each other’s differences
•Cultural diversity can be defined as the coexistence of different
ethnic, biological sex, racial and socioeconomic groups within one
social unit.
•According to the National Institute of Health (2016), nurses must
also be sensitive to cultural factors to provide culturally respectful
care to people from diverse backgrounds.
 3. SUBCULTURE
A subculture is a large group of people who are members of the
larger cultural group but who have certain ethnic, occupational
or physical characteristics, which are not common to the larger
culture.
 ASSIMILATION
🠶 Assimilation is a process of cultural change in which two cultures
come in close contact and one culture dominates the minority culture
and people of minority culture gradually lose all of the markers that
set it apart as a separate culture in the first place.
🠶 In cultural assimilation, the minority group or culture comes to
resemble a society's majority group and assumes the values, behaviors
and beliefs of another group. Also, changes are observed in majority
group culture as well.
🠶 Markers of change in assimilation include languages, food, customs or
occupation.
🠶 Assimilation is usually a two-way process.
 ACCULTURATION
⯈Acculturation is defined as “the process of cultural change that occurs
when individuals from different cultural backgrounds come into
prolonged, continuous, first-hand contact with each other.”
—Redfield, Linton, & Herskovits (1936)
⯈It is the cultural modification of an individual, group, or people by
adapting to or borrowing traits from another culture.
⯈This type of change is much more likely to happen during voluntary
migrations or peaceful coexistence.
 CULTURE SHOCK
▶ A person may experience culture shock when placed in a different
culture, which he/she perceives as different or strange.
▶ Culture shock may result in psychological discomfort or disturbances,
because the patterns of behavior a person found acceptable and
effective in his/her own culture, may not be adequate or even not
acceptable in the new culture.
▶ The person may then feel fearful, foolish, incompetent, inadequate or
humiliated. These feelings can eventually lead to frustration, anxiety,
and loss of self-esteem.
 ETHNICITY
Ethnicity is defined as a sense of identification with a collective culture group,
largely based on the group members’ common heritage.

An ethnic group or ethnicity is the grouping of people who identify with each
other based on shared attributes that distinguish them from other groups such as a
common set of history culture, traditions, language, religion, nation, ancestry,
society or social treatment within their residing areas.

One belongs to a specific ethnic group either through birth or through the adoption
of characteristics of that group.

People with an ethnic group generally share unique cultural and social beliefs and
behavior pattens, including language, religious practice, food preferences and
employment patterns
 RACE
DEFINITION FIVE CATEGORIES OF RACE
• Asian
•Racial categories are typically based • American Indian or Alaska Native
on specific physical characteristics such • Black or African American
as skin pigmentation, facial features, • Native Hawaiian or Other Pacific
and body stature and hair stature Islander
• White

American Indian African American Native Hawaiian White

DIFFERENCE BETWEEN ETHNICITY
AND RACE
TRANSCULTURAL
NURSING
 TRANSCULTURAL NURSING
DEFINITION

Transcultural nursing is defined as a comparative study of cultures to

understand similarities (culture universal) and differences (culture-specific)
beyond the human groups.
—Leininger (1991 and 2002)

• Transcultural nursing is a distinct nursing specialty, which focuses on global

cultures and comparative cultural caring, health and nursing phenomena.
 AIM OF TRANSCULTURAL NURSING

• The primary aim of this transcultural nursing is to provide culturally

congruent (same) nursing care.
 NURSES AND TRANSCULTURAL NURSING
To be an effective transcultural nurse:
 Nurses should possess the ability to recognize and appreciate cultural
differences in healthcare values, beliefs and customs.
 Nurses shouldn’t only be familiar with the religious customs, values and
beliefs of patients, but also how someone’s way of life, their modes of
thought, and their unique customs can abundantly affect them in how they
deal with health, illness, healing, disease and death.
 Nurses can provide culturally competent comprehensive patient care to the
patients if they are having knowledge related to various religions and
cultures.
 CULTURAL
COMPETENCE
 CULTURAL COMPETENCE

DEFINITION CULTURAL COMPETENCE

COMPONENTS
• Cultural competence is the ability of the
healthcare workers to bridge cultural gaps • Developing positive attitudes
in caring, work without cultural towards cultural differences
differences and enable patients and •
Being aware of one’s own world
families to achieve meaningful and
view.
supportive patient care.
• Gaining knowledge of different
cultural practices and world views.
• Developing skills for communication
and interaction across cultures.
 POPULATION COMMON HEALTH PROBLEM
Asians • Hypertension
• Liver Cancer
• Thalassemia
African Americans • Sickle Cell Anemia
COMMON HEALTH • Stroke
DISORDERS IN A • Hypertension
SPECIFIC Native Americans • Heart Disease
and alaska Natives • Liver Cirrhosis
POPULATION • Diabetes Mellitus
GROUP Hispanics • Diabetes Mellitus
Whites • Breast Cancer
• Heart Disease
• Hypertension
•Diabetes mellitus
• obesity
 GENERAL CONSIDERATIONS IN PROVIDING
CULTURALLY COMPETENT CARE

1. PHYSIOLOGICAL DIFFERENCES ACROSS RACIAL AND ETHNIC GROUPS

• Research studies have shown that certain racial and ethnic groups are more prone to
certain diseases or conditions.

2. GENDER ROLES

• In some cultures, the man is the dominant family member and generally makes
decisions for the family. In male-dominant cultures, women are often passive.
• Also, there are cultures in which women are dominant.
• Knowing who is dominant in the family is important when planning nursing care.
3. RESPONSE TO PAIN
• Expressions and behaviors exhibited by people in pain are culturally influenced.
• Important culture-sensitive considerations:
 Recognize that culture is an important component of individuality, and that each
person holds (and has the right to hold) various beliefs about pain.
 Respect the patient’s right to respond to pain in his/her own manner.
 Never stereotype a patient’s perceptions of pain responses based on the person’s
culture.

4. LANGUAGE AND COMMUNICATION

• Linguistic competence refers to the ability of caregivers and organizations to
understand and effectively respond to the needs of patients and their families in a
health care encounter.
• Therefore, nurses who work in a geographic area with a high population of residents,
who speak a language other than the primary language, should learn pertinent words
and phrases in that language.
5. FOOD PREFERENCES
• Food preferences and food preparation methods often are culturally influenced.
• Patients with cultural food preferences may not be able to select appealing foods and
thus may be at risk for inadequate nutrition.

6. FAMILY SUPPORT
• In many cultural and ethnic groups, people have large, extended families and consider
the needs of any family member to be equal to or greater than their own.
• They may be unwilling to share private information about family members with those
outside the family including nurses.
• Therefore nurses need to be keen about these considerations while providing care to the
patients.
 NURSES’ RESPONSIBILITY IN ASSURING
CULTURAL COMPETENCE IN HEALTH CARE

• Ensure that all patients and families receive understandable, effective, and respectful care..
• Ensure that nurses at all levels and across all disciplines receive ongoing education and
training in culturally and linguistically appropriate service delivery.
• Offer and provide language assistance services.
• Make available easily understood patient-related materials.
• Ensure that data on the individual patient’s/ family’s race, ethnicity, and spoken and written
language are collected in health records, integrated into the organization’s management
information systems and periodically updated.
• Maintain a current demographic, cultural, and epidemiologic profile of the community, as well
as needs assessment, to accurately plan for and implement services that respond to the cultural
and linguistic characteristics of the service area.
 CULTURAL INFLUENCES ON HEALTH AND
ILLNESS
• People who value the beliefs about health, illness, and health care are influenced by
cultural and ethnic groups.
• For example, in some groups, illnesses are classified as either natural or unnatural.
‘Natural illnesses’ are caused by dangerous agents, such as cold air or impurities in the
air, water or food. ‘Unnatural illnesses’ are punishments for failing to follow God’s
rules, resulting in evil forces or witchcraft causing physical or mental health problems.
• In some cultures, the power to heal is thought to be a gift from God bestowed on certain
people.
• People in these cultures believe that these folk or traditional healers know what is
wrong with them through divine intervention and experience.
• People from different cultures may also have different beliefs about the best way
to treat an illness or disease.

• Other traditional therapies include the use of cutaneous stimulation,

therapeutic touch, acupuncture and acupressure.

• Cutaneous stimulation by massage, vibration, heat, cold or nerve stimulation

reduces the intensity of the sensation of pain.
• Therapeutic touch is an intentional act that involves an energy transfer from the
healer to the patient to stimulate the patient’s healing potential.
• Acupuncture, long used in China, is a method of preventing, diagnosing, and
treating pain and disease by inserting special needles into the body at specified
locations.
• Acupressure involves a deep-pressure massage of appropriate points of the body.
 CULTURALLY
RESPECTFUL NURSING
CARE
 CULTURALLY RESPECTFUL NURSING CARE
Providing culturally respectful nursing care means that nursing care is
planned and implemented in a way that is sensitive to the needs of
individuals, families and groups from diverse cultural populations within
society.
 STEPS FOR PROVIDING CULTURALLY
APPROPRIATE CARE
1. SELF AWARENESS OF CULTURE

• Before providing culturally responsive care to patients from diverse backgrounds, nurses need
to become aware of the role of cultural influences in their own life.
• Objectively examine self-values, beliefs, emotions, attitudes, practices and family experiences.

2. DEVELOP CULTURAL KNOWLEDGE

• Nurses must learn as much as possible about the belief system and practices of people in the
community and of patients in the area of work
• If nurses are motivated by empathy, sincerity, respect and concern, nurses’ attitude will convey
this, and most patients will respond positively.
3. INCORPORATION OF CULTURAL PRACTICES IN HEALTH CARE

• Incorporate factors from the patient’s cultural background into health care whenever
possible, if the practices would not be harmful to the patient’s health.
• Contradicting or ignoring the patient’s cultural background may result in the patient
refusing care or not following prescribed treatment.

4. RESPECT CULTURE APPROPRIATE FAMILY ROLES

• Consider the cultural role of the family member who makes most of the decisions.
• In some cultures, it is the husband or father, whereas in others it may be another
respected elder. To disregard this person’s role or to proceed with nursing care that is
not approved by this person can result in conflict, disagreement or in disregard for the
patient and family values.
• Be careful to involve this dominant family member in the nursing care planning.
5. AVOID FORCING CHANGE
• Health practices are part of the overall culture and changing them may have negative
implications for the person.
• Provide support and reinforcement for the patient if it is necessary to change a health practice
with a cultural basis.
• Do not force patients to participate in care that conflicts with their values. If a patient is forced
to accept such care, resulting feelings of guilt and alienation from a religious or cultural
group are likely to threaten the patient’s health and well-being.

6. SEEK CULTURAL ASSISTANCE

• Seek assistance from the respected family member, or traditional healer, as appropriate, so that
the patient is more likely to accept nursing care.
• Acknowledging the role of the patient’s traditional healer can be an important way of
building trust.
• Folk medicine practitioners can also work closely with professional nurses in the interest of
the patient and family. Such efforts promote mutual understanding, respect, cooperation and
better patient outcomes.
SPIRITUALITY
 SPIRITUAL DIMENSION
DEFINITION

The spiritual dimension is described as the need for meaning, purpose

and fulfillment in life, hope/will to leave; belief and faith and it is
important for the attainment of an overall sense of health, well-being
and quality of life.
CONCEPTS RELATED TO SPIRITUALITY
AND SPIRITUAL HEALTH

Faith Hope Religion

Spirituality Spiritual
wellbeing
 FAITH
DEFINITION

• Faith is generally defined as a confident belief in something for

which there is no proof or material evidence.
• It can involve a person, idea, or thing and is usually followed by
activities related to the ideals or values of that belief. For
example, if a person has faith in his/her doctor, nurse or healer, the
person will be more likely to adhere to a prescribed regimen or
care plan to experience benefits.
 HOPE
DEFINITION

•Hope is defined as an optimistic state of mind that is based on an

expectation of positive outcomes concerning events and
circumstances in one’s life or the world at large.
•Hope allows a person to embrace the reality of suffering without
escaping from it (false hope) or being suffocated by it (despair,
helplessness, hopelessness).
•Hope is unique to each person.
 RELIGION
DEFINITION

•Religion can be referred to as an organized system of beliefs about

a higher power that often includes set forms of spiritual practices,
worship and codes of conduct.
 RELIGION
DEFINITION

•Religion can be referred to as an organized system of beliefs about

a higher power that often includes set forms of spiritual practices,
worship and codes of conduct.
 SPIRITUALITY
DEFINITION

• “The Quality that involves deep feeling and beliefs of a religious nature, rather
than the physical parts of life.”
— Cambridge Dictionary

• “ Spiritual means relating to people;s thoughts and beliefs, rather than to their
bodies and physical surroundings.”
— Collins Dictionary
 SPIRITUAL HEALTH OR
SPIRITUAL WELL-BEING
DEFINITION

•Spiritual health or spiritual well-being is defined as the condition

that exists when the person’s universal spiritual needs for meaning
and purpose, love and belonging, and forgiveness are met.

•Spiritual wellbeing means the ability to experience and integrate

meaning and purpose in life through a person’s connectedness with
self, others, art, music, literature, nature or a power greater than
oneself.
FACTORS AFFECTING
SPIRITUALITY
 FACTORS AFFECTING SPIRITUALITY
1. DEVELOPMENTAL CONSIDERATIONS
• As the child matures, life experiences usually influence and mature the child’s
spiritual beliefs.

2. FAMILY
• A child’s parents play a key role in the development of the child’s spirituality.
What parents explicitly teach a child about spirituality and religion is generally
less important than what the child learns about spirituality, life and self from the
parents’ behavior.

3. ETHNIC BACKGROUND
• A person’s culture and formal religion significantly decide whether the person’s
approach to religion is doing something, for continually striving for harmony.
4. FORMAL RELIGION

• Religion determines the ethical code that defines right and wrong for an individual.
Religion provides an identity to a person and strongly influences its spirituality.

5. LIFE EVENTS

• Both positive and negative life experiences can influence spirituality, and they in turn
are influenced by the meaning of a person’s spiritual beliefs.
SPIRITUAL PROBLEM IN
ACUTE, CHRONIC,
TERMINAL ILLNESS &
NEAR DEATH
EXPERIENCE
 SPIRITUAL BELIEFS IN ILLNESS
• During Acute Illness, Spiritual beliefs provide comfort, strength and support to the
patient.

• During Chronic Illness, Spirituality is beneficial for maintaining self-esteem,

providing a sense of meaning and purpose, giving emotional comfort providing a
sense of hope.

• During terminal illness spiritual support is associated with better quality of life.

• During near-death experience, spirituality leads to increased compassion, altruism

and sense of purpose in life and decreased fear of death, competitiveness and
materialistic interests.
 DEALING WITH
SPIRITUAL
DISTRESS/PROBLEMS
 DEALING WITH SPIRITUAL
DISTRESS/ PROBLEMS
DEFINITION

• Spiritual Distress may be specified as spiritual pain, alienation, anxiety, guilt, anger,
loss or despair.
— O’ Brien, 1982

• Spiritual Distress can be defined as “The impaired ability to experience and integrate
meaning and purpose in life through connectedness with self, others, art, music,
literature, nature, and/or a power greater than oneself.”
 ETIOLOGY FOR SPIRITUAL SIGNS OF SPIRITUAL
DISTRESS/ PROBLEMS DISTRESS/ PROBLEMS

Common etiologies include: • Sudden changes in spiritual practices

(Neglect, Rejection, Fanatical
• Inability to reconcile a current life
Devotion)
situation (e.g., illness, death of
loved person, divorce) with • Mood Changes (Anger, Frequent
spiritual beliefs (“God is all- Crying, Apathy, Depression)
powerful, all-loving, all-wise, and • Sudden Interest in Spiritual matters
He cares about me”) (Reading religious books or watching
• Separation from the religious religious programs, Visits to Clergy)
community or supports. • Disturbed Sleep
 NURSING PROCESS FOR SPIRITUAL
HEALTH AND DISTRESS

NURSING ASSESSMENT
• Nursing assessment of the patient’s spirituality— including spiritual beliefs
and practices, the effect of these beliefs on everyday living and health,
spiritual distress, and spiritual needs—should be addressed in each
comprehensive nursing history collection.
• Observe the patient’s behavior for signs of spiritual distress.
• Nurses must also keep in mind that problems with spiritual distress often do
not surface easily.
 NURSING DIAGNOSIS

• Spiritual distress possibility related to feelings of guilt and alienation from God,
loss or death of loved ones, chronic or terminal illness, etc. as evidenced by
questioning why “God has done this”; inquiries about praying in a; insomnia;
no appetite.
• Spiritual pain possibly related to an inability to accept the loss or death of a loved
one etc. possibly evidenced by verbalization, grief etc.
• Spiritual anxiety possibly related to challenged belief and value system.
• Spiritual guilt possibly related to failure to live according to religious rules.
• Spiritual anger possibly related to an inability to accept illness.
• Spiritual loss possibly related to terminal illness; anticipatory grieving; inability to
find comfort in religion.
• Spiritual despair possibly related to feeling that no one (not even God) cares.
 OUTCOME IDENTIFICATION AND PLANNING

Goals and expected outcomes for patients in spiritual distress, need to be individualized
and may include a patient achieving some of the following:

• Identify spiritual beliefs that meet needs for meaning and purpose, love and
relatedness, and forgiveness.
• Develop spiritual practices that nurture communion with the inner self, with God or a
higher power, and with the world.
• Identifying spiritual supports (e.g., spiritual reading, faith, community).
• Reporting or demonstrating a decrease in spiritual distress after successful
intervention.
 NURSING INTERVENTION OF SPIRITUAL CARE
1. OFFER SUPPORTIVE OR HEALING PRESENCE
• Supportive presence communicates value and respect to the patients.
• The basic nursing communication skills are helpful in establishing a supportive
presence.

2. FACILITATING THE SPIRITUAL PRACTICES

• Make the patient familiarwith the religious services available within the hospital.
• Respect the patient’s need for privacyduring periods of prayer.
• Allow patient to follow religious dietary.
• Arrange for the patient’s spiritual or religious service provider/priest to visit if the patient
wishes so.
• If the patient has a conflict between spiritual beliefs and the proposed medical treatment,
assist the patient in discussing this concern.
3. NURSING SPIRITUALITY

• Be helpful by recommending techniques a patient might use to develop a relationship

with his/her inner world and ways to manifest spiritual energy in the outer world (such
as loving relationships, compassion, forgiveness, joy, etc.).
• These techniques can be prayer, reflection, dream analysis, nature walks, enjoying art,
etc.

4. PRAYING WITH PATIENTS

• The nurse can take the lead from the patient by asking, “How would you like us to
pray?” Consider the patient’s religious background along with the type of prayers that
have been meaningful in the past.
• Always keep in mind that prayer should not block communication with the patient.
5. PERFORMING SPIRITUAL COUNSELING

• Communicate spiritual beliefs.

• Explore the origin of the patient’sspiritual beliefs and practices.
• Identify life factors that affect the patient’s spiritual beliefs and cause spiritual
distress.

6. RESOLVING CONFLICTS BETWEEN SPIRITUAL BELIEFS AND MEDICAL

TREATMENT

• Both the patient and members of the patient’s family may experience conflict between a
particular spiritual belief and a proposed medical treatment or health option. The patient
may want assistance when conferring with the spiritual adviser about a particular
procedure.
• The nurse’s role is to help the patient obtain the information needed to make an informed
decision and to support the patient’s decision- making. Because what the nurse says and
the way it is said may powerfully influence the patient’s decision, so it is important to
maintain objectivity.
 NURSING EVALUATION

In general, the nurse evaluates the patient’s ability to accomplish the

following:

• Identify some spiritual belief that gives meaning and purpose to everyday
life.
• Move toward a healthy acceptance of the current
situation: illness, pain, suffering, impending death.
• Develop mutually caring relationships.
• Express peaceful acceptance of limitations and feeling.
• Express the ability to forgive others and to live in the present.