Cultural Awareness

Cultural Awareness

Re: Topic 4 DQ 1

It is very important for nurses to understand different cultures and their practices to be able to fully and holistic care for patients. The methods a nurse can use to gather cultural information from patients include using models. One model that can be used is Campinha-Bacote’s model that involves the nurse’s inner reflection and self-journey in providing culturally competent nursing care. This is done by asking culturally appropriate questions that help the nurse identify needs such as when the patient seeks treatment from others when ill? What fears does the patient have about their sickness or becoming ill? And what types of treatments are acceptable? The nurse also assesses the patient’s social, economic, and physical environments that contribute to the patient’s level of risk (Falkner, 2018).

According to Falkner (2018), cultural competence is to be respectful and responsive to the health beliefs and practices as well as the cultural and linguistic needs of diverse population groups (Falkner, 2018). The nurse must take the time to understand their patients’ culture in order for them to be able to relate and help their patients. In order to educate patients effectively and empower them to promote their own health, the nurse must fully engage with them and become acclimated to their specific needs (Falkner, 2018). This will enable nurses to provide holistic care to their patients resulting in better patient outcomes.

Culture is “a pattern of traditions, beliefs, values, norms, symbols, and meaning among a group of people” (Falkner, 2018). Nurses can demonstrate cultural competency in nursing practice by suspending their personal biases and fully respect patients in spite of differences, being aware of differences related to culture and adjusting plans of care accordingly as well as remaining sensitive and respectful of choices patients may make based on their culture, using Campinha Bacote’s theory explained above and Transcultural nursing which is the study of cultural competence and how to apply it to patient care on a daily basis (Falkner, 2018).


Falkner, A. (2018). Cultural Awareness. In Grand Canyon University (Ed.), (2018). Health Promotion: Health & Wellness Across the Continuum (Chapter 3). Retrieved from

Essential Questions
· What is the global impact of health, wellness, and the delivery of care on emerging populations?

· What nursing theories can be utilized when providing culturally competent care to patients?

· What is the impact of race, culture, and ethnicity on individual and collective identity, and how does this influence beliefs regarding health?

· What are some cultural factors that may affect care for emerging populations?

· How do nurses work with individuals, families, communities, and social-cultural networks to influence health promotion?

Cultural competence in nursing is an absolute necessity. As populations grow and become more diverse, understanding different cultures and their practices and respecting these differences is imperative to providing holistic care to patients in every health care setting. In order to educate patients effectively and empower them to promote their own health, the nurse must fully engage with them and become acclimated to their specific needs. This chapter will provide details on how to become culturally aware and apply cultural sensitivity to nursing care, particularly as a nurse educator. Health promotion education will encompass nutrition education and cultural aspects will be discussed.

Health Disparities
· Nursing & Conceptual Frameworks

According to the Center for Disease Control (CDC) (2015a), health disparities are the “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations,” (para. 1). Disadvantaged populations include a wide range of ethnicities. Ethnicity differs from race in that it encompasses ideas and practices of a group that shares commonalities of race, language, history, religion, and/or country or place of origin. Race involves ancestry and shared or common physical characteristics. In an effort to support the growing population of disadvantaged persons worldwide, the World Health Organization (WHO) has formulated the following goals centered on global awareness and improvement of health disparities.

· Promoting development

· Fostering health security

· Strengthening health systems

· Researching disparities, health risks, and effective solutions

· Enhancing partnerships

· Improving performance

Nurses are a crucial component to achieving these goals and must be keenly aware of the challenges such populations face. Emerging populations within the United States include:

· Arab Americans

· Asian Americans and Pacific Islanders

· Black/African Americans

· Latino/Hispanic Americans

· Native Americans/Alaskan Natives

· Homeless

· Lesbian/Gay/Bisexual/Transgender/Questioning (LGBTQ)

· Refugees

The federal government has recognized the challenges emerging populations face and has taken steps to promote and support health within these populations. The National Institute of Health (NIH), National Center on Minority Health and Health Disparities (NCMHD), the Office of Disease Prevention and Health Promotion (ODPHP), and the U.S. Department of Health and Human Services (HHS) have all collaborated to formulate plans to help decrease these disparities. Among the more prominently known and mentioned programs is Healthy People 2020. This initiative created by the ODPHP is composed of many goals all focused on health promotion in the United States, including the country’s emerging and disadvantaged populations.

Case Study
Mohammed immigrated to America from Saudi Arabia with his wife and two small children in 1995. Though they have lived and worked in America for more than 20 years, they have not yet acclimated to Western culture and do not feel truly at home. Because of the political climate, Mohammed has often felt a great deal of discrimination. Though it is not always blatant, the staring and whispers have been enough to make him feel incriminated. He and his family are devout Muslims, and his wife and daughter have often felt endangered in public wearing their hijabs. They have not sought much medical treatment out of fear of being harassed. Now, Mohammed is hospitalized with chest pain and is being informed he must undergo open heart surgery. He is nervous and feels that the whispers, laughing, and stares he receives from the hospital staff are about him, his family, and his culture. His nurse, Ben, admits to his manager that he does feel a bit uncomfortable caring for Mohammed’s family because he is unfamiliar with their culture, and what he does know about Middle Eastern people comes from what he sees in the news media, most of which is associated with terrorism.

Check for Understanding

How can Ben provide culturally competent care for Mohammed and his family given his apprehensions?

Health Equality
· Nursing & Conceptual Frameworks

· Health Promotion & Education

Health equality is based on the premise that all individuals deserve high quality, easily accessible, and affordable health care regardless of ethnicity or race. Unfortunately, the socioeconomically disadvantaged have poor access to quality health care and ultimately have higher rates of illness and premature death (Egen, Beatty, Blackley, Brown, & Wykoff, 2017). Nurses have a duty to provide and advocate for quality care for persons from all backgrounds, in spite of personal bias. Acknowledgment of this inequality is essential to formulating a plan of action that leads to health equality. Equally imperative for the nurse to understand is the concept of health equity, which is the provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH) (Brennan Ramirez, Baker, & Metzler, 2008).

Nurses are in a unique position to advocate for patients’ needs. Nurses are often the first point of contact for patients and are able to form trusting relationships through which the nurse is able to glean important information regarding patients’ needs. In dealing with health inequity, nurses must utilize the power of assessment to identify patients at risk. Once these inequities have been identified, nurses can work together with the patient and interdisciplinary team to come up with a plan of care that helps the patient attain proper resources to meet his or her goals.

There are many frameworks or models within health care that guide nurses and the health care team in identifying and addressing patients’ cultural needs. The nurse utilizes these models in order to personalize the plan of care and provide individualized care that encompasses cultural needs. One such framework is Campinha-Bacote’s (2011) model of cultural competence (see Figure 3.1).

Figure 3.1
Campinha Bacote Cultural Competence Model
Figure is a Venn diagram that represents the Campinha Bacote Cultural Competence Model.

Note. Adapted from “Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence,” by J. Campinha-Bacote, 2011, OJIN: The Online Journal of Issues in Nursing, 16. Copyright 2011 by OJIN: The Online Journal of Issues in Nursing.
The Campinha Bacote model involves the nurse’s inner reflection and self-journey in providing culturally competent nursing care; it also guides the nurse to provide culturally sensitive care by teaching nurses cultural skills (Campinha-Bacote, 2011).

Cultural skill is guided by Madeleine Leininger’s culture care theory in which Leininger states that cultural assessment “is the 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 people being served,” (Campinha-Bacote, 2011, para. 6).

This is done by asking culturally appropriate questions that help the nurse identify needs, such as:

· When do you seek treatment from others when you are ill?

· What do you fear most about your sickness or becoming ill?

· What types of treatments are acceptable to you?

· How do you feel your illness affects you in your daily life?

In addition, nurses must also take into consideration the patient’s SDOH. This includes the assessment of the patient’s social, economic, and physical environments that contribute to the patient’s level of risk. Assessing these determinants is a primary step in achieving cultural competence. These factors, which are directly related to the patient’s culture and belief system, have a significant impact on a patient’s overall health status. In essence, these needs are, at times, the basic necessities of life, such as stable housing and nutrition needs that must be addressed before other health concerns become the focus of care (Theiss & Regenstein, 2017).


Sheila is a 41-year-old female patient being treated for hypertension. She goes to the nearby urgent care center for persistent headache, and the intake nurse discovers her blood pressure is 172/90. After thorough discussion and assessing for her SDOH, the nurse finds that Sheila has recently become homeless and cannot afford her medications. The nurse understands that resources need to be provided to meet Sheila’s basic needs in order for her to remain compliant with her medical treatment regimen.

Figure 3.2
Social Determinants of Health
The figure represents the social determinants of health (SDOH) by showing one main circle surrounded by five circles that are connected with a single line. The main circle represents SDOH and the five circles represent key areas of SDOH. Starting at the top and moving clockwise, the five circles represent the key areas of neighborhood and built environment, health and health care, social and community context, education, and economic stability.

Cultural Awareness
· Nursing & Conceptual Frameworks

Nurses have the unique opportunity to learn about many cultures and grow their cultural competency skills because of their frequent, if not daily, care of patients from different cultures (Rahimaghaee & Mozdbar, 2017). Culture is “a pattern of traditions, beliefs, values, norms, symbols and meanings among a group of people,” (Byrne, 2016, p. 114). There are many different cultures, all with varying values and beliefs.

Values are the beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group. These beliefs often have heavy influence on perception of health in many ways, including health promotion, health maintenance, when to seek care and treatment, and what types of treatments are acceptable. Value orientation differs in that the collective values of a society shape its overall personality. It is the nurse’s responsibility to understand that some cultural beliefs may incorporate health practices that are considered unsafe or unhealthy to other cultures that do not share the same beliefs.

· Safety & Quality

· Health Promotion & Education

A controversial example of this is the practice of female genital mutilation. Female genital mutilation, also known as female genital circumcision, is a practice in which the external female genitalia is partially or totally removed for nonmedical purposes (World Health Organization [WHO], 2018). This practice is seen in countries within the Middle East as well as Africa and parts of Southeast Asia.

The controversy for Western society, as well as other developed countries, lies in the many risks this practice poses to a woman’s health, in addition to the practice being viewed as a violation of human rights (Momoh, Olufade, & Redman-Pinard, 2016). In light of this cultural practice, the nurse must remain sensitive when addressing patients who may have undergone this practice. This includes avoiding the term mutilation, as this might be considered disrespectful to women who have had the procedure and consider it to be a normal part of their culture and not a form of mutilation or cruelty (Momoh et al., 2016).

The nurse must also take child protection issues into account and advocate for patient safety if a minor is at risk for undergoing this procedure. Other controversial practices include refusal of blood or blood products, male circumcision, and beliefs surrounding death and dying. Each culture has different views on different aspects of health that need to be respected, regardless of personal feelings surrounding the practice.

Cultural Competence
What does it mean to be culturally competent? As nurses, caring for all persons regardless of ethnicity, socioeconomic background, race, or culture, is expected. To provide patients with basic nursing care, nurses must have the ability to suspend personal biases and fully respect patients in spite of differences. Providing culturally competent care is a major element in helping to eliminate outstanding health disparities worldwide. Cultural competency does not mean becoming an expert on every culture encountered, but it does mean that nurses should recognize what they do and do not know in order to provide appropriate care.

Cultural competency means being aware of differences related to culture and adjusting plans of care accordingly as well as remaining sensitive and respectful of choices patients may make based on their culture. Campinha Bacote’s cultural competence model is a nursing theory that aids nurses in this process. Becoming culturally competent is considered a continual process that requires continuous education, self-awareness, and evaluation in order to provide holistic, culturally competent nursing care (Campinha-Bacote, 2011). With the influx of immigrants into the United States and the rise in ethnic minorities, nurses will be faced with the issue of culturally competent care on a daily basis. Cultural competence is just one component of providing integrated health care, which includes treating the patient in a holistic way that addresses all of their psychosocial and physical health care needs.

Within different cultural traditions, there are varying healing systems that are specific to maintaining and restoring health; they are traditional and nontraditional care systems (see Table 3.1). Traditional care systems embody more of the health care modalities seen in Western medicine, such as seeking medical attention from a licensed professional.

Nontraditional systems take a more natural approach, utilizing herbs and traditional practices for healing versus modern medicine modalities of care (Gale, 2014). There is a growing acceptance of the use of complementary alternative medicine (CAM) within the United States, which uses a combination of traditional treatments with alternative therapies such as massage, aromatherapy, or acupuncture (Lavretsky, 2017).

Table 3.1
Traditional and Nontraditional Healing Systems



Care Philosophy


“Carative” (not necessarily treatment for a total cure)


Specializations depending on ailment

Holistic and individualized


Professional, including clinics and offices

Homes and community centers


Pharmaceuticals, advanced technological treatments, and use of “modern medicine”

Herbs, charms, amulets, massage therapy, and meditation


Licensed professional

Healers, shaman, spiritualists, priests, and medicine man


Ancillary staff at hospital or professional care setting/facility

Family and friends


Insurance, self-pay


Health Philosophy

Influenced by scientific methods, definitions, and research

Continuous search for balance

Note. Adapted from “Complementary and Alternative Healthcare: Is it Evidence-Based?”, by S. Tabish, 2008, International Journal of Health Sciences, 2, V-IX. Copyright 2008 by the International Journal of Health Sciences.
Transcultural Nursing

Madeleine Leininger (1991) developed the culture care theory, which recognizes the importance of cultural care in nursing. This is the fundamental basis for transcultural nursing, which is the study of cultural competence and how to apply it to patient care on a daily basis. The theory helps nurses understand elements that influence the patient’s well-being such as religion, culture, and economic factors. This theory also highlights the importance of human caring in all patient interactions and that caring is the true basis of nursing care. The nurse acknowledges and respects cultural differences and formulates a plan of care that is specific to the patient’s individualized cultural needs (de Oliveira Carvalho, Santiago da Rocha, & de Souza Rocha, 2015). The concepts that are central to this theory and guide the nurse’s care are as follows.

· Cultural preservation is the nurse’s ability to retain and respect the patient’s cultural practices and traditions while providing nursing care.

· Cultural accommodation involves the nurse going above and beyond to accommodate a patient’s specific cultural needs.

· Cultural repatterning is the gentle suggestion of modifying certain cultural practices that could cause harm or interrupt the current medical treatments being provided.

The nurse utilizes these skills to provide appropriate, culturally sensitive nursing care to the patient (de Oliveira Carvalho et al, 2015). The sunrise model (see Figure 3.3) illustrates how the elements involved in cultural care affect one another as well as the nurse’s actions and care, all of which contribute to the individual’s health. At the center of the model is the healthy, balanced patient. The patient’s health is directly influenced by a variety of factors, including social, religious, economic, and cultural; collectively these are referred to as the patient’s cultural care worldview. The nurse considers all elements within the patient’s worldview and understands that they each play an important role in affecting the patient’s health. Below the healthy, balanced patient, the model shows the different ways in which the patient may seek restoring health, including folk care, nursing care, and professional systems. Below this are the elements of cultural care that the nurse utilizes in order to provide culturally congruent nursing care to the patient.

Figure 3.3
Leininger’s Sunrise Model
The figure is a visual representation of Leninger’s Sunrise Model.

Note. Adapted from “The Sunrise Model: A Contribution to the Teaching of Nursing Consultation in Collective Health,” by L. Pereira de Melo, 2013, in American Journal of Nursing Research, 1(1), 20-23. Copyright 2013 by the Science and Education Publishing.
Patient Care and Safety
· Safety & Quality

Safe nursing practice begins with thorough assessment. In order to provide safe care to multicultural patients, proper cultural assessment is a necessity. As previously described, each culture may have their own set of values and beliefs that could affect their plan of care. This also includes family dynamics, such as the decision maker within the family. This is important when discussing course of treatment, as it may be considered rude to discuss these details without a particular family member present. Taking detailed notes on family history is also crucial. Factors such as divorce, involvement of extended family members, power of attorney, end-of-life wishes, paternity, adoption, child custody, and familial violence all play important roles in the patient’s individualized plan of care. The nurse should take all of these elements into consideration and perform an adequate assessment to gather such details, customizing the patient’s plan of care to accommodate his or her needs.

When addressing the needs of emerging populations and immigrants, another topic that should be investigated is access to resources. The patient may be new to the area and/or country and may and may not have an awareness of local custom or approaches to navigate complex systems such as the health care system. In addition, they could simply lack the foundational knowledge, or prior experience necessary to access medical services. Education with interpretive services should be made available to ensure a basic understanding of the information being delivered. Collaboration with interdisciplinary team members ensures effective patient management as well as smooth transition of care.

Vulnerable populations are groups of people who require special attention related to well-being and safety, including pregnant women, human fetuses, neonates, children, cognitively impaired, prisoners, students, employees, uninsured, seniors, immigrants, and the educationally disadvantaged (Samuel-Nakamura, Leads, Cobb, Nguyen Truax, & Schanche Hodge, 2017). Vulnerable populations warrant the protection and care of federal agencies as well as health care institutions in order to ensure safe, effective, appropriate, affordable, and accessible health care. Nurses should be aware of these populations and work together with the interdisciplinary health care team to provide resources to these patients in order to ensure that they receive adequate health care.

Health Literacy
· Health Promotion & Education

Nurses have all had experiences in which they go to great lengths to educate a patient regarding a topic only to receive a very confused look or have a patient’s family member tell them the patient did not understand the information just communicated. Of course, this confusion can be caused from a number of communication issues, but the patient’s health literacy may not be a factor the nurse thinks to consider. In the nurse’s effort to expedite care and optimize time in an already stretched thin shift, the nurse might forget the need to slow down or speak in a way that is understandable to those who do not comprehend medical jargon. While medical professionals are capable of deciphering medical terms, even the most educated individual may not understand such terms. Moreover, patients may acknowledge and agree to the presented facts out of embarrassment or anxiety, leaving the nurse unaware that they did not understand. This issue comes with repercussions such as readmission and adverse health outcomes related to poor maintenance or neglected follow-up care (Johnson, 2015).

Figure 3.4
Health Literacy
The figure illustrates what happens to patients who have low health literacy, specifically that they are more likely to visit emergency rooms, have more hospital stays, are less likely to follow treatment plans, and have higher mortality rates.

Nurses must stay abreast of patients’ education needs, especially health literacy and the patients’ ability to fully understand recommendations and education provided. Comprehension is vital to enabling the patient to make informed decisions regarding their health care decisions. Crucial elements include the use of layman’s terms when describing medical procedures or anatomy and the use of the teach back method in which the nurse asks the patient or caregiver/family to repeat what was just explained to them in their own words. In this way, the nurse can determine what they did or did not understand so that clarifications can be made (Tamura-Lis, 2013).

Also important to the education process is limiting “yes or no” questions. These types of questions do not allow for patients to speak freely, and most patients tend to answer simply and without seeking clarification. Instead, the nurse should use open-ended questions, such as, “Can you tell me why it is important to check your blood sugars daily?” This presents an opportunity for further discussion between the nurse and patient. Speaking slowly in concise sentences, sticking to only two or three topics at a time, and supplementing presented material with video media have all been proven to be effective delivery methods for providing patient education (Johnson, 2015).

Health Promotion
· Health Promotion & Education

Nutrition is a central component to healthy living. Within much of Western civilization, foods are readily accessible and often highly processed and laden with extra calories, fat, and sugar. These foods can be less expensive than healthier options as well, making healthy choices less accessible for low-income families and individuals. Food is also a key element in daily social life as well, often taking center stage during celebrations, gatherings, and many events.

As a result, the United States, along with other countries around the world, faces a growing crisis of obesity and associated comorbidities. Obesity, diabetes, hypertension, heart disease, cancer, and stroke, along with other diseases, have all become more prominent and have a direct correlation to poor dietary intake (Patience, 2016). Nurses have always been an important proponent in promoting wellness. As nurses’ roles continue to grow and advance, it is important for them to be knowledgeable about patient education needs such as nutrition and activity. This section will explore these elements and details. In order to address the growing concern of obesity and overall health, the ODPHP has developed Healthy People 2020, in which a series of recommendations and implementation programs have been initiated to promote wellness.

Healthy People 2020
As part of a national effort to improve health, ODPHP created initiatives to improve prominent health issues in the United States. Addressing nutrition and obesity is one of the main initiatives because statistics show that nearly 1 in 3 adults is considered obese, and approximately 81.6% of adults do not get the recommended amount of daily activity (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). The ODPHP’s overarching goal is to help persons within the United States live healthy, long lives and provide them the resources to avoid preventable diseases related to poor health. Indicators also point to an alarming number of Americans not consuming anywhere near the recommended amount of fruits and vegetables and a large proportion living sedentary lifestyles, all of which have been proven to increase the development of noncommunicable diseases (ODPHP, n.d.). Moreover, it is evident that American society has shifted from being a country of nutritional deficit-related diseases to one of noncommunicable diseases related to nutritional excess and overconsumption. Such a shift requires the attention of governmental bodies as well as health professionals who work closely within communities to promote and restore health in an ever-growing population with longer life expectancies.

While Healthy People 2020 targets several subjects related to overall health, the program’s focus on nutrition involves helping individuals achieve optimum weight status by teaching them to eat well-balanced meals in order to avoid chronic illness development associated with obesity (ODPHP, n.d.). Central to the issue of nutrition are recommendations such as decreasing fats, sugars, salts, and alcohol as well as learning to incorporate nutrient dense foods. Objectives specific to nutrition include healthier food access, work- and school-related programs, combating obesity, food insecurity, and nutrient deficiencies. Their overarching goals for helping individuals attain wellness include the following.

· Eliminate preventable disease.

· Achieve health equity, and improve health of all groups.

· Create social and physical environments that promote wellness.

· Promote health development and healthy behaviors (ODPHP, n.d.).

The Healthy People website provides links and resources such as, which provides easy to understand recommendations for dietary intake, including the recommended intake of whole grains, fruits, vegetables, carbohydrates, and fats (United States Department of Agriculture [USDA], n.d.). This valuable resource also provides information regarding the nutritional content of the different food groups and why they are essential to health. The website also has tools such as personalized food trackers to visualize typical daily intake and a body mass index (BMI) calculator to determine a baseline health status.

The Healthy People website delivers evidence-based studies, clinical advisories, as well as consumer advice, which is the resource most relevant to the general population. Within the topic of consumer advice, a collection of links is available, providing resources on a plethora of topics, including healthy snack tips for parents, heart health, shopping list tips, and eating healthy during pregnancy. These resources can help nurses to guide their patients in the health promotion and education process (ODPHP, n.d.). Though disease prevention and health promotion are ideal, the issue remains that health-related disparities are increasing in the United States and must be understood in order to create a plan of action for change in the future.

Initiatives for Emerging Populations
With respect to the goals for Healthy People 2020, the HHS developed specific health-related initiatives for individuals, including those within emerging populations. Each varying initiative is directed at achieving the following overall goals of helping individuals across the United States achieve wellness.

· Increase the proportion of persons with medical insurance.

· Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that collect data on LGBTQ populations.

· Increase the proportion of population-based Healthy People 2020 objectives for which national data are available by race and ethnicity.

· Eliminate very low food security among children.

· Increase the proportion of persons with diabetes who receive formal diabetes education.

Disease Processes and Nutrition
· Health Promotion & Education

Nutrition can be a defining factor in attaining optimal or poor health. What is put into the body has a direct impact on its functioning capacity, and poor nutrition can lead to the development of a number of diseases. This chapter focuses briefly on six diseases that are directly linked to nutrition:

· Obesity

· Hypertension

· Diabetes Mellitus (DM)

· Heart Disease

· Cancer

· Stroke

It should be noted that four of these diseases—diabetes, heart disease, stroke and cancer—are some of the leading causes of death in the United States and, therefore, take precedence and require the most amount of attention for health promotion and education, especially from the nurse’s perspective (CDC, 2017a).

Obesity is a prominent and growing concern in the United States, leading to a host of other diseases that result in poor patient outcomes (Lu, Dickin, & Dollahite, 2014). Genetics as well as hormonal imbalances play a causative role in the development of obesity; however, modifiable factors, such as dietary intake and physical activity, remain the driving forces of disease prevention (CDC, 2015c). Bearing all of this in mind, it is crucial to focus on encouraging lifestyle changes that involve proper dietary intake, weight loss and maintenance, increased physical activity, and mental health wellness, as appropriate, to help individuals live their best life.

Hypertension is the elevation in blood pressure greater than 140mmHg systolic and/or a diastolic greater than 90mmHg (American Heart Association, 2017). Multiple risk factors are involved in its development including obesity, DM, genetics, and familial tendency. Again, this disease process is related to the others described within the text, particularly obesity. While this disease can be placed under the umbrella of heart disease, its prominence warrants individual discussion. Fortunately, many of the risk factors associated with hypertension are related to modifiable changes that can be made by the individual. While it is imperative to reinforce lifestyle changes, it is important to emphasize adherence to medical management, such as prescribed medications, in order to manage this disease process and avoid associated complications. This makes health promotion all the more important in helping patients with heart disease achieve a healthy life (American Heart Association, 2017).

Most nurses have an understanding of diabetes disease process and have cared for numerous patients with this diagnosis. This discussion relates specifically to DM type 2, in which insulin is resistant and does not respond appropriately to the influx of glucose received during the digestion process, as well as a decreased amount of insulin production overall (American Diabetes Association, 2015). Prolonged and persistent elevation in glucose levels leads to DM and a wide range of comorbidities associated with it such as obesity. Left untreated or undiagnosed, persistent hyperglycemia can lead to devastating effects such as kidney failure, heart disease, neuropathy, stroke, and death (CDC, 2017b). Empowering patients with the tools to make effective changes is essential to promoting health for these patients.

Heart Disease
Heart disease is a broad term used to encompass a number of cardiovascular conditions, including coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension, and high cholesterol (hypocholesteremia) (Mayo Clinic, 2018). With each of these disease processes, the effects and subsequent required management are often lifelong and life altering, requiring medical supervision and care and a great deal of lifestyle modification. Compliance becomes an issue with disease maintenance, as these illnesses often require a combination of pharmacotherapy and lifestyle changes (Mayo Clinic, 2018).

Cancer is the rapid multiplication of abnormal cells that invade surrounding tissues and organs (American Cancer Society, 2015). Causes for cancer are multifactorial and can arise from a combination of genetic, environmental, and lifestyle influences. Nurses should be aware of the emotional and psychosocial impact this disease can take and use their therapeutic communication skills and display true human compassion in working with these patients. Focus should also be placed on screenings in order to detect early stages of cancer so that treatment can begin as soon as possible. Early diagnosis and intervention is associated with a higher rate of survival; therefore, every effort to prevent and treat early should be exhausted in order to intercept tragedy. Once again the primary focus for promoting wellness and preventing disease is centered on dietary modification and lifestyle changes that promote weight loss, weight management, and increased activity (Freedman et al., 2014).

Stroke or cerebrovascular accident (CVA) is the irreversible damage to part of the brain tissue caused by blockage of the vessels or hemorrhagic event. The emphasis of this discussion will be on thrombotic strokes, which are caused by occlusions related to arteriosclerosis. Multiple risk factors contribute to the buildup of plaque within the cerebral vessels leading to partial or total occlusion and the resultant stroke. Paralysis, aphasia, dysphagia, and motor deficits are only a few of the effects this disease can have on patients, leading to an enormous change in quality of life that affects the patient and all those involved in the patient’s care (American Stroke Association, 2012). As previously discussed, these diseases can be prevented, at least in part, with health promotion measures, including nutrition (see Table 3.2).

Table 3.2
Chronic Illnesses and Nutrition Recommendations
Disease Process

Dietary Recommendations


· Wide variety of fruits and vegetables

· Whole grains

· Limit processed foods and foods high in fat and sugar

· Lean proteins

· Nuts and legumes in moderation

· Low-fat or fat-free dairy products

· Avoid alcohol

· Smaller portions

· Medical management as indicated

· Increase physical activity slowly


· Increase physical activity

· Medical management as indicated

· “DASH” (Dietary Approach to Stop Hypertension) diet includes:

· Limited sodium – 1,500-2,300 mg per day (low or standard plan based on individual needs)

· Emphasis on whole fruits and vegetables

· Whole grains

· Lean protein sources

· Low-fat or fat-free dairy products

· Limited high-sugar foods

· Avoid alcohol

· Limit high-fat foods

· Limit caffeine consumption

· Nuts and legumes in moderation


· Increased activity as recommended by medical professionals managing care

· Medical management for medications if indicated

· Low glycemic index foods such as:

· Legumes

· Dark leafy vegetables

· Whole grains

· Fish

· Fat-free dairy products

· Berries

· Sweet potatoes

· Citrus fruits

· Other recommendations consistent with previously mentioned foods such as:

· Avoiding alcohol

· Limiting foods high in fat and/or sugar content

· Avoiding processed foods

· Nuts and legumes in moderation

Heart Disease

· Whole grains

· Lean protein sources; limit or eliminate red meats

· Variety of fruits and vegetables

· Fat-free or low-fat dairy products

· Limit high-fat and/or high-sugar foods

· Limit processed foods

· Increased activity based on medical recommendations

· Limit sodium if indicated

· Nuts and legumes in moderation


· Whole grains

· Lean protein sources

· Variety of fruits and vegetables (the more the better)

· Fat-free or low-fat dairy products

· Limit high-fat and/or high-sugar foods

· Limit processed foods

· Nuts and legumes in moderation

· Increase water intake

· Limit or eliminate alcohol


· Whole grains

· Lean protein sources; limit or eliminate red meats

· Variety of fruits and vegetables

· Fat-free or low-fat dairy products

· Limit high-fat and/or high-sugar foods

· Limit processed foods

· Increased activity based on medical recommendations and therapy treatments for post stroke victims

· Limit sodium if indicated

· Nuts and legumes in moderation

Note. Adapted from “Dietary Guidelines for Americans 2015-2020.” by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture. Copyright 2015 by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture.
Nutrition Guidelines
The importance of eating a well-balanced diet is not a new concept. From childhood, the notion of eating well is instituted into early education and promoted in a wide variety of platforms. The basics, such as the food pyramid and limiting foods that are high in fat and sugar, are elements with which many individuals in American society are at the least, vaguely familiar. The issue of compliance arises due to the abundance of highly-processed, convenient, and inexpensive sources of comfort food.

Regardless of these reasons, reiteration of the proper dietary guidelines in order to promote good health is necessary. The U.S. Department of Agriculture (USDA) develops recommendations regarding proper dietary intake and helps teach these guidelines by way of Internet resources and school, work, and outreach programs throughout the country. Their website is a resource that provides a number of tools and advice regarding dietary intake for both adults and children.

The basic recommendations have not changed dramatically over the past 50 years. The basics include the involvement of five primary food groups:

· Fruits

· Vegetables

· Grains

· Protein

· Dairy

Instead of seeing these groups presented in the pyramid that some may remember from the 1990s, the new guidelines are featured on a plate system in which each group is divided based on the daily recommendation. The recommendations for each group are specific depending on age group, sex, and physical activity. In general, the average adult’s daily food consumption should include:

· 2 cups of fruit,

· 2.5 cups of vegetables,

· 6-7 ounces of whole grains,

· 5.5-6 ounces of protein,

· 3 cups of dairy, and

· 5-6 teaspoons of oils/fats (U.S. Department of Health and Human Services [HHS] & USDA, 2015).

There is also advice regarding beverage choices, such as avoiding drinks with added sugars and reducing alcohol consumption. Rather than focusing all attention on adhering to the specific dietary intake recommendations, the website focuses on helping individuals make small changes in their diets, such as switching to low fat or fat-free dairy products and substituting fruit for sugary desserts (Booze, Hardison, & Haven, 2017).

Figure 3.5
My Plate
The figure presents portion sizes of a healthy plate of food (as defined by the U.S. Department of Agriculture on its website). The two largest sections are vegetables and grains, accompanied by two smaller sections of fruit and protein. A cup of dairy is set to the side of the plate.

Figure has many silhouettes of people doing various athletic activities, such as yoga, golf, basketball, soccer, tennis, jogging, weight lifting, and football.

Physical activity is also addressed within this resource, providing tips to increase daily activity, such as taking the stairs instead of the elevator or parking farther away from the entrance of one’s destination. This is vital to promoting wellness because sedentary or low-activity level lifestyles are major contributors to the development of the disease processes discussed in this chapter. The recommendations made are also tailored depending on age, sex, and overall health of the individual. In general, adults are advised to obtain approximately 2.5 hours of moderate physical activity per week at a minimum and include weight-bearing exercise within their regimen for bone strength (HHS & USDA, 2015).

Nurse Driven Nutrition Education
· Health Promotion & Education

The role of educator is necessary in every role nurses may assume throughout their careers. In the nurses’ endeavor to provide holistic care to all patients, health promotion is a key factor in providing patients with the tools to live full, healthy lives. Being knowledgeable regarding prominent noncommunicable diseases and proper dietary recommendations is the first step for nurses to learn to assist their patients in making healthier choices. The next step is learning how to educate their patients.

Nurses have largely leaned on Nola Pender’s health promotion model as a guide to help educate patients on such changes (see Figure 3.6). The model focuses on different factors that can influence a patient’s ability or willingness to absorb information and make a viable change in his or her life. These factors include willingness to change, perceived benefits and barriers, situational influences, and a commitment to change (Khodaveisi, Omidi, Farokhi, & Soltanian, 2017). Nurses should take these aspects into consideration when delivering education regarding dietary intake and lifestyle modifications. If a patient is not ready, willing, or able to institute change, the information provided may not sink in, potentially leading to frustration for both the nurse and the patient and/or family. Not being able to visualize the result of their hard work can be challenging, especially in a profession in which recurrent readmissions for similar diagnoses are often seen in acute care settings. An example of this could be the diabetic patient who has been educated multiple times regarding proper diet, but comes to the emergency room on a monthly basis because of hyperglycemic episodes.

Figure 3.6
Pender’s Health Promotion Model
Figure is of Pender’s Health Promotion Model. The first circle is prior related behavior. From there, there are four boxes: perceived barriers, perceived self-efficacy, perceived benefits, and activity related. There are arrows pointing back to prior related behavior and arrows pointing forward to immediate competing demands and commitment to plan of action. The 4 boxes (perceived barriers, perceived self-efficacy, perceived benefits and activity related) represent immediate competing demands that may impact the person’s commitment to the plan of action that will eventually lead to health promoting behaviors. The second circle is personal factors followed by 2 boxes which are interpersonal influences and situational influences, these also directly affect the plan of action as well as health promoting behaviors. The arrows portrayed in the image stem from the primary circles and lead to the end goal which is health promoting behaviors.

Note. Adapted from Health Promotion in Nursing Practice (2nd ed.), by N. J. Pender, 1987. Copyright 1987 by Pearson Education.
Ultimately the power to change remains in the patient’s hands; whether or not they follow through with the advice of medical professionals is not within the nurse’s control, leaving the nurse with a sense of helplessness. Keep in mind that while many patients may not make changes, there will be some who do and will benefit greatly for it. The work that nurses do is sacred, and while not seeing the fruits of their labor can be deflating at times, nurses can rest assured that they do create positive change for their patients as a whole. A barrier to effective teaching seen throughout health care is health care literacy. An inability to convey important health care information has a direct impact on patient outcomes as well as health care costs; therefore, it is in the nurse’s best interest to become familiar with improved ways to provide health promotion education (Johnson, 2014).

Cultural Considerations and Nutrition
As cultural diversity continues to expand and grow within the United States, it is important to examine the differences in how cultures view nutrition and how these differences affect overall health. This is a key factor in providing culturally competent nursing care. Nutrition is rudimentary to all people regardless of culture; however, different cultures have varying traditions, customs, practices, religions, and routines that impact daily nutritional life. Food culture focuses on how the differences between cultures affect nutritional intake, including dietary preferences, food preparation and storage, food restrictions, and food-safety practices (Garnweidner, Terragni, Pettersen, & Mosdol, 2012).

Nurses must take the concept of food culture and cultural sensitivity into consideration when assessing individuals or families for nutritional health. The assessment process is essential to giving the nurse a clear indicator of the individual’s needs. When evaluating an individual or family regarding cultural aspects, the nurse should include questions related to dietary intake and what that might look like to them. This might include preferences, food preparation methods, prohibited foods, celebratory foods, and customs related to tradition and holidays. When addressing patients who require education regarding one of the diseases discussed in this chapter, simply advising them to eat well may become a challenge.


The nurse has a Mexican-American patient who is obese and recently diagnosed with DM and hypertension. The nurse discovers that part of the patient’s culture involves eating large family meals together on a frequent basis. The meals are typically prepared with lard, served in very large portions, and include few or no vegetables, all of which is inconsistent with the proper recommendations for a diabetic patient. The nurse must be sensitive when making suggestions for change within this patient’s life, telling the patient she must stop eating what she is used to will likely not illicit any kind of change. Instead, the nurse may consider suggesting preparing the meal in a different way, such as baking instead of frying, omitting lard from the preparation of the meals, and cutting portions by half. In this way, the patient can make small changes while still remaining consistent with her cultural practices.

Community Resources
The figure identifies examples of community resources by providing images circling the words "community resources." The images depict a group of three people, some fresh fruits and vegetables, a medical kit, a heart, a piggy bank with some money going into it, and an open book with a question mark in the middle of the book.

Nurses must also take into consideration patient access to resources enabling patient populations to adhere to a healthy life. The government has many programs available to aid communities in obtaining resources such as healthy foods and health care. While the resources discussed previously, such as Healthy People 2020 and ChooseMyPlate, are beneficial, the nurse must consider the patient who has no Internet access to utilize such resources, as well as other socioeconomic concerns that prohibit patients from living well. Each of these government programs provide invaluable resources aiming to provide not only financial assistance to purchase foods, but also education regarding healthy eating and available community resources.

Supplemental Nutrition Assistance Program (SNAP)
Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, is a government program that provides assistance to low-income families and individuals to purchase groceries that they might not otherwise have the resources to obtain. Qualified persons receive an allotment of money, based on income and total family size, on a type of debit card that can be used at qualified stores to purchase groceries. This allows the individual to purchase food items such as grains, fruits, vegetables, proteins, and dairy products (USDA, 2018c).

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a government-sponsored program that gives assistance to pregnant and postpartum mothers, as well as infants and children up to age 5 that are determined to have nutritional-related risks and have low income and/or minimal resources available to them. The program not only offers financial support for nutritional supplementation, but provides valuable resources to its recipients, such as breastfeeding support and substance abuse referral programs (USDA, 2018d).

Child Nutrition Programs
Child Nutrition Programs (CNP) cover a wide range of assistance programs for children such as Team Nutrition, School Breakfast Program, Child and Adult Care Food Program, National School Lunch Program, Summer Food Service Program, and Special Milk Program. Each of these programs primarily focuses on children coming from low-income families to ensure that they receive adequate nutrition. The programs also focus on health promotion and education from a young age to build healthy habits early on (USDA, 2018b).

Nutrition Programs for the Elderly
There are a number of resources available for senior citizens as well, including Senior Farmer’s Market Nutrition Program, Elderly Nutrition Program, Nutrition Services Incentive Program and Administration for Community Living: Nutrition Services. Each of these provides assistance to low-income seniors with nutritional deficits who would otherwise be unable to purchase healthy foods. In addition to financial resources, these programs also provide education and free health screenings to the elderly who may not otherwise have access these resources (USDA, 2018a).

Hunger and Food Security Resources
Hunger and food security resources programs include Commodity Supplemental Food Program, Food Distribution Program on Indian Reservations, and the Emergency Food Assistance Program. These programs offer food services to a wide range of people in low income socioeconomic conditions at no cost depending on qualifications for such assistance. The Food Distribution Program is centered on supplementing these groups with foods grown in the United States to support American agriculture (USDA, 2018a).

The complexities of health promotion are multifaceted and continue to change along with society’s needs. Nurses must stay current on the challenges society faces and the interventions necessary to promote wellness. Weight-related diseases are a prominent concern throughout the United States and require attention in order to prevent further devastation related to its effects. Best practice for dietary and lifestyle changes to help prevent and manage such diseases are at the forefront of patient education for these issues. Nurses should be aware of community resources available to their patients in order to better assist them in promoting healthy living. Nurses must also be aware of patients’ varying education needs with regard to health literacy and cultural sensitivity. Nurses will continue to serve as a catalyst for creating positive changes that will optimize patients’ lives in the future.

Emerging Populations
The figure represents emerging populations by depicting several young boys of various ethnic backgrounds holding American flags, framed within the shape of the United States.

In order to provide adequate, culturally competent care, it is essential that major cultures are identified and explored so nurses have a basic understanding of these cultures’ overall health issues and cultural aspects of care that will be observed (see Table 3.3).

Arab Americans
Arab Americans originate from countries within the Middle East region, including Lebanon, Syria, Iran, Iraq, Egypt, Yemen, and Jordan. The health afflictions experienced by this ethnic group include diseases such as diabetes and coronary artery disease. This group is also at high risk for mental health issues related to discrimination. There is also a prevalence of tobacco use, which increases the risk for tobacco-associated diseases such as lung cancer and chronic obstructive pulmonary disease (COPD) (Substance Abuse and Mental Health Services Administration [SAMHSA]; 2018; Prevention Research Center, 2013).

Cultural aspects of care for Arab Americans are multifactorial. Family is central to their culture as is religion, which is typically Islam. They uphold values of modesty and have specific dietary rules and prayer rituals. They often prefer same-sex caregivers to preserve their value of modesty. There can be many barriers for the Arab American patient as discrimination is a very real fear that often discourages them from seeking medical attention. Care should be taken to attend to language barrier needs as well.

Asian Americans/Pacific Islanders
Asian Americans and Pacific Islanders encompass a very large number of countries of origin, including Japan, China, Vietnam, North and South Korea, Taiwan, Philippines, India, Sri Lanka, Pakistan, Nepal, and others. Such a large number of countries of origin makes their respective cultures extraordinarily diverse. People from this cultural group have a high prevalence of COPD, hepatitis B, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and liver disease (SAMHSA, 2018).

Cultural aspects of care that should be considered include understanding that family is a primary focus for this culture group. Older family members are highly respected and have unquestioned authority. Typically speaking, the oldest male in the family is the decision maker. Personal conflict in public is frowned upon, and physician recommendations are highly respected. Their respect for a medical professional’s advice may lead to agreement with every recommendation without thorough consideration or inquiry. The nurse should be aware of this and ensure adequate clarification for the patient and family.

There is also a level of shame associated with seeking treatment for psychological disorders; the nurse should be aware that the patient may not disclose feelings of depression or other psychological distress simply because it is not typical within this culture. This sense of embarrassment carries over to other aspects of health such as sexual wellness. Often sex is considered taboo to talk about, and many Asian Americans may neglect to seek preventative treatment, such as breast examinations or pap smears, because it may be considered embarrassing for them.

Asian folk medicine is a strong part of Asian American culture. These methodologies are heavily influenced by Chinese medicine, for which Taoism is the theoretical foundation. The Tao is based on the concept of balancing opposing forces: yin and yang. Practices related to it can be seen in Western medicine as well, including acupuncture, herbalism, and martial arts. These types of care modalities can be collectively described as CAM.

African Americans/Blacks
African American culture encompasses persons of descent from any Black racial group in the continent of Africa. African Americans have been a longstanding marginalized ethnic group in America and continue to face adversity and discrimination in the areas of business, education, politics, and leadership. Unfortunately, the socioeconomic component that afflicts this group most prominently is poverty and lack of health insurance. Diseases that are most prominent for African Americans include diabetes, hypertension, obesity, cancer, heart disease, and HIV/AIDS (SAMHSA, 2018).

Cultural considerations regarding health care for this culture group center on family and religion. The family is by far the most important aspect and is seen as the source of strength and support. An extension of this is seen in their ties to religion and the church. For African Americans, the church is not solely a house of worship, but rather as a community center providing a source of comradery and purpose. In addition, persons within this culture value prayer and believe in praying for healing in times of sickness. They tend to view health as the ability to fulfill expectation of their given role (e.g., mother, father).

Also, of note, some groups in certain areas of the United States such as the South, still rely on folk medicine and health practices to achieve wellness. Remedies such as the use of roots, herbs, rituals, and ceremonies are often utilized. In some instances, a voodoo priest or priestess may be consulted for advice and guidance regarding health.

American Indians/Alaskan Natives
American Indians and Alaskan Natives (AIAN) encompass persons of North or South American descent who affiliate with a tribe. There are more than 500 federally recognized tribes within the United States, with the Cherokee being the largest. Persons within this culture group continue to experience high rates of poverty, low income, and inaccessibility to health care. Many health issues this culture group faces stem from their socioeconomic misfortune. Persons within the AIAN culture have high incidences of heart disease, cancer, diabetes, stroke, obesity, substance abuse (specifically alcohol), teenage pregnancy, liver disease, hepatitis, sudden infant death syndrome (SIDS), mental health concerns, and high rates of suicide (SAMHSA, 2018).

There are several considerations for nurses to contemplate when addressing health and wellness of patients from this culture. As in other cultures discussed, family is very important to AIAN persons. They also value communal sharing of resources and tend not to focus on planning for the future, but rather the here and now. This may become evident to the nurse when trying to discuss a patient’s long-term outcome following an acute illness or accident. Persons within the AIAN culture also view health as a balance between self and nature. Any violation to nature or the natural order can be seen as direct cause of illness or poor health.

There is also a strong component related to spirituality for AIAN persons. Many use traditional medicinal practices and uphold cultural ceremonies in their everyday lives. They may seek out the care of traditional medicine men or women within their community rather than seek out medical attention from a licensed professional. These faith healers carry out healing ceremonies and may concoct drugs, medicine, and poisons in order to restore balance and wellness.

Latino/Hispanic Americans
Latino Americans include a wide range of people from many countries such as Mexico, Cuba, Puerto Rico, and countries within South or Central America. The largest minority group within the United States, they face health issues primarily caused by lack of access to preventative care, lack of insurance, and language barriers. Leading health issues among this culture group are heart disease, cancer, HIV/AIDS, stroke, and diabetes (SAMHSA, 2018; CDC, 2015b).

Cultural considerations of health once again include family and religion. The family is so important to this culture that the needs of family in its entirety often supersede the needs of a specific individual. Elders within the family are consulted prior to any major decisions being made within the family. Latino individuals rely heavily on prayer, particularly during illness or when someone is dying. They believe in the concept of hot and cold when it comes to disease. This theory views illness as an imbalance that requires an opposing force to restore health. For instance, if someone is afflicted with a fever (hot) they should be given something cold to drink. Persons within this culture also have a strong sense of superstition and attribute illness to supernatural causes. They also rely on folk healers and home remedies including rituals, herbs, use of medals and amulets, and prayer.

There is a growing crisis of homelessness in the United States that may be overlooked as a defined culture. Homelessness can be observed when an individual lacks secure living conditions as a result of limited resources and poverty. Homelessness occurs for a variety of reasons, including low income, loss of employment, undiagnosed or untreated mental illness, veteran status, and inability to keep up with incoming expenses. Homelessness also occurs for people with health issues who must choose between being able to pay for the care they need to treat an illness or paying for rent (National Health Care for the Homeless Council, 2011).

Persons who end up homeless are exposed to a number of environmental risks that lead to disease. Lack of proper nutrition, clean water, unsanitary conditions, increased stress levels, and exposure to violence all contribute to the development of complex medical issues. In addition, these persons have a much higher incidence of psychiatric disorders, substance abuse, and HIV/AIDS.

Cultural considerations the nurse must take in to account for persons within the homeless community are numerous. Many patients within this category have no insurance, income, or means to adhere to follow-up care, meaning the treatment they are receiving in the present moment is likely the only treatment they will receive for the foreseeable future. The nurse must take the opportunity allotted to them to provide them with as much education and as many resources as possible. It is also imperative to work with the interdisciplinary health care team members to locate resources for the patient, such as housing and government insurance (Hodge, DiPietro, & Horton-Newell, 2017).

Lesbian/Gay/Bisexual/Transgender/Questioning (LGBTQ)
The LGBTQ community is a growing culture that warrants acknowledgment, support, and attention from the medical community. Persons within this culture come from all ethnic, racial, and religious backgrounds. They are a growing minority group in America and have faced a great deal of adversity and discrimination. Their determination and will to stand up for equality has led to many breakthroughs in achieving equal rights under the law, but much work still needs to be done. Persons within this culture group face health issues such as sexually transmitted infections (STIs), HIV/AIDS, substance abuse, tobacco use, mental illness, and suicide (Landry, 2017).

Cultural considerations for the nurse to contemplate when caring for patients within this culture include considering transgender patients’ identity and addressing them as the gender they identify with at all times. Doing so shows respect and helps to gain a provider/patient trust relationship. The nurse must also be aware of their own personal biases and feelings toward LGBTQ individuals and suspend them in order to care for these patients holistically. Choosing to suspend personal beliefs and biases means choosing to advocate and support patients without agreeing with or condoning their personal choices. Mental health assessment must be taken into account as many of these patients, particularly adolescents, may be victims of bullying and become depressed and have thoughts of suicide (Bratsis, 2014). The nurse must always be an advocate for the patient and help to formulate a plan of care that is individualized. Sensitivity should be taken when discussing partner relationships and the need for HIV/AIDS testing, resources, and/or treatment.

Refugee and Immigrant Population
Over the past few decades, there has been an influx of refugees and immigrants to different areas of the world. The WHO states “globally, there are an estimated 250 million international immigrants and an estimated 65 million people forcibly displaced from their homes,” (WHO, n.d., para. 1). Refugees are defined as people who seek asylum in a country other than their country of origin because of fear of discrimination for racial, ethnic, religious, or political reasons. Immigrants are people who leave their countries of origin to seek permanent residence within another one.

Immigration occurs for a variety of reasons, including job opportunities, poor living conditions, medical attention, and the desire for equal rights. Refugees face a host of health problems, such as hypertension, arthritis, diabetes, chronic respiratory diseases, cardiovascular diseases, and mental illness such as depression and post-traumatic stress disorder (PTSD) (Hunter, 2016). Immigrants typically have a range of health issues that relate to their ethnic backgrounds but have higher incidences of mental illness related to stress. Persons within these emerging populations can be from any ethnicity or racial background. An example are the Syrian refugees who have fled in large numbers to varying countries around the world.

Cultural considerations for this population are complex. The nurse must consider the patients’ ethnicity association as well as their refugee or immigrant status, which can have its own set of health repercussions. Mental health assessment must be taken into careful consideration, as many refugee patients have endured tragic conditions that can lead to crippling mental illness. Lack of finances, insurance, language barriers, loss of family support, inaccessibility to health care, fear of being ostracized, and fear of deportation can all impact these patients’ ability to attain necessary health care. Nurses should be aware of these issues and advocate for the patients’ needs as well as help them to access necessary resources. The WHO works with federal agencies from countries worldwide to help the refugee population attain the health care they need.

Table 3.3
Emerging Populations
Emerging Population

Common Health Issues

Important Cultural Components

Health Care Considerations

Arab Americans

· DM



· Lung Cancer

· Mental Health

· Religion

· Family

· Modesty

· Same-Sex Caregivers

· Language Barriers

· Familial Decision Making

Asian Americans/Pacific Islanders


· Hepatitis B


· Tuberculosis

· Liver Disease

· Family

· Elder Importance

· Privacy

· Use of CAM

· Avoidance of Care

· Familial Decision Making

· Language Barriers

· Same-Sex Caregivers

African Americans/Blacks

· DM

· Heart Disease


· Cancer


· Obesity

· Religion

· Family

· High Rates of Poverty

· Chaplain Services

· Familial Decision Making

· Socioeconomic Needs

American Indians/Alaskan Natives

· Heart Disease

· Cancer

· DM

· Stroke

· Obesity

· Substance Abuse (specifically alcohol)

· Teenage Pregnancy

· Liver Disease

· Hepatitis

· Sudden Infant Death Syndrome (SIDS)

· Mental Health

· Suicide

· High Rates of Poverty

· Access to Resources

· Spirituality

· Family

· Folk Healers

· Socioeconomic Needs

· Familial Decision Making

· Language Barriers

Latino/Hispanic Americans

· Heart Disease


· Stroke

· DM

· Family

· Religion

· Elder Respect

· Folk Healers

· Chaplain Services

· Familial Decision Making

· Language Barriers

Rural Population/Homeless

· Mental Health

· Substance Abuse


· Hepatitis

· Range of Other Medical Diseases

· Uninsured

· No Access to Resources

· No Follow-Up Care

· Poverty

· Instability

· Resource Management

· Collaboration of Care

· Crisis Intervention

Lesbian/Gay/Bisexual/Transgender/Queer/Questioning (LGBTQ)

· Mental Health

· Substance Abuse

· Suicide


· Fear of Discrimination

· Sense of Community

· Crisis Intervention

· Resource Management

· Caregiver Sensitivity

· Partner Involvement

Immigrant and Refugee Population

· Hypertension

· Arthritis

· DM


· Cardiovascular Diseases

· Mental Illness (particularly PTSD)

· Poverty

· Access to Resources

· Fear of Deportation

· Uninsured

· Instability

· Resource Management

· Crisis Intervention

· Collaboration of Care

· Language Barriers

Note. (CDC, 2015b; National Health Care for the Homeless Council, 2011; Hunter, 2016; Landry, 2017; Prevention Research Center, 2013).
Spiritual Practices and Health
Throughout the discussion of the many emerging populations, there is a common element of spirituality and/or religion. This commonality warrants nurses to assess for specific values, beliefs, practices, and spiritual care that may influence their plan of care. While there are a variety of questionnaires available to assist with collecting such information, the nurse may find that open conversation is one of the optimal ways to discover the patient’s spiritual needs as well as help solidify a trusting patient/provider relationship. The nurse should offer appropriate spiritual resources as available to the patient and family throughout the length of stay, regardless of patient prognosis. The Joint Commission has made it evident that spiritual care is of great importance and has outlined recommendations specific to the provision of spiritual care that help to guide the health care provider in caring for patients’ spiritual needs. Their recommendations highlight the importance of assessing a patient’s religion and associated customs/practices and emphasizes the importance of addressing these needs in order to provide fully competent nursing care. While no specific tool is recommended over others, the HOPE tool and the Spiritual Health are examples of widely utilized spiritual assessment tools (The Joint Commission, n.d.).

Assessment Tools
· Health Promotion & Education

Above all, the nurse’s best tool is the assessment; beginning the nursing process with the assessment is best practice. Thorough assessment gives the nurse the picture of the patient that is necessary to provide individualized care. The nurse may use Campinha-Bacote’s cultural competency model to help guide the process as an asset to performing a thorough assessment. The nurse utilizes the power of data collection to gather pieces of info crucial to completing a complete assessment. The Heritage Assessment Tool (HAT) is an effective tool nurses often use to gather cultural information on their patients (see Figure 3.8).

Figure 3.8
Heritage Assessment Tool
Heritage Assessment Tool

Where was your mother born?

Where was your father born?

Where were your grandparents born?

Your mother’s mother?

Your mother’s father?

Your father’s mother?

Your father’s father?

How many brothers and sisters do you have?

In what setting did you grow up?




In what country did your parents grow up?



How old were you when you came to the United States?

How old were your parents when they came to the United States?



Who lived with you when you were growing up?

Have you maintained contact with




Brothers and sisters

Are you and your spouse from the same ethnic background?

What kind of school did you attend?




Do you currently live in a neighborhood in which the neighbors are the same religion and ethnic background as yourself?

Do you belong to a religious institution?

Would you describe yourself as an active member?

How often do you attend your religious institution?

More than once a week



Special holidays only


Do you practice your religion at home?

If yes, please specify:


Bible reading


Celebrating religious holidays

Do you prepare foods of your ethnic background?

Do you participate in ethnic activities?

The HAT is a succinct survey that assists the nurse in obtaining basic but crucial information regarding the patient’s culture, beliefs, needs, and practices that may affect his or her care and treatment. Such data is helpful not only to structure the plan of care, but also to educate nurses adequately regarding new cultures that will expand their cultural competence. There are a number of similar tools to assist in gathering data related to culture. Regardless of the tool being used, the importance lies in the way in which the data is used to care for the patient.

Nurse Response to Emerging Populations and Health
· Leadership & Advocacy

Nurses have a fundamental obligation to address the changing needs of patients. As emerging populations grow, it is imperative that nurses advocate and support changes that are needed to help these populations live well. The American Nurses Association’s (ANA) Code of Ethics (ANA, 2015) incorporates several provision statements based upon advocating for patients’ rights and the importance of treating patients with dignity and respect. In Table 3.4, statements that can be directly correlated with cultural competence appear in blue text.

Table 3.4
ANA Code of Ethics Provision Statements
Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2

The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 6

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 7

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 9

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Note. Adapted from “Code of Ethics with Interpretive Statements,” by the American Nurses Association, 2015. Copyright 2015 by the American Nurses Association.
ANA Diversity Awareness Mission Statement
The ANA recognizes cultural competence as an imperative part of nursing and describes its importance in their Diversity Awareness Mission Statement. The statement encourages nurses to continue developing their awareness of cultural and diversity issues as well as acknowledge their personal attitudes and perceptions that could impact care for such patients (ANA, n.d.). In addition to the emerging populations discussed within this chapter, the ANA recognizes that the following groups warrant attention from nursing.

· Bariatric patients

· Geriatric patients

· Uninsured

· Mental health community

As these patient populations continue to grow, so too does the demand for nurses to be culturally sensitive and aware of their varying needs.

Ethnic Minority Fellowship Program: A Focus on Mental Health
· Leadership & Advocacy

While the discussion of cultural diversity has largely been focused on the emerging patient populations, the topic of cultural diversity of health care workers/nurses has been acknowledged as well. The ANA has recognized the lack of diversity in the nursing workforce. Evidence suggests patients from varying ethnic backgrounds with mental health diagnoses have increased positive outcomes when their caregivers are from diverse ethnic backgrounds. The ANA and the Substance Abuse and Mental Health Services Administration (SAMHSA) have developed the Minority Fellowship Program (MFP), which grants funds to assist nurses from minority populations in attaining doctorate degrees with an emphasis in mental health. Their overarching goal is to

increase the number of rigorously educated nurses from under-represented ethnic minority groups in order to conduct research about mental health issues…assume leadership roles…expand mental health literature about minority populations…and function as members of interdisciplinary research and treatment teams with the intent of improving the mental health status of ethnic/minority populations. (ANA, n.d., para. 1)

The program has existed for three decades now, working with the mental health community to help empower nurses by enabling them to achieve higher education in order to help ease this growing disparity.

Scholarly Work: Advancing Evidence Based Practice
· The Future of Nursing

A component familiar to nurses is evidence-based practice (EBP). EBP is the catalyst for driving change within nursing practice. Cultural competency will continue to be essential to nursing, therefore, research and EBP are necessary to its continued development. There are several journals that produce scholarly works based on culturally competent care, such as the Journal of Cultural Diversity and the Journal of Multicultural Nursing and Health.

National Response: Federal Programs
The need for more thorough culturally competent care has warranted the assistance and attention of many federal agencies. With the changes following the Patient Protection and Affordable Care Act (ACA), many hospital expansion initiatives have been instituted to better address health promotion and cultural needs of the growing population of insured individuals. In fact, one of the primary focuses of the ACA is prevention and community health overall (Heiman & Artiga, 2015). The National Institutes of Health (NIH) support many programs that aim to improve health for identified emerging populations, such as the Clear Communication Program, which helps to provide resources to overcome language and health literacy barriers in health care. The NIH also supports the Office of Minority Health (OMH), which advocates for National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) (see Table 3.5). According to the OMH (2016) website, the goal of the CLAS standards is “to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health and health care organizations to implement culturally and linguistically appropriate services,” (para. 1). Such guidelines are utilized and implemented in many different health care settings in order to better achieve culturally competent care.

Table 3.5
CLAS Guidelines
National Enhanced Culturally and Linguistically Appropriate Service Standards

Principal Standard

Standard 1: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership and Workforce

Standard 2: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.

Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

Standard 4: Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance

Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

Standard 7: Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement and Accountability

Standard 9: Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.

Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.

Standard 11: Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

Standard 12: Conduct regular assessments of community health assets and needs, and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

Standard 13: Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

Standard 14: Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Note. Adapted from “Enhanced Cultural and Linguistic Services Standards: Not Just Language Anymore,” by V. Sanders-Thompson, 2016, Washington University in St. Louis Institute for Public Health. Copyright 2016 by the Washington University in St. Louis.
In correlation with the OMH, the National Partnership for Action (NPA) developed the National Stakeholder Strategy for Achieving Health Equity. This document is a collection of advice from leaders throughout the country who acknowledge the need for cultural care and their ideas for developing solutions for decreasing health disparities among emerging populations and developing a culturally competent workforce. The National Institute on Minority Health and Health Disparities (NIMHD) focuses on research and implemented EBP to improve health for ethnic minority groups and decrease health disparities among these groups.

Collaboration among government, the private sector, and health care professionals is necessary to see changes occur in cultural competent care. Through the implementation of interventions such as CLAS guidelines, and the continued education of health care workers regarding cultural competence, a health care workforce can be built that will help decrease health disparities among minority groups.

Reflective Summary
Culturally competent care is a foundation for providing holistic nursing care. Nurses have a duty to provide culturally sensitive care and to be aware of the ever-changing emerging populations within the United States. Nurses provide resources, advocate for patients, and promote health and wellness by providing education regarding best nutrition practices. Proper initial assessment for cultural needs is important in individualizing care for each patient. Federal agencies recognize the need for culturally competent care and work together to formulate plans to help decrease health disparities among disadvantaged groups. Moving forward, it is evident that cooperation among many agencies and health care workers is required in order to help reduce and eliminate the health disparities that affect persons from emerging population groups nationwide.

Key Terms
Complementary Alternative Medicine (CAM): Term for therapies that have not been accepted as part of conventional Western medicine such as yoga, acupuncture, and meditation.

Cultural Competence: To be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups.

Culture: Traditional beliefs and values shared among a group of people.

Emerging Populations: Populations or ethnic groups that have not achieved institutional power or recognition.

Ethnic Group: People within a community who share the same ethnicity.

Ethnicity: A group of people who share a common culture, religion, and/or language.

Health Disparities: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.

Health Equity: Provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH).

Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care that enables them to improve their health by making positive decisions.

Homelessness: Individual who lacks permanent residence.

Immigrant: Those who leave their native country to take up permanent residence in foreign country.

Minority Group: People who lack social power within society, often ethnically diverse groups.

Nontraditional Care System: Health care based on traditional methods or remedies such as herbal medicine.

Race: Group of people with a common ancestry defined by similar physical traits.

Refugee: An individual or group of people seeking asylum in a country other than their country of origin because of fear of discrimination for racial, ethnic, religious, or political reasons.

Taoism: Principles of religion rooted in ancient Chinese culture.

Traditional Care System: Health care based on traditional Western medicine’s modality of care and treatments.

Transcultural Nursing: The study of providing culturally competent nursing care.

Values: The beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group.

Vulnerable Populations: People who require special attention related to well being and safety, including persons who cannot advocate for their own needs such as children, prisoners, and cognitively impaired.

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