5.4: Diversity, Equity, and Inclusion

Learning Objectives

By the end of this section, you will be able to:

• Define important considerations related to providing equal, diverse, and inclusive nursing care
• Identify factors that can prevent diversity and inclusion
• Explain how barriers to communication affect diversity and inclusion

Diversity and inclusion create an environment that encourages different ideas, cultures, backgrounds, and experiences. This type of environment allows nurses to provide more comprehensive and effective care to their patients. Diversity, equality, and inclusion foster a culture of mutual respect, understanding, and support which can lead to improved patient outcomes. Additionally, diversity and inclusion can help to reduce health disparities which can improve healthcare access and quality for communities that are traditionally underserved. Ultimately, diversity and inclusion are critical components of successful nursing practice that can help to ensure that all patients receive the best possible care.

Equality

The principle of ensuring that all individuals, regardless of their background or socioeconomic status, have equal access to healthcare resources and opportunities is called health equality (CDC, 2022b). When everyone has a fair opportunity to obtain optimal health, health equity is achieved (CDC, 2022a). Both equity and equality are important considerations when providing inclusive nursing care (Figure 5.7).

Figure 5.7 Health equality is providing the same resources and opportunities to all individuals, while health equity is ensuring that everyone has access to the resources they need to attain the same level of health, addressing systemic disparities and promoting fairness. (CC BY 4.0; Rice University & OpenStax)

A standard linked to fairness for all in society is justice, a principle and moral obligation to act on the basis of equality and equity. The ANA states this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety) but also fairness in all operations of societal structures. This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence.

The CDC (2022a) discusses diversity and inclusion as important factors in health equity considerations. Diversity refers to the existence of societies, communities, or subcultures that differ substantially from one another. Cultural competence means respecting and appreciating these similarities and differences. Inclusion is the practice of creating an environment in which individuals of all backgrounds feel respected, valued, and supported (CDC, 2022b). There are numerous factors that can prevent diversity, inclusion, and justice. These can in turn create health disparities that limit access to care and decrease outcomes for certain groups.

Race/Ethnic Heritage

Race is a socially constructed idea because there are no true scientifically or biologically distinct races. Humans are not biologically different from each other. However, race and ethnicity have an undeniable effect on healthcare access and outcomes. In racism, it is presumed that races are distinct from one another and that there is a hierarchy to race, implying that races are unequal. As healthcare providers, nurses have an obligation to recognize the impact of racism on their patients and the communities they serve. In the United States, race and ethnic background have long played a role in health disparities among different populations.

Most underrepresented populations experience higher rates of chronic disease and premature death compared to the rates among White populations; however, some individuals from underrepresented groups, such as Asian and Hispanic immigrants, experience lower rates (National Academies of Sciences, Engineering, and Medicine, 2017a). American Indian, Alaska Native, and Black populations experience the highest infant mortality rates, while Asian and Pacific Islander populations experience the lowest (Figure 5.8). Black people are more likely than White people to die prematurely from heart disease, and Black men are twice as likely as White men to die prematurely from stroke.

Figure 5.8 Infant mortality rates by race and ethnicity for the United States illustrate discrepancies between groups. (data source: Center for Disease Control and Prevention; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Implicit bias related to race and ethnicity has been repeatedly shown in research to negatively affect patient care and outcomes. Nurses should also be sensitive to the fact that individuals from certain ethnicities may be distrusting of healthcare professionals due to cultural history and other factors.

Religion

Throughout human history, spirituality and health have often gone hand-in-hand. In many healing traditions, healers also serve as religious leaders (Figure 5.9). Many people consult and rely on their religious and spiritual beliefs when making medical decisions. For instance, Jehovah’s Witnesses do not accept whole blood, plasma, and platelets because they believe that this might interfere with eternal salvation; they believe it is against God’s will to accept blood products and will therefore not allow blood transfusions. A person’s religious beliefs can affect their diet, what medications they will take, and approaches to death and dying. Healthcare providers must be prepared to take patients’ religious and spiritual preferences into account as an important part of the treatment plan (Swihart et al., 2022). A thorough cultural assessment should include information on a patient’s religious or spiritual beliefs that might affect their care.

Figure 5.9 Religion and health are closely intertwined for many people. (credit: “Guatemalan Clergymen Lead Sunday Mass Aboard USNS Comfort” by Navy Medicine/Flickr, Public Domain)

Age

Older adults struggle with some limitations in their care related to their age. Studies have shown that healthcare providers are more likely to assume that older patients’ conditions, such as cognitive decline, are due to their age and to deny them certain treatments as compared to younger patients (Hughes et al., 2020). Older patients also tend to be undertreated for pain and depression. Older adults are more likely to live in poverty and have limited access to transportation, which can make it difficult to get to medical appointments.

Gender Identity and Sexual Orientation

A person’s inner sensibility that they are a man, a woman, or perhaps neither is gender identity. The term cisgender is used to describe a person whose identity matches their sex assigned at birth. To the extent that a person’s gender identity does not conform with the sex assigned to them at birth, they may identify as transgender or as gender nonbinary. The term transgender refers to someone whose gender identity or expression differs from traditional cultural gender roles for one’s sex assigned at birth. Transgender people, like cisgender people, may be sexually oriented toward men, women, both sexes, or neither sex. Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms. Sharing pronouns as part of a basic introduction to a patient can assist a transgender patient to feel secure sharing their pronouns in a healthcare setting. Asking a patient for their pronoun (he, she, they, ze) is considered part of a nursing assessment.

There is a strong body of research showing a history of gender bias in health care (Hughes et al., 2020). Providers are more likely to believe that the health complaints of women result from emotional instead of physical causes compared to men. There is also a demonstrated history of underdiagnosis and undertreatment of cardiovascular disease in women when compared to men.

A person’s physical and emotional interest or desire for others is their sexual orientation. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors. The acronym LGBTQIA+ stands for lesbian, gay, bisexual, transgender, queer or questioning, intersex, or asexual in reference to sexual orientation. (The “+” is sometimes added after LGBTQIA+ to capture additional orientations.) Historically, individuals within the LGBTQIA+ community have experienced discrimination and prejudice from healthcare providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this group of people in recent years, members of the LGBTQIA+ community continue to experience significant health disparities.

Disability

Disabilities can be present from birth or acquired later in life. They can be physical, cognitive, or mental health related. Adults with disabilities are more likely than adults with no disabilities to report poor health, including higher rates of obesity, diabetes, smoking, lack of physical activity, and cardiovascular disease. Adults with disabilities are also more likely to live in poverty, and even those with health insurance are less likely than adults without disabilities to seek care. Adults with disabilities also cite common stereotypes, bias, and beliefs among providers as barriers to care (VanPuymbrouck et al., 2020). Examples include lack of appropriate equipment to transfer patients with disabilities, or a healthcare provider’s assumption that the patient is unhealthy or fragile simply because they have disabilities.

Education Level

Differences in educational levels can affect how people access healthcare services and understand health information to make informed decisions. The higher a person’s level of education, the higher is their life expectancy and the more likely they are to access preventative and screening services (Viinikainen et al., 2022). People with lower education levels are more likely to have higher weight and to engage in risky activities such as smoking and heavy drinking (Viinikainen et al., 2022). In the United States, the health disparities between the most educated and least educated people have been increasing over the last forty years, leading to an increasing discrepancy in morbidity and mortality rates among these groups (Viinikainen et al., 2022).

Physical Characteristics

Certain physical characteristics have the potential to create barriers to care. Patients who are deaf or blind may need accommodations to ensure that communication is clear and accurate. American Sign Language interpreters can be sought for patients who are deaf. Educational materials and consent forms printed in Braille can assist blind populations.

Socioeconomic Status

In the United States, socioeconomic status is a major determinant of health status. Individuals from low socioeconomic groups, including those experiencing homelessness or living in poverty, are prone to higher rates of diseases like heart disease, diabetes, stroke, and obesity (Baggett et al., 2013; Fazel et al., 2014; National Academies of Sciences, Engineering, and Medicine, 2017b). This is attributed to their limited opportunities for early prevention and a lack of resources to adhere to standard treatment plans (Baggett et al., 2013; Fazel et al., 2014; National Academies of Sciences, Engineering, and Medicine, 2017b). For instance, someone experiencing homelessness is unable to perform clean dressing changes daily without adequate access to water. They also have higher rates of infant mortality, substance misuse, and shorter life expectancies. Additionally, they may report avoiding care because they feel discrimination from healthcare workers (Hughes et al., 2020).

In 2021, the majority of Americans relied on privately purchased insurance for their health care. Most of this insurance is made available through employers. About 35 percent of the population holds a public form of insurance in the form of Medicaid or Medicare. Medicare is for those who have been determined to need special care such as older people or those who experience certain disabilities. Medicaid is for those who need aid in receiving care, such as people who meet certain low-income guidelines (Keisler-Starkey & Bunch, 2022).

Veteran Status

Military veterans often have complex needs due to physical and psychological trauma sustained during military service and socioeconomic issues that arise after discharge (Figure 5.10). Many veterans struggle with a lack of access to healthcare benefits, sometimes based on residing in rural locations that do not have veteran-specific healthcare facilities. The Veterans Administration offers free health care to veterans who meet certain low-income guidelines, allowing these patients to be seen at any facility.

Figure 5.10 Veterans are an especially at-risk population who often have complex needs. (credit: “210512-N-QB805-0110” by Navy Medicine/Flickr, Public Domain)

Factors Preventing Sensitivity to Diversity

Sensitivity to diversity can be hindered by several factors that are related to a person’s experiences, attitudes, and knowledge. One significant factor is a lack of exposure to diverse individuals and cultures. Limited exposure can lead to a lack of understanding and appreciation for diversity. Stereotyping and prejudice can also contribute to insensitivity, as preconceived notions or stereotypes about certain groups can lead to discrimination and bias. Personal biases can influence perceptions and attitudes toward different groups, leading to insensitivity. Additionally, a lack of education or awareness about different cultures and backgrounds can lead to misunderstandings. Overcoming these barriers requires ongoing education, open-mindedness, and a willingness to learn about and appreciate different cultures and backgrounds. It also requires actively challenging one’s biases and seeking out opportunities for exposure to diversity.

Stereotyping

The assumption that a person has the attributes, traits, beliefs, and values of a cultural group because they are a member of that group is termed stereotyping. Engaging in stereotyping prevents the ability to identify people’s needs on an individual level. One common stereotype is the assumption that all older patients are forgetful or have memory problems. This stereotype can lead to medical professionals overlooking or dismissing legitimate concerns or symptoms of older patients, attributing them solely to age-related memory decline, which can in turn lead to misdiagnosis or delayed treatment. Stereotypes can be harmful to patients and must be avoided. Culturally competent care extends beyond general knowledge of a cultural group to knowledge of the individual themself.

Cultural Imposition

The imposition of one’s own values, beliefs, and practices upon another person or group is cultural imposition. Cultural imposition runs counter to cultural humility and can manifest in various ways. Examples include disregarding a patient’s cultural practices, beliefs, and values when making medical decisions, or imposing Western medical practices on non-Western cultures without consideration for their unique cultural beliefs and practices. For instance, healthcare providers may fail to consider a patient’s traditional healing practices or the role of family members in healthcare decisions, which can lead to a breakdown in communication and a lack of trust between patients and healthcare providers. Cultural awareness can help the nurse recognize their own biases and avoid cultural imposition.

Cultural Blindness

The belief that all cultural groups are the same and share identical experiences is cultural blindness (Bhattacharya et al., 2019). Different cultural groups can have vastly different experiences within the healthcare system. Cultural blindness might lead a nurse to conclude that all treatment services are adequate for all patients, contributing to the continuation of policies that prevent diversity and inclusion. For instance, a hospital might stock consent forms available in English and Spanish exclusively. However, despite a significant local Vietnamese population, the nurse consistently faces difficulty in locating consent forms in Vietnamese for these patients. This is a result of system-wide cultural blindness. Once the nurse identifies the issue, they can escalate it and have the issue addressed by having adequate Vietnamese-language consent forms available for the patient population.

To address cultural blindness in health care, providers should receive regular cultural competency training and actively work to understand and respect the diverse backgrounds of their patients. This includes learning about cultural beliefs and practices related to health and illness, as well as developing effective communication strategies that bridge language and cultural barriers.

Culture Conflict

A culture conflict occurs when there is tension or opposition between different cultures. Often, the dominant culture weakens the cultural practices of the minority group as a result (APA, n.d.b). Culture conflict can arise in many ways, such as when a patient’s cultural beliefs around illness and healing differ from those of the healthcare provider, or when a patient’s cultural practices conflict with medical protocols. For example, a patient who refuses to receive a blood transfusion due to religious beliefs may have conflict with the nurse who sees this treatment as medically necessary.

Culture conflict can also arise when healthcare providers make assumptions or judgments about patients based on their cultural background, leading to biases and discrimination. This can result in disparities in healthcare access and outcomes for patients from diverse backgrounds. Nurses should approach such conflicts with cultural humility to ensure they are resolved without damage to the nurse-patient relationship.

Barriers to Communication

It is necessary to overcome communication barriers to maximize the patients’ opportunities for the highest quality care. According to the Agency for Healthcare Research and Quality (2020), approximately three out of 100 people in the United States have a hearing disability, and two out of 100 have a visual disability to the extent that they are blind or have trouble seeing even with corrective vision wear. Various strategies can help improve the communication process for these patients.

For patients with hearing barriers, offer print materials, text telephones (TTYs), or videos with captioning. Sign language interpreters use American Sign Language or Signed English; there are also oral and cued-speech interpreters who use articulation and gestures. When having conversations, make sure the television or other sources of background noise are silenced and the surrounding environment is free of distracting noise.

For patients with sight barriers, make sure that the lighting is at their comfort level. Whenever possible, provide assistance in the form of audio recordings, large-print materials, and screen magnifiers. Text-to-speech or Braille output screen reading software is also available.

Linguistic Competence

According to a recent study, nine percent of the U.S. population has limited English proficiency (Agency for Healthcare Research and Quality [AHRQ], 2020). Linguistically competent care aims to help reduce these discrepancies. The AHRQ defines linguistic competence as “providing readily available, culturally appropriate oral and written language services to limited English proficiency members through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators” (AHRQ, 2019).

Educational materials, instructions, and consent forms should be offered in the patient’s preferred language and written using simple language. When caring for a patient whose primary language is not English and they have a limited ability to speak, read, write, or understand the English language, seek the services of a trained medical interpreter. Healthcare facilities are mandated by The Joint Commission to provide qualified medical interpreters. Use of a trained medical interpreter is linked to fewer communication errors, shorter hospital stays, reduced thirty-day readmission rates, and improved patient satisfaction.

Refrain from asking a family member to act as an interpreter. The patient may withhold sensitive information from them, or family members may possibly edit or change the information provided. Unfamiliarity with medical terminology can also cause misunderstanding and errors.

Medical interpreters may be on-site or available by videoconferencing or telephone. The nurse should also consider coordinating patient and family member conversations with other healthcare team members to streamline communication, while being aware of cultural implications such as who can discuss what healthcare topics and who makes the decisions. When possible, obtain a medical interpreter of the same gender as the patient to prevent potential embarrassment if a sensitive matter is being discussed.

Some additional guidelines for working with a medical interpreter are as follows:

• Allow extra time for the interview or conversation with the patient.
• Whenever possible, meet with the interpreter beforehand to provide background.
• Document the name of the medical interpreter in the progress note.
• Always face and address the patient directly, using a normal tone of voice. Do not direct questions or conversation to the interpreter.
• Speak in the first person (using “I”).
• Avoid using idioms, such as, “Are you feeling under the weather today?” Avoid abbreviations, slang, jokes, and jargon.
• Speak in short paragraphs or sentences. Ask only one question at a time. Allow sufficient time for the interpreter to finish interpreting before beginning another statement or topic.
• Ask the patient to repeat any instructions and explanations given to verify that they understood.