Embracing Cultural Diversity in Health Care: Developing Cultural Competence
Purpose and scope
The purpose of this best practice guideline (BPG) is to promote a healthy work environment for nurses by identifying best practices for embracing diversity within health care organizations. The guideline is relevant to all domains and settings where nurses practice.
The recommendations in this guideline address:
- Culturally competent practices in the workplace
- Individual competencies, management practices and institutional policies that reflect culturally competent practices
- Transformational strategies for embracing diversity at the level of the individual, group, organization, and health care system
- Educational requirements and strategies to ensure a culturally competent workforce • Policy changes to support and sustain culturally competent practices
- Future research opportunities
Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada: Registered Nurses’ Association of Ontario.
Recommendations
Recommendation 1: Perform self-reflection of one’s own values/beliefs, incorporating feedback from peers.
Recommendation 2: Express an awareness of one’s own views of differences among people (e.g. different opinions, different world views, different races, different values, different views of society).
Recommendation 3: State and continually explore, through reflection and feedback, how one’s own biases, personal values, and beliefs, affect others.
Recommendation 4: Identify cultural differences among clients and colleagues in the practice setting.
Recommendation 5: Acknowledge one’s own feelings and behaviours toward working with clients, families and colleagues who have different cultural backgrounds, health behaviours, belief systems, and work practices.
Recommendation 6: Explore one’s strategies for resolving conflicts that arise between self and colleagues and/or clients from diverse groups.
Recommendation 7: Identify and seek guidance, support, knowledge and skills from role models who demonstrate cultural proficiency.
Recommendation 8: Recognize and address inequitable, discriminatory, and/or racist behaviours or institutional practices when they occur.
Recommendation 9: Acknowledge the presence or absence of individuals from diverse cultural backgrounds at all levels in the workplace, reflecting the cultural makeup of the clients or community being served.
Recommendation 10: Reflect and act on ways to be inclusive in all aspects of one's practice.
Recommendation 1: Are aware of different communication styles and the influence of culture on communication.
Recommendation 2: Are aware of one’s preferred communication style, its strengths and limitations, and how it affects colleagues and recipients of care.
Recommendation 3: Seek feedback from clients and colleagues, and participate in communication validation exercises (e.g. role-playing exercises, case studies).
Recommendation 4: Use a range of communication skills to effectively communicate with clients and colleagues (e.g. empathetic listening, reflecting, non-judgmental open-ended questioning).
Recommendation 5: Seek and participate in learning opportunities that include a focus on communication and diversity
Recommendation 1: Articulate, implement, and evaluate the effectiveness of a mission statement, values and corporate strategic plans that emphasize the value of cultural diversity and competence.
Recommendation 2: Dedicate funding in the budget, including funding for human resources and expertise to plan, implement and evaluate strategies to strengthen diversity in the workplace.
Recommendation 3: Integrate cultural competence into the organization’s Code of Conduct and enforce the code. (Codes of conduct implemented in work settings must reflect the principles of the existing Canadian Charter of Rights and Freedoms, and be consistent with provincial/territorial human rights codes.)
Recommendation 4: Develop policies, guidelines and processes to address change and conflict.
Recommendation 5: Implement, evaluate and adapt policies and guidelines that are respectful of cultural diversity, integrate cultural competence and eliminate discriminatory practices.
Recommendation 6: Implement and evaluate strategies to develop leadership skills for succession planning that target under-represented populations to address the organization’s identified gaps and inequities.
Recommendation 1: Identify and monitor the cultural, ethnoracial, linguistic and demographic profile of the workforce in the organization and in the communities it serves on a systematic basis.
Recommendation 2: Identify gaps by asking, “Who is not here who should be here?” (e.g. men, First Nations people, other ethnic groups) and develop a plan to address the gaps.
Recommendation 3: Establish outreach processes in collaboration with cultural communities and other organizations to recruit a culturally diverse population for the workforce.
Recommendation 4: Purposefully seek applications from qualified professionals of diverse cultural backgrounds to recruit to all levels of the organization, including leadership roles so that the organization is reflective of the communities served.
Recommendation 5: Review and amend all steps in recruitment processes (e.g. wording of job advertisements, role profiles, credentials required) to assess cultural competence and remove systemic biases in the selection process.
Recommendation 1: Plan employee orientation and continuing education programs, based on culturally sensitive preferred learning styles, assumptions and behaviours within culturally diverse groups.
Recommendation 2: Develop educational strategies to address the diversity of preferred learning styles and behaviours within employee groups.
Recommendation 3: Follow a cultural diversity model in implementing education and training for cultural competence (see examples in Appendix B).
Recommendation 4: Provide employees with ongoing continuing education on concepts and skills related to diversity and culture including:
- Communication
- Cultural conflict
- Competence models
- Culturally-appropriate assessments
Recommendation 5: Allocate fiscal and human resources, as part of the operating budget for educational strategies to promote cultural competence.
Recommendation 6: Evaluate the results of cultural competence education and adapt strategies as appropriate.
Recommendation 7: Work with national and jurisdictional organizations to collectively monitor the diversity of the workforce and the extent that diverse cultural and linguistic communities, ethnoracial groups, and demographic characteristics are represented.
Recommendation 8: Work with national and jurisdictional organizations to collectively establish mechanisms to address barriers to the recruitment and retention of underrepresented groups within the workforce.
Recommendation 1: Assess the unique learning needs of internationally educated nurses and the staff who will work with them.
Recommendation 2: Establish support and mentoring programs for internationally educated nurses and the existing members of the workforce who will work with them.
Recommendation 3: Implement and promote programs to help internationally educated nurses transition successfully into Canadian practice settings.
Recommendation 4: Establish competency-based orientation and continuing education for internationally educated nurses, with a focus on:
- Introduction to Canadian multicultural society, the health-care system, and nursing as a profession in Canada
- Language nuances and social norms
- Psychosocial skills
- Human rights
- Employer and employee expectations, rights, and responsibilities
- Mentoring
Recommendation 1: Set an initial and over-arching tone of inclusivity, and set expectations regarding understanding and embracing diversity.
Recommendation 2: Provide special consideration in the curriculum to teaching about:
- respect, acceptance, empathy, inclusivity, collegiality, and valuing differences
- Canadian society, the health care system, and nursing as a profession in Canada
- Language nuances and social norms
- Psychosocial skills
- Human rights
Recommendation 3: Incorporate and evaluate theoretical cultural competence models as part of the nursing curriculum.
Recommendation 4: Develop and implement core competencies in humanities that include concepts and skills related to cultural competence and addressing racism and discrimination.
Recommendation 5: Incorporate diverse learning styles and strategies into the development and delivery of the curriculum.
Recommendation 6: Monitor and evaluate the impact of cultural competence education.
Recommendation 7: Identify and address the professional, theoretical and cultural biases in curriculum content.
Recommendation 8: Identify and monitor the cultural demographics of students in all programs (undergraduate, graduate). Questions about issues such as ethnic background, place of origin, or sexual orientation must be asked with sensitivity, kept confidential, and not used against the subjects being questioned. Answering these kinds of questions is always optional, with no penalty attached to choosing not to answer.
Recommendation 9: Undertake purposeful outreach initiatives to encourage applications from First Nations’ peoples students and students from other culturally diverse backgrounds.
Recommendation 10: Include cultural competence as part of student orientation, development and expectations of professional behaviour.
Recommendation 11: Identify and meet the specific learning needs of the growing population of culturally diverse students coming into nursing programs.
Recommendation 12: Monitor the academic success and attrition rates of students in relation to in relation to cultural, ethnoracial, linguistic, and demographic characteristics to determine the presence of correlations and identify areas for support.
Recommendation 13: Adopt formal policies and transparent processes that are consistent with the Canadian Charter of Rights and Freedoms to address discrimination, harassment, and intolerance occurring within the school or during academic activities
Recommendation 1: Make every effort to include diverse populations as subjects of research.
Recommendation 2: Direct funding to explore diversity issues as topics of research in order to reduce disparities across populations (e.g. the impact of diversity variables on job satisfaction and retention).
Recommendation 3: Conduct research to:
- Determine the contributions, strengths, and benefits of the inclusion of health professionals from diverse cultures
- Identify key challenges and barriers regarding cultural diversity in the workplace
- Evaluate the impact of strategies (e.g. cultural competence education) implemented to address diversity challenges in work and education settings
Recommendation 4: Conduct research to identify strategies to embrace diversity challenges in workplace and educational settings, with special attention to attracting, graduating and retaining nurses from diverse cultural backgrounds, including First Nations’ peoples nurses.
Recommendation 1: Develop, disseminate and operationalize accountability expectations of employers around mission statements, hiring policies, promotion opportunities, and career advancement that maximize the potential of all health system employees and seek out under-represented groups.
Recommendation 2: Require that employers, schools and regulators measure and describe the cultural demographics of the Canadian nursing workforce and Canadian nursing students.
Recommendation 3: Fund programs and research in which diversity, discrimination, vulnerable populations and disparities will be a focus, or are a foundational theme.
Recommendation 4: Include and monitor cultural diversity of workforces and populations being served in the criteria for budgets/funding applications submitted by hospitals, community agencies and other publicly-funded service providers.
Recommendation 5: Package and disseminate accessible data on the cultural demographics of communities to employers and educational institutions to assist them shape their strategic plans regarding diversity initiatives.
Recommendation 1: Embed diversity proactively and systematically throughout all mission statements, values, corporate strategic plans and outcome measures.
Recommendation 2: Develop, test and modify (as appropriate) clear cultural competence indicators in standards for accreditation.
Recommendation 3: Collaborate with employers or educational institutions they accredit to collectively monitor the diversity of the workforce or the student body and the extent that diverse cultural and linguistic communities, ethnoracial groups, and demographic characteristics are represented.
Recommendation 4: Work with employers or educational institutions they accredit to collectively establish mechanisms to address barriers to the recruitment and retention of under-represented groups within the workforce and educational institutions.
Recommendation 1: Serve as role models by including diverse representation within their workforce, memberships, leadership, board and committees, and staff.
Recommendation 2: Establish outreach programs, and purposefully encourage the participation of members and leaders from diverse groups.
Recommendation 3: Consistently embrace diversity in policies and procedures, values, mission statements, and codes of conduct.
Recommendation 4: Reflect the importance of diversity and cultural competence in guidelines and educational materials developed by the association.
Recommendation 5: Establish mechanisms and structures that foster transparency and encourage feedback from members.
Recommendation 6: Develop and communicate common lobbying messages for diversity in collaboration with other associations to achieve more effective political lobbying.
Recommendation 7: Educate members and the public regarding positions on diversity, inclusively and cultural competence.
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Revision status
Current edition published: April 2007
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