AJN Article - Jan 2001 Issues Update: Rethinking the Relationship Between Nursing and Diversity

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Issues Update

American Journal of Nursing - January, 2001 - Volume 101, Issue 1

Rethinking the Relationship Between Nursing and Diversity
Creating a 'culture of inclusion'

By Malika B. Gooden, MPH
Cornelia P. Porter, PhD, RN, FAAN
Rose I. Gonzalez, MPS, RN
and Barbara L. Mims, PhD, RN

Are you comfortable only with those who are similar to you? Do you find learning about other peoples’ traditions and social customs to be a chore? Are you so comfortable with similar people that you’re indifferent to people who are different? If so, you’re not alone.

Such questions are becoming increasingly important to the nursing profession as the demographics of the patient population change. Nurses are being called upon to create innovative ways of relating to people of diverse racial and ethnic backgrounds, many of whose health disparities threaten the welfare of the nation. Epidemiological data indicate that, across all age groups, racial and ethnic minorities still bear a disproportionately greater burden of disease and disability (such as heart disease, infant mortality, and stroke).

The issue of ‘diversity’

People have learned to think about diversity in terms of skin color—historically, in this country, black and white. But as the population grows, our society is becoming a kaleidoscope of racial and ethnic groups, behaviors, values, world perspectives, social customs, and attitudes.

Our nation’s increasing pluralism is evidenced by the changes to the racial and ethnic classifications on the 2000 census forms: the numerous nonscientific racial and ethnic categories and subcategories demonstrate the ways in which racial and ethnic boundaries have blurred. The reclassifications also herald the importance of rethinking racial and ethnic identity: that it’s determined more often by self-identification than by the rigid definitions of a social system wherein race is the predominant defining factor.

Despite this blurring of boundaries, like many people, nurses have been conditioned by this country’s history of racial inequality and have learned to label people. This labeling has become socially ingrained and is the hallmark of the institutionalization of race relations. 1 The outcome can sometimes be a disconnect between the patient-centered orientation of nursing and actual interactions with “different” patients; the disconnect can at times produce a sense of culture shock or alienation in nurses and patients alike. Both may find their values, beliefs, and behavior challenged, causing overwhelming discomfort to all. 2

Nurses and the ‘difference paradigm’

To safeguard human dignity, to circumvent uncertainty and discomfort, and to respect individuality, nursing has embraced the ethic of caring as the sine qua non of the profession, along with concepts of “diversity” and “multiculturalism” as perspectives for interpersonal relations with patients of all races and ethnicities. But regrettably, disabilities, sexual orientation, gender, social class, physical appearance (such as obesity), and ideologies (such as differing political or religious views) have yet to be incorporated into nursing’s concept of “diversity.”

Although there may be acceptance of the “difference paradigm” among some nurses, the outcome has not been consistently favorable because other nurses still view patients as composites of stereotypical characteristics, and variations within groups are not recognized. What happens then to the individualized, patient-centered approach to care? To effectively deliver patient-centered care to a diverse patient population, nurses need to reflect upon their values and beliefs, seek direction from their professional organizations, and modify their own behavior.

Approaching the topic of diversity

“Diversity” means different things to different people. Differences left unacknowledged can cause feelings of exclusion and culture shock. Yet talking about differences is often stymied by the “paralysis of political correctness,” according to Valda Ford of the Center for Human Diversity. Ford’s statement implies that there exists a greater concern with appearances than with being authentic or understanding another’s perspective. We may be afraid to look foolish, to offend, or to appear to be the “loser” in a power relationship. And while most of us do not consciously decide what we are going to believe—we inherit many beliefs without challenging them—we also adopt beliefs that are grounded in experience. We form stereotypes of groups that are different from us because of our very real physical and social separateness from each other.

Despite the difficulties, there are several ways of initiating discussion among nurses about diversity.

  • Nurses might begin by defining racial and ethnic minority as a subset of the population that has a disproportionately high risk of exposure to factors that compromise health (such as environmental toxins, poverty, lack of health care access, poor housing).
  • To better understand diversity, discussions among coworkers might take the form of forums on Internet bulletin boards addressing issues such as the chilly psychological climate and isolation that nurses—and patients—have experienced.
  • Groups of coworkers could create supportive work environments 3 , 4 in which to discuss issues of diversity related to nursing care. Such discussions can encompass individual strengths and weaknesses and feelings about particular patients.

Each of these approaches could foster greater understanding and an appreciation of all kinds of differences, thus creating a “culture of inclusion.”

Nursing’s national voice

The nursing profession has been racially integrated for about 50 years. In an effort to improve race relations in the profession and raise awareness about diversity, the American Nurses Association has initiated several efforts: it has written a series of position statements (for example, Discrimination and Racism in Health Care, Discrimination Against Gays and Lesbians in the Military, Decade of Disabled Persons, Cultural Diversity in Nursing Care); it has created councils and task forces to address issues of diversity in health care; and it has worked diligently for legislation to improve the health of members of racial and ethnic minorities (the Agenda for Health Care Reform and the Nurse Education Act are two examples). Moreover, the ANA’s commitment to the incorporation of the concept of diversity into its activities is evidenced by its participation as the only nursing organization on the Steering Committee to Eliminate Racial and Ethnic Disparities in Health, cosponsored by the Department of Health and Human Services and the American Public Health Association.

Although the ANA has participated with others and developed policies and positions to address “the eradication of discrimination and racism in the profession of nursing, in the education of nurses, in the practice of nursing, as well as in the organizations in which nurses work,"5 only small steps have been taken to actively implement strategies recommended in the policy and position statements.

One of the ANA’s goals is a diverse workforce. As the “national voice of nursing,” the ANA has an unparalleled opportunity to communicate to 2.6 million nurses the importance of integrating the concept of diversity into their “core issues” (workplace rights, appropriate staffing, workplace health and safety, continuing competence, and patient safety and advocacy), helping to focus resources and shape the ANA’s identity, for the benefit of members and nonmembers. Each of these core issues provides an invaluable opportunity for the “national voice of nursing” to concretely demonstrate its commitment to a diversified workforce.

If the nursing profession is to help close the health-disparity gap and improve the welfare of this nation, it is imperative that nurses rethink the relationship between nursing and diversity.


1. Bonilla-Silva E. Rethinking racism: toward a structural interpretation. Am Sociol Rev 1997;62(3):465-80.

2. Lynch EW, Hanson MJ, editors. Developing cross-cultural competence: a guide for working with young children and their families. Baltimore: P. H. Brookes; 1992.

3. Belbin RM. Team roles at work. Oxford: Butterworth-Heinemann; 1993.

4. Garcia MH. An anthropological approach to multicultural diversity training. J Appl Behav Sci 1995;31(4):490-504.

5. American Nurses Association. Position statement: Discrimination and Racism in Health Care. 1997.