In the 21st century, we see the diversity of the American population becoming deeper and broader in scope, with nursing and healthcare needing to rise to the challenge of meeting the needs of a wide variety of patients from a plethora of cultures, belief systems, and groups.

Culture and Cultural Competence

According to the Centers for Disease Control and Prevention, “culture can be defined by group membership, such as racial, ethnic, linguistic or geographical groups, or as a collection of beliefs, values, customs, ways of thinking, communicating, and behaving specific to a group”. 

The U.S. Department of Health and Human Services (HHS) adds, “Culture can also refer to other characteristics such as age, gender, sexual orientation, disability, religion, income level, education, or profession.” The HHS defines cultural competence as “the ability to interact effectively with people of different cultures, and as a result, ensure the needs of all community members are addressed.” We’ll add here that sexual and gender identity also represent significant cultures in need of sensitivity, understanding in the context of healthcare delivery. 

The Nursing Profession vs the Overall Population

While the U.S. population continues to steadily grow more diverse, the nursing profession itself has not kept pace. 

In terms of the nursing profession in the United States, 69.1% are reported to identify as non-Hispanic white as compared to 60.4% of the overall population. And while 11.8% of RNs are non-Hispanic Black,  13.4% of the American population is identified as African American or non-Hispanic Black. Considering that the Hispanic percentage of the U.S. population is approximately 18.3%, we note that only 7.5% of RNs are Hispanic. 

The nursing profession itself does not accurately represent the citizens that it serves, and this poses a challenge in terms of providing culturally competent care.

Vulnerable Populations


According to the Institute for Value Based Medicine, disparities related to cultural differences are pervasive: 

Despite efforts and goals in the United States to reduce or eliminate disparities in healthcare by 2010, significant disparities, including risk factors, access to healthcare, morbidity, and mortality, continue in vulnerable populations. For example, studies find that Americans living in poverty are much more likely to be in fair or poor health and have disabling conditions, and are less likely to have used many types of healthcare.

Vulnerable populations include the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness. It may also include rural residents, who often encounter barriers to accessing healthcare services. The vulnerability of these individuals is enhanced by race, ethnicity, age, sex, and factors such as income, insurance coverage (or lack thereof), and absence of a usual source of care. Their health and healthcare problems intersect with social factors, including housing, poverty, and inadequate education.

The Commonwealth Fund adds: 

People with low incomes experience the U.S. health system’s shortcomings more acutely. Disproportionately minority, this vulnerable population is more likely to lack health insurance and adequate social supports than more affluent Americans. Extensive research shows that people with socioeconomic disadvantages have greater difficulty obtaining health care, receive lower-quality care, and experience poorer health outcomes.

When it comes to culturally competent care, we must recognize that those who are most vulnerable to experiencing disparities are members of groups who may, if not for culturally sensitive and competent care, be mistreated, undertreated, or fall through the cracks of the safety net that has failed them. Where do we turn for guidance? 

Transcultural Nursing

During the 1950’s, Dr. Madeleine Leininger introduced the concept of transcultural nursing and spearheaded the founding of the Transcultural Nursing Society. Her Culture Care Theory guided the establishment of models that address cultural values. 

Within this framework, the following areas of human life are considered:

  • Age
  • Communication and language
  • Dress
  • Use of space
  • Gender considerations
  • Sexual orientation
  • Ability/Disability
  • Occupation
  • Socioeconomic status
  • Interpersonal relationships
  • Appearance
  • Foods and meal preparation-related life ways

Approaches and Solutions

As the world continues to diversify and previously unacknowledged cultural groups and sub-groups claim their existence and unique vulnerabilities, nursing practice must respond proactively. 

The American Nurses Association has identified three main categories of competencies that every nurse should embody in order to provide increasingly culturally competent care. These are, 1) self-assessment, wherein the nurse identifies their own beliefs, values, and heritage; 2) the identification and respect of differences between one’s self and others; and, 3) the advocacy and promotion of policies and practices that lend themselves to equal access and non-discrimination. 

Based on the leadership of the U.S. Department of Health and Human Services Office of Minority Health, the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards) “aim to improve health care quality and advance health equity by establishing a framework for organizations to serve the nation’s increasingly diverse communities.” Their principal standard is to “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.”

We can see from the aforementioned sources, as well as those too numerous to elucidate here, that constant improvement, ongoing research, individual and organizational accountability, and inspired leadership are central to promoting common standards of culturally competent healthcare and nursing care delivery. 

Individual nurses can take it upon themselves to learn and grow, and organizations can lead by example by providing appaorpriate evidence-based education. We can also be collectively involved in the recruitment of a more racially diverse pool of students who can diversify the nursing workforce and bring their cultural identities to the table.

At this poignant time in history when the Black Lives Matter movement and broad conversations about social inequities are front and center, there is no better time for the healthcare industry and its member professions to look deeply at themselves and then do the work that can serve to level the playing field and provide equal care and attention to all. After all, every patient who walks through our doors is in need of compassion, empathy, and basic understanding of who they are as unique human beings, and it is our duty to meet them with open minds, open hearts, and the tools to provide the culturally competent care that we know can truly be delivered.

Learn more on topics of care in a diverse patient population with our Cultural Competency with Religious, Ethnic, and LGBTQ+ Considerations Nursing CE Course worth 2 ANCC contact hours.