by 2060. In certain parts of the country, including California, Texas, Florida, New York and Illinois, Hispanic populations are growing rapidly, and in some, they already comprise more than 50% of the population. Hispanics constitute the largest minority group in the U.S.8 Ideally, a nursing staff in a particular facility should reflect the


diversity of the community it serves, but this is often not the case. According to the 2008 National Survey of Registered Nurses, the RN workforce is overwhelmingly non-Hispanic white (almost 83.2%)9,10


The percentage of non-white or Hispanic nursing gradu-


ates increased from 12% of the total nursing population in 1985 to 22.5% in 2008. Nursing is more diverse than the previous national survey in 2004.9


In addition, within the U.S. healthcare system,


for example, men are at higher levels of management, and as D.O. Weber, a contributing editor for Health Forum Journal, puts it, less than 2% in management positions are people from “cultural com- plexion types that qualify in this country for the label minority.”11 Differences among staff can create problems in communication


and lead to conflicts that affect how the team works together. However, for nurses to be able to work effectively with staff from other cultures, they need to become aware of their own cultural values, beliefs and behaviors, and understand how these factors influence their communication with other staff members and patients, as well as their decision making and clinical practice. The same principles nurses use to give culturally competent care to patients also apply to the work group. According to the National Standards for Cul- turally and Linguistically Competent Services (commonly referred to as the CLAS Standards), to be culturally competent means to use a set of behaviors, attitudes, skills and policies to help staff and organizations to work effectively with people of different cultures.12


Differences in work styles The values, beliefs and practices that bind a society together are evident in the workplace. Expectations about work styles, role relationships, taking initiative and concepts of time are examples of these cultural influences. Hierarchical versus egalitarian work styles: All societies have


a system of social structure. The structure of some societies is hierarchical, while the structure of others is egalitarian. In hier- archical societies, status is based on such characteristics as age, sex, occupation and wealth. Status differences are considered very important, and those who have high status positions, such as a boss, supervisor, or an officer of the law, are given great respect.13


participate in childcare, have careers, and are able to hold public sector jobs and political office. It’s acceptable to challenge people in authority. It’s all right to disagree with a supervisor or a teacher. In the healthcare workplace, people from hierarchical societies may


find it inappropriate or uncomfortable to question any authority figure, such as the physician, nurse or supervisor. Their concept of nursing may be rooted in the old-fashioned “handmaiden” tradition seen in the U.S. in the 1940s and 1950s, still present in many countries world- wide. Physicians from this cultural tradition may object to assertive nurses who question their orders. Nurses from a hierarchical tradition may expect to work under the direction of a supervisor or physician, rather than practice in an autonomous role. They might hesitate to question decisions made by those supervising them or take initiative to perform work on their own. On the other hand, staff members from more egalitarian societies will find it easier to question or challenge authority figures and to work more collaboratively with them because their cultural experience has prepared them to feel equal to others. In the clinical example mentioned earlier, the Latino supervisor


probably believed he had the best interest of his staff in mind when he made unilateral decisions for the unit. His cultural experiences contributed to that belief. For example, if the Latino supervisor came to this country as an adult, his cultural experience most likely taught him that someone in authority, especially a man, needs to take responsibility for those he supervises. The nurses who were primarily young and white, on the other hand, expected a more egalitarian work style. They wanted equal input into the decision-making process. These differences are culturally based. To work more effectively together, the Latino supervisor needs to understand and appreciate the expectations and previous experi- ences of the staff. At the same time, the nurses have to consider that the supervisor has based his decisions on his perceived role in the hierarchy, not because he lacks respect for their knowledge and ability. To work effectively with this supervisor, they may have to find more subtle ways of expressing their ideas, feelings or suggestions. Role relationships and “Face”: Hierarchical order is connected


In most hierarchical societies, men hold a lot of power.


For example, most Muslim societies are hierarchical, with men having a great deal of power over women and children. Men make the political, financial and healthcare decisions for the family, and in general, their authority is not often challenged. In Latino soci- eties, although men dominate decision making outside the home, women have authority to make decisions about family purchases and finances. However, health decisions are frequently joint family decisions that may involve not only husband and wife, but also the extended family and those related through cultural kinship. In egalitarian societies, everyone is supposed to be equal. Although not always achieved, equality is the ideal.14


Status and power often


depend on personal qualities, such as competence, leadership ability and expertise. A person may have status in one area, such as a job, but not in the home. The traditional Euro-American culture is organized around egalitarian principles. For example, both women and men


26 Visit us at NURSE.com • 2016


closely to role relationships. In some societies, roles are strictly defined. For example, in Asian cultures, the status connected to a particular role is respected greatly. People don’t directly question or disagree with someone of higher status, such as a physician or teacher. To do so is considered disrespectful, because it makes the person in authority lose face. Similarly, in many societies, people strictly adhere to gender roles. In some African societies, for example, men are considered superior to women, and it’s considered inappropriate for women to tell men what to do. Problems can occur when women supervise men from male-dominated societies, as is often the case in healthcare settings. Face has been defined as a projected image of one’s self in a relational situation.15


While a universal concept, the definition of


face varies greatly according to culture. Face involves the favorable sense of social self-worth and the estimated worth of others in a social situation.15


Included in this concept is self-face, or the concern


for one’s own image or reputation. Also included is the concept of other-face, which is the concern for the image of another, and mutual-face, or the concern for both parties’ images and/or rela- tionship. In collectivist cultures (African, Arab, Asian, Latin and southern European), the concept of face encompasses not only concern for the person, but also for his or her family, work unit and community.15


The concept of face for members of these cultures


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