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The challenges of diversity

April 1, 2011
Cultural competency indicates respect for a broad range of differences

Cultural competency indicates respect for a broad range of differences

by Mary Therese Keating-Biltucci, RDH, BS

When looked at in the simplest terms, the word diversity means to have different qualities. Cultural diversity is the recognition and appreciation of the characteristics that make us unique individuals. Authors such as Mark McKinney focus cultural diversity around race by stressing how we must make more progress toward the goal of a multicultural society by ensuring that the foundations of the Civil Rights Movement never be forgotten. He goes on to say that racism is alive and well in the U.S., and this influences the health-care industry today.1

Diversities are as old as man and originally varied by geographical location, but modern man has made travel from one continent to another so common that most continents have become melting pots. As a result, our differences are to the point that we must teach one another how to deal with our diversities in order to provide social cohesiveness. Diversity in the health-care workplace is not simply learning to deal with other races or recognizing what the Civil Rights Movement accomplished, but is about all races, cultures, personalities, ages, genders, and all other aspects that make us individuals.2

This review of the literature will look at the broad scope of diversity, and how this diversity can influence our understanding of patients and coworkers in the dental or health-care system. The categories of diversity this review will examine are the extensive perspectives of all our differences. These include personality, culture, gender, ethnicity, socioeconomics, age, education, geographic origin, and religious beliefs. In addition, this review can provide tools to recognize that because of our differences, reactions to events and situations can be barriers to effective communication in health care. 3

What is good about diversity?

In the U.S. today, African Americans are 12% of our population, Hispanics 15%, Asians or Pacific Islanders 4%, and Native Americans .8%.4 These population shifts describe the patients we treat as well as the people who deliver care, and they necessitate redefining the delivery of effective care. Realizing the changing demographics of our patient base helps us discover the challenges and opportunities of the health-care field. Equally important is that through recognizing and embracing our diversities, we can positively engage each other so that we meet the global challenges of multiculturalism today and for the future.5

The scope of health-care diversity

The theory or definition of diversity must be examined in order to appreciate the complexities of the concept. Many authors discuss their perception of diversity as demographic differences,6 culture,7 race, and ethnicity.8 Review of the literature in an attempt to define the scope of diversity by using the search criteria of "diversity," "culture," and "multiculturalism" provides a disparate and confusing picture. This review of the literature will provide a broad definition of diversity as it relates to all differences inherent in human beings in an attempt to understand the conflicts human beings face in health care and all facets of our society.

Lee Gardenswartz and Anita Rowe describe the dimensions of diversity as personality, internal dimensions, external dimensions, and organizational dimensions. These contain a framework for the role that our differences play in the health-care setting. The authors begin their discussion with the difference that is the most basic principle of diversity – our personality. Gardenswartz and Rowe use a diversity wheel (visit to view an example) as a visual organizer to show how all the dimensions of diversity come together and impact our lives every minute of every day.9

Personality is at the center of our differences and defines how we interact and how effectively we communicate with one another, which ultimately hinders or helps our relationships.

How we see ourselves is often much different from how others see us. We may feel that as providers and coworkers, we are approachable and open to discussing issues or concerns, but others may not see us that way. Author David A. Harrison refers to this aspect of diversity as consciousness. Many people are surprised at the differences in perception and the insights that can be gained from communicating about personalities.10

Internal dimensions

Outside the core of a personality are six internal dimensions of diversity that depict how we see ourselves, how we see others, and what our expectations are for ourselves and others. These internal dimensions are age, race, gender, sexual orientation, ethnicity, and physical ability. These are generally out of our control, but assumptions based on these internal dimensions can dramatically block effective communication.11

Age can be a significant difference, for instance, the patient who is a post-war baby boomer raised by parents from the Depression can be a striking contrast to the '80s-born Generation X health-care provider. Researcher David Harrison found that time lessened the effects of age in group dynmaics but not with initial interaction.12 When the young and the old meet by the patient bed, dental chair, interview table, or reception desk, they must recognize and allow for these differences in all communications.13

Negative expectations about gender roles also still exist in our society, but many gender differences should be celebrated. Women physicians statistically spend more time with their patients and communicate "horizontally," or through their peers, than others on their organizational team, while their male counterparts are "vertical" communicators, meaning they communicate up and down the organization chain of command. However, male physicians who are aggressive are perceived as take charge leaders, whereas women who exhibit the same qualities are viewed as arrogant and pushy.14

Ethnicity is a more unfamiliar concept of diversity that is often confused with race or skin color. Ethnicity is the native language and culture that defines one's heritage of daily norms, holiday observations, food preferences, language, and social or group affiliations. How we define or categorize ethnicity is difficult to answer or find agreement. Some people proudly announce their heritage as both from their country of origin as well as the country in which they currently reside, such as the African American or Irish American. Others define themselves only by their country of origin, such as the Cuban, Russian, or Canadian.15 In a study by Courtenay et al., they found that ethnic groups differed in their health beliefs and actions, so culturally appropriate health promotion and prevention is necessary.16 Subtle aspects of ethnicity can be much more difficult to identify. Eye contact as a facet of some cultures is seen as respectful, while other cultures view eye contact as unassertive or deceitful. Most people are unaware of these subtle cultural differences and may see their own views as better or even universal.17

Cultural guidelines become so deeply a part of us that we are often unaware we are operating under these rules. Culture refers to our beliefs, attitudes, practices, and goals we share with those from the same culture. Only when we are in conflict with others do we recognize that there are differences between us that force us to make comparisons. Our ethnocentricity, which is the collective pride of a group, may conclude in certain instances that our cultural norms are the right ones and others as wrong. When we recognize our reactions to situations as cultural interpretations, we can increase the knowledge and awareness of other cultures and amend our interpretations of them.18

Physical and mental disability was reported in 19.6% of males and 17.6% of females by the U.S. Census Bureau.19 A physical disability can be an obvious one such as paralysis or blindness, but many are not noticeable, such as hearing loss, learning disabilities, and mental illness. We are often uncomfortable around these patients and may find it easier to ignore their disability when in fact addressing it will help the patient and provider toward a more successful encounter. Physical disability also includes negative stereotypes about extreme body sizes. Researchers such as Paul Klaczynski found that some believe obesity is due to personality disorders.20 Health care specialists who treat patients for obesity were also found to have negative associations towards obese persons.21 Author Nicole Crossrow found in focus group research that obese people experienced weight-based stigmatization in most aspects of their lives.22 Obesity is now recognized as a disability and not a personality defect, so we can reevaluate how we deal with these patients.

Most heterosexuals express sexual orientation unconsciously, but persons of other orientations are not as free or comfortable doing the same. Assumptions and expectations about sexual orientation are widespread in our culture.23 Office staff, providers, and patients must receive the same quality of care and respect afforded to everyone.

Race or skin color is the first thing we notice about someone. How many of us work toward becoming "color blind" because we assume that this is a compliment to someone of another race?24 Author Philip Mazzocco's research shows that "color blind" thinking to de-emphasize differences actually masks disparities. Avoiding conversation, Mazzocco says, about the social theory of race does not make it go away; it just makes it more difficult to address.25 It is important to recognize that we can understand, appreciate, and value the differences of other races. Health-care providers must recognize the physical vulnerabilities and strengths of race as well as the inequalities in treatment. 26,27

External dimensions

The third layer of diversity that is outside our internal dimensions are the external influences of our life experiences, and the choices we make in our lives that influence our attitudes, situations, and opportunities. Because of these controls, external dimensions of religion, marital status, parental status, and appearance may cause others to make assumptions about us.28

In 1965, the Immigration and Naturalization Act brought people from all over the world into the United States for yet another wave of immigration that has become the backbone and definition of who we are as a country. Today the United States has become the most religiously diverse nation on earth with the traditions of Islamic, Hindu, Buddhist, Jain, Sikh, Zoroastrian, African, and Afro-Caribbean.29

In health-care centers, the level of education of employees is varied and can include anywhere from a GED to a PhD in a single department. These various levels can be intimidating to staff members who work alongside someone who may have much more or much less education than they do. Less educated patients may feel less able to articulate what they are experiencing, and as a result acquire less clarification about procedures or pain options.30

Marital status may seem an odd diversity concept, but in some cultures marital status is a significant determinant. Researchers Claire Etaugh and Joann Malstrom found married people to be rated as more secure, happier, and reliable than people who never married.31 Many employers also indicate that they are reluctant to hire single people because of a perceived lack of responsibility, commitment, work ethic, and dependability. Single people complain they are asked to work overtime, extra shifts, or weekends more often than their married counterparts. Norms of marital status may also have variations by ethnic groups, with single females as head of household in 44% of Puerto Rican households and 43% of African American households, while single Caucasian households are at 13%.32

Parental status is also an indicator for unequal treatment by employers. Staff members that are parents may be admonished for days missed due to a child's illness or frequent phone calls to day-care providers. Socioeconomic levels and single parent households dictate the need for parents of young children to work, but they also need consideration for behaviors related to childcare.33

Someone's appearance is a common influence on our opinions, even though we learn not to "judge a book by its cover." Tattoos and body piercing are common today, but how many of us would hire someone with multiple tattoos and piercings? Turbans, yarmulkes, headscarves, and facial veils can also be common sights in academic centers and health-care centers. Which of these sights are a turnoff and invoke an unconscious negative response? Our reactions to others who are considerably different in appearance may cause us to treat them less effectively than others.34,35

Geographic location of staff and patients is also significant, with country of origin and specific region of a city where people come from affecting behaviors and attitudes. Rural and urban inhabitants often view one another as subordinates and may practice stereotypical actions or beliefs.36

Organizational dimensions

The next layer of diversity in the health-care workplace is the specifics of the organization that can help or hinder staff teamwork and effectiveness. Every organization has a hierarchy that defines the reporting structure. This chain of command can have positive as well as negative effects on the staff. Rivalry often exists when people feel an "us against them" attitude. Seniority, management status, union affiliation, work location, and work content are all differences that can influence how well a workplace runs and the quality of patient care.37

Obtaining cultural competency

Many developmental models exist that promote or encourage intercultural competence. Health care that stresses teamwork and culturally sensitive care is working toward developing these necessary tools. Conceptual models of cultural competence have been developed that can be used by all health disciplines in order to function in an increasingly multicultural society.38

However, in order to obtain this proficiency, authors Stephanie Reich and Jennifer Reich argue that cultural competence is not uniformly defined. In addition, of particular importance is that cultural competence is a process and not an end statement, so no one can fully achieve cultural competence.39 The difficulty also lies with something Weber points out – that all social relationships are rooted in a power struggle. In our species in communal situations, persons in positions of authority will typically act in ways that produce sanctions, and control and promote some practices over others. Power determines decisions, definitions, values, and resources allocations of the people in an organization. Those who are in positions of power will need to keep in mind what the cultural differences are so that collaborations are productive.40

Acquiring cultural competence in a contemporary multicultural society may sound complicated, but it is simply respect for others who are different from us. However, this is not a quick solution because our human instincts are to be wary of others who are different. In addition to this barrier is the actual definition of diversity, which has different meanings to different people and social groups. The most common meaning is that the cultures from which we originate or the implied meaning of ethnicity and race defines our differences. The actual definition of culture is the shared beliefs and practices of groups of people, but we must also consider that we all belong to multiple cultural groups because of our multicultural societies.

Attaining cultural competency can be an overwhelming mission, but is necessary at every level of our society. Including diversity training as a required workplace topic or academic course may not be enough and may only serve to stigmatize this concept as a new phenomenon. Instead, if we celebrate what makes each of us different, we can then respect these qualities in the home, the school playground, our workplace, and our universities, where we need to emulate and practice these challenges every day.

Mary Therese Biltucci, RDH, BS, is the clinical research manager and craniofacial team dental coordinator in Eastman Institute for Oral Health at the University of Rochester in Rochester, N.Y. She can be contacted at [email protected].


1 McKinney MA. Healthcare Diversity. 2007. Baltimore; Publishamerica, LLLP, p34.

2 Gardenswartz L, Rowe A. Managing Diversity in Health Care. 1998. San Francisco, CA; Jossey-Bass, p. xvii-xxi.

3 Gardenswartz L, Rowe A. Managing Diversity in Health Care. p. xvii-xxi.

4 2008 American Community Survey 1-Year Estimates. United States Census Bureau. Retrieved 2009-12-08.

5 Gardenswartz L, Rowe A. Managing Diversity in Health Care. pp. 1-4.

6 Jackson SE, Stone VK, Alvarez EB. (1992). Socialization amidst diversity: The impact of demographics on work team old-timers and newcomers. In L. L. Cummings & B. M. Staw (Eds.), Research in organizational behavior, Vol. 15, pp. 45-109. Greenwich, CT: JAI.

7 Vega WA. Theoretical and pragmatic implications of cultural diversity for community research American Journal of Community Psychology Springer 20,3 pp375-391.

8 Fearon JD. (2003). Ethnic and cultural diversity by country*. Journal of Economic Growth, 8(2), 195-222.

9 Gardenswartz L. pp. 13-14.

10 Harrison DA, Price KH, Bell MP. (1998). Beyond relational demography: Time and the effects of surface-and deep-level diversity on work group cohesion. Academy of Management Journal, 41(1), 96-107.

11 Gardenswartz L. p. 16-17.

12 Harrison DA, Price KH, Bell MP. (1998) p.96.

13 Gardenswartz L. p. 17.

14 Gardenswartz L. p.18.

15 Fearon JD. (2003) p.197.

16 Courtenay WH, Mccreary DR, Merighi JR. (2002). Gender and ethnic differences in health beliefs and behaviors. Journal of Health Psychology, 7(3), 219.

17 Gardenswartz L. p. 20-22.

18 Stanfield JH. (1985). The ethnocentric basis of social science knowledge production. Review of Research in Education, , 387-415.

19 Waldrop J, Stern SM. (2003). Disability status, 2000 US Dept. of Commerce, Economics and Statistics Administration, US Census Bureau.

20 Klaczynski PA, Goold KW, Mudry JJ. Culture, Obesity Stereotypes, Self-Esteem and the "Thin Ideal": A Social Identity Perspective. Journal of Youth and Adolescence. August 2004; 33,4 p.1.

21 Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes Relat Metab Disord. 2001; 25(10): 1525-31.

22 Crossrow NHF, Jeffery RW, McGuire MT. Understanding Weight Stigmatization: A Focus Group Study. Journal of Nutrition Education. July-August 2001;33(4); 208-214.

23 Gardenswartz L. p. 22-23.

24 Gardenswartz L. p. 23-24.

25 Mazzocco PJ, Brock TC, Brock GJ, Olson KR, Banaji MR. The Cost of Being Black: White Americans' Perceptions and the Question of Reparations. Du Bois Review (2006), 3:2:261-297.

26 Cochran-Smith M. Color Blindness and Basket Making Are Not the Answers: Confronting the Dilemmas of Race, Culture, and Language Diversity in Teacher Education. American Educational Research Journal; 1995; Vol. 32, No. 3, 493-522.

27 Gardenswartz L. p. 23-24.

28 Gardenswartz L. p. 24.

29 Eck DL. (2001). A new religious america HarperCollins San Francisco, CA.

30 Gardenswartz L. p. 25.

31 Etaugh C, Malstrom J. The effect of marital status on person perception. Journal of Marriage and Family; (43);4 pp.801-805.

32 Aguirre-Molina M, Molina CW. (1990). Ethnic/racial populations and worksite health promotion. Occupational Medicine (Philadelphia, Pa.), 5(4), 789-806.

33 Gardenswartz L. p. 26-27.

34 Wernerson E, Sweden J. Valuing Diversity

35 Gardenswartz L. p. 27-29.

36 Gardenswartz L. p. 29-30.

37 Gardenswartz L. p. 30-34.

38 Purnell L. A description of the purnell model for cultural competence. Journal of Transcultural Nursing. January 2000, 11(1); pp 40-46.

39 Reich SM, Reich JA. Cultural competence in Interdisciplinary collaborations: A method for respecting diversity in research partnerships. Am J Community Psychol. 2006; 38; p 51-62.

40 Weber M. Definitions of Sociology and Social Action.

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