aRTICLE REVIEW

International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 17 Susan Walsh, MSN, RNC PURPOSE . To formulate a plan of care for a culturally diverse population and develop a resource for the healthcare team in providing culturally competent care. DATA SOURCES . Books, journal articles. DATA SYNTHESIS . Healthcare workers are challenged to provide appropriate care for an increasingly diverse population. A cluster of nursing diagnoses were used to develop a plan of care addressing the unique challenges of caring for a diverse population served by a community hospital. CONCLUSION . A care plan was devised and inserted into the nursing diagnosis–based nursing documentation computer system for easy access when needed. PRACTICE IMPLICATIONS . A care plan for a diverse population can promote respectful and excellent care for every patient. Search terms: Care plans, cultural competence, diversity, nursing diagnosis Elaboration d’un plan de soin pour des patients de cultures différentes BUT . Elaborer un plan de soin pour une population de culture différente et développer une ressource pour l’équipe de santé, qui doit dispenser des soins culturels compétents. SOURCES DE DONNÉES . Manuels, articles de revues. SYNTHÈSE DES DONNÉES .Dispenser des soins appropriés à une population de cultures variées représente un défi pour les soignants. Un groupe de diagnostics infirmiers fut utilisé pour élaborer un plan de soin destiné à une population multiculturelle, fréquentant un hôpital communautaire. CONCLUSIONS . Un plan de soin fut élaboré et inclus dans le système de soin informatisé, basé sur les diagnostics infirmiers afin d’en faciliter l’accès aux soignants. IMPLICATIONS POUR LA PRATIQUE .Un plan de soin destiné à une population multiculturelle peut promouvoir des soins empreints de respect et d’excellence pour tous les patients. Mots-clés: Compétence culturelle, diversité culturelle, diagnostics infirmiers, plan de soin Formulation of a Plan of Care for Culturally Diverse Patients Translation by Cécile Boisvert, MSN, RN 18 International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 Formulation of a Plan of Care for Culturally Diverse Patients Elaboração de um plano de cuidados para pacientes culturalmente diversos OBJETIVO . Formular um plano de cuidados para uma população culturalmente diversa e desenvolver um recurso para a equipe de saúde oferecer um cuidado culturalmente competente. FONTE DE DADOS . Livros, artigos em periódicos. SÍNTESE DOS DADOS . Trabalhadores da saúde têm o desafio de oferecer uma assistência apropriada para uma população cada vez mais diversificada. Um agrupamento de diagnósticos de enfermagem foi utilizado para desenvolver um plano de cuidados abordando os desafios únicos de assistir uma população diversificada, servida por um hospital comunitário. CONCLUSÃO . Um plano de cuidados foi criado e inserido no sistema informatizado de docu- mentação de enfermagem fundamentado em diagnósticos de enfermagem, para fácil acesso sempre que necessário. IMPLICAÇÕES PARA A PRÁTICA .Um plano de cuidados para uma população diversificada pode promover uma assistência respeitosa e excelente para cada paciente. Palavras para busca: Competência cultural, diversidade, diagnóstico de enfermagem, planos de cuidados Translation by Shigemi Kamitsuru, PhD, RN Translation by Jeanne Michel, PhD, RN, and Alba de Barros, PhD, RN International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 19 Formulación de un plan de cuidados para pacientes de diversas culturas PROPÓSITO . Formular un plan de cuidados para una población culturalmente diversa y desarrollar recursos para que el equipo de cuidados de salud proporcione cuidados culturalmente competentes. FUENTES DE DATOS .Libros, artículos. SÍNTESIS DE LOS DATOS .Los trabajadores sanitarios se enfrentan al reto de proporcionar cuidados apropiados a una población que cada vez es más diversa. Se ha utilizado un grupo de diagnósticos de enfermería, para desarrollar un plan de cuidados dirigido al desafío de cuidar a una población culturalmente diversa que es atendida en un medio hospitalario. CONCLUSIONES . Se desarrolló un plan de cuidados basado en los diagnósticos de enfermería, para facilitar el acceso cuando fuera necesario y se insertó en un sistema informático, para documentar la atención enfermera. IMPLICACIONES PARA LA PRÁCTICA .Un plan de cuidados para una población culturalmente diversa, puede promocionar cuidados excelentes y respetuosos para cada paciente. Términos de búsqueda: Competencia cultural, diversidad, diagnósticos de enfermería, planes de cuidados Susan Walsh, MSN, RNC, is a staff nurse in the neonatal intensive care unit at Saint Elizabeth Regional Medical Center in Lincoln, NE.

M aintaining proficiency and competency in provid- ing health care to patients and their families has become more and more challenging. The ethnic population within the continental United States has increased, and the needs of these diverse groups are unique and unfa- miliar to many healthcare workers. According to the U.S.

Census Bureau, the number of foreign-born residents in the United States increased from 19.8 million to slightly more than 28 million between 1990 and 2000. And by the year 2050, whites will account for less than half the pop- ulation (Griffin, 2002).

In order to improve care for a wider range of diverse patient populations, a community hospital in the central United States expanded its definition of cultural diver- sity to include religion, physical or mental challenges, and nontraditional family units as well as ethnicity. The population of individuals with physical and mental chal- lenges has increased as well. Recent estimates are that 19.7% of the U.S. population has some level of disability and that 12.3% of the population has a severe disability, indicating a large population with diverse healthcare needs (U.S. Department of Commerce [USDC], 2001).

Often these healthcare needs contribute to differences in communication ability as well as different perceptions of health and illness. Healthcare workers care for patients and their significant others from nontraditional families on a daily basis. In 1990, there were more than 7 million single-parent families in the United States, as well as 3.9 million or 5.5% of American children living with a grandparent (USDC). With the increase of diversity of languages spoken, definitions of the family unit, and healthcare practices, it is easy for healthcare facilities to become overwhelmed with developing appropriate re- sources and care plans for meeting the challenge. This ar- ticle discusses the formulation of a care plan to assist healthcare providers in meeting the needs of a diverse population. Translation by Mercedes Ugalde, MHS, RN 20 International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 Providing culturally competent care is assessed using direct observation of care, testing, and monitoring of patient/associate satisfaction surveys, and personal encounters.

The Office of Civil Rights within the USDHHS has ad- ditional policies (2001a). Title VI, the Civil Rights Act, prohibits discrimination toward individuals with limited English proficiency (LEP). This act not only addresses appropriate interpreter services and regulations but also provides for equal access to federally assisted programs.

Interpretation of this act, by the Office of Civil Rights, states that the “key to providing meaningful access for LEP persons is to ensure that the recipient/covered en- tity and LEP person can communicate effectively” (p. 8).

Staff members need training so that they understand the organization’s policy on provision of interpretation ser- vices and are able to implement it effectively.

The Magnet Nursing Services Recognition Program for Excellence in Nursing Services of the American Nurses Credentialing Center (ANCC) awards “magnet status” to hospitals that display major attributes of excel- lence (McClure & Hinshaw, 2002). One of these major at- tributes is “attention to patient, family, and staff cultural and ethnic diversity” (Gasda, 2002, p. 45). Magnet appli- cation requirements include Standard XI: Ethics Mea- surement Criterion 11.4, which addresses “fostering a nondiscriminatory climate in which care is delivered in a manner that is culturally sensitive and that is reflective of the cultural diversity that exists within the organization” (ANCC, 2003 – 2004, p. 115). Sources of evidence of com- pliance to this standard include assessment of the diver- sity of the patients cared for within the healthcare organi- zation, culturally sensitive policies affecting patients and staff, as well as cultural education programs for staff.

A recent report published by the National Academy of Sciences (2002) addressed racial and ethnic disparities.

The Academy concluded that, based on an increasingly diverse U.S. population, the initiation of training pro- grams for healthcare associates was a promising inter- vention strategy to reduce healthcare disparities. Diver- sity educational programs that begin with enhancement of healthcare associates’ awareness of cultural and social Formulation of a Plan of Care for Culturally Diverse Patients Literature Review Requirements of Accrediting Agencies and Government Guidelines Several accrediting agencies advocate for more cultur- ally sensitive workplaces. The Joint Commission on Ac- creditation of Health Care Organizations (JCAHO, 2003) addresses ethical issues related to providing care in its “Standard and Intent Statements for Patient Rights.” The Patient Rights and Organizational Ethics Standard 1 di- rects hospital structure be based upon “the patient’s right to care that is considerate and respectful of his or her personal values and beliefs” (p. 77). The Education Stan- dards state that the goals of effective patient and family education are to be integrated with the patients’ spiri- tual, psychosocial, and cultural values. Further elabora- tion of this concept can be found in the Education Stan- dards: “[D]esigning education processes includes . . . the physical, cognitive, cultural, social, and economic charac- teristics of the patients being taught” and “The hospital selects and makes available educational resources, in a form the patient can understand, based on patient learn- ing needs” (pp. 156 – 157). Various teaching methods and resources including interpretative services, special de- vices, videotapes, and other teaching materials are listed as potential necessary educational aids.

The Office of Minority Health within the U.S. Depart- ment of Health and Human Services (USDHHS) has set national Culturally and Linguistically Appropriate Ser- vices (CLAS) standards for linguistically appropriate and culturally sensitive healthcare services (USDHHS, 2001b). Standard 1 directs healthcare organizations to provide patients and consumers with “effective, under- standable, and respectful care that is provided in a man- ner compatible with their healthcare beliefs and practices and preferred language” (p. 7). Standard 3 articulates the expectation that healthcare organizations provide staff at all levels with ongoing education and training in cultur- ally appropriate service delivery. Methods of implement- ing these standards include providing appropriate cul- tural education and training and assessment of skills. International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 21 and mental and physical characteristics, but also com- munication skills, educational background, religion, pri- mary language, work experience, income level, geo- graphic locale, experience in the military, and family status.

Dreher and MacNaughton (2002) agreed with previ- ous definitions of cultural competency in nursing, but defined two major areas of competency. The first was structure and content related to clinical interaction be- tween the patient and nurse. The second focus required the nurse to become knowledgeable about patients’ lifestyles, behaviors, and health patterns and apply this knowledge to providing care. The authors further cau- tioned the healthcare provider about making assump- tions and generalizations that individuals from the same cultural group are all the same. Ford (2003), a nationally recognized speaker on cultural diversity, supported this belief and encouraged healthcare providers to simply ask their patients about their specific cultural needs. The clinical nurse needs to have a strong background con- cerning cultural norms, but needs to personalize and in- dividualize care for the patient and family. The Mayo Clinic in Rochester, MN, articulates a nursing philosophy that “meeting patient needs comes first and this means providing culturally competent care to all patients” (Leinonen & Smith, 2002, p. 260).

Nursing Diagnosis Nursing diagnoses, particularly the NANDA (2001) taxonomy, have been accused of being insensitive with regard to cultural considerations. Leininger criticized the NANDA classifications because they are not based on any international or transcultural data (Carpenito- Moyet, 2002). Leininger (1990) also believes that many diseases and illnesses are directly related to specific cul- tures that need to be understood by nurses. These dis- eases and illnesses formulate different expressions of health care, wellness, and illness. Leininger further be- lieves that experts or individuals from that culture should construct culturally specific nursing diagnoses based on that culture. factors that influence healthcare, as well as implementa- tion methods to apply information, are also valuable ways to decrease this disparity.

Cultural Competence Cultural competence has been discussed extensively in the nursing literature. In order to formulate either a diver- sity diagnosis or a nursing care plan, cultural competence needed to be defined. Leininger (1999) stated that cultur- ally competent care is using knowledge that has been learned about a specific culture and applying it in sensi- tive, creative, and meaningful ways when providing care to individuals from diverse backgrounds. The goal is to deliver culturally competent care to patients and their families, in other words, excellent nursing care in the con- text of the patient’s cultural and or religious beliefs.

Alexander (2002) defined cultural competence as “a set of congruent behaviors, attitudes and polices that come together in a system, agency, or among profession- als and enables that system, agency, or those profession- als to work effectively in cross-cultural situations” (p. 30).

Alexander stated that one cannot manage diversity with- out valuing diversity. Employees at every level within a healthcare organization, regardless of age, sexual orienta- tion, race, ethnic background, or religion, have the pri- mary goal to care for patients and their needs. This ne- cessitates cultural competence education for employees at every level within the organization.

Burchum (2002) described cultural competence as an ongoing developmental process that is based on in- creased knowledge and skills specific to cultural sensitiv- ity, understanding, interaction, and awareness. For nurses providing competence in cultural care, it means that care is individualized and appropriate in regard to the patient’s cultural values, beliefs, and practices. Pa- tients are empowered by providers’ commitment to de- veloping cultural competence. Frusti, Niesen, and Cam- pion (2003) stated that diversity competence is “an individual’s ability to respect each person’s uniqueness” (p. 31). They believe that diversity not only includes sex- ual orientation, age, gender, ethnic backgrounds, race, 22 International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 Plan of Care Saint Elizabeth Regional Medical Center recognized the need to provide a structured resource for nurses car- ing for the growing number of diverse patients. An ex- tensive literature review focused on diversity, culture, and cultural competency. Development of a care plan that contained a cluster of pertinent nursing diagnoses for culturally diverse patients evolved as the best option (Table 1). Relevant nursing diagnoses were identified, and expected outcomes and nursing interventions de- fined for each nursing diagnosis. This structured re- source/care plan became a positive and proactive re- sponse to the needs of the diverse patient population. By developing such care plans, we sought to avoid the neg- ative stereotypes such as use of nursing diagnoses of noncomplianceor “nonadherence” that may be a result of cultural barriers to understanding or acceptance.

The facility for which this care plan was designed elected to include not only diversity of culture but also religion, physical, or mental challenges and nontradi- tional family units. The cultural diversity care plan be- came an adjunct to the general admission care plan for all patients. This care plan addresses the unique chal- lenges in caring for a diverse population and serves as a resource for the healthcare team in providing culturally competent care. Following the nursing process and using the NANDA diagnoses, this care plan was easily incor- porated into the hospital’s clinical documentation sys- tem. The care plan is prefaced with the premise that every patient evidences some level of cultural and reli- gious diversity, but when the level of diversity hampers health promotion and disease recovery, special strategies need to be implemented (Lipson, Dibble, & Minarik, 2000; NANDA, 2001; Sparks & Taylor, 2001).

The first nursing diagnosis identified on the care plan is impaired verbal communication.This diagnosis encom- passes not only inability to speak, but also hearing deficits and difficulty in expressing thoughts. Interven- tions include interpreter services, alternative communi- cation methods, providing health information resources in the familiar language, and recognition of importance Formulation of a Plan of Care for Culturally Diverse Patients Carpenito-Moyet (2002) pointed out that a nursing di- agnosis cannot be a judgment that nurses make with re- gard to their client and family’s responses to illness based on the nurse’s own values, responses, or cultural perspec- tive. Errors in nursing diagnosis, however, can occur if the nurse is unfamiliar with a specific culture and their beliefs.

This presents two major challenges to the nurse. One is that the nurse needs to be familiar with numerous cul- tures, beliefs, practices, and responses to illness, wellness, and stress. The greater challenge is to avoid cultural stereotypes and be open-minded and nonjudgmental in identifying and implementing nursing diagnoses and care plans. Every patient has personal values, perspectives, and interpretations of wellness and disease. Lack of familiarity with the diverse patient’s unique customs may create bar- riers to provision of respectful and excellent care.

Culture can be present in all domains of life, and this poses an additional complication to developing a care plan specific to diversity (Tripp-Reimer, Brink, & Pinkham, 1999). Any nursing diagnosis that deals with behavior has the potential to have a cultural cause and need. A number of nursing diagnoses can be directly linked to differences in cultural values. Primary exam- ples are nursing diagnoses such as ineffective coping, non- compliance, knowledge deficit, impaired verbal communica- tion, altered parenting, anxiety, andsocial isolation.

Removing the consideration of diversity from any of these nursing diagnoses opens the possibility of missing the influence of diversity issues on the diagnosis and ul- timately successful intervention strategies.

The option of using alternative nursing interventions or outcome classification systems was explored by a group of professional nurses within the organization as part of the care planning process. The Nursing Interven- tions Classification (NIC) and Nursing Outcomes Classi- fication (NOC) presented similar dilemmas when at- tempting development of a specific diversity diagnosis (McCloskey & Bulechek, 2000; Tripp-Reimer et al., 1999).

Using either the NIC or NOC classification systems pre- sented an additional conflict for our facility in that our clinical documentation system was formatted on nurs- ing diagnoses alone. International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 23 Table 1. Nursing Care Plan for Culturally Diverse Patients DefinitionEvery patient evidences cultural and religious diversity. However, when the level of diversity hampers health promotion and disease recovery, altering strategies need to be implemented.

Clinical Problem/Nursing Diagnosis Expected Outcome Nursing Intervention Impaired verbal communication related to ■Patient will communicate needs ■Assess need for interpreter. ■Inability to speak dominant language and ability to understand ■Assist in intervention with alternative commu- ■Hearing deficit instructions effectively. nication methods such as sign language, inter-■Difficulty in expressing thought ■Patient is satisfied with staff ’s preter services, and hearing enhancement de- verbally or recognition of differences. vices. ■Inability to speak ■Use health-information resources in patient’s familiar language if possible.

■Recognize importance of variations in personal space, nonverbal communication, and touch for specific individuals.

■Use resources to enhance communications with the verbally impaired.

Ineffective health maintenancerelated to ■Evidence and behavior of ■Determine discrepancy factors between pa- ■Cultural patterns nonsupportive of improving health measures. tient’s health needs and religious and cultural wellness patterns.

■History of non-health-seeking behaviors ■Provide support and logic for necessary change in health practices: contact religious or cultural leaders as needed.

■Supply resource information that is specific and sensitive to patient’s heritage.

Knowledge deficitrelated to ■Patient will demonstrate specific ■Select teaching strategies that are best suited for ■Lack of familiarity with information knowledge application. the patient’s learning needs and heritage.

resources ■Utilize resources/interpreter services that ac- ■Communication barrierscommodate the patient and family appropriately.■Cultural and religious practices that are ■Have patient/family give return verbalization incongruent with wellness and/or demonstration of newly learned skills.

■Emphasize importance of new knowledge to disease recovery and health promotion.

■Acknowledge efforts.■Provide resources and support for maintaining new healthcare knowledge and practice in community setting.

Imbalanced nutritionrelated to ■Patient is satisfied with nutritional ■Assess and acknowledge specific dietary requests. ■Specific cultural and religious patterns choices and culturally sensitive ■Refer to nutritionist as needed.

and restrictions information.■Integrate specific cultural requests with healthy ■Unavailability of usual preference of ■Patient weight is within normal diet and health improvement.

food because of hospital setting limits within necessary time ■Provide diet choices based on religious rules ■Conflict with specific disease/diet/ frame. and cultural preferences. (Consult Culture and health improvement and cultural and ■Patient’s lab work is within normal Nursing Care: A Pocket Guide[Lipson, Dibble, & religious restrictions limits within necessary time Minarik, 2000] regarding hot/cold balance, frame. fasting, and typical foods.) Compromised family copingrelated to ■Family will increase participation ■Assess effects that illness has had on the family. ■Lack of familiar ethnic and religious in patient’s care. ■Integrate typical culture-specific family com- resources in the healthcare setting, ■Patient/family will indicate munication patterns. ■Nontraditional family units verbally or behaviorally better ■Encourage family participation in health care ■Lack of privacy understanding and acceptance. for the patient.■Specific religious or cultural beliefs ■Incorporate religious and cultural requests ■Disease severity whenever possible.■Role disparity brought on by communi- ■Be sensitive to unique cultural family patterns.

cation deficits or disease■Encourage support system for family.

■Use specific resources within hospital (e.g.. pas- toral care, social services, case managers) and within community (Asian Community Center, Faces of Middle East, Catholic Social Services, Lincoln Action Program). This plan of care may be reproduced for noncommercial purposes without permission from the author. of personal space, nonverbal communication, and touch for specific individuals (Andrews, Boyle, & Carr, 2003; Cox et. al., 2002; Joyce & Villanueva, 2000; Lipson et al., 2000). A specific clinical example might be not only hav- ing a competent interpreter for a Hispanic couple with an infant in the neonatal intensive care unit, but also posting at the infant’s bedside in Spanish milestone weight gains according to age. Additional resources in Spanish that review the infant’s care and treatment plan should be available to reinforce and enhance communi- cation for these parents.

The next nursing diagnosis, ineffective health mainte- nance,includes cultural patterns that may not be sup- portive of wellness and a history of poor health-seeking behaviors. Interventions include determining discrepan- cies between the patient’s health needs and religious and cultural patterns. Additional interventions include provi- sion of support and logic necessary for change of behav- iors and supplying resource information specific to the patient’s heritage (Andrews et al., 2003; NANDA, 2001; Tucker, Canobbio, Paquette, & Wells, 2000). An example of discrepancy in health-seeking behaviors was seen in a Vietnamese family who brought their toddler to the emergency department with a persistent high fever. The child had numerous bruises. The healthcare worker de- termined that the parents had been using coin rubbing (cao gio) as a home remedy to treat the child’s fever. A culturally competent provider would be sensitive to this practice, but would provide support and explain the logic behind a healthcare regimen that may include an- tibiotics, lab screening, and earlier access to health care (Davis, 2000; Lipson et al., 2000).

The third nursing diagnosis isknowledge deficit.Lack of familiarity with informational resources, communica- tion barriers, and cultural and religious practices that are incongruent with wellness are all related to having a deficit in knowledge. Nursing interventions must be cen- tered on provision of teaching strategies best suited to the patient’s learning needs and heritage. Use of re- sources and teaching tactics that accommodate patients and their families appropriately, provision of resources, and support for maintenance of new healthcare knowl- 24 International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 edge and practice in the community setting (Carpenito- Moyet, 2002; Lipson et al., 2000; NANDA, 2001) are in- corporated into the care plan. An example of interven- tions to address this nursing diagnosis would be including the mother, sister, and mother-in-law in active participation and support for an Arab-American woman who is in labor. Since in this tradition fathers do not par- ticipate in the birth process, teaching strategies and com- fort measures need to be directed at those who can sup- port the patient in labor. Healthcare providers must realize that lack of participation by a Arab-American fa- ther in the birth process does not constitute neglect or lack of interest. If no female family members are avail- able, Arab-American women may require the encour- agement and support of alternative individuals, and nurses must provide education for the support system that is present (Kridli, 2002; Lipson et al., 2000).

Imbalanced nutritioncan be the result of specific cul- tural and religious patterns and restrictions, but also of unavailability of usual food preferences during hospital- ization. Food preferences may be in conflict with a spe- cific disease, diet or health improvement needs, and cul- tural or religious restrictions. Referral to a culturally sensitive nutritionist is an important component and re- source for the intervention for this diagnosis. Additional interventions include integration of specific cultural re- quests into a healthy dietary plan, as well as health im- provement and diet choices based on religious rules and cultural preferences (Andrews et al., 2003; Lipson et al., 2000; NANDA, 2001). The following example demon- strates how specific cultural patterns can be integrated into a specific disease care regimen. A middle-age male of Middle-Eastern descent who practiced traditional eth- nic patterns presented to the clinic with newly diagnosed diabetes. The healthcare provider in conjunction with a dietician integrated insulin and blood sugar monitoring around the patient’s traditional meal pattern of having the largest meal around 2 P.M. (Lipson et al., 2000).

Compromised family coping is the final nursing diagno- sis in the care plan. This diagnosis is related to lack of fa- miliar ethnic and religious resources in the healthcare setting, nontraditional family units, lack of privacy, spe- Formulation of a Plan of Care for Culturally Diverse Patients cific religious or cultural beliefs, disease severity, and role disparity brought on by communication deficits or dis- ease. Nursing interventions include assessment and inte- gration of the illness beliefs and the specific family cul- tural patterns. Religious and culturally related requests are implemented whenever possible. Encouragement and sensitivity to family values are emphasized. Use of “within the walls” as well as community resources are identified (Andrews et al., 2003; Cox et al., 1995; Lipson et al., 2000; NANDA, 2001).

There are numerous opportunities for incorporating re- ligious and cultural requests within the healthcare setting.

A Native American family’s wish to see their terminally ill, ventilator-dependent infant on a traditional papoose board with a large family tribal ceremony demonstrated a unique challenge. Culturally sensitive healthcare workers working with neonatologists, primary nursing staff, respi- ratory therapists, and family members enabled the family to safely position the infant on a papoose board and trans- port the infant to an area where all tribal members could be present for the ceremony. Nursing interventions may include sensitivity to unique cultural family patterns. For example, grandparents who are assuming the role of par- ents may need additional updated health information on child care and support for their expanded role. Single par- ents may need additional resources for accessing respite care options. Family units that have a family member physically unavailable (e.g., deployed overseas, incarcer- ated) may need innovative nursing interventions. Digital cameras, e-mail, Red Cross communications, and support groups may need to be used.

Additional Practice Implications This nursing care plan has been integrated into the general admission care plans for all patients at our facil- ity. It is available online via Intranet resource manuals at all times for easy access and referral. The intent is that this plan of care will guide healthcare workers in target- ing the needs and resources for any patient with diver- sity. The ultimate goal is to promote respect and provide excellent patient care for every individual, including International Journal of Nursing Terminologies and Classifications Volume 15, No. 1, January-March, 2004 25 those with unique diversities. Compliance with govern- ment guidelines is evidenced within the clinical docu- mentation system that integrates care plans and nursing documentation. This care plan also provides a prompt for referral to multidisciplinary team members to orga- nize their care and prioritize resources for these patients.

Conclusion Expanding the definition of culture to include diver- sity of culture, plus religion, physical, or mental chal- lenges and nontraditional family units allowed us to im- prove care for the increasing number of patients with diversity. This care plan focuses on the uniqueness and positive opportunities and challenges of working with diverse populations.

Author contact: [email protected], with a copy to the Editor:

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U.S. Department of Commerce, Economics and Statistics Administra- tion. (2001). Bureau of the census: Americans with disabilities, single-par- ent families and co-resident grandparents.Retrieved June 16, 2003, from http://landview.census.gov/population U.S. Department of Health and Human Services. (2001a). Office of Civil Rights Policy Guidance Title VI prohibition against national origin dis- crimination as it affects persons with limited English proficiency.Re- trieved February 5, 2003, from www.hhs.gov/ocr/lep/guide.html U.S. Department of Health and Human Services. (2001b). Office of Minority Health National Standards for culturally and linguistically appropriate services in health care [OPHS Publication No. 8069]. Washington, DC: Author. NEW NANDA’s Electronic Database & Classification 2003–2004 • A relationship database in 5 digit, numeric format • Contains all 167 diagnoses, their definitions, defining characteristics, and related factors For prices and information, contact NANDA International 800.647.9002 [email protected]