International Journal of Nursing Terminologies and Classificat.docx

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
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.
Maintaining 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
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
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.

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,
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
noncompliance or �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
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, and social 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.
Table 1. Nursing Care Plan for Culturally Diverse Patients
Definition Every 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 maintenance related 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 deficit related 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 barriers commodate 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 nutrition related 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 coping related 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 is knowledge 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-

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 nutrition can 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-
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
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:
[email protected]
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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]

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