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 Praise for
Cultural Sensibility in Healthcare
“Using the concept of cultural sensibility, Sally Ellis Fletcher provides readers with
a range of challenging but accessible activities to help them explore their own
histories and how their unique culture influences their healthcare provision.
Although written for nurses, this book will be invaluable to anyone who wants to
understand their perspectives better so that they can deliver excellent care to all
patients through mutual understanding, openness, respect, and constructive
dialogue.”

–Nisha Dogra, PhD, BM, FRPsych

Professor in Psychiatry Education and Honorary
Consultant in Child and Adolescent Psychiatry
Director of MSc in Child and Adolescent Mental Health,
University of Leicester

“Sally Ellis Fletcher does an outstanding job outlining the essentials for a deeper
understanding of cultural diversity, inclusivity, and culturally appropriate
healthcare. Her sincere approach encourages her audience to think more clearly
about the impact of cultural competency—recognizing biases, prejudices, and
stereotypes—as it relates to nurses. The discussion questions at the end of each
chapter provoke thought and emotion. Cultural Sensibility in Healthcare is a must-
read for all patient-centered care providers!”

–Bob Patterson, MSN, RN

President, American Assembly for Men in Nursing
Administrative Director, California Institute for Nursing and Health Care
Doctoral Student, University of San Francisco

“Cultural Sensibility in Healthcare is the first workbook I’ve found compelling and
personally useful in my lifetime. The central construct of ‘cultural sensibility’ goes
beyond the traditional cultural group approach by offering a culturally based
framework for individualizing healthcare. The author’s interactive, conversational
style, linked with well-thought-out exercises, engages the reader’s critical and
reflective thinking about cultural sensibility. Although focused on patient
[consumer]-provider relationships, the content is equally applicable to healthcare
worker/interprofessional relationships.”
 –Madeline H. Schmitt, PhD, RN, FAAN, FNAP
Professor Emerita
University of Rochester School of Nursing

“Cultural Sensibility in Healthcare is a welcomed tool for engaging pre-licensed

nursing students and other health professionals in the process of becoming more
open in achieving complete and quality care for all patients and clients. For
emerging professionals, starting with an awareness of their own beliefs and
attitude toward health and illness is essential for growing toward ‘cultural
sensibility.’ The scenarios, discussion questions, and guided self-reflective activities
are innovative, educational, and engaging.”

–Patricia Coleman, PhD

Special Advisor to the Dean on Multicultural Affairs
Assistant Professor
Faculty Lead, Second Career Program
University of Michigan School of Nursing, Ann Arbor
 CULTURAL SENSIBILITY
IN HEALTHCARE
A Personal & Professional Guidebook

Sally N. Ellis Fletcher, PhD, RN, FNAP

Copyright © 2015 by Sigma Theta Tau International
All rights reserved. This book is protected by copyright. No part of it may be
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The Honor Society of Nursing, Sigma Theta Tau International (STTI) is a
nonprofit organization founded in 1922 whose mission is advancing world
health and celebrating nursing excellence in scholarship, leadership, and
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ISBN: 9781937554958
EPUB ISBN: 9781937554965
PDF ISBN: 9781937554972
MOBI ISBN: 9781937554989
 Library of Congress Cataloging-in-Publication Data
Fletcher, Sally N. Ellis, 1954- author.
Cultural sensibility in healthcare : a personal & professional guidebook / Sally N.
Ellis Fletcher.
p. ; cm.
ISBN 978-1-937554-95-8 (print : alk. paper) -- ISBN 978-1-937554-96-5 (epub) -
- ISBN 978-1-937554-97-2 (pdf) -- ISBN 978-1-937554-98-9 (mobi)
I. Title.
[DNLM: 1. Cultural Diversity. 2. Attitude of Health Personnel. 3. Cultural
Competency. 4. Delivery of Health Care. WA 31]
RA427.8
362.1--dc23
2015014983

First Printing, 2015

PUBLISHER: Dustin Sullivan PRINCIPAL BOOK EDITOR: Carla Hall
ACQUISITIONS EDITOR: Emily DEVELOPMENT EDITOR: Tonya
Hatch Maddox Cupp
EDITORIAL COORDINATOR: Paula COPY EDITOR: Keith Cline
Jeffers
COVER DESIGNER: Rebecca PROOFREADER: Todd Lothery
Batchelor
COVER ILLUSTRATOR: Justine INDEXER: Jane Palmer
Beckett
INTERIOR DESIGN: Rebecca
Batchelor
Dedication
This guidebook is dedicated to my amazing family and friends, who supported me
in this project. Throughout my career, many persons have honored me by sharing
their experiences related to cultural diversity and inclusivity. My heartfelt respect
and appreciation are extended to each of you.
Acknowledgments
Special acknowledgment is given to Patricia Chiverton, EdD, RN, FNAP; Mary-
Therese Behar Dombeck, PhD, DMin, APRN; Sheldon D. Fields, PhD, ARNP, FNP-
BC, AACRN, DPNAP, FAANP; and Jeanne Tuel Grace, PhD, RN, WHNP.
About the Author
Sally N. Ellis Fletcher, PhD, RN, FNAP, is licensed to practice nursing in the
states of Kansas, Missouri, and New York. She has taught or served in a clinical
capacity in private, public, urban, and rural organizations. Her professional
passions are nursing, education, diversity, multiculturalism, entrepreneur-ship,
mentoring, and humanitarianism. She has served on the advisory board for a
humanitarian mission trip to Ghana, West Africa, for which she planned and
facilitated indigenous and U.S. healthcare providers in delivering healthcare. She is
on the board of a local shelter for women and their children who’ve experienced
domestic violence. During her most recent academic tenure, Ellis Fletcher created
and designed a program to assist students enrolled in the accelerated education
track with socialization, career planning, and cultural inclusiveness in nursing. She
also served as co-chair of the Dean’s Advisory Council for Cultural Diversity and
Inclusiveness and as one of the School of Nursing’s faculty diversity officers. Her
most recent clinical position was as a clinical nurse researcher who developed the
office of Clinical Nurse Research at a Midwestern medical center.
Table of Contents
About the Author
Foreword
Introduction

1 Cultural Sensibility: Personal and

Professional
Seeing the World From Our Own Perspective
Becoming a Healthcare Provider: A Timeline of Influences
Keeping Control of Distractors
Categorical Knowledge Limitations
Cultural Sensibility Benefits
Summary
References

2 Common Ground: Terms and Definitions

Teenage Communication
Fumble: Trying to Score a Communication Touchdown
Definitions
Power Differential: The Power of Healthcare Providers
Summary
References

3 Lessening the Impact of Cultural Clashes

Healthcare: A Fertile Environment for Cultural Clashes
Scenarios
 Cultural Clashes
Avoiding Cultural Clashes
Culturally Appropriate and Sensitive Healthcare
Summary
References

4 Healthcare Disparities: They Affect Us All

Social Determinants of Health
The Economic Determinant
Healthcare Provider Power
Summary
References

5 Bracketing, Critical Thinking, and

Reflection-in-Action
Biases, Prejudices, and Stereotypes
Bracketing
Critical Thinking
Reflection-in-Action
Combining the Processes: Critical Thinking and Reflection-in-
Action
Summary
References

6 Yes, We’re Alike, But the Differences

Matter
1% or 0.1%: Small Difference, Huge Impact
Newsflash: Men and Women Differ, Too
Summary
 References

7 Epilogue
Cultural Sensibility: Getting There
The Elephant in the Room
But You’re Pretty!
It’s Dr. Larson to You
References

Index
Foreword
History and circumstances are asking all of us to examine vestiges of
the past that continue to plague us today and, at the same time,
embrace deeper insights of respectfully being with each other. As we
craft impactful responses to the requests, tremendous
understanding, a willingness to be vulnerable, and a honing of our
due diligence skills will be necessary. This timely book adds further
to what we know works and escorts new perspectives and
considerations since bias, prejudice, discrimination, and micro and
macro aggressions continue to be evident in the caregiving and
therapeutic processes.

Moving beyond the rhetoric requires well-defined goals and

methodologies for achieving them. Not only do we need to stretch
the minds of students and faculty about diversity, we also need to
talk about the manifestations of inclusive excellence. Broader than
just race, gender, or ethnicity, diversity includes cultural differences
such as age, generational differences, socioeconomic status, sexual
orientation, religion, body alterations (i.e., tattoos, piercings), body
size, disability, marital status, veteran status, professional
experience, and educational background. The intersections of all
these differences can and often do—in both bold and subtle ways,
wearing the bright garments of uniqueness—remind us that all
encounters are cultural encounters. Nevertheless, the uniqueness
provides the context for care, and this must never be considered as
insignificant.

Invisible dynamics related to power and perspective always exist

because of people’s cultural awareness and proficiency. Making them
visible helps to explain the tensions and dynamics encountered when
people come together to create solutions for the future.
Understanding these concepts and applying the strategies covered in
the book chapters can help improve you and the preparation of your
students as well as team members—be they faculty or other
healthcare providers with their interprofessional experiences. So
what and how do we make the spaces in our places of the mind and
the physical environment? What good, timely, and wicked questions
worthy of answers and why this book was written! Use it for some
action-centered pedagogy.

After reading this work, I was reminded of something Nietzsche once

said in reference to Diogenes, the Greek philosopher living in the
fourth century BC. Before I provide the quote, I should share a bit
more about this philosopher. Diogenes now is thought of as an
unconventional thinker with a cutting wit and repartee who taught
his fellow citizens largely by pantomimic gesture and example. One
day, he was reported to have gone about the city in clear daylight
with a lit lantern looking about as if he had lost something. When
people came up to ask what he was trying to find, he answered:
“Even with a lamp in broad daylight, I cannot find a real human
being,” and when people pointed to themselves, he chased them
with a stick shouting, “It is a real human being I want.” Bizarre as
this may seem, Diogenes’ antics did jar the moral consciousness of
some, and even now, it nudges us to reflect on the question we are
still asking and should always ask: What is the nature of a human
being? And what does it mean to ask this question? Now as
promised, the Nietzsche quote that came to the forefront of mind
was, “Whoever is searching for the human being first must find the
lantern.” Like Diogenes, Sally Ellis Fletcher’s book is a lamp throwing
some light on the complexity of how to be culturally relevant. I
recommend it for your teaching, curriculum adaptations, and
personal growth.

–G. Rumay Alexander, EdD, RN, FAAN

Professor and Director-Office of Multicultural Affairs
University of North Carolina at Chapel Hill School of Nursing
Introduction
If you are interested in cultural inclusiveness, cultural competence,
cultural humility, and cultural diversity, I encourage you to continue
reading. Using various activities such as journaling, word games, and
scenarios, this guidebook asks you to use critical and reflective
thinking skills to explore the process of cultural sensibility. What is
cultural sensibility? In short, cultural sensibility refers to deliberate
behaviors that proactively provide an enriched provider–
consumer/patient interaction, where the healthcare provider
acknowledges cultural issues and situations through thoughtful
reasoning, responsiveness, and discreet (attentive, considerate, and
observant) interactions.

I was searching for a term that implied practical, applied behaviors,

attitudes, and approaches to equip healthcare workers in what is
currently discussed as cultural competence, cultural sensitivity,
cultural humility, cultural diversity, and various other terms that
highlight differences and the grouping of individuals according to
their lack of similarity with healthcare workers. These terms are not
wrong, negative, or bad, and they have a critical place in the
evolving continuum addressing cultural implications in the delivery of
healthcare. However, these terms do not equip healthcare workers
with skills to address personal issues of bias and stereotypes that
can lead to provider-biased healthcare and contribute to healthcare
disparities. Drawing from definitions, synonyms, and antonyms in
thesauruses and dictionaries, I examined existing cultural terms in
search of a word that would emphasize behaviors and attitudes
when combined with the word culture. The best term was sensibility,
which describes a responsiveness of both the conscious and
emotional senses. From this review, the definition of cultural
sensibility was envisioned.
A review of the literature identified an earlier grappling by Dogra
(2003) with concepts surrounding cultural diversity. Her work
compared two models for teaching cultural diversity: cultural
expertise and her term cultural sensibility. Later she used her
comparisons to explore medical students’ learning about cultural
diversity beyond the expertise (categorical) approach of teaching
cultural group differences and utilized her concept of cultural
sensibility (Dogra & Karnik, 2003). The authors drew clear
distinctions between:

• Cultural expertise: Proficiency in applying facts

• Cultural sensitivity: The degree of compassion and
understanding
• Cultural sensibility: A broader perspective that implies an
action toward openness
Cultural sensibility offers healthcare providers a process that
encourages them to first consider their own attitudes, biases, beliefs,
and prejudices through self-reflection. The process of self-reflection
allows us the opportunity to accept or change our biases, beliefs,
and prejudices. Most important, however, it allows us to recognize
that these areas have the potential to interfere with effective
healthcare interactions.

In each chapter of this guidebook, you have an opportunity to reflect

on the actions described in various scenarios and perhaps identify
similar experiences from your professional practice. As you do so,
you can start to leverage historical experiences to enhance in-the-
moment clinical experiences using reflection-in-action (Albanese,
2006) and thus create culturally sensible healthcare encounters.

Target Audience
This guidebook is primarily designed for nurses and prelicensed
nurses who are interested in cultural diversity, inclusivity, and
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