1. Crespo-Fierro, Michele PhD, MPH, RN, AACRN


Building trust in the nurse-patient relationship.


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The 2020 census revealed that more than 40% of the U.S. population now identifies as non-White1-a proportion that is expected to grow as the country continues to diversify. Within this group there are various health and health care disparities. Black and Indigenous women are two to three times more likely to experience maternal mortality than White women.2 Among Hispanic Americans, COVID-19 was the leading cause of death in 2020, and this population also has a higher rate of low-birth-weight infants than non-Hispanic White Americans.3 In addition, the Asian American community has higher rates of type 2 diabetes and cancer.4

Figure. Michele Cres... - Click to enlarge in new windowFigure. Michele Crespo-Fierro

Patients in diverse populations face other health care challenges, such as having lower rates of health insurance and less access to a regular health care provider. They often experience communication challenges when the provider doesn't speak their language and interpreter services aren't available. Fear of revealing their immigration status can prevent people from seeking care, resulting in delays in treatment. People from diverse communities may distrust the health care system as a result of their own past experiences or those of others.5 One way to address these disparities is by fostering a diverse nursing workforce that can provide culturally and linguistically congruent care.


The benefits. Cultural concordance, meaning a shared cultural background, between patient and nurse can help patients feel more at ease. Nurses who have a similar background to the patient would likely recognize the patient's cultural values and illness prevention practices,6 as well as experiences of structural and social determinants of health. This could help prevent misunderstandings when the patient describes strategies to manage health problems. Language concordance, or speaking the same language, is also important. If the nurse speaks the patient's language and/or dialect, health teaching will be better understood by the patient and/or caregiver, which can improve care plan and discharge planning discussions, and result in shared decision-making and patient-centered care.


A shared language and culture can help build trust in the nurse-patient relationship. This leads to easier communication with the patient and family and the sharing of more information. A more thorough assessment sets the stage for the nursing process to be better aligned with the patient's needs. In this scenario, the nurse-a representative of the health care system-demonstrates trustworthiness and contributes to reducing mistrust. Diverse nurses can also educate the health care team by sharing cultural health meanings and practices and modeling the caring behaviors that patients desire. Diverse perspectives and experiences bring innovative ideas to the health care team.


Some precautions. While diverse nurses can provide many benefits to diverse patients, they should not be expected to solely care for patients from their own community. This can lead to role strain and to relieving others of their responsibility to deliver culturally congruent care. Nurses who speak the same language as a patient are not a replacement for an interpreter, especially when obtaining consent. Being a native or fluent speaker of a language doesn't necessarily mean being familiar with medical terminology in that language. Nurses who wish to obtain that knowledge can be certified as medical interpreters.


Diverse nurses are not free of bias. Cultures have belief systems that include racism-sometimes called colorism-and classism. Although a nurse and a patient might share a culture and/or a country, conflicts may still exist that could complicate care. Efforts to reduce bias are useful for all nurses in all care encounters and settings.


Increasing the diversity of nurses on hospital units is not an easy task. Racism must be eliminated within nursing education to allow diverse nurses to be prepared for licensure.7 We also need to examine the restrictions placed on foreign nurses when they seek licensure in the United States. Increased diversity in nurse staffing alone will not reduce health disparities-other structural issues must also be addressed. Racism within the health care system, which is often expressed through implicit and explicit bias toward patients and their families, also contributes to health disparities8 and must be eradicated. Structural and social determinants of health should be addressed through health policy and legislation. Taking the steps necessary to achieving health equity will create more healthful environments and lead to a lasting reduction in health disparities.




1. Frey WH. New 2020 census results show increased diversity countering decade-long declines in America's white and youth populations. Washington, DC: Brookings Institution; 2021 Aug 13. [Context Link]


2. Petersen EE, et al Racial/ethnic disparities in pregnancy-related deaths-United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2019;68(35):762-5. [Context Link]


3. U.S. Department of Health and Human Services, Office of Minority Health. Profile: Hispanic/Latino Americans. Washington, DC; 2022 Sep 26. Minority population profiles; [Context Link]


4. National Institute on Minority Health and Health Disparities. The Center for Asian Health engages communities in research to reduce Asian American health disparities. Bethesda, MD: National Institutes of Health; 2022 Aug 17. [Context Link]


5. Funk C, Lopez MH. Hispanic Americans' trust in and engagement with science. Washington, DC: Pew Research Center; 2022 Jun 14. [Context Link]


6. McFarland MR, Wehbe-Alamah HB. Leininger's theory of culture care diversity and universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs 2019;30(6):540-57. [Context Link]


7. National Commission to Address Racism in Nursing. Racism in nursing. Silver Spring, MD; 2022. Report series; [Context Link]


8. Hall WJ, et al Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105(12):e60-e76. [Context Link]