Education key to meeting needs of diverse nation
Education key to meeting needs of diverse nation
This strategy can increase cultural competence’
In 1990, 20% of Americans identified themselves as minorities. This year, it’s estimated that number has increased to 25%. What will this mean to your agency and its work?
If you are located in a metropolitan area, you’ve probably already begun to see the effects. Fewer and fewer clients speak English as a first language, and some may have cultural backgrounds that pose challenges for care.
At Inova VNA Home Health in Alexandria, VA, Mary Curry Narayan, MSN, RN, CS, CTN, has seen an ever-increasing diversity in the community she has served over the past 20 years.
"In Fairfax County, which is one of three counties that we deliver care to, there are over 100 different languages spoken within the school system," says Narayan, education coordinator and clinical specialist for Inova. "All those kids are sometimes sick, and they have parents who are sick and grandparents who are sick."
Narayan says agencies need to take steps not only to overcome language barriers, but also to ensure the care they deliver matches the cultural needs of their patients.
"Delivering care from a white European background or mentality sometimes does not meet the needs of these patients, and therefore the outcomes aren’t as good for them," she says. "Care can actually be much more costly for patients that come from a different culture than the providers come from, just because we’re not all on the same page to get to the same goal at the same time."
The federal government intervenes
The federal government has taken an interest in the matter, issuing standards for assuring cultural competence in health care organizations. At this point, the standards, issued by the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services, are not mandatory, says Guadalupe Pacheco, MSW, special assistant to the OMH director.
But he anticipates that agencies such as the Health Care Financing Administration may use the standards to strengthen their own requirements. Pacheco notes that the Office of Civil Rights (OCR) issued written guidance this year directing health care providers on how they should meet federal civil rights requirements regarding language assistance to patients who
do not speak English.
Those "persons with limited English skills," as the government describes them, represent a significant barrier to care when they are referred to home health agencies.
Narayan says that in most cases, Inova learns before admission when a patient has trouble with English. But even with that preparation, a nurse can be thrown for a loop.
"When we get a referral from the hospital, it will be mentioned that there is a language barrier," she says. "But most of the time, they’ll say, but the daughter speaks English,’ or something like that. And when you get out there, the daughter’s not there. You thought you were going to have an interpreter, but you don’t."
And in many cases, using a family member or neighbor to interpret is inappropriate, Narayan says.
"In many homes, for instance, the only ones who speak English are the kids, yet you’re having them translate very difficult news or complex care that may be beyond them," she says. "Or it may be inappropriate for them to tell their parents because they are children, and it’s just not done in the culture."
The OCR guidance published in August states that health providers cannot require family members to serve as interpreters and that a person with limited English has the right to receive free interpreting services. However, if a person requests that a family member translate, it is allowed.
Interpreters breach language barrier
Inova has begun using interpreters provided by the Northern Virginia Area Health Education Center. These interpreters are specifically trained in medical translation. Narayan says she is proposing a research project that would fund greater use of the interpreters, especially on the most important assessment and training visits. She notes that without research funding, her agency couldn’t afford to send interpreters on as many visits.
Inova also uses Language Line Services in Monterey, CA, formerly known as the AT&T Language Line. This service provides phone hookups to a medically trained interpreter who takes turns speaking with the patient and the provider.
"There is a lot that can be lost in that kind of [telephone] translation, but it’s certainly better than no interpreter at all," she says. "Our agency does have a contract with Language Line, and all our clinicians are given the telephone number, so if they find themselves in a home where they need the translation, they can avail themselves of that service."
Narayan says that in addition to translating questions and answers, the interpreter can serve as a sort of cultural broker, explaining cultural nuances that can help a provider understand the situation better. But even with that assistance, a nurse or aide can struggle with the differences between her own culture and that of the patient. The different diets eaten by people from different ethnic backgrounds can play havoc with one-size-fits-all nutritional teaching, for example.
"Say you have a diabetic patient, and the patient comes from Asia," she says. "When you’re trying to do diabetic teaching about different food groups, you may be looking at pictures that come from an American diet. If the patient is shopping at an Asian store and eating totally different types of foods, then your diet is not matching."
If a family has a different eating pattern — for example eating a heavy lunch and light breakfast and dinner — that can interfere with the prescribed insulin regimen, which is tailored to a Western style diet.
Narayan notes that other cultures may have foods they associate with certain illnesses. "If you’re not aware of that, when you’re doing your patient education, teaching this patient about when and how to take the insulin, your patient’s going to end up in the emergency room."
Other health practices also can create problems, based on religious or ethnic beliefs or simply what patients are accustomed to. In many religions, for example, it would be inappropriate for a patient to receive intimate care from someone of the opposite gender. In some cultures, patients wouldn’t be expected to make decisions about their own care, leaving that up to family members.
Education, sensitivity key
Narayan suggests these steps for an agency wanting to improve its cultural competence:
• Educate yourself and your staff. If you note that the demographics of your area have changed, learn everything about the new cultures you can. Narayan suggests checking a number of resources that provide information about the language and culture of different ethnic groups.
"If I know I’m going to the home of a patient who is first generation from Cambodia, there are a number of manuals and resources that are available now for health care providers," she says. "If I were going to go see a patient from a culture I’d never been to before, one of the first things I’d try to do is first read up a little about that patient’s culture of origin."
If the culture is one that many of your staff will be expected to see on visits, provide them with inservices to give them some background on the culture.
• Pay attention to cultural cues in assessment. Narayan says a cultural assessment can help alert a nurse to issues that may come up during care. Many of the questions involved in a cultural assessment are the same ones asked in a standard assessment, but the nurse is conscious of the possible cultural aspects of the questions.
Narayan uses a pain assessment as an example. "People respond differently to pain in other cultures," she says. "I’m trying to find out what’s the worst pain you’ve had in the past, how did you deal with it, what kind of medications did you take, and who did you go to for help?
"You want to ask these questions of anybody, but it becomes particularly important when you’re trying to figure out whether there are some cultural differences in the way people react to pain," Narayan says. "There are cultures that tend to be more stoic and cultures that tend to be more expressive in how they react to pain."
If the nurse’s culture expects one response to pain, and the patient is expressing another, it can lead to confusion, she says. "It’s the same thing for nutrition, medications, the psychosocial assessment you do for a patient."
Discover the cultural overlay
Narayan refers to a technique called the "explanatory model" for finding the cultural overlay of a patient’s health problem. "You start out by asking what’s wrong — What do you call this problem that you have?’" she says. "When did the problem start? What caused the problem? What might others think is wrong with you? How does this illness work? What do you fear about this problem? How have you treated the illness? Who can help you? How long will the problem last? Is it serious?’"
• Don’t jump to conclusions. Try to find out as much about a patient’s background as possible without assuming that he or she necessarily will mirror stereotypes of a "typical" person from another culture.
Narayan’s hypothetical Cambodian family, for example, may have spent years in this country or may have been educated here. The family may have come here from France or some other country and adopted that culture’s patterns. "You’ll get a name of a patient that sounds like it must be very foreign — it sounds like you’re going to have some cultural or linguistic challenges — and they’re as Americanized as you are."
• Recruitment. Make an effort to recruit staff from the predominant cultures in your area. They can serve as "cultural brokers" to alert others to potential barriers to care. They also carry with them a personal understanding of the challenges of operating in a foreign environment.
"I’ve given inservices to our home health aides, and I’m amazed at how culturally sensitive they are," she says. "I would say the reason for this is that most of them come from a different culture."
• Promote flexibility and sensitivity. Staff should be encouraged to be flexible when cultural issues come up that they didn’t expect. "Be willing to learn from the patient," Narayan says. "You have to approach this with openness. It’s not your goals you’re trying to meet — you’re trying to meet the goals of health and well-being for the patient."
Sources
• Mary Curry Narayan, Education Coordinator/Clinical Specialist, Inova VNA Home Health, 5701-D General Washington Drive, Alexandria, VA 22312. Phone: (703) 321-2906. Fax: (703) 321-9168. E-mail: [email protected].
• Guadalupe Pacheco, Special Assistant to the Director, Office of Minority Health, U.S. Department of Health and Human Services, 5515 Security Lane, Rockwall Building No. 2, 10th Floor, Suite 1000, Rockville, MD 20852. Phone: (301) 443-3379. Fax: (301) 594-0767.
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