Don't wait to address cultural diversity
Patients, staff are changing; so should you
The nation is less than two years away from having a population that is at least one-third ethnically diverse. In communities across the country, home health agencies increasingly are dealing with patients who speak different languages and have unfamiliar customs.
This sometimes can lead to problems for health care providers. For instance, front page newspaper headlines in Greenville, SC, recently reported that the city's largest local hospital would not give epidurals to non-English-speaking pregnant women during their labor and delivery, unless a translator was present. Hospital officials told the Greenville News that they would not administer an epidural to women who could not be told about the health risks involved in the procedure. And since the hospital has few bilingual employees, often there is no one available to translate.
Like hundreds of other communities nationwide, Greenville, SC, has become more diverse in recent years, as Asian and Hispanic immigrants have moved there for jobs.
Private duty providers must confront these issues, and some experts say they should start making changes now. "It is the number two factor in customer satisfaction. You won't succeed unless you respect your clients' culture," says Judith Walden, RN, MHA, administrator and chief executive officer of Honolulu-based Kokua Nurses.
>"Because of the changing population, there are more people who are culturally diverse," says Ruth Davidhizar, RN, DNS, CS, FAAN, dean of nursing for Bethel College in Mishawaka, IN. "Nurses and other health care providers must be much more sensitive to non-white clients. Traditionally, in health care we've been very oriented to mainstream Caucasian patients: Things are in English, and we have a value system that's basically white in mainstream medicine," she adds.
While large cities and small towns along the nation's borders traditionally have been the main places where immigrant populations settled, this no longer is true. Non-English-speaking immigrants increasingly are moving into stalwart white communities throughout the United States.
This means that private duty providers will need to find solutions to language and cultural barriers between staff and patients, experts suggest. (See Private Duty Homecare, January 1997, p. 4.)/P>
Providers face a number of the following multicultural issues, according to sources:
1. Patient education needs to be bilingual and multicultural.
A "yes" from a patient of a different culture is not always a yes, says Steven B. Dowd, EdD, RT(R), professor at the University of Alabama at Birmingham. And patients who speak very little English may not understand a nurse's explanations about why they need to continue taking an antibiotic, Davidhizar explains.
These communication conflicts can make it difficult for field staff to assess whether a patient understands and is willing to comply with their own care responsibilities, Dowd says. "It's very important that health professionals be able to assess what the patient is really telling them."
For example, "We have an Asian community here, and it tends to be the cultural pattern that when a health care worker tells you something, you smile and nod out of respect," Davidhizar explains. This leads the home care nurse to believe her patient understands and agrees. Yet when she see the same patient two weeks later, she learns the patient has not been taking the medication or following the instructions. "Nodding and smiling only meant the patient was showing respect," she adds.
Translating patient education materials into a variety of languages can quickly become expensive. But providers may discover a wealth of translation resources among their culturally diverse staff. For example, the VNA of Greater Lowell in Lowell, MA, created patient teaching materials in Spanish and Cambodian, says Marianne Wiacek, RN, BSN, quality assurance nurse. One of the agency's nurses created the Cambodian material, and a clerical employee and physical therapist worked on the Spanish handouts, she reports.
2. People of different ethnic backgrounds may have different biological responses.
"There are so many people who do not understand the biological variations that are germane to people because of their race," says Joyce Newman Giger, EdD, RN, CS, FAAN, a professor of graduate studies at the University of Alabama at Birmingham's School of Nursing. Giger and Davidhizar co-authored a book titled Transcultural nursing: Assessment and intervention, published by Mosby Year Book of St. Louis in 1995. The third edition will be published next year.
"Very many nurses tell me they don't understand what they should be looking for in terms of biological variations," Giger adds.
Giger teaches and writes about the different biological responses. These variations may include the following:
- racial-anatomical characteristics;
- growth and developmental patterns;
- body systems;
- skin and hair physiology;
- mucous membranes;
- disease prevalence and resistance to disease.
Home care nurses need to be aware of biological differences because it could help them better understand problems their patients might have in using certain medications. For instance, some of the medications used to treat hypertension are ineffective on African Americans because their bodies are incapable of metabolizing the drug. The same medication given to a Caucasian person will work as expected, Giger explains. Or a Chinese patient may tolerate only half of the typical dosage of a specific medication, she adds.
Another example of a biological variation is that African Americans are at higher risk for cardiovascular heart disease, cancer, diabetes, and other chronic illnesses, Giger says.
Nurses are often unaware of these differences because most of the medical research in the United States has focused on white men, and until recently, medical and nursing schools did not teach students about biological variations, she says.
3. Communication styles vary between cultures.
Even specific minority groups have different communication styles and languages, such as more than 40 Asian and Pacific Islander groups and over 500 American Indian tribal groups. Communications vary in several ways, according to experts.
- Dialect: Regional forms of a language could present communication barriers even between people who were born in the same country. For example, a Chinese field nurse may not be able to communicate with a Chinese patient because she speaks Mandarin and the patient Cantonese, two distinct dialects.
- Style, emotional tone, and volume: These pertain to the way people speak in social situations. People in some cultural groups, for example, may speak louder in groups, while others speak more softly. Field staff should be careful not to interpret one person's loud tone for anger or another person's soft tone for indecisiveness or incompetence, sources advise.
- Use of touch and gestures: Nonverbal communication also varies widely in different cultures, and this can vary even when an immigrant learns to speak English.
For instance, touching people might be appropriate behavior in some cultures, but is absolutely unacceptable in others. Orthodox Jewish men will not shake hands with women, and an orthodox Jewish woman will never touch another man. In some Asian cultures, eye-to-eye contact, touching the head, waving one's arm, and pointing at people with one's toe are considered rude and disrespectful behaviors. And many common American gestures are offensive to people from other countries, notes Veroneca Burgess, an attorney and principal of Baltimore-based Judicial Review, an employee training consulting firm.
4. Social organization, family hierarchy, and spiritual beliefs may be different.
The Amish, Hispanic, and some Asian American families are male-dominated. And for the Amish and many Asians, any discussion at all about sexual activity is taboo.
The Hispanic culture places such a strong emphasis on the family that often a home health nurse may find better patient compliance if the entire family participates in any patient education.
Minorities often retain their own spiritual health beliefs while they receive western medical treatment, Davidhizar says. "Patients may come to the hospital with their herbs and their own spiritual advisor - their shaman," Davidhizar says. "So caregivers need to be much more broad-minded than they used to be and be sensitive, incorporating the patient's values into the treatment plan."
5. Time perception may vary.
Some cultures may not value timeliness to the extent it's valued in the United States.
Some Puerto Rican, African American, and Mexican American cultures tend to be "present" oriented. This means many individuals in these groups do not focus on planning for the future. So if a nurse says she will be at the person's home at a specific time and on a specific day, the patient may or may not be prepared for the visit.
"This white medical system is very oriented to the clock, and you have to show up at the right moment," Davidhizar says. Field staff should keep this in mind and give patients very specific instructions about follow-up appointments, she advises.
When serving such a diverse population it may be difficult to always meet others' expectations. "But you must understand cultural differences. You must be tuned-in and observe and take cues from the situation and ask preferences," says Walden.