Model helps CMs deliver multicultural care
Model helps CMs deliver multicultural care
Addressing cultural issues boosts compliance
By Ruth Davidhizar, RN, DNS, CS, FAAN
Dean of Nursing
Bethel College, Mishawaka, IN
Gregory Bechtel, MPH, PhD
Associate Professor of Community Nursing
Medical College of Georgia, Augusta
Joyce Newman Giger, EdD, RN, CS, FAAN
Professor of Graduate Studies
University of Alabama at Birmingham
The face of America is changing. The U.S. Department of Commerce in Washington, DC, predicts that by the year 2000, 33% of Americans will be members of ethnically diverse cultures. By the year 2050, the majority of people living in the United States will be from ethnically diverse cultural groups. This change in population demographics will present significant challenges for case managers who often are unfamiliar with different cultural beliefs and practices.
Case managers must consider the unique cultural backgrounds of their patients to provide optimal care. For example, a Vietnamese patient may smile and appear to agree with the case manager even when the patient does not understand the case manager's instructions. In the Vietnamese culture, nodding the head is an indication of respect and not necessarily an indication of agreement or understanding. That may lead to misunderstanding when the patient fails to comply with prescribed treatment plans. The case manager may perceive the patient as noncompliant when the patient simply did not understand directions.
Providing culturally relevant care is not a simple process. The case manager must be aware of differing health practices and beliefs of patients and their families to optimize compliance with care. Efficient and effective case management links culturally specific health patterns with prevailing health resources.
The six-part model described here provides a cultural assessment tool for case managers. The model includes the following cultural components, which impact case management:
1. communication;
2. space;
3. social organization;
4. time;
5. environmental control;
6. biologic variations.
The model enables case managers to collect information simultaneously in specific areas that tend to differ among people from different cultural groups. Even case managers who only communicate with patients by telephone will benefit from an enhanced understanding of cultural differences. In addition, sharing culture-related insights with home health and hospital staff caring for your patient will increase both your patient's satisfaction and his or her compliance with treatment plans.
1. Communication. Effective communication is often the most significant challenge to case managers working with patients from diverse cultural backgrounds. It overlaps all other areas of the model.
Communication is particularly difficult when the primary language of the patient is not the primary language of the case manager. When an interpreter is used, the case manager must be cautious that the communication intended is being received because content is often lost during translation. (For more information on the proper use of interpreters and how culture impacts case management, see p. 100.)
Both verbal and nonverbal communication are learned through culture. The task of observing and interpreting a patients' nonverbal behavior is made more difficult because behavioral and verbal cues are often quite subtle. Adult patients may show fleeting changes in facial expression and small or quick eye movements. Those subtle communication cues vary from culture to culture but are essential in optimizing communication.
Nonverbal communication can be misunderstood easily. Case managers must be careful in the content of their communication with patients and in the manner and tone used in the communication. An assessment of communication must consider:
· dialect;
· language style;
· volume, or silence;
· touch;
· context of speech or emotional tone;
· body language.
Dialect differs among cultural groups. For example, there are 10 recognized Hispanic/Latino groups and more than 40 Asian American/Pacific Islander groups. In addition to dialect, identical words can have different meanings in different cultures.
Even when the language is the same, the words may be used differently. Some Chinese-Americans and Vietnamese-Americans, for example, avoid using the word no because they associate it with disrespect. Instead, patients from these cultures may use silence in place of the word no. The volume or pitch of the speaker's voice also varies by culture. For example, Asian-Americans have a greater tendency to speak softly, while African-Americans tend to be more vocal.
Nonverbal communication also impacts effective case management. Touch often assists communication. However, touching is considered taboo in many cultures. An Orthodox Jewish woman avoids shaking hands and, in fact, touching of any kind with a man who is not her husband. Similarly, some Asian women avoid shaking hands with each other or with men. In many Asian cultures, touching the head, eye-to-eye contact, waving arms, turning palms upward, and pointing with a toe is considered rude and disrespectful.
Context of speech and emotional tone refer to the use of emotion when communicating. Context of speech also refers to "small talk." Eskimos precede any significant interaction with small talk. To the busy case manager, that may appear to be a waste of time. However, small talk is essential to establishing positive relationships with some patients.
Body language speaks volumes
Finally, body language refers to the use of stances, gestures, and eye contact when communicating with others. In some groups, turning one's palms up has sexual implications even though for most Americans it means acquiescence. In addition, the use and length of eye contact also varies among cultural groups. For example, persons from India may avoid direct eye contact with persons in higher or lower socioeconomic groups.
Posture and body movements readily convey positive and negative attitudes. Nonverbal cues associated with positive attitudes include a relaxed but alert posture, leaning toward the other person, direct eye contact, and relaxed, still hands. Slumping or leaning away from another person or gazing at the ceiling and drumming fingers signal a negative attitude. In the health care setting, patient satisfaction increases when case managers face the patient, lean forward, and look directly in the patient's eyes.
2. Space. Space refers to the physical distance needed between people to enhance verbal and nonverbal communication. Spatial requirements vary among individuals of different cultures, and all communication occurs in the context of space. All individuals claim a certain territory around themselves in which they feel comfortable. Violation of the patient's personal space causes discomfort and often results in the patient's refusal of treatment, noncompliance, or overt anger.
The preferred distance between people in the United States is generally two to three feet. Since nursing care and medical procedures fall within this distance, case managers and care providers should inform patients in advance and proceed with reassurance and adequate explanations. Moving away from the patient for a moment after a procedure allows an interlude of breathing room.
Case managers and care providers always should explain to patients why their personal space is being invaded and the duration of the close contact. When patients understand the benefit of this violation of cultural upbringing, tolerance and acceptance are more likely.
3. Social Organization. Family structure and organization, religious values and beliefs, and culture relate to both role and role assignment within group settings and affect adherence to recommended treatment plans. Some cultural groups extend family beyond normal bloodlines and have very large extended families. Nonfamily living in the same home as the patients or persons responsible for bringing patients to the hospital may be integral to the family.
The family's perception of the case manager's authority and problem solving skills may influence compliance with the treatment plan. For example, both African-Americans and Hispanic-Americans tend to stress cooperation within the family and community to help individuals in distress. The concept of "autonomy" in health care may be quite foreign to persons in a culture where decision making is shared and decisions are made in the context of the family.
4. Time. Cultural groups can be oriented to the past, present, or future. Cultures focusing on the past attempt to maintain traditions and have little motivation to form future goals. Cultures that focus on the present often are unappreciative of the past and may not plan for the future. Cultures with future orientation organize present activities to achieve future goals and are more likely to show up on time for health care appointments and take medications on schedule.
Time isn't always money
Time is an important aspect of interpersonal communication that is often overlooked. Most North Americans and Northern Europeans equate time with money. Time is measured in incremental periods defined by clocks or calendars and can be segmented and scheduled.
This is not true for all cultures, however. Native Americans and patients from Iran and Afghanistan may have difficulty with the segmented concept of time. In these cases, case mangers may be more successful relating self-care activities to social interactions such as mealtimes rather than clock time.
5. Environmental control. Environmental control refers to the ability to plan activities that control nature. Many Americans believe that they have control of their health and are likely to seek primary health care before serious problems occur.
However, other cultures believe illness and death are predetermined, and they are unmo tivated to seek preventive health care. These individuals are not as receptive to lifestyle changes.
6. Biological variations. Biological differences are less understood than other cultural and racial variations. Physical features, skin color, body size, even enzyme differences can be traced to biologic adjustments to the environment made over time.
There is a direct relationship between race and body structure, skin color, enzyme differences, genetic variations, physiologic jaundice, twining, susceptibility to disease, and nutritional deficiencies.
Case managers must understand differences and similarities among individuals from different cultures to provide competent care. Case managers also bring a personal cultural heritage to their interactions with patients. Using the six component cultural assessment model, case managers can optimize care among individuals, families, and communities.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.