Gentle probing offers cultural insights
Gentle probing offers cultural insights
How to help patients open up
It isn't easy for case managers to gather the cultural insights needed to develop culturally competent treatment plans. Patients bring with them rituals, health beliefs, and practices they may be reluctant to share, notes Ann Wood Washington, PhD, a clinical psychologist in the department of surgery/division of transplantation at the University of Illinois at Chicago Medical Center.
"There is a saying in the African-American community that you don't tell all your business to strangers," says Washington. "Many African-Americans will apply home remedies first before seeking help from a physician. That's OK if they're not immunosuppressed. But we've had a few patients who have lost toes after soaking them in Epsom salts at home without reporting to their providers that they had skin eruptions."
Washington trains medical students to empow er patients to contribute to their care. "A patient may be reluctant to tell their physician or case manager what remedies they are using from the health food store," says Washington. "Instead of a direct question, try something more like: 'Mr. Jones, when you have a cold, what kinds of things do you do?'" she suggests.
Case managers and care providers are often in too great a hurry to gather data, says Washington. "We have to give patients more of an opportunity for conversation and dialogue." And sometimes gathering information requires taking the time to visit, she adds. "This is true for many older patients. An older African-American woman may ask a young resident to come over, `honey,' and sit down. It's important for residents to understand that this is not a sign of infantilization. If you take the time to sit down, patients open up and the data you gather becomes richer."
Many patients will bring cultural items into the hospital with them, Washington notes. "Native American patients may bring amulets or medi cine bags given to them at birth to promote good health. Guatemalan patients may bring worry dolls to tuck under their pillows, and many patients now bring oil or prayer cloths to put on their gowns or pillows," Washington says. "It's important for staff not to be bothered by those things. Having them will bring comfort to patients."
Of course, effective case management is always more difficult if the case manager and patient speak different languages. "We have in-house interpreters. I always meet with the interpreter before interviewing a patient," Washington says. "I go over the kinds of information I need. I allow no personal questions or elaboration. It's difficult for someone who is not clinically trained to be in the same room with a countryman and not be able to have a conversation, but I insist that interpreters not vary from the prepared questions to ensure that the interview is clean and valid." In addition, Washington cautions case managers not to use children or other family members as interpreters. "I never use family members except to get telephone numbers or addresses."
Washington says non-English-speaking patients appreciate case managers and care providers who make an effort to speak their native language, even if it's only a few words. "I make an effort to at least greet patients in their own language. It's sweet how much they appreciate my attempts. It's reassuring to patients if someone really tries to speak their language," she says. "It tells them you cared enough to try." (For more on the importance of communication and language to culturally competent case management, see column, p. 97.)
However, she cautions case managers not to attempt dialects. "Dialects rarely flow well off the tongue of individuals outside the group. I think it's best to always use standard English. There are boundaries we must respect," Washington says.
It's not possible for case managers to understand all aspects of a patient's culture, but they do need basic information to provide culturally competent care. That information includes:
· roles of individuals in the community based on gender and age;
· behavior patterns specific to cultural groups;
· cognitive styles;
· values;
· dietary practices.
"There are some dietary factors that seem obvious," she says. "But there also may be some indigenous foods common to the culture that increase or decrease the patient's symptoms or influence the effectiveness of medications."
Finally, Washington suggests that case managers look at their own personal baggage. "They should think about what they are bringing to the encounter and examine their own preconceptions, prejudices, and fears," she says.
"Developing cultural competence is similar to being a detective. Understanding the impact of culture on our patients is a way of making sure we do our part to help patients regain a state of wellness or maintain their dignity in difficult health situations."
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