Don't wait to address cultural diversity
Your patients, staff are changing; so should you
Experts predict that the United States is less than two years away from having a population that is more than 30% ethnic, or culturally diverse. In communities across the country, home health agencies increasingly deal with patients who speak different languages and have unfamiliar customs.
This sometimes leads to problems for health care providers. For instance, front-page newspaper headlines in the mid-sized city of Greenville, SC, recently reported that the city's largest local hospital refused to administer 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 given informed consent 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 has become more diverse in recent years, as Asian and Hispanic immigrants come in search of employment.
As in the case of the hospital in Greenville, hospital home health agencies also must confront these issues, and some experts say the time to make changes is now.
"Because of the changing population, nurses and other health care providers must be much more sensitive to non-white clients," says Ruth Davidhizar, RN, DNS, CS, FAAN, dean of nursing for Bethel College in Mishawaka, IN. "Traditionally in health care, we've been very oriented to mainstream Caucasian patients. Materials are in English, and we have a value system that's basically white in mainstream medicine."
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 the South and Midwest. "I was just in Texas, and there was an advertisement on a wall announcing that there were jobs in Indiana where the unemployment rate is 2%," Davidhizar says.
The changing face of American communities demands that home health agencies and other providers find solutions to language and cultural barriers between staff and patients, says Davidhizar. She and other health care professionals note that there are several key issues that must be addressed in a multicultural environment. Those include:
· Patient education needs to be bilingual and multicultural.
"The real problem we're having is with compliance," Davidhizar says. Patients who speak very little English may not understand a nurse's explanations about why they need to continue taking an antibiotic, for instance, she says.
In addition, a patient's "yes" is not always a true "yes" when nurses deal with patients from different cultures, adds Steven B. Dowd, EdD, RT(R), professor at the University of Alabama at Birmingham. This communication conflict makes it difficult for home care workers to assess whether a patient understands and is willing to comply with patient education, he says. "It's very important that health professionals be able to assess what the patient is really telling them," Dowd adds.
Davidhizar gives this example: "We have an Asian community here. It tends to be the cultural pattern that when a health care worker tells you something, you smile and nod out of respect." This leads home care nurses to believe the patient understands and agrees. Then when the nurse sees the same patient two weeks later, it's clear that the patient has not been taking the medication or following the instructions. "Nodding and smiling only meant the patient was showing respect," Davidhizar explains.
Standards established by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, require home care agencies offer education that is appropriate to the client's and family's needs and ability to read. So culturally sensitive patient education should be a priority, she says.
Some home health agencies have found ways to create bilingual materials by using their own employees as translators. 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 staff nurse of the full-service agency that serves northern Massachusetts and southern New Hampshire. One of the agency's nurses created the Cambodian material, and a clerical employee and physical therapist worked on the Spanish handouts, Wiacek says.
· People of different ethnic backgrounds may have different biological responses.
"There are 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.
"Many nurses tell me they don't understand what they should be looking for in terms of biological variations," Giger adds. She teaches and writes about those different biological responses. 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.
For example, recent studies confirm that African Americans metabolize nicotine differently, absorbing more of it when they smoke, Giger says.
Home care nurses must be aware of biological differences because it could help them better understand problems their patients may experience with certain medications. For instance, some medications used to treat hypertension are ineffective on African Americans because their bodies are incapable of metabolizing those drugs. The same medication given to a Caucasian patient will work as expected, Giger explains.
Or, perhaps a Chinese American patient might be able to tolerate only half of the typical dosage of a specific medication, Giger 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 often are unaware of these differences because most of the medical research in the United States has focused on Caucasian men, and until recently, medical and nursing schools did not teach students about biological variations, Giger states.
· Communication styles vary between cultures.
Even within specific minority groups there are different communication styles and languages. For example, there are more than 40 Asian and Pacific Islander groups and more than 500 American Indian tribal groups.
Davidhizar, Giger, and Dowd say the main elements of communication include the following:
- Dialect: Regional forms of a language sometimes present communication barriers even between people who were born in the same country. For example, a home care agency might have a Chinese nurse who is unable to speak with a Chinese patient because they speak different dialects.
- Style, emotional tone, and volume: People in some cultural groups may speak louder in groups, while others speak more softly. A nurse or other health care professional must be careful not to interpret one person's loud tone for anger or another person's soft tone for indecisiveness or incompetence.
- 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 a man other than a close family member. In some Asian cultures, eye-to-eye contact, touching the head, waving arms, and pointing at people with one's toe are considered rude and disrespectful behaviors.
· Social organization, family hierarchy, and spiritual beliefs may vary.
The Amish, Hispanic, and some Asian-American families are male-dominated. And for the Amish and many Asians, any discussion at all about sexuality is taboo.
The Hispanic culture places such a strong emphasis on the family that often a home health nurse might find better patient compliance if the entire family participates in patient education.
In addition, minorities often retain their own spiritual health beliefs while receiving Western medical treatment, Davidhizar says. "Patients may come to the hospital with their herbs and their own spiritual advisor, their shaman," she says. "Caregivers need to be more broad-minded than they used to be and be sensitive, incorporating the patient's values into the treatment plan."
· Time perception may vary.
Some cultures may not value timeliness to the extent it's valued in the United States. Puerto Rican, African American, and Mexican American cultures tend to be "present" oriented, notes Davidhizar. This means many individuals in these groups do not focus on planning for the future. If home care workers say they will be at the person's home at a specific time on a specific day, the patient may or may not be prepared for the visit.
"This [mainstream] medical system is very oriented to the clock, and you have to show up at the right moment," Davidhizar says. Home health staff should keep this in mind and give patients very specific instructions about follow-up appointments.
(Editor's note: 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.)
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