cover story
Cultural competence is the key to quality health care in the 20th century and beyond.
By Carrie L. Adkins
In the Saint Louis Cemetery #1 in New Orleans, the tomb of voodoo queen Marie Laveau is littered with pieces of herbs twisted in colored flannel, bricks wrapped in aluminum foil and geometrically arranged coins, bones and beans.1
Perhaps one of the people that left some herbs, carefully selected for their healing properties, has recently been admitted to a nursing home–a traditional, Western, medical model of a nursing home.
Will her needs be fully met? Not just her physical needs, but her psychological? Her spiritual? If not, can we justify neglecting that part of her because it is different from that of the dominant culture?
What about medical needs such as pain control? If she belongs to a minority group, chances are she won’t get the relief she needs. A recent study found that 65 percent of minority patients with disease-related pain did not receive recommended amounts of analgesics.2
Were these patients unable to communicate their needs? Or did they willingly not take the medication for fear of drug addiction and abuse? By understanding a patient’s cultural background, providers can better understand that patient’s needs, and provide better care.
UNDERSTANDING DIFFERENCES
For example, in Hispanic, Native American and Asian cultures, it is often considered inappropriate to complain about pain or discomfort, says Pat Huls, RN, BSN, CRNH, case manager and SNF specialist at Hospice of the Valley, Phoenix, Ariz. In the African-American community, fears of drug abuse often prevent patients from taking needed pain killers.
“To not pay attention to the racial or cultural heritage of our patients is to make a judgement that those things are not important,” writes Deborah Washington, MSN, RN, director of diversity, patient care services at Massachusetts General Hospital, Boston.3
First, providers must understand that culture doesn’t mean skin color. There are infinite cultures, based on not just race or birthplace, but gender, experiences, socioeconomic status, education, occupation, norms, values and religion.
“Everyone has a culture, not just the people who look like they do,” explains Josepha Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN, transcultural health care consultant at Transcultural C.A.R.E. Associates, Cincinnati, Ohio.
And every culture has beliefs and needs that color the care its members need. Because meeting those needs can be challenging, ADVANCE spoke with some of the leading experts in cultural competence for a few tips.
DON’T STEREOTYPE
“Some people may see the world as the ‘basic four food groups,’ that is, they see people as only fitting into the following four ethnic groups: African American, European American, Asian and Hispanic,” Dr. Campinha-Bacote told her audience at the Association for Rehabilitation Nurses annual meeting, held in October in Dallas. But the nuances of cultural differences are much more complex. Not only are we faced with a myriad of different ethnic groups, cultures and societies, but each one is internally diverse.4
The term Native American refers to over 400 tribes, Hispanic covers more than 20 distinct ethnic groups, Asia encompasses 18 countries, and Black could mean everything from Jamaican to African. While African-American serves as the politically correct descriptor of all Black U.S. citizens, it incorrectly implies that all Black people are of African descent.
Superficial cultural knowledge can be more dangerous that no knowledge at all if practitioners use it to stereotype.5 For example, a nurse may know that many Black patients are wary of pain medications and assume that her Black patient feels the same way. Even though the patient may be very uncomfortable, he may not receive the medication he needs and wants.
BE FLEXIBLE
Many cultures have important beliefs and rituals that may seem silly or inconvenient to staff. But when a patient is sick or nearing death, these rituals are even more important to patients and family, and caregivers must be prepared to handle them.
The staff of a small hospital in Northern Arizona couldn’t figure out why a group of Native American patients seemed to be continually falling out of their beds. Not until they consulted an anthropologist did they learn that the beds were facing North to South, which, according to that particular tribe, is the direction of death and illness. When the patients moved to the floor, they positioned themselves East to West, in the direction of health. To accommodate the hospital’s desire for the patients to stay in bed and the patients’ desire to be in the proper direction, the staff simply had to move the beds.
In India, private hospitals allow patients’ relatives to spend the night in the hospital. If a patient’s room is not large enough to accommodate another bed, relatives spread mattresses in the hospital corridors.6
Similarly, Judaism holds that it is every person’s obligation to visit and comfort the sick, and visitors mustn’t leave the room while a patient is dying.7 Muslim tradition also calls for a large gathering of family and friends when a patient is dying.7, 8
Consider the following simple, but significant, rituals:
* Many Muslim patients consider it important to face toward Mecca, in the direction of prayer, as death approaches.8
* Many Hindus6 and Orthodox Jews7 move the body of a dying person onto the floor, so that the soul can depart more
easily.
* Many Orthodox Jews,8 Pacific Islanders3 and Native Americans9 open a window when someone dies for the soul to depart.
* Many Orthodox Jews observe the Sabbath from sundown on Friday to sundown on Saturday. During this time, they won’t turn on lights or use call buttons.5
Although opening a window for a patient who is dying at home may not be difficult, doing so in a facility with sealed windows may be more of a problem. But with
flexibility and ingenuity and, most importantly, communication, staff, family and patients can work together to find ways
to blend patients’ needs with a facility’s
abilities.
Cultural competence is not about doing things exactly like they would be done in a patient’s home country, Dr. Campinha-Bacote stresses. It’s about finding a middle ground where both patient and provider are comfortable and satisfied.
THE LANGUAGE BARRIER
Finding that middle ground can often be complicated by language barriers. When working with non-English speaking patients, practitioners may not ask questions because they do not expect to understand the patient’s response. At the same time, a patient may give up trying to communicate for the same reason.10
This is often a terrible mistake. Many people who seem to speak poor English may actually speak better once you get to know them–their lack of fluency may be shyness. This is especially true among Asian women who may expect their husband to speak for them even if they know the language better.10
By employing a translator, practitioners can often overcome not just the language, but also the cultural barrier. But this is not without risk. Two people who speak Spanish may not necessarily be from the same country, let alone culture. Even using a family member to translate may pose certain problems. Dr. Campinha-Bacote tells the story of an Asian woman who needed a hysterectomy. According to her cultural beliefs, it was inappropriate for her son, who was serving as the translator, to discuss his mother’s gynecological health. Instead, he told his mother that she would be having abdominal surgery.
When treating non-English speaking patients, don’t limit yourself to verbal communication, but use pictures, diagrams and charts.11 Nonverbal communication is doubly important with patients whose English may be less than perfect. Martha Jane Hackett, BSN, RN, CNM, director of the OB/GYN unit at South Cove Community Health Center in Boston and Quincy, Mass., suggests training employees by showing them videotapes of patients with the sound turned off. This can teach them to watch a patient’s facial expressions and actions, to give clues to how the person truly feels or what he or she needs.3
Even when patients do speak fluent English, they may not directly ask for what they need. Many Native Americans, for example, use metaphor to describe their symptoms. Stories about a friend or neighbor may give you powerful clues as to what the patient is experiencing, Huls says. Some cultures, such as Japanese, may feel that asking a health care worker questions is
disrespectful.
Huls has several suggestions for enhancing communication with patients of other cultures:
* Determine the patient’s level of fluency in English and arrange for an interpreter, if needed.
* Ask the patient how he or she wishes to be addressed. Some cultures prefer formal address, while others prefer first-name
basis.
* Allow the patient to choose the seating arrangement for comfortable personal space and eye contact. As Americans, we are generally raised to believe that eye contact is crucial. It signifies honesty, trustworthiness and attention. But many other cultures, such as Asian, Hispanic and Native American, consider direct eye contact disrespectful.
* Avoid slang, technical jargon and complex sentences.
* Use open-ended questions to obtain more information.
KNOW WHAT NOT TO SAY
The standard of care in the United States is to tell patients the truth about illness and impending death and to obtain their informed consent for procedures. But patients do not always welcome this practice.
Consider diagnosing a patient with terminal cancer. You tell the patient, right? Not necessarily. Blackhall et al.12 found that if your patient is Korean- or Mexican-American, chances are that the family and patient believe that only the family–not the patient–should know the diagnosis or prognosis. If life-support is necessary, the decision also may lie with the family and not the patient. Similar sentiments are seen in Spain, France, Japan, China and Eastern Europe.
Of course acculturation, age and socioeconomic status all play roles in each patient’s beliefs. Blackhall suggests that the differences among each ethnic group are related to culture rather than demographics, which vary with ethnicity.
Withholding information from a patient may not be intended to deprive that person, but rather to protect him or her. Anecdotal evidence suggests that Chinese and Ethiopian families believe telling the patient bad news will cause them to lose hope. Similarly, traditional Navajos believe that thought and language shape reality and control events. Consequently, telling a Navajo that cancer may kill him or her is seen as a curse.13
USING CULTURAL
CARE NEGOTIATION
Sometimes health care practitioners think patients are difficult or noncompliant, when there is actually a simple miscommunication. Dr. Campina-Bacote relates the story of a young Hispanic woman who believed in hot and cold diseases and treatments, a common practice in some Hispanic communities.
The patient suffered from a gynecological infection that required tetracycline for treatment. While the patient was willing to take the tetracycline, her own remedy posed a problem. A “hot” disease needs to be treated with a “cold” remedy, she explained to the doctor, and the remedy she needed was milk. When the doctor tried to convince her that she couldn’t take tetracycline with milk, she chose her own treatment over the medical one as the more important.
Frustrated, the physician consulted Dr. Campinha-Bacote, who implemented the LEARN model15:
* Listen to the patient and understand the source of the problem. The patient’s belief system mandated that she drink milk for her condition. Her doctor’s belief system mandated that she take tetracycline. These treatments were incompatible.
* Explain yourself. Dr. Campinha-Bacote explained to the patient why tetracycline should not be taken with milk.
* Acknowledge the differences. A medical model vs. a hot/cold model.
* Recognize the similarities. Both parties wanted the patient to get well.
* Negotiate. First, Dr. Campinha-Bacote tried to get the patient to drink her milk at other times of the day or to drink another cold liquid with the drug instead. When that didn’t work, she negotiated with the doctor to use a different antibiotic that could be taken with milk.
“Cultural care negotiation is about everyone keeping a little bit of themselves and including other world views that are not hostile to one’s own world views,” Dr. Campinha-Bacote explains.
When working with a patient from a different background, it’s important to know what kind of beliefs and values they hold. For instance, what folk remedies are they using? What are their beliefs about the disease and wellness?5
GAIN INSIGHT
Becoming culturally competent is not an event, Dr. Campinha-Bacote says, but a process of becoming culturally aware of one’s biases, prejudices, and internal feelings toward culturally and ethnically diverse groups; culturally knowledge able of other’s values, beliefs, practices and biological variations; and culturally skillful by conducting cultural assessments.
Furthermore, it involves having cultural encounters to prevent possible stereotypes; and having cultural desire, which is the genuine motivation to want to provide culturally responsive health care services to diverse populations.16
References
1. Klein V. New Orleans Ghosts, (1996) Metairie: Lycanthrope Press.
2. Modica P. Inadequate treatment more common among minorities, study finds. Medical Tribune: Family Physician Edition 1997;38(20). Via http://www.medscpe. com/jobson/MedTrib/familyphys/1997/v38.n20/Inadequat10/23/98.
3. Lester N. Cultural Competence: A nursing dialogue, part two. AJN 1998;98(9):36-43.
4. Parkes CM, Laungani P and Young B. Eds. Introduction. Death and Bereavement Across Cultures, (1997) New York: Routledge.
5. Lester N. Cultural competence: A nursing dialogue. Via www.ajn.org.continu ing/CE/VIEWARTICLE.CFM?ART_ID= a808026.
6. Launguni P. Death in a Hindu family. Death and Bereavement Across Cultures (1997) New York: Routledge.
7. Levine E. Jewish views and customs on death. Death and Bereavement Across Cultures (1997) New York: Routledge.
8. Jonker G. The many facets of Islam: Death, dying and disposal between orthodox rule and historical convention. Death and Bereavement Across Cultures (1997) New York: Routledge.
9. Huls P. Lecture handouts from the American Academy of Hospice and Palliative Medicine conference.
10. Cultural diversity: It’s impact on death, dying and grief. 1998.
11. Parkes CM. Help for the dying and the bereaved. Death and Bereavement Across Cultures (1997) New York: Routledge.
12. LePostollec M. Bridging the culture gap: Treating with a global perspective.
ADVANCE for Physical Therapists and Physical Therapy Assistants. 1998;9(37):35-37.
13. Blackhall L, Murphy S, Frank G, Michel V, Azen S. Ethnicity and atti-
tudes toward patient autonomy. JAMA 1995;274(10):820-825.
14. Carrese J and Rhodes L. Western bioethics on the Navajo reservation: Benefit or harm? JAMA 1995;274(10):826-829.
15. Berlin E. and Fowkes W. A teaching framework for cross-cultural health care. The Western Journal of Medicine 1982; 139(6):934-948.
16. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: A culturally competent model of health Care. Ohio: Transcultural C.A.R.E. Associates.
Carrie Adkins is associate editor of ADVANCE.
Case in Point
An Exercise in Cultural Competence
When you enter the home of Jesus and Rosa Messa in urban Northeast Philadelphia, what you notice first is a striking ethnic palette. Pink walls adorned by religious artwork softly surround deep red carpeting. A statuette of a Catholic saint sits gracefully on the living room mantel. In the couple’s bedroom, only steps away, a photo of a nun in her habit hangs over the bed. The Mother Superior is their daughter.
Twenty-nine years ago, Jesus moved his wife, nine sons and three daughters from Columbia to Philadelphia for a chance at the American dream. The family farm, where Jesus delivered all 12 of his children, never had electricity.
Their South American homeland also was not known for its cutting-edge medicine. In fact, until last year, 92-year-old Jesus and Rosa, 90, never received regular medical care.
Things changed two years ago, when one of the Messas’ sons was killed in an accident while visiting Columbia. Shortly after, Rosa suffered two debilitating strokes, rendering her voiceless and bedridden. Never leaving his wife’s side, Jesus became decreasingly mobile and increasingly weak. He began suffering from frequent falls, and his asthma and COPD worsened.
“A few months ago, he was much stronger,” says son Joe Mesa. “I didn’t realize how weak he had become.”
Eldest daughter Maria Mesa, who lives with the couple and serves as Rosa’s full-time caregiver, suddenly needed help caring for her father.
Jesus was then introduced to American home care.
According to Linda Farren, RRT, lead respiratory therapist at Apria Healthcare, Boothwyn, Pa., Jesus receives “the home care norm–primarily low-tech oxygen services.” A patient service technician visits him once a week, and a respiratory therapist comes when needed. But Jesus’s is not such a seemingly simple case. Only one member of the Messa family–son Joe–speaks English.
Before dispatching staff to the Messa residence, the home health agency must find out whether Joe will be there to translate. If not, Apria sends a Spanish-speaking patient service technician, ensuring the agency’s cultural competence.
–Elicia H. Geller
Getting to the Bottom of It
Questions to ask ethnic patients:
* How do you describe the problem that brought you here?
* What do you think caused your illness?
* What have you or your family done so far to treat this illness?
* I have done all I can. Do you think someone else could help?
* Have you seen him or her?
* What did they say was wrong?
* What did they recommend?
* Did you try it?
* What can I do to help you?
Source: Huls P. Lecture American Academy of Hospice and Palliative Medicine conference. Cultural diversity: It’s impact on death, dying and grief. 1998.
Ethnic Pharmacology
Many ethnic differences are more than skin deep.
If you’re lucky enough to be a white male in the United States, the medical community probably knows a great deal about how your body works, says Josepha Campinha-Bacote, PhD, RN, CS, CTN, FAAN, transcultural health care consultant at Transcultural C.A.R.E., Cincinnati, Ohio. But if you happen to be a minority, you may be in for some medical and pharmaceutical surprises.
Take hypertension, for example. For years, physicians thought that African American patients were noncompliant with their pharmaceutical regimens. Beta-blockers, the drug of choice several years ago, clearly worked for most of the European-American patients that used them, so the only explanation for the lack of efficacy in the African-American population was that patients weren’t taking them. Or was it?
GENETIC DIFFERENCES
Miraculously, when physicians switched African-American patients to calcium channel blockers, most patients responded. The patients weren’t neglecting their beta-blockers–their physicians were giving them the wrong drugs, Dr. Campinha-Bacote explains.
Researchers recognize that many ethnic differences are more than skin deep. The medical community has long seen ethnic variations in disease states: Hispanics are twice as likely as whites to have diabetes, Vietnamese women are five times more likely than white women to die from cervical cancer, and the decline in AIDS-related deaths is occurring 13 percent less rapidly among African Americans than whites.1
A culturally competent physician can use this information to more accurately diagnose at-risk patients. Consider the following: A physician sees a patient for severe fatigue. When the physician discovers that the patient is Cape Verdean, he realizes that he is at a heightened risk for multiple sclerosis. He tests for the disease, receives positive results and begins treatment immediately. Had the physician not known about Cape Verdeans’ heightened risk of MS, would the patient have been so quickly and accurately diagnosed?
THE PHARMACOLOGICAL SIDE
When pharmacology enters the picture, ignorance can spell death, Dr. Campinha-Bacote says. African Americans, for example, may have a fatal reaction to specific neuroleptics, while Hispanics have the highest rates of TCA toxicity with tricyclic antidepressants.
But practitioners need to remember that all patients are different. A Hispanic patient, for example, could be Cuban, Mexican, Puerto Rican or a variety of other ethnic backgrounds. Tricyclics may be harmless for a Cuban patient and fatal for a Puerto Rican. Many Hispanics also have African heritage, which may expose them to diseases such as sickle cell anemia.
Ignorance is no longer an excuse as physicians and nurses may now find themselves with serious lawsuits, Dr. Campinha-Bacote warns. Ethnic pharmacology is a reality and providers need to master it.
Reference
1. Worcester S. Minorities getting left out of clinical research. Pediatric News 1998;32(10):65. Accessed via www.medscape.com/IMNG/Pediatric News/ 1998/v.32.n10/pn3210.65.02.h10/23/98
–Carrie L. Adkins
The Many Faces of Post-acute Providers
“Today I supervised a third-year resident from Croatia and planned a research project with a first-year resident from Russia. … At this morning’s team meeting, doctors from the Philippines, Columbia and Tennessee planned treatment for patients from Poland, Greece and Cambodia.” 1
–David Hellerstein, MD
Cultural diversity in health care doesn’t come without challenges. From homophobia to racism, “nontraditional” caregivers may face more difficulties than shrinking budgets. Some male patients, for example, don’t want male nurses touching them, while other patients don’t believe men can be compassionate and caring. Ethnically diverse providers may encounter blatant racism, especially in home care
settings.2
Even when patients and caregivers accept each other, differences may create barriers to symptom management, especially with elderly or confused patients, says Pat Huls, RN, BSN, CRNH, case manager and SNF specialist at Hospice of the Valley, Phoenix, Ariz.
“We’re already reading between the lines, and someone from a different culture may miss subtle nuances,” Huls says. Plus, language barriers may make it difficult for patients to make themselves understood.
But differences aren’t always deficits, says Josepha Campinha-Bacote, PhD, RN, CS, CTN, FAAN. “When you see a weakness (in a colleague from another culture),” she asks, “can you see it as a potential strength?” Similarly, when you see a barrier, such as a different language or upbringing, look at the learning experiences it can provide.
Dr. Hellerstein agrees. “Explaining our manner of practicing medicine to people from other cultures is like teaching American slang to a native of France or Thailand. Inevitably we reexamine our own ways in the process,” he writes.
Reference
1. Hellerstein D. Our own private détente: How an American doctor, a Chinese resident, and a Russian patient broke the ethnic barriers in an urban hospital. Hippocrates 1997;10(7). Via. http://www.medscape.com/time/hippocrates/ 1996/v10.n07/InPractice7-96.html
2. Lester N. Cultural Competence Pat 2: A nursing dialogue. AJN 1998 98(9):36-43.
–Carrie L. Adkins
