Managing cultural diversity: the art of communication.
--Michel Eyquem de Montaigne (1533-1592)
In the United States at the end of the 20th century, "cultural diversity" is more than just a sociological term; it is a way of life and a way of doing business. In the health care industry, cultural diversity has become an important concept in providing effective patient care. Effectively managing cultural diversity in the health care environment requires a complex set of skills and a thorough understanding of the concept. As the demographics of the U.S. patient population shift, profound changes will be necessary in the way health care is taught, provided and administered.
Today, people who belong to ethnic or racial minority groups make up 25% of the U.S. population: 12% are African Americans, 9% are Hispanics, 2.9% are Asians and 1% represent other groups. By the turn of the century, however, it is predicted that approximately 33% of Americans will originate from ethnically diverse groups.[1-4] Thanks to improvements in global communications and transportation, the United States is quickly becoming a more heterogeneous place, and increased cultural diversity is an inevitable part of this trend.[1,2,5]
In this changing environment, an understanding of cultural diversity and its importance in the effective delivery of health care is paramount. Not only will patients originate from ethnically and culturally diverse groups, but health care workers also will represent a variety of cultural backgrounds, underscoring the need for cultural awareness training in all aspects of the health care profession.
Understanding Cultural Diversity
As the American population continues to diversify, it is essential that health care professionals become sensitized to the myriad factors involved in the effective treatment of multicultural, multilingual patients.[6-9] Data suggest that major shifts will occur in U.S. demographics in the next few years, particularly in border states, providing a catalyst for standardized, cross-cultural training for health care providers.
Demographic shifts also will require a change in the provider-patient relationship. The traditional physician-patient role was based on a Eurocentric, universalist approach to treatment[11,12] in which the same approach was considered equally effective for all patients regardless of their cultural heritage or ethnicity. This paradigm was based on the belief that human emotions are common to all.
An example of this approach is the commonly held belief that all women, regardless of their backgrounds, have a strong maternal instinct and will put the welfare of their children above anything else. This strategy is limited, of course, by its disregard for cultural differences, religious beliefs or individual choices that might alter behavior patterns. For example, drug-addicted mothers may subvert their maternal instincts in order to quench their appetite for drugs, allowing their children to suffer from malnourishment, neglect or abuse. In this case, the drug-culture psyche usurps the addict's maternal instinct. The universalist belief about motherhood, therefore, is inadequate.
In an attempt to rectify this limited approach to patient management, the concept of a culture-specific model of physician-patient interaction was developed.[6,13] In this model, the values, beliefs and cultures of different groups are studied and students are encouraged to become familiar with a variety of cultures as well as their own. In this approach, differences between groups are studied and the similarities of individuals within groups are emphasized.
However, the culture-specific model is not without limitations. To be successful, this strategy relies on a "mastery" of numerous cultures,[7-9] which can be difficult to achieve. Usually, there is little time available for the health care professional to develop or master a specific knowledge of the multitude of cultural groups seen in the workplace. In addition, the culturespecific model has been criticized as simplistic and stereotypical in its approach.
Addressing Cultural Diversity in Health Care
Cross-cultural encounters in the delivery of health care will continue to proliferate. In fact, the increasing ethnic and racial diversity of patients and health care professionals alike will make cross-cultural interactions the norm rather than the exception. Obviously, there is a need for an effective way in which to incorporate diversity training into the health care curriculum and work environment.
Appreciating the role of culture in the health care process has been studied by the nursing profession for more than 30 years.[2-4,14-17] The field of transcultural nursing was established to support the need for the development of culture-specific care, culturally congruent care and culturally sensitive care. Although transcultural nursing is a recognized and respected force in health care, some critics have found fault with the model. Three of the primary objections to this approach are:
* Transcultural nursing is a simplistic and reductionistic concept in which culture is not viewed as a dynamic force, nor influenced to a great extent by an individual's experiences. There is an implicit tendency to assume that what is true of one individual in a group is generally characteristic of the rest of the group.
* Transcultural nursing focuses on particular beliefs or practices without delving into the historic development of the behavior. For example, the fact that certain African tribes view female circumcision as a normal and important rite of passage for young women is in stark contrast to the Western view of female circumcision as a dangerous, cruel and barbaric practice grounded in superstition.
* Transcultural nursing does not take into consideration the effects of outside influences on an individual that may have resulted from factors such as emigration.
Still another objection to the model of transcultural nursing is that its goal is to generate cultural awareness by encouraging "appropriate" behavior -- behavior that is not offensive -- and to try to do the right or appropriate thing, whatever that may be. For example, using culturally appropriate gestures may be considered a goal of effective intercultural communication. To some, however, this behavior can be equated to a series of communication "tricks," particularly since it is impossible for a single individual to memorize all of the different culturally specific gestures or behaviors that might be required.
A more commonsense approach to transcultural nursing might be the view that cultural diversity is a given, a fact of life. One must come to the understanding that all human interactions are governed to a large extent by culture. Achieving successful communication between cultures is the result of understanding that differences are normal and to be expected.
Developing an Understanding of Culture
One can't begin to develop an appreciation of cultural diversity without first understanding the concept of culture. Culture can be defined in several ways. According to one definition, culture is an integrated system of learned patterns of behavior, ideas and products characteristic of a society. It is a philosophy of life and death. Culture is passed on from generation to generation as beliefs, values and mores by parents, other family members and teachers.
Another definition of culture is "the deposit of knowledge, experiences, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a large group of people in the course of generations through individual and group [experiences]."
A third, more common, definition of culture is "a socially constructed and historically transmitted pattern of symbols, meaning, premises, and rules."
The common theme throughout all these definitions is the description of culture as a dynamic, constantly evolving process. Culture is what we do and how we do it; culture is what we consider "normal" thinking and behavior. In other words, culture is assimilated from life by living. It is like an heirloom passed from one generation to the next.
Culture also is a collective process that is individualized and subject to modification due to outside influences. The most important characteristic of culture is that it provides people with a means of survival and a common method of communication within their own cultural group.
It is this very notion of intracultural communication that helps explain problems of cross-cultural communication. What is deemed appropriate or is an accepted form of communication within one culture may be misunderstood or perhaps even distasteful in another culture. The key to diversity awareness is understanding that culture is both an internal and external force; it is almost like a veneer that must be penetrated to encourage successful communication.
Several approaches have been proposed to aid health care professionals in cross-cultural encounters with patients. Not surprisingly, most focus on the importance of effective communication skills.
Communication is a transaction between parties in which information is exchanged. More specifically, it is the simultaneous transmission and reception of information between people. For communication to be considered transactional, it requires mutual and simultaneous perception. Problems occur when one party is not paying attention; mutual contact is essential. The parties involved must assume a role relationship: friends, coworkers, doctor-patient, parent-child. These roles enable communication.
Communication requires a set of culturally specific, implicit rules that are ingrained from childhood. Transactional communication is defined by its context, e.g., how and when communication takes place, the parties involved, etc. All communication episodes are unique, and successful communication requires adaptability and flexibility. As Nance states, "Communication is a complex process that involves the perception and judgment of all involved."
However, communication is more than just the transfer of information. It is how information is conveyed and how it is received. Each person assimilates information through a unique filter created through cultural and personal experiences. The unique nature of this filter increases the chances that this information might be misinterpreted, misconstrued or ignored.
Communication is not just the transfer of information, it is the understanding of the information. Communicating without getting the "right" message across to the recipient is a wasted effort. Unfortunately, this situation frequently occurs, particularly in communications between health care professionals and patients. The health care professional may believe that he or she has communicated effectively and may even ask the patient to repeat what has been discussed to be certain that the patient heard what was said. The patient then may be asked to sign a consent form acknowledging that he or she heard and understood the implications of the information discussed. But does this imply understanding on the part of the patients? In some cultures, agreement with an authority figure is a matter of respect, not necessarily understanding.
As an example of this type of miscommunication, Geist describes a situation in which an older Chinese woman was instructed by her physician to return for a follow-up visit. The patient smiled and nodded her head, but never returned. Additional investigation revealed that the woman never had any intention of returning and that she had nodded out of respect, not compliance. A cultural trait known as "accommodation" was at work in this situation. The message was relayed and received correctly by the patient, but the meaning of her response was obscured by a culturespecific variation that prevented her from telling her physician that she would not be returning.
Nonverbal communication also plays an important role in the exchange of information. It has been speculated that as much as 93% of the total impact of communication is the result of nonverbal factors. Some of these factors include eye contact, hand and body gestures, facial expressions and posture, as well as personal accessories such as an individual's choice of clothing, hair style or jewelry.
The key to successful communication is the realization that communication is more than just the words that are spoken; it is the entire context of the exchange of information, where the communication takes place, when it occurs, how the participants behave, how they dress, how they stand, the tone of their voices and much more. When considering the tools required to foster successful communication between health care professionals and patients, it is important to keep these factors in mind. Considering all of the factors involved in the successful transmission of information, it is not surprising that information can easily be miscommunicated or misinterpreted. It is important to remember that successful communication depends not so much on the words that are spoken or exchanged, but that the meaning is understood.
Particularly in the practice of medicine, it is important that communication between cultures focus on the reduction of uncertainty and foster an environment of trust between the health care practitioner and the patient. This is accomplished by setting a common ground from which to communicate. Nance explains that by establishing a common ground between parties, it is possible to miscommunicate or behave inappropriately without offending the other party. Common ground is characterized by sincerity, patience and a mutual goal of learning.
Once a common ground has been established, the communicator must realize the role of communication in the recipient's culture. In some cultures, called "high-context cultures," the role of verbal information is minimized, and information is transmitted in the physical sense or it is internalized. An example of a high-context culture is the Japanese, who are skilled at perceiving and interpreting nonverbal messages and usually assume that their conversational partner has the same skills. For instance, a Japanese wife is expected to know what her husband wants without asking him. To ask him would demonstrate her inadequacy.
This is in stark contrast to a "low-context" culture, in which the primary emphasis in communication is placed on the spoken word. Americans, the Swiss and Germans are examples of low-context cultures. In the United States, for instance, it is common for couples who are experiencing communication problems to seek the help of a counselor who may encourage both parties to "speak their minds."
Successful intercultural communication is contingent upon the development of trust between both parties and the development of an understanding of the various degrees of importance each party places on verbal and nonverbal communication. By developing an appreciation for the significance that each party places on various forms of communication, an effective transfer of information is possible.
Nance identifies three basic principles that are essential for health care professionals who wish to increase their odds in favor of a successful intercultural encounter:
* A multicultural perspective. In adopting a multicultural perspective, the health care professional acknowledges the validity of all cultures as important and indicative of the heritage of the individuals from that culture.
* A historical view. To understand a culture, it is important to understand the history and politics surrounding the formation of that culture. Cultural patterns generally have a basis in reason, and in many cases those reasons can be better understood with a sense of the history leading up to and surrounding those events.
* An individualistic approach. By treating each patient as a unique individual, health care workers can avoid stereotypes and acknowledge that the actions or beliefs of a particular member of a cultural group are not necessarily characteristic of the group as a whole. Likewise, what is characteristic of a group in general is not always characteristic of the individual. Individual experiences help to shape a person and often are superimposed over the cultural heritage of any one person.
Consider, for example, the case of Timothy McVeigh, convicted of the 1995 bombing of the Alfred P. Murrah federal building in Oklahoma City. Were McVeigh's actions characteristic of all Desert Storm veterans? Of all people raised in single-parent households? Of all young white men? Certainly not; McVeigh's actions were those of an individual.
While this analogy may seem somewhat simplistic, it nevertheless underscores the point that individualism is not usurped by the cultural norm. Instead, the cultural norm serves merely as a framework upon which individual personalities are shaped.
Providing Culturally Competent Care
Increasingly, health care professionals are being called upon to deliver patient care that is not only technically competent, but also culturally competent. Cultural competence is defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals that enable that system, agency, or those professionals to work effectively in cross-cultural situations."[3,24]
In 1992 the American Academy of Nursing Experts Panel on Culturally Competent Health Care defined culturally competent care as care that is sensitive to issues related to culture, race, gender and sexual orientation. This care is to be provided by health care professionals who understand and use cultural nursing theory in the provision of care. Cultural competence is a process in which the health care professional continues to attempt to work effectively within the cultural context of the patient.[3,25]
Developed by Campinha-Bacote, the culturally competent model of care is based on four components: cultural awareness, cultural knowledge, cultural skill and cultural encounter. (See Fig. 1.)
[Figure 1 ILLUSTRATION OMITTED]
Cultural awareness is a deliberate learning process during which the health care professional becomes familiar with the beliefs, values and practices of a patient's culture. To accomplish this effectively, the health care professional must first understand his or her own cultural background and explore possible biases or prejudices toward other cultures. People tend to be somewhat ethnocentric in their approach to others and may impose their beliefs or value systems on others without realizing it. This tendency is referred to as cultural imposition, and it is imperative that the health care professional recognize his or her own prejudices before becoming truly culturally aware.
In the educational setting, several techniques are available to help educators teach and encourage cultural awareness among their students. Pedersen advocates a variety of experiential exercises in which participants engage in role playing, role reversals and simulation of encounters; field trips; self-guided reading; review of critical incidents; group discussions; audiovisual presentations; interviews with consultants and experts in the field; and bicultural observations. The goal of these exercises is to increase the student's awareness of the similarities and differences between his or her background and that of the patient.
In addition, tools have been developed to help educators assess their students' level of cultural awareness. The Developmental Model of Ethnosensitivity evaluates students' ability to comprehend cross-cultural issues and offers strategies for improving these skills. The model is based on a continuum of sensitivity that begins by addressing each student's fear of the unknown or, in this case, explaining unfamiliar customs or beliefs. The model then moves through a variety of stages including denial or overgeneralization, superiority or negative stereotyping, minimization and reductionism, relativism (an acceptance of differences) and empathy, all with the ultimate goal of developing an ethnosensitive attitude toward the other cultures.[3,26]
Cultural knowledge is the process by which the health care professional obtains a comprehensive education about various cultures. Obviously, it is not possible to become familiar with all aspects of all cultures; instead, the goal is to become familiar with some of the ideas, practices and lifestyles that are characteristic of some of the major cultures that the health care professional might encounter in his or her practice. Table 1 provides a brief overview of cultural comparisons of some of the major ethnic groups in the United States.
Table 1 Attitudes and Behaviors of Cultural Groups in America Regarding Illness and Health Care(*)
Note: The beliefs, practices, traits and preferences listed here should not be considered definitive. Every patient should be treated as an individual, and care should be taken to avoid ethnic or racial stereotypes.
Focus often is on acute care rather than preventive
care. Illness and disease may be viewed as being
related to bad luck or chance. Some patients may
have a lack of understanding of or misconceptions
about biomedical approaches that limit their seeking
medical attention. Home care often is tried first
before seeking medical care. Patients may not feel
comfortable relating home care remedies tried
before medical attention for fear of being misunderstood
or criticized. Family structure is important,
with strong matriarchal roles. Chinese
Health is viewed as a state of spiritual and physical
harmony with nature. Holistic, traditional approach
to illness incorporates acupuncture and herbal medicine.
Taking medications when feeling well may be
an alien concept to some. Elderly have high status
and are cared for by children or grandchildren;
young defer to old in decision making. Patients may
not be accustomed to being touched by strangers,
may avoid direct eye contact and may require
increased personal distance (greater than arm's
length). Mental illness is stigmatized. Eastern Indian
Disease is believed to be caused by an upset in
body balance, and medical care often is sought only
in acute situations. In traditional families, women
are dependent and men often receive preferential
treatment. Direct eye contact is considered disrespectful
and an invasion of privacy. Handshakes
are permitted between men only. Patients may quietly
bear pain, although pain relief medications are
accepted. The head motions for "yes" and "no" are
the opposites of those used by Anglo Americans. Filipino
Health promotion is important, although formal care
may not be sought except in acute situations.
Patients may be stoic when experiencing pain,
believing it is the will of God. When offering pain
medication, the offer may need to be repeated more
than once before the patient accepts it. Patients may
be hesitant to give a. "no" answer and will instead
remain quiet. Family may want to participate in
patient's health care. Mental illness is stigmatized. Haitian
Biomedical and magico-religious approaches to
health care. Belief in voodoo, prayer, healing and
the protective power of God, although Western medicine
is sought more often than traditional. Many
patients have a high tolerance for pain and discomfort.
The extended family is important and participates
in decision making; women bear major
responsibility for caring for ill family members. Iraqi
Family and elder care are stressed. One or more
family members may accompany the patient and
wish to be present for all exams, and the eldest
member of the family may answer all questions on
the patient's behalf. Relief from pain is expected
immediately, and patients may request relief measures
persistently. Religion influences health behaviors.
Muslim practices and rituals should be incorporated
into care if possible (e.g., prayer five times
daily, facing Mecca, avoidance of pork, fasting).
Caregivers of the same sex as the patient are preferred
or demanded. Israeli
Medical and surgical procedures are not performed
on Sabbath or holy days unless the condition is
threatening. The Jewish liturgy includes many
prayers for the sick, and their use is encouraged. A
rabbi or official representative may be sought
regarding Jewish traditions. A male patient who is a
strict observer of the faith may wish to keep a prayer
shawl, cap and other special symbols with him.
Prayers often are chanted, and privacy is desire,
during prayer. May follow specific dietary restrictions,
e.g., no pork or predatory fowl, milk and meat
dishes never mixed, kosher foods. Patients may
expect members of the health care team to be
assertive. Family provides attention and support. Japanese
Magico-religious approach to health leads some to
consult with priests before important activities or
decisions; biomedical approaches also accepted by
some. Family members often participate in care
of the patient. Family interdependence is highly
valued, so self-care may not be viewed positively.
Strong respect for social rank; titles may be used
instead of names. The physician is expected to
know best and to use good judgment. Patients
require increased personal space (more than
arm's length). Direct eye contact is considered a
personal affront. May avoid saying "no" directly. Mexican
Combination of biomedical, magico-religious and
traditional approaches to health care. Common
beliefs include mal ojo (evil eye), susto (illness
resulting from a traumatic emotional event or a
scare), mal puesto (a hex or illness imposed by
another), mal aire (bad air, exposure to drafts).
Self-medication is widely practiced. Patients may
have a deep mistrust of the health care system,
and family decisions sometimes can overrule
health care provider decisions. Practitioners
sometimes are viewed as outsiders. Native American
Combination of Western and Native American
medicine often is used to maintain or regain
health. Community and family members' presence
and prayers are very important when an illness
occurs. Ceremonies often are performed to
assist the patient via self-empowerment to restore
personal harmony and balance. Patients may not
ask questions because they expect the health
care provider to tell them what they need to know. Saudi
Approaches to care include biomedical, holistic,
magico-religious and traditional. Islamic beliefs
and culture are present in all aspects of care.
The patient likes to be an active participant in his
or her own health care. Many believe that invasive
treatments such as intravenous infusions and
injections are the most effective. In most cases, a
health care provider who is the same sex as the
patient is preferred. May prefer to relate to others
of common identity and may be hesitant to share
personal information with a health care provider
who is viewed as a stranger. Care is rendered in
the context of the family.
(*) Table adapted from: Sieh A, Brentin LK. The Nurse Communicates with Culturally Diverse People. Philadelphia, Pa: WB Saunders; 1997. Table includes information from: Geissler E. Pocket Guide to Cultural Assessment. St. Louis, Mo: Mosby-Year Book; 1994.
In addition to cultural differences between groups, there may be physiological or biological differences as well. For example, researchers have recently discovered that people from different ethnic or racial groups may have significant differences in their metabolism rates, responses to drugs and side effects from medications or treatments. In an effort to better understand the genetic nature and the potential implications of these phenomena, a new research field known as ethnic pharmacology has been established.[14,28]
Much of this research has focused on how people of different ethnic backgrounds respond to pain medications that affect the central nervous system. One study showed that Chinese patients required lower dosages of benzodiazepines, tricyclic antidepressants, atropine and propranolol than Anglo patients. In addition, when comparable doses of these medications were delivered to both groups, the patients of Chinese descent experienced an increase in side effects. Researchers hypothesize that people of Chinese ancestry metabolize the medications differently and dosages must be adjusted to obtain a therapeutic effect with minimal side effects.
Cultural skill refers to the process of learning to conduct a cultural assessment. This involves a detailed assessment of individuals, groups and communities regarding their beliefs and practices to determine whether particular interventions or adaptations on the part of the health care professional are required to provide optimal care.[3,16] The health care provider must take the time to learn about the patient's perception regarding health care to determine how that care should be administered.
When conducting a cultural assessment, it is important for the health care practitioner to approach each client as an individual, beating in mind that many factors are at work in creating a cultural group. For example, location, gender, age, religion, sexual orientation, occupation and socioeconomic status are all factors involved in the makeup of an individual. These factors can have tremendous influence over the way a particular patient expresses illness or health and reacts to medical treatment. Although it may seem confusing at first, when using cultural assessment it is always important to view the patient within the context of his or her culture, and also as an individual influenced by a variety of factors related to his or her culture.
For example, while two individuals of Polish descent may both be female, born in 1957 and raised in Warsaw, one may be Catholic and the other may be Jewish, bringing significantly different cultural beliefs and practices into their respective cultural assessments. Obviously, to disregard religious affiliation as a factor in the cultural assessment of the women in this example could result in an incomplete assessment, perhaps providing an inaccurate perspective of their respective cultural backgrounds and belief systems.
Several cultural assessment tools are available. Leininger describes one model of cultural assessment in which nine different areas are addressed:
* Patterns of lifestyle.
* Specific cultural values.
* Cultural taboos and myths.
* World view and ethnocentric tendencies.
* General features that the client perceives as different or similar to other cultures.
* Health and life care rituals and rites of passage to maintain health.
* Degree of cultural change.
* Caring behaviors.
* Folk and professional health care systems.
According to Leininger, the most important factors required in an accurate cultural assessment are to maintain a broad, objective and open attitude toward individuals and their cultures and to avoid seeing all individuals as being alike.[3,16]
It also is important for health care practitioners to guard against the development of the "cultural blind spot syndrome" in which care givers sometimes assume that because a patient may look or act in ways similar to him or her, those similarities mean there are no cultural differences between the patient and the health care provider, or there are no culture barriers that might hamper optimal treatment. This assumption often proves to be incorrect.
Another model useful in cultural assessment is Bloch's Assessment Guide for Ethnic/Cultural Variations.[3,30] This system is based on data collection from four areas: cultural, sociological, physiological and psychological. Cultural data includes information such as place of birth, values, beliefs and customs, healing practices and language. The CONFHER model uses seven variables to evaluate the cultural aspects of communication, orientation, nutrition, family relationships, health beliefs, education and religion (hence the acronym).
Yet another model proposed by Giger and Davidhizar[3,15] incorporates six factors important in cultural expression:
* Communication. Vocabulary, grammatical structure, voice qualities, rhythm, speed, silence, facial expressions and body posture all can vary from culture to culture.
* Space. In some cultures, people are territorial and do not like others to encroach upon their own personal space. In other cultures, personal space is shared. Health care workers must respect how members of various cultural backgrounds view their personal space.
* Environmental control. The need to control or manipulate our environment can differ from culture to culture.
* Time. Some cultures focus on the past and are tradition-based; others are present-oriented and "live for today"; others look toward the future and tend to postpone immediate gratification in favor of future gain.
* Social organization. The family unit is at the center of almost every culture. How a particular culture views the family unit might affect how a member is treated when he or she becomes ill.
* Biological variations. Scientific evidence shows that members of specific races or ethnic groups can be more prone -- or more resistant -- to certain diseases or illnesses.
No matter which model is used, the goal of conducting a cultural assessment is to develop a mutually acceptable and culturally sensitive treatment regimen for the patient. The health care provider must acknowledge the patient's right to his or her cultural beliefs and practices, and it is essential that these factors be understood and respected by the care giver.
This is a process in which the care giver engages in cross-cultural interactions with clients from diverse backgrounds. The goal is to prevent the health care practitioner from assuming that after a few encounters with a particular group, he or she is knowledgeable about the group as a whole. For example, in an urban environment a radiologic technologist may perform mammography on hundreds of white women over the course of a year. Based upon those interactions, the technologist eventually may come to expect all mammography patients to behave in the same way. However, in parts of the country such as Ohio or Pennsylvania, the patient might be of Amish descent, and her reaction to breast examination may be completely different. Because of her cultural background, the Amish patient may prefer a more modest examination.
As a result, when circumstances permit, health care providers should take the opportunity to interact with patients from diverse cultures. Direct contact with patients from differing backgrounds can help increase the provider's knowledge of a particular group and may help to alleviate certain prejudices or negative stereotypes that the health care provider may not even be aware of. Cultural encounters are the surest way to prevent stereotyping that might occur when the health care giver's experience is based solely on classroom knowledge. Face-to-face contact humanizes the relationship between the care provider and patient, particularly in cases in which both parties are from different cultures.
Diversity Training in the Hospital Setting
The Joint Commission on Accreditation of Healthcare Organizations has stated that "the impact of the person's culture is an important component of the assessment process" and must be taken into consideration to provide patient care and patient education in an individualized manner. Accomplishing this goal can be problematic in certain clinical settings, particularly in situations where the majority of health care providers and patients are from a relatively homogenous background and where minimal cultural diversity is the norm. In these cases, it may be difficult to convince staff members that diversity training is truly warranted and not just another halfhearted attempt at some corporately mandated quality management program.
An interesting case was documented by nurse educators at the three facilities that make up the Upper Valley Medical Centers (UVMC) in Ohio. At these facilities, 99% of the nurses were of European-American descent. Furthermore, it was extremely unusual for the nurses in these facilities to encounter a patient from a cultural background different from their own. As a result, the majority of the nurses did not see a need for cultural awareness or cultural competence training. In fact, many of them viewed it as a threatening proposition.
The primary objective of the nurse educators at UVMC was to convince staff members that cultural diversity encompasses more than just a patient's ethnic background and to establish the principle that every patient has a right to culturally relevant care.
Prior to beginning diversity training, the nurse educators discussed perceived problems and ways to overcome them. A major concern involved dealing with the nurses' own insecurities. The nurses worried that they might be forced to admit their own prejudices and discuss their own personal beliefs. Another potential problem was the lack of interest in the concept. The educators decided to proceed in as nonthreatening a manner as possible, while searching for ways to increase interest in the program.
The Campinha-Bacote Culturally Competent Model of Care was used as the basis for the program, and since this model is a continuous process, the program was divided into four sections. Each session was based on one of Campinha-Bacote's components of care: cultural awareness, cultural knowledge, cultural skill and cultural encounter. Nurses were permitted to attend any of the sessions, and they received continuing education credit for participating in the program.[3,25]
The segment on cultural awareness provided attendees with experiential contact and direct interaction with individuals from another culture. After completing the exercise, some of the attendees commented on how unaware they were of how their own backgrounds and cultural biases lead them to view someone else's behavior negatively.
The UVMC educators based their class on cultural knowledge around a game invented specifically for the purpose, "cultural bingo." Attendees were required to interact with members of differing cultures, asking questions about various practices and beliefs pertinent to those individuals. The first participant to get the correct answers to four questions won "bingo" and received a culturally sensitive prize. Participants considered the exercise to be a fun, yet informative way to learn and discuss cultural differences.
In all, 90% of the attendees in the UVMC program rated their training as good to excellent. These strategies can be adapted with minimal effort in any setting to help staff members become culturally aware by learning about themselves and other cultures. The Culturally Competent Model of Care can help health educators lay the foundation for culturally competent, sensitive care. By structuring these activities in a voluntary, nonthreatening and fun way, programs such as the one developed by UVMC can provide a positive learning experience for health care providers.
Language as a Barrier to Communication
Language barriers between health care professionals and patients can exist on many levels. Published estimates indicate that more than 12% of people living in the United States today do not speak English fluently. If the rates of cultural diversity continue as predicted, that percentage is expected to grow dramatically.[33,34] Obviously, when the health care provider and the patient do not share a similar culture or language, communication problems can occur.
Difficulties in communication can compromise the patient's care in many ways, possibly resulting in noncompliance with medication regimens. Tuberculosis patients, for example, may not understand the seriousness of failing to refill their medications or failing to take them for the period of time required. They may not be aware of the dangers of developing drug resistance or the danger of contagion that they pose to their family and friends.
Likewise, patients who have undergone surgery and are released from the hospital may not understand the need to comply with postoperative treatment plans. Or, they may understand the physician's instructions to rest following surgery, but purposely choose not to comply. For an unmarried working woman who is the sole supporter of a family, rest may not be an option. As a result, she may feign understanding in order to avoid a potentially embarrassing confrontation, thereby unwittingly sabotaging her chances of an uncomplicated recovery. The potential for misunderstandings are infinite, and an attempt must be made by the health care practitioner to address any potential communication errors.
Communication can be hampered even when both parties are from the same culture and speak the same language. In this case, the difficulty in communication is primarily related to the patient's ability to understand the intended meaning of the information provided by the health care professional. Although the care giver may have spoken correctly and conveyed the proper information, the patient may have difficulties in receiving and understanding that information. A primary factor in this failure to communicate is related to the "language of science."
While physicians and other health care professionals are familiar with medical jargon, most patients are not. The patient's knowledge of medical vocabulary can vary from nonexistent to a professional level of understanding. Samora and colleagues relate a humorous situation in which the patient, the physician and the nurse, all speaking English, failed to communicate. The patient was unfamiliar with some of the technical terms used by the physician and nurse. It is interesting to note that neither the nurse nor the physician ever suspected that the patient couldn't understand their questions. The patient tells the story:
...Like I told you, I think it would be nice if
they would reduce the language to where a person
with hardly no education could understand
these people; but me, I'm so frank myself that I
tell them, "Look, let's knock this thing down and
let's speak English to me because I don't know
what the devil you're talking about." And they
always have; the doctors I've went to and those
that seen my children have always been very nice
about it. In other words, they knock it down to
where it is just plain English to me. But this doctor
kept coming in every day and asking, "Have
you voided?" So I'd say, "No." So in comes the
nurse with some paraphernalia that was scary. So
I said, "What the devil are you going to do?" And
she said, "I am going to catheterize you, you
haven't voided." Well of course I knew what
catheterization was. I said, "You are going to pay
hell. I've peed every day since I've been here." I
said, "Is that what he said?" And she said, "Of
course, Rusty, didn't you know?" And I said
"Well, why didn't he just ask me if I'd peed? I'd
have told him."
As this example shows, it is the health care provider's responsibility to determine whether the information that he or she has conveyed to the patient is indeed received and processed so that both parties are in agreement regarding the meaning of that information. Simply asking the patient to repeat the information verbatim does not guarantee that the patient grasped the meaning of that information. A common method of gauging understanding is to ask the patient to explain the information in his or her own words so that the health care giver can correct any erroneous information and be certain that the meaning was understood as intended.
In cases where language barriers exist between the health care provider and the patient, several options are available. One solution is to recruit the services of a bilingual staff member or to enlist the help of a friend or relative of the patient to act as a translator. Most large hospitals and some health maintenance organizations employ or hire contract workers as certified medical interpreters in a variety of languages. In addition, some health care facilities use commercial translation services such as the AT&T Language Line. Commercial services are generally available by phone, providing 24-hour access to interpreters in more than 120 languages.
Obviously, trained medical interpreters are preferred when a patient does not speak English, but these services can be expensive and may be difficult to arrange in off-hours or during an emergency. When using untrained translators or friends or relatives to translate, it is important to consider the potential for misunderstandings that could result in malpractice suits.
Without a clear line of communication between patient and health care provider, medical care will ultimately be compromised. Failure to communicate with people from cultural backgrounds different than our own can be attributed to a variety of factors, including a lack of cultural awareness, an ignorance of cultural norms and language barriers. As the U.S. population becomes more diverse, cultural awareness training will assume a more prominent role in health care education. Improving the health care practitioner's ability to communicate effectively will serve to increase the quality of care delivered to patients, resulting in better outcomes, improved levels of patient satisfaction and reduced health care costs.
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Julliana Newman, B.A., ELS, is a certified editor of the life sciences. Her Radiologic Technology article titled "Early Detection Techniques in Breast Cancer Management" recently was awarded the 1997 Rose Kushner Award from the American Medical Writers Association for writing achievement in the field of breast cancer. The award was sponsored by the AMWA and Zeneca Pharmaceuticals. Ms. Newman resides in Albuquerque, N.M.
Reprint requests may be sent to the American Society of Radiologic Technologists, Publications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.
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|Title Annotation:||includes continuing education post-test|
|Date:||Jan 1, 1998|
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