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'We can work it out' should be motto in addressing conflicting cultural beliefs
Set systems in place to address differences and demolish barriers
Cultural traditions that conflict with Western medicine can be a barrier to safe and effective patient care so it is important to identify them and work out a plan with patients and family members that will result in good outcomes.
It is possible to address cultural preferences without compromising patient safety, says Yvonne Brookes, RN, manager of clinical instructors and patient education liaison for Baptist Health South Florida in Coral Gables.
"We need to be able to sanction other methods of prevention or healing and not necessarily make moral judgments on the behavior of patients. We can't always adhere to the Western system of health care delivery completely. For safer care, we need to merge systems. There are lots of ways we can maintain safety while recognizing other methods patients may have of healing, thus bringing Western medicine and alternative methods together," she explains.
In order to have culturally appropriate health care, staff members must work with patients and families to accommodate their customs and beliefs without compromising safety, says Leslie Catron, RN, a clinical educator at Children's Hospital Central California in Madera.
For example, when a Hmong child is being prepped for surgery and there is a piece of yarn tied to his or her wrist, it is taped off rather than removed because it is understood the yarn was blessed by the family's priest for healing; if it is cut off, the family would feel the child would not heal.
Catron says the palliative care program at the hospital is strong and ensures that each family's religious requirements are met when a child dies. For example, the hospital has worked with a family's Shaman following the death of a child, permitting burnt offerings on the grass outside the window instead of the traditional way, which is under the bed.
To provide culturally appropriate care it is important to know the population base that the medical center serves. The second largest group of Hmong immigrants in the United States settled in the Madera area.
Also, Catron says about 46% of the patient population at Children's Hospital is Spanish-speaking. The central valley of California is an agricultural area that attracts farm workers from the rural parts of Mexico. From March through October, there are as many as 400,000 Mexicans in the area who do not speak English or understand the health care system.
Because the hospital's policy is to treat patients regardless of their ability to pay, the Mexican farm workers with sick children seek medical care at Children's Hospital. The health care institution has set in place an interpreter services department that is strong in Spanish. There are about 20 Spanish interpreters available Monday through Friday from 7:30 a.m. to 5:30 p.m., with interpreters on-call after hours. In addition, there is a Spanish interpreter in the emergency department 24 hours a day, seven days a week.
Understanding that many of the farm workers are from poor rural areas of Mexico, handouts in Spanish are written at a low grade level. The goal is to write at a fifth-grade level in a question-and-answer format. In addition, more and more pamphlets are being created with a lot of pictures, says Catron.
Learn to fill in the blanks
While knowing your patient population base is helpful, it is important to remember patients and their families are not cut from an identical cultural mold.
"It is not always true a person from a certain culture will act a certain way," says Silvia Goldstein, senior medical translator and language assistance for the University of Texas M.D. Anderson Cancer Center in Houston.
It is important to see each situation as unique and not depend on stereotypes, she explains. However, for culturally appropriate health care, a general knowledge of the culture is helpful. At M.D. Anderson, the interpreter services department has created a manual with bulleted lists of basic beliefs, customs, and traditions to aid communication between staff and patients from other countries. (For details about an on-line cultural manual that is available, see box below.)
Cultural profiles available on-line for various groups
Harborview Medical Center has developed a web site that describes the cultural beliefs, medical issues, and other related issues pertinent to the health care of several ethnic groups that recently immigrated to the United States. The information can be found at www.ethnomed.org.
Culturally specific pages include a profile on each group. Currently groups covered are Amharic, Cambodian, Chinese, Eritrean, Ethiopian, Hispanic, Oromo, Somali, Tigrean, and Vietnamese.
Printable patient education handouts on various topics are also available on the web site.
In addition, the interpreters act as cultural bridges. To enhance their skills in this area, the interpreters are continuously studying the various countries the cancer center serves to understand what is happening politically and socially. For example, Brookes says that in some cultures, people are mistrustful of those in authority because their leaders were not good to them. In the medical environment, everyone who is taking care of a patient is considered a person in authority, she explains. In such cases, patients must be made to feel comfortable with health care workers so they will learn to trust them.
Connecting with patients by learning their life stories is an important element of bridging the cultural gap as well, says Brookes. Today, medicine is fast-paced and people are in and out of the hospital quickly; therefore, patients often are treated as medical objects and detached from their life story.
To connect with patients, staff members at Baptist Health South Florida are trained to explore ways of meeting the patient's needs within the limits of the hospital setting. This means they must learn to recognize patients' needs, determine what is important to them, and come to know the patients, says Brookes.
To learn about the cultural beliefs of patients, Children's Hospital Central California has seven questions that address cultural and religious needs on the admissions database. These include:
The answers to the questions are written on the patient's chart and included in the interdisciplinary care plan. There is a section on the care plan for the nurse to determine what needs to be done with the information, such as contacting a social worker, explains Catron.
Set systems in place
Finding ways to address the needs of a culturally diverse patient base often involves setting systems in place to target specific requirements. For example, it is common for Baptist Health South Florida to receive patients from the Miccosukee Indian Reservation, who have many special requests — for example, wanting to be turned a certain way.
When a patient from this group is admitted there is an automatic referral to pastoral care or social work so a staff member from one of these departments can help recognize and address the patient's needs.
While it is important to accommodate the patient in as many ways as possible, each health care facility has a method for delivering care and teaching patients what to expect is one way to help them feel more comfortable. That is why M.D. Anderson Cancer Center uses its interpreters to explain how the health care team works and what is expected of them, says Goldstein. For example, many times, patients from another country will expect the physician to make a treatment decision but at the cancer center patients often must make an educated choice between two options.
Harborview Medical Center in Seattle is in the process of creating an educational tool for patients that explains what the facility has to offer, what a person's stay will be like, what health care team members will interact with them, and what they might expect from each. The way to deliver the information has not been determined yet but the web or a CD-ROM is being considered, says Ella Mae Kurashige, RN, BSN, MSN, manager of patient education at Harborview Patient and Family Resource Center.
Also in the works is a class to help people be better patients. Kurashige envisions the class as a partnership, with the instructor interacting with participants, listening to their concerns, and providing answers. For example, in some cultures, people never ask questions of people in authority and the class could help them learn to ask questions and give them permission to ask.
With so many people on a medical team, it is important for health care professionals to educate patients about their job. Often Brookes will tell people who do not share her cultural beliefs that she is trained to make sure patients follow a certain medical regimen. She also tells the patient she wants to learn what he or she thinks is possible.
"You educate them as to what we have to do in our job, but at the same time you want to have a two-way conversation and agreement with them as well," explains Brookes.
For more information about culturally appropriate care, contact: