Are you misjudging your culturally diverse patients?

Misunderstandings can be dangerous

A Hispanic 13-year old girl with abdominal pain is accompanied by her father, who offers to act as a translator. An Asian woman says she has severe pain, but her facial expression and body language appear calm and serene. An African-American woman is experiencing pressure across her chest, but only tells you that she has a feeling of dread.

These are all situations that can result in a patient being discharged with a life-threatening injury, if you don't "cross the chasm that can exist across cultures," warns Kathleen Dracup, DNSc, RN, dean of the University of California — San Francisco School of Nursing and former emergency nurse. "In the ED, every person who walks in is a stranger to you," she says. "Building a sense of trust and rapport is all the more challenging when you are dealing with diversity of race, gender, or culture."

If your patient tells you their symptoms in "a culturally defined way," it can lead to the wrong diagnosis, says Dracup. For example, if the ED nurse comes from a Mediterranean culture where pain is displayed dramatically, a stoic patient's clinical presentation might not be taken seriously because the nurse is looking for thrashing around, facial grimaces, and other body language.

"If the ED nurse doesn't ask the right questions, they are going to frame the problem incorrectly," says Dracup. "The patient may even be sent home — a disastrous consequence for a condition like acute coronary syndrome."

To meet the needs of culturally diverse patients in your ED, do the following:

Be flexible in the way you communicate.

When a large Arabic family was injured in an auto accident, the men in the family were wailing and throwing themselves on the beds of the injured patients, getting in the way of ED nursing care, recalls Deborah A. Keim, BSN, RN, MICN, educator for the ED at University of California — Los Angeles (UCLA) Medical Center. ED nurses determined that the elderly mother was the head of the family.

"We found that if we sent all information through her, we had a much easier time," says Keim. "Once we figured out that the grandmother was the 'go-to' and calming force in this family, we were able to care for them unhindered."

Give training and resources to nurses.

"Cultural diversity is a big issue for us and many other EDs across the country. We are always looking to improve in this regard," says Keim. "We have a very diverse patient population, and we expect our staff to be culturally competent."

During orientation, ED nurses attend a lecture on healing practices in different cultures, given by one of the department's educators or managers. They also receive a packet on cultural diversity in health care with a self-study assessment to complete, written by a faculty member at UCLA School of Medicine.

ED nurses use a pocket guide to quickly obtain information on ethnic groups, including verbal and nonverbal communication, tone of voice, privacy, activities of daily living, food practices, symptom management including response to pain, birth and death rituals, family relationships, illness beliefs, and health practices.

"We have it located in a central room so staff can use it for quick reference," says Keim.

Utilize appropriate translation services.

If a patient is unable to speak English, nurses at UCLA's ED use telephone interpretation services. "If the patient presents in extremis, we try to get baseline information from them or the family. After lifesaving treatment, we prefer staff to utilize professional interpretive services," says Keim.

At University of California — San Francisco Medical Center, a triage nurse recently used telephone translation services for a patient who spoke Cantonese and no English, and the nurse learned that he had been experiencing chest pain and nausea for three hours. An electrocardiogram was given immediately, which revealed that the man was having an acute myocardial infarction.

Tina Quon, RN, MSN, CNS, BC, clinical nurse specialist for the Division of Emergency Medicine, says, "Although we had three staff members in the department who spoke Cantonese, the use of staff and family members as interpreters is discouraged when consents, diagnoses, treatment, interventions are discussed."

Instead, the hospital's in-house interpreter was called to come to the ED as soon as possible and arrived simultaneously with the on-call cardiologist, who happened to speak fluent Cantonese. "He discussed the diagnosis, cardiac catheterization procedure, and consent process with the interpreter and family at the bedside," says Quon. "The patient received a full explanation of the procedure and process, and we made sure he had no further questions."

For this particular patient, it was essential that the eldest son approved of the medical decision making and interventions, adds Quon.

The man immediately was transported to the cardiac catheterization lab, where he received a coronary stent for an occlusion of the left anterior descending artery. "If translation services were not available, we would not have been able to get this patient to the right place at the right time," says Quon. "We were able to obtain our core measure of door-to-balloon within four hours, and the patient was discharged from the hospital three days later."

For more information on caring for culturally diverse patients in the ED, contact:

  • Kathleen Dracup, DNSc, RN, University of California, San Francisco, School of Nursing, Phone: (415) 476-1805. Fax: (415) 476-9707. E-mail: kathleen.dracup@nursing.ucsf.edu.
  • Deborah A. Keim, BSN, RN, MICN, Emergency Department, University of California — Los Angeles Medical Center. Phone: (310) 794-5823. E-mail: DKeim@mednet.ucla.edu.
  • Tina Quon, RN, MSN, CNS, BC, Clinical Nurse Specialist, Division of Emergency Medicine, University of California — San Francisco Medical Center. Phone: (415) 353-1444. Fax: (415) 353-1799. E-mail: tina.quon@ucsfmedctr.org.
  • Culture & Clinical Care is a reference providing culturally appropriate health care to 35 ethnic groups. The cost is $33.95 plus $8 shipping. To order, contact University of California — San Francisco Nursing Press. Phone: (415) 476-4992. Fax: (415) 476-2373. E-mail: Emily.Huang@nursing.ucsf.edu.
  • A report from The Joint Commission, One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, gives a framework for meeting the needs of culturally diverse patients. To download a free copy of the report, go to www.jointcommission.org/PatientSafety/HLC.