By Jeanie Davis

Are your international patients struggling to adapt to life in a U.S. hospital? Have you experienced difficulty interpreting their needs? Do you believe that their care has suffered due to these difficulties? It is imperative that case managers take extra care to help them adapt.

With the increased diversity among today’s hospital patients, case managers must be careful to understand each patient’s culture, says Victoria Showunmi, RN, MSN, MBA, CCM, who emigrated from Nigeria 17 years ago. She has worked as a case manager at the MD Anderson Cancer Center in Houston for the past five years — a hospital with a large international patient population.

Showunmi has been instrumental in coordinating programs to help fellow case managers become culturally competent, she says. “People coming from different worlds have different expectations of the healthcare system.”

Her own experience in making the transition to U.S. culture is a great example. “There are terms that do not exist in my culture, such as ‘hospice,’” she says. “It’s the same challenge for our patients, and we need to understand that to meet their needs.”

Showunmi explains that culturally competent care provides many benefits, including:

  • Potential to improve health outcomes;
  • Effective use of healthcare resources;
  • Increased patient satisfaction;
  • Increased efficiency and effectiveness of staff;
  • Reduction in medical errors and lawsuits.

She defines “culture” as all integrated patterns of human behavior that include language, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Communication, courtesies, rituals, roles, customs, relationships, practices, expected behaviors, values, thoughts, and manners of interacting all are reflected in culture, she explains.

Cultural competence, Showunmi says, is “having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs in order to deliver the best care.”

She advises that in healthcare, certain cultural practices often cause concerns, including:

  • Language and communications;
  • Religious beliefs;
  • Healing practices and preferences;
  • Family involvement;
  • Pain management;
  • End-of-life care.

Case managers are obligated to respect the rights and inherent dignity of their patients, Showunmi says. “They must also act with integrity and fidelity with patients,” she explains. While this is not always easy, especially when there are language differences, case managers must accept each patient’s differences, she explains.

Showunmi gives this advice for cultural communication:

• Listen, engage, and educate. A translator should be a priority, when necessary. Then, start the conversation with simply asking the patient or family member how people from their culture view things related to healthcare. For example, some cultures believe one must tolerate pain and should not need pain medications. But other cultures have low tolerance for pain and can buy pain medications over the counter. “You can explain that pain medications are not bad, that they can help you do things you need to do,” Showunmi explains.

• Assess and acknowledge a request. This shows respect. For example, in some cultures, the entire extended family will gather at the hospital to care for a loved one. In the Hispanic population, the entire family is involved in the care of the patient. “It’s not uncommon to see 15 to 20 people in the room,” Showunmi says. “Grandparents, grandchildren, everyone.”

Negotiate a middle ground where everyone is comfortable. She advises case managers to accommodate the big family group. “Make the effort to accommodate them as much as possible when discussing plan of care or goals of care,” she says. “But also negotiate the visiting hours and the number of guests that can stay overnight.” Also, she advises using a translator so they can understand.

• Approach each patient with an open mind. The case manager must be open to the patient’s culture, advises Showunmi. It helps to ask about the family’s expectations at various milestones in the patient’s care. “In the Chinese culture, when the patient is about to pass, they must lay on something [personal mattress or bed] from their home,” she explains. “They should be allowed to bring things to the hospital like a comforter or a pillow to accommodate their culture. This shows you acknowledge their culture.”

Another example: “In some cultures, the male makes all the decisions. The female will say, ‘Whatever my husband says.’ You can explain that in this country, you have your own right to make a decision about your medical care. Explain why the test or treatment is necessary, so we can provide you with the best care,” she advises.

• Recognize that direct eye contact can be interpreted in different ways. “Not making eye contact can be a sign of respect,” Showunmi says. “Don’t think they are not listening.” Ask patients questions to ensure good communication.

Touching another person is restricted in some cultures, she says. “Some religions do not allow a male to touch a woman,” she says. “Most people understand that holding someone’s hand can be a sign of comfort, if you do it in a way that shows you care about them.”

• “Yes” and “No” can be misinterpreted. “In some cultures, it is customary to say ‘yes’ to everything,” says Showunmi. “They don’t want to sound disrespectful.” When asking a question, phrase it so another response is required, she advises. “Don’t ask them if they feel pain; ask what level of pain are they tolerating.”

• Respect religious beliefs. For example, it may go against some religious beliefs to receive a blood transfusion. Or, visitors may be prevented from seeing some patients. Her advice: “Ask each patient, ‘What are your preferences?’ You don’t want to generalize about any religion, but do what you can to respect their wishes.”

For instance, Christians may request a priest; Jewish people may want a rabbi for prayers and blessings before a major procedure. For Muslims, make accommodations for daily prayer, five times per day.

Showunmi advises training staff in cultural awareness. Staff members and others can provide presentations about their cultures. “Our diversity in the U.S. will continue to increase, so we must prepare to meet our patients’ needs as much as we can.”

Case managers may invite people from outside their organizations to provide education on specific cultures, she adds. “There are several local groups in the community who cater for specific populations. They may be a very good resource.”