Prepare staff and provide the tools to meet needs of culturally diverse patients

Though cultural lessons help, basic educational techniques still apply

Cultural diversity impacts patient education in many ways. Staff must be taught about the differences between cultures so that they provide appropriate teaching. They also must learn how to access interpreters when patients don’t speak English and allot extra time for teaching in such situations.

Tools to help staff teach patients of varying cultures need to be available, in addition to a means of providing written information in foreign languages to patients as needed.

Health care institutions have come up with a variety of methods to address these issues. At Phoenix Children’s Hospital, educators are given a pocket card created by Arthur Kleinman, a medical anthropologist from Harvard University in Cambridge, MA. One side of the care has eight questions for assessment that help to identify where health care professionals and patients agree and where they differ on the health problem being addressed. 

The other side of the card has the goals of patient and family education and how to evaluate understanding. Staff members are encouraged to use it with all patients because those in the medical field have their own "medical" culture that has its own language and behavior norms. Therefore, every patient they interact with is outside their culture, says Fran London, MS, RN, health education specialist at The Emily Center, Phoenix Children’s Hospital.

"Consequently, we need to approach every patient and family member as a culture outside of our own," says London.

To teach staff various cultural norms, The Ohio State University Medical Center in Columbus conducts inservices on various units targeting population groups that staff see in large numbers, such as patients from Somalia. Also, available to staff via the medical center’s patient education web site are links to information on ethnic groups.

"These sites provide help if I am not available or they can’t get someone in customer services to address the issues for them," says Diane Moyer, RN, MS, program manager for consumer health education at The Ohio State University Medical Center.

Because people from around the world come to Deborah Heart and Lung Center in Browns Mills, NJ, staff members routinely see patients from a wide array of cultures. Recently, two children from Tanzania were admitted for open-heart surgery and were accompanied by their mothers, who spoke no English. This is a common scenario because Deborah participants in the Children of the World Program, which helps families with medical care.

To meet the needs of these and other families, staff are prepared for diversity. Once a month, a country is featured and all the food prepared in the cafeteria features that culture and their music is played. "This month was Bastille Day for the French, so we had French cuisine. Next month, Jamaica will be featured because of Jamaican Independence Day. "We try to tie it with a holiday they are celebrating," says Laura Gebers, BSN, RN, BC, Patient Care Services Program health education coordinator, at Deborah Heart and Lung Center.

Gebers posts a flyer on the intranet with information about the culture of the featured country and what health care providers would need to know to provide care for these patients. The information also is posted outside the cafeteria.

Annually, the center brings in a professional presenter from another culture to explain how staff can be sensitive to patients from that particular culture. Last year, the presenter was from the Amish community.

Also helpful to staff is a small library of books that offer the nuances of various cultures, which are kept in Gebers’ office and in some of the units.

One of the greatest personal skills an educator could have, whether working with a patient from another culture or not, is the ability to listen, says London. Each educator should pay attention to who the learner is and what he or she knows, understands, and believes, she says.

"Teaching should always be individualized to the needs and abilities of the learner and culture is always a contributing factor," says London.

To teach patients with cultures different from their own, educators need patience, an open mind, empathy, a desire to think outside the box, the ability to work in tandem with an oral interpreter, and the ability to adapt to a very different environment where a new style or methods might need to be used, says Andrea Henry, multicultural services coordinator at Children’s Healthcare of Atlanta.

Interpreters can add to complexity

Even good teaching techniques can’t overcome a language barrier. In order to teach, an interpreter must be contacted. One of the problems The Ohio State University Medical Center has is providing quick and easy access to interpreters because the demand has been increasing and there are not enough of them available in the community.

"Even with interpreters on staff there are still delays when there are multiple patients coming in at different locations within our system," says Moyer.

To provide interpretive services, the medical center has several trained interpreters on staff and a contract with an outside agency. Staff also have access to a telephone interpreter service but don’t like to use it unless they have to, preferring to have the interpreter present.

When employees are hired at Deborah Heart and Lung Center, they are asked what languages they speak. Those designated as interpreters go through a medical interpretation training course. It originally was taught by an outside consultant who also taught a few key individuals to be trainers, says Gebers. There are, of course, privacy and confidentiality issues involved when using an interpreter, she says.

At Children’s Healthcare of Atlanta, interpreters must have superior dual language fluency, terminology fluency, superior verbatim memory, and adhere to ethical standards for medical interpreters. They are evaluated for these skills annually.

"We have staff interpreters, agency interpreters, telephonic interpreters, and limited use of volunteer interpreters and bilingual employees," says Henry.

When a patient at The Ohio State University Medical Center requests that a family member interpret, it is allowed, but discouraged if the communication entails a legal document or consent form. It is possible that a family member might withhold information knowing that if the patient knew all the facts he or she might not sign a consent form and then it would not fully be informed consent, says Moyer.

Another problem with allowing family members to interpret is their lack of training. "Even though they know their own language, nonprofessionals may not know the medical terms or they may not understand how to provide an overview of what the physician is saying even if there aren’t words in that language to say it exactly as he said it," says Moyer.

Educators need to know that an interpreter will likely affect his or her flow and style of teaching because pauses must be made and clarification and elaboration often is needed, says Henry. "The educator must strive to make eye contact in an appropriate manner considering the interpreter might inadvertently become the focus for both the educator and the patient," she says.

It’s best for the educator to think of the interpreter as a microphone, someone to voice their words and their meaning and to capture the spirit and the tone of their teaching, says Henry. "Ultimately, it is the responsibility of the educator to teach and the responsibility of the interpreter to accurately and completely convey the educator’s words of wisdom," she says.

Reinforce education

The educator should ask open-ended questions, following the teaching session to ensure that the patient understands, says Henry. "Let them talk about their way of doing things or how they perceive your way matching their way," she says.

After the educator, with the aid of an interpreter, has covered the teaching components, it is important that the patient receive some sort of written information that patients or family members can refer to later, says Moyer. This is particularly important when patients are being prepped for tests and procedures or being discharged, she says. Written materials are appropriate because even if the patient is not literate, there usually is someone in his or her family or community who can read.

When written materials are not available, either in the appropriate language or topic at Deborah Heart and Lung Center, the information is written down for the patient. There is a service that the center uses that promises a 24-hour turnaround. "If we have someone admitted and we know we need certain discharge instructions, we would send that to them to do," says Gebers.

Teaching always should be done in interactive conversation with clear and simple written materials used as a reference, says London. "Paying attention to your learner and how he or she acts around printed materials gives you the best cues for literacy assessment," she says.

While teaching always takes time, it is even more time consuming when done with the help of an interpreter. The language barrier complicates the teaching a bit because the educator is talking through a third person. Also, you use more show and tell, says Moyer.

Once, while teaching a group of Russians about diabetes, Moyer told them that they could eat a half-cup of pasta. The interpreter told her to show the group a measuring cup so they would know what she meant; because in Russia, cooks use whatever size cup they pull from their cupboard.

"It’s important to ask the interpreter to have the patient explain what was said to them," says Moyer. For example, the patient might explain how they will know if their blood sugar is too high or if they should call the doctor.

Allow patients to maintain as much of their culture and dignity as possible, says Gebers. This is accomplished by integrating their beliefs into their care and education, she says.

If a patient’s cultural beliefs and ethnic practices are not taken into account, they will not follow instructions, says Moyer. Sometimes it is give and take on these issues. "Educators need to be aware of cultural components for they will have a lot better follow through if they are connecting with that patient," she explains.


For more information about educating culturally diverse patients, contact:

Laura Gebers, BSN, RN, BC, Patient Care Services Program Health Education Coordinator, Deborah Heart and Lung Center, Patient Care Services, 200 Trenton Road, Browns Mills, NJ 08015. Telephone: (609) 893-1200, ext. 5258. E-mail:

Andrea Henry, Multicultural Services Coordinator, Children’s Healthcare of Atlanta. E-mail:

Fran London, MS, RN, Health Education Specialist, The Emily Center, Phoenix Children’s Hospital, 1919 E. Thomas Road, Phoenix, AZ 85016-7710. Telephone: (602) 546-1395. E-mail:

Diane Moyer, RN, MS, Program Manager for Consumer Health Education, The Ohio State University Medical Center, Department Consumer/Corporate Health Education & Wellness, 1375 Perry St., Fifth Floor, Columbus, OH 43210. Telephone: (614) 293-3191. E-mail: