Make sure that you are culturally competent

CMs should prepare to treat a diverse population

Case managers shouldn’t wait for their hospitals to institute cultural competency initiatives. They should try to become more aware of their patients’ culture and beliefs on their own and make it a continuing process, asserts Joyce E. Vaughn, RN, CCM, a Louisville, KY-based case management consultant and former hospital case manager.

"A lot of people’s beliefs have a big effect on how they perceive their illness and how compliant they will be. It affects what treatments they will undergo and what they won’t undergo. Case managers should understand their patients’ values and difference and incorporate them into the diagnostic and treatment process," Vaughn says.

By 2010, the U.S. Census Bureau predicts that 45% of the population in the United States will be minorities, Vaughn points out.

"There are going to be a lot of people who will require quality health care, and we have to prepare for it," she says.

Don’t think that immigrants are going to adjust quickly to American culture and Western medicine. History says otherwise, she says.

"When our ancestors were coming into this country through Ellis Island, social workers and doctors theorized that they would assimilate into the American way of life and become just like us. But it didn’t happen that way. They brought their own ideas and culture with them. You can see that in big cities with areas like Little Italy or Chinatown. Those of ethnicity or culture often stay within their dominant culture demographics," Vaughn says.

Any facility receiving any kind of federal funds is mandated by law to become culturally competent.

The U.S. Department of Health and Human Services, the Health Resources Services Administration, and the Centers for Medicare & Medicaid Services advocate that people who deliver services to the culturally diverse be culturally competent, Vaughn says.

The Case Management Society of America, the Joint Commission on Accreditation of Healthcare Organization (JCAHO), the National Committee for Quality Assurance, and many other health care organizations also promote standards that require cultural and linguistical competency among the health care team, she adds.

"It’s not just one of those trendy things, and it’s not just something else for case managers to do. It’s here to stay, and it’s one of those things that everyone in health care should be involved in," she adds.

Cultural competency isn’t something that can be covered only in a one-day seminar. It’s an evolving process, sort of a continuing quality improvement initiative, and one case managers should focus on, Vaughn says.

"Cultural competency is not just knowing that Jehovah’s Witnesses will refuse blood transfusions or having someone on your staff who speaks a little Spanish. It’s more in-depth than that. Cultural competency is a skill that requires that a person be educated to deliver services to all segments of the population," Vaughn says.

Not understanding a patient’s cultural practices and values can make it much more difficult for a case manager to establish rapport, she says.

"When a patient meets a case manager for the first time, this sets up how the relationship is likely to go. If the patient doesn’t feel comfortable with the case manager, he or she may feel like the case manager won’t help them and may not trust them. To be effective, case managers have to get off to the right start, and that means understanding the culture of the person you are treating," she says.

Understanding cultural differences

Understanding how various cultures approach human relationships can be useful, she adds. For instance, many people in health care call patients by their first name in an effort to be friendly, but in some cultures, this is a sign of disrespect.

Americans often feel that someone who avoids eye contact is trying to hide something or doesn’t like them; but in some cultures, people are taught that looking people in the eye is disrespectful, she adds.

In a number of cultures, chubby babies are looked at as healthy babies. The case manager needs to understand this in order to convince the parents of the future health problems the child could face if he or she continues to overeat.

Having interpreters who understand medical terms rather than relying on family members of patients also is important, Vaughn points out.

"While JCAHO doesn’t approve or allow children as interpreters, case managers know that it is quite common for people to show up with their children as interpreters," she says. Many times, elderly people who don’t speak English may come to the hospital with a grandchild to use as an interpreter. "The problems arise when an older person is embarrassed to tell a child about their complaint or it’s something the child doesn’t understand and may not be able to translate," Vaughn adds.

The staff at the hospital where she previously worked developed signs in between eight and 12 of the most commonly spoken languages in the United States and posted them throughout the hospital.

When someone who did not speak English came in, the staff got him or her to point to the language on the sign. If there was not a staff member who spoke the language, the hospital knew which interpreter to call.

She suggests that hospitals develop posters showing a variety of nationalities and booklets in other languages for their waiting room.

"Not every patient is a blonde, blue-eyed person. Hospitals should put up pictures that represent the people they serve," she says.

Here are some other suggestions from Vaughn on how hospital care managers can better serve people from different cultures:

• Encourage your hospital’s medical library to get videos in the languages your patients speak. For instance, pre-surgical videos or those explaining tests and procedures don’t have much meaning if they’re in English and the patient doesn’t understand.

• Develop materials that your patients can read to let them know what is going on while you are waiting for the interpreter. For instance, print an explanation of common procedures written in the languages of your biggest populations.

• Develop a checkoff list in the language your patients can understand and use it to gather patient information.

• If you belong to a nursing organization, a church group, or another organization, invite a person who belongs to a different ethnic or cultural population to speak to your organization about his or her views on health and wellness.

• Volunteer at local community centers that serve a diverse population. It’s a great way to learn firsthand about different cultures and races.

• Learn another language, one that you might use with the patients you manage.

• Hire more culturally diverse case managers.

"The more culturally diverse your staff are, the better you’re going to do when you get a patient from another culture," she says.

Editor’s note: The Transcultural Nursing Society, with headquarters in Livonia, MI, offers information to nurses on caring for patients of different cultures, values, and beliefs as well as a transcultural nursing certification. For more information, visit their web site at Telephone: (888) 432-5470.

The U.S. Department of Health and Human Services Office of Minority Health has published a guide on 14 culturally and linguistically appropriate services. For more information, go to: