Seminar takes sensitivity into homes of clients

Home staff must respect customs, religious beliefs

A culturally insensitive remark to the grandchild of a patient not only resulted in the home care nurse being thrown out of the home, but also resulted in a major change in the way the home care and hospice program of Catholic Health Service (CHS) of Long Island addressed cultural differences between patients and employees.

Although the remark was bad enough, the worst part of the situation was the fact that the nurse was clueless about why the fuss was being made and refused to apologize to the family, says Keith Kertland, president and chief executive officer of CHS Home Care and Hospice in Hauppauge, NY.

In the three years since the incident, CHS Home Care has implemented a one-day cultural sensitivity seminar that all 450 employees are required to attend and has added members of the minorities represented in the community to the board, he says. "We are also translating patient information into more languages and developing a resource book that identifies cultural issues that home care employees are likely to encounter," Kertland adds.

While home care agencies have studied the need to address language barriers, there is more to consider than just language when your patients have a different cultural background, points out Mary Jo Clark, RN, BSN, MSA, home care management consultant for RBC Limited, a management consulting firm in Staatsburg, NY. "Sometimes, your nonverbal communication can offend," she says. For example, in many Asian cultures, direct eye contact is disrespectful, she points out.

The need for cultural competence is growing, Clark says. "It is no longer just the metropolitan areas that have a variety of cultures," she notes. With resettlement of refugees from different parts of the world, even smaller towns and rural areas have people with different languages and customs, she adds.

It is even more important for home care employees to be aware of cultural differences than hospital employees, says Ann Hutchinson, RN, BSN, clinical supervisor of the Downriver Office of Henry Ford Home Health in Lincoln Park, MI. "In the hospital, patients surrender themselves to the hospital routine because they are the guests of the hospital," she says. "In home care, we are guests in the patients’ homes, so we need to respect their customs," she explains.

In addition to cultural competence seminars that all employees must attend, Henry Ford Home Care employees take a cultural competence exam each year, Hutchinson says. The exam follows a review of the health system’s Multicultural Resource Guide (see resource box, below) that contains detailed descriptions of different customs, beliefs, religions, and practices for more that 20 different groups, she says.

Cultural Diversity Resources

The Henry Ford Health System Multicultural Resource Guide contains background, family, social, food, spiritual, and health practice information on more than 20 cultural, racial, and religious groups. Copies of the book can be purchased for $29.95. For more information or to order the book, contact Karen Giovannini at (313) 874-3766 or

Language Line Services, One Lower Ragsdale Drive, Building 2, Monterey, CA 93940. Telephone: (800) 752-0093, ext. 441. E-mail: Web site: Provides over-the-phone interpretation and document translation services in more than 140 languages. Interpreters are available 24 hours a day, 7 days a week, 365 days per year. A variety of subscription plans are available depending on how much time is needed per month.

Language barriers are handled in a variety of ways. "We use family members, staff members, or Language Line," Hutchinson says. (See resource box, above.) "Our branch office has a number of Hispanic patients, so all of our staff members have learned some rudimentary Spanish," she adds.

It’s important to find out if there is a language barrier when the referral is first received, Hutchinson says. "This gives you time to make arrangements before the first visit."

During the initial referral, you should ask not only about language but about religion and nationality as well, Clark points out. "Although you can’t put every patient in a box and expect them to act exactly like everyone else with the same language, religion, or nationality, you can research the traditional customs prior to the first visit so you won’t be surprised," she says. For example, an Asian family may expect the nurse to remove her shoes and wear slippers, she points out. "The nurse should be prepared for this so that her reaction doesn’t offend the family," she adds.

Understanding different beliefs also improves communication, Kertland points out. "One of our hospice nurses wanted to report a Muslim family to adult protective service because they had the patient lying on a mattress on the floor rather than a bed," he says. "It wasn’t abuse. Muslims believe that you should be close to the earth and facing Mecca when dying, so the family was following their religious practice," he says.

Culture-related questions are raised at case conferences, Hutchinson says. "In addition to reviewing the patient’s progress, we take the opportunity to discuss cultural issues that may have arisen during the visits so we can all learn from them" she says.

"In the Arab culture, it is rude to expose the soles of the feet," she says. "This presents a problem when the nurse is conducting a diabetic foot exam." Situations like this rely on the development of a trusting relationship so that the nurse can explain the rationale for the exam and make sure it is conducted in a private place, she adds.

Hiring employees from the same populations as your patients also will help your agency, Clark points out. "Although you won’t always be able to assign only Jamaican nurses to Jamaican patients, just having the diversity on staff will help everyone learn more about different cultures," she says. Be sure you hire staff members who are open to experiencing new things, no matter what their backgrounds are, she adds.

Although hiring aides and nurses is a challenge all by itself, Clark suggests that home care agencies work with local community and religious groups to promote their own agency as an employer and talk about the need for aides and nurses.

As you evaluate your agency’s ability to provide care to patients of different cultures and backgrounds, be sure not to forget about the different backgrounds of your own employees, Hutchinson says. "The easiest way to make sure we are respectful of our patients’ differences is to make sure we respect our colleagues’ differences," she says.

Even with resource guides, research, and preparation before the first visit, sometimes the best way to make sure you don’t offend patients and their families is to ask what their preferences are, Hutchinson says. "Not every family has the same beliefs that other people of the same background have. When we ask their preferences, we show that we are aware of differences and want to respect the family’s customs."