Multicultural road map makes decisions easier

Guide steers staff through cultural differences

Making an informed and accurate assessment of a patient is one of the most challenging aspects of care, but ensuring the assessment incorporates religious or ethnic beliefs is even more challenging.

Unfortunately, many ethics committees are faced with making decisions that could be avoided if a patient’s religious, cultural, or ethnic beliefs were considered.

Taking a proactive approach to that dilemma, the Family Education Program at Children’s Hospital in Boston has armed staff with a tool to help ensure a patient’s cultural, religious, or ethnic beliefs are incorporated into the plan of care. The weapon: a Multicultural Information and Resource Guide that is available on every unit within the hospital.

Beware of generalizations

"We encourage staff to use this guide to help make a comprehensive cultural assessment of the patient and family. While we urge them to use the guide as a foundation for the assessment, we also stress to not overgeneralize or attribute certain characteristics to all members of a cultural or ethnic group," says Anne A. Knights, RN, MS, coordinator of the Family Education Program and Family Resource Center at Children’s Hospital.

Knights is a co-author of the guide, along with the hospital’s director of social work, Helen Clinton, LCSW, and its director of pastoral care, Mary Robinson, MA, MDiv.

The need for the guide was twofold, she says. "First, there was an increase in patients from on-traditional cultures, religions, countries, and languages. Secondly, informal staff surveys indicated that more information about these groups was a definite need on the units."

To help staff with potential problems associated with cultural or ethnic beliefs, the guide gives examples of questions to ask to determine patients or their families beliefs and values systems, Knights adds. (See box, above right.)

The guide was introduced in July 1997 at multidisciplinary staff meetings after a six-month development and writing process, Knights says.

"We wanted to introduce the guide by hand-delivering it and discussing the content. That helps guard against stereotypes and misinformation," she says. (For a sample page of the guide, see p. 34.)

The development proved to be a difficult task. "The African American sheet was difficult because it was a culture within a culture, and it was interesting, for example, to talk about language and dietary habits. We were very nervous about sounding patronizing, stereotypical, judgmental, or offensive while still trying to accurately portray the sense of injustice that results in mistrust."

Respecting individual differences

The group’s primary fear in developing the guide was that the information wouldn’t be used. "We were afraid that staff would read the sheets, not read the sample questions, and make a judgment based on what they read, not getting at the individual’s beliefs and traditions," Knights says.

The issue of privacy, for example, is found in most every culture.

"We put signs on doors of patients who are Muslim instructing staff to give advance notice of entering the room so that the mother can properly cover her face.

"Or if the patient’s care is being discussed, we’ll make sure the father is there, because he is considered the parent who makes decisions and has eye contact with the physician or caregiver," she says.

Compiled by multidisciplinary group

The guide was developed by a multicultural subcommittee, which included the following departments:

• social services;

• pastoral care;

• patient education;

• interpreter services;

• community benefits;

• nursing.

The guide is based on the concept of the explanatory model of illness, Knights explains, and was developed by medical anthropologist Arthur Kleinman, MD.1

"The explanatory model promotes understanding of one’s cultural background as the foundation of an individualized plan of care. Certain questions can help the provider establish a relationship and exchange important information with the family," she says.

The following are a few examples of the questions included in the model:

• What brings you here?

• What do you call your child’s illness?

• What have you, family members, and others — such as nurses, physicians, spiritual healers, or other caregivers — done so far?

• How has the illness affected the life of your child?

• How has the illness affected the life of your family?

• What do you expect to happen here?

• What worries you most about the illness and treatment?

The subcommittee’s goal from the start was to keep the guide updated, she says. To help staff stay abreast of the changes, the information is posted on the hospital’s Intranet. Staff who log on are tracked using an electronic counter.

"That way, we can measure the number of people reading the information," she adds. Also, informal surveys help determine areas where information is needed.

"We are continually updating and identifying new ways to use the guide in teaching. We’re making a video, for example, to demonstrate how providers and families talk about cultural traditions."


1. Kleinman A. Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978; 88:251-258.