To work with culturally diverse patients, tailor lessons to individual

Teaching must be flexible, instructors willing to adapt info to culture

America is home to immigrants from around the world who bring with them customs and beliefs that are not commonly practiced in the United States. In patient education, these differences in culture must be addressed before teaching can take place.

Educators must be willing to learn from the patient and tailor instructions to the patients’ needs as they would with any patient, says Yvonne Brookes, RN, patient education liaison at Baptist Health Systems of South Florida in Miami. There is no blueprint for Chinese patients or Hispanic patients, she explains.

People within a culture are not carbon copies of one another. For example, there may be a dominant religion within a country that would influence patient compliance, but an individual born there may not adhere to those religious practices. Also, many people who immigrate assimilate into the culture of their adopted nation, or their belief system becomes a blend of both cultures.

To teach the patient a medical regimen or bring about behavioral changes, the educator must properly assess for cultural barriers and devise ways to overcome them.

Communication is the key, says Raquel Diaz-Sprague, MS, MLHR, a lecturer at The Ohio State University in Columbus and president of Columbus-based Technical Support, a translation and interpretation company. Health care workers must learn how to communicate with patients from diverse cultures. What the patient is told, and how he or she interprets the meaning of the instruction, might be different. (To learn how to use interpreters, see story, p. 31.)

For example, the diabetes educator might schedule an appointment with a patient for a half-hour teaching session and expect him or her to show up on time so as not to inconvenience the next patient scheduled. However, in some cultures, promptness is not expected.

"The patient may consider anything within 45 minutes of the appointment time OK, but in the United States, it is expected that you come before the appointment time. The problem is that the people involved have different assumptions," says Diaz-Sprague.

To control misunderstandings, Brookes tells staff never to assume anything. Instead, they should ask the patient. For example, to find out if it is important to involve family in the education process, ask whom the patient wants present when discussing his or her care. If giving the patient a special diet to follow, ask the patient if there is anything about the diet plan that will be difficult to follow. Health care professionals must interact with the patient to get the needed information to create a suitable education plan, says Brookes.

Barriers are best identified if the questions are open-ended, says Susan Karlins, MPH, patient education coordinator at Valley Health Plan in San Jose, CA. Yes or no questions provide more of an opportunity for the patient to withhold important information. In many cultures, it is considered respectful to always agree with authority figures, such as health care providers, she explains.

Follow basic communication skills by active listening, clarifying, paraphrasing, prioritizing, and summarizing what the patient says.

"Don’t interrupt the patient as he or she explains. Also, encourage the patient to elaborate before you as the educator give advice or make recommendations," advises Karlins.

Study culture of patient group

Culture can impact the way the message is delivered and even the information that the patient provides. Therefore, educate staff on the dominant cultures that comprise the hospital’s major patient groups, says Diaz-Sprague.

"Some say that educating staff about a culture the hospital serves would foster stereotyping. Others say it enhances and enriches interactions. I agree with the second view," she says.

For each patient group the hospital serves, staff should learn about the country the patient group immigrated from, the dominant religion, what types of foods they eat, and their family relations. Although, they should be instructed that the traits are indicative as a group and individuals may not fit the profile, says Diaz-Sprague. (To learn how two hospitals developed systems to meet the educational needs of Spanish-speaking patients, see story, p. 33.)

Know the immigration history of the patient groups the hospital serves, says Rebecca Nelson, MA, program manager for community development at The Ohio State University Medical Center.

"You want to know what kind of traumas they have gone through before arriving because it helps you understand why a group acts or reacts the way it does," she explains.

To gather information on a patient group, conduct a standard research review on the Internet and a literature search at the library on cross-cultural health education and health care, she advises. A good place to start is the Web site for the U.S. Department of Health and Human Services Office of Minority Health in Washington, DC ( However, to obtain specifics on the group your hospital serves, talk to community leaders who live and work in their neighborhoods. Also, talk to professionals such as social workers who provide services to the community.

Make sure that staff also are taught how to be flexible, open-minded, and patient, says Nelson. A good way to foster these skills is to offer training programs that are frequently used for customer service representatives, such as "dealing with difficult customers." These training programs are usually available through the human resources department, says Nelson. The skills, along with cultural facts, will help health care professionals educate patients from diverse cultures.

To educate patients from other cultures, health care professionals must understand that their perspective of health care has been shaped by their own culture as well, says Karlins.

"Health care professionals need to be aware of their own culture and how it affects their heath-related beliefs and behaviors. This helps them see the whole perspective with their interaction with patients, rather than labeling the patient’s culture as the problem," she explains.

For example, Americans tend to be direct in their approach and consider getting right to the point a virtue. People in many Latino cultures, however, prefer polite conversation before addressing the medical issue. Also, many cultures are more formal than Americans and address others by surnames. It is a form of respect.

"If respect is not demonstrated and rapport isn’t established, patients may not be able to hear what you have to say," says Karlins.

Cultural concerns must be addressed before teaching can take place. If cultural concerns are ignored, the health care professional might alienate the patient. "They will create conflict and misunderstanding, and the patient will disregard the information," adds Brookes.

Treatment may be delayed until an acute episode occurs, which may result in serious injury or even death, says Karlins. Also, the patient or a family member may decide to use only a home remedy for a serious illness.

"Health care workers need to keep in mind that patients from other cultures may not understand the concept of controlling health. Also, the methods of modern medicine may be foreign to them," says Karlins.