Culture Clues’ help staff understand diverse patients

Understanding different cultures improves care

Before clinical staff at the University of Washington Medical Center in Seattle provide care to a patient from another culture, they consult the hospital’s Culture Clues, one-page laminated sheets with key points about a particular culture and how its members generally perceive health care.

The Culture Clues were suggested by a multidisciplinary team that brainstormed ways the hospital could help staff feel more comfortable in dealing with other cultures, says Cezanne Garcia, MPH, CHES, associate director of patient and family-centered care and education for the hospital. "We have a hospital with 5,000 employees, and it is a challenge to get even an hour of training for everyone. The team asked for a referral tool that would give them targeted information before they go in for a care encounter with patients of other cultures," she says.

The team researched the practices and beliefs of people in the cultures they serve and asked the clinicians to help prioritize what information the Culture Clues should contain. They suggested information on who in the family or the community should be consulted on health care issues, who makes the decision, issues related to touching, eye contact, modesty, and body language, and how patients’ religious or cultural beliefs could affect their participation in the health care plan.

Among the cultures represented on the 14 Culture Clues, Garcia and her team developed are Russian, Somali, Vietnamese, and Spanish. Patients at the hospital speak up to 80 different languages. In a typical month, the hospital serves patients speaking 40 different languages, Garcia reports.

"We have a really diverse community with people from Russia, Latino countries, and different regions of Asia and Africa. They speak a variety of different languages and have a variety of different cultural beliefs and practices," adds Brian Giddens, LICSW, ACSW, associate director of social work.

Before issuing the cards, the team had practitioners or staff from each culture group look over them as sort of a litmus test.

"It’s one thing to find out information in the literature, but a person living in contemporary times in this country may look at things differently," Garcia says.

The Culture Clues are not intended to provide all the information a clinician needs to know about the patient’s culture, she points out. "It gives the caregivers immediate information and ways to frame questions to find out what is important and who the family’s decision maker is. It gives them places they can go for additional information with the hope that they will be encouraged to continue with their learning."

For instance, it may say that people from a particular culture are uncomfortable with direct eye contact, that they aren’t comfortable being touched, or that they prefer a female provider.

The team also has developed tip sheets to help with end-of-life issues for their Latino and Russian populations. "This is an important stage of the care experience and one where we need to be cognizant of the family’s beliefs related to death and burial and how they want to say goodbye," Garcia says.

A third tool is language cards, developed through its interpreter services. The 3 x 5 cards contain basic phrases such as "May I help you?" in the key languages spoken by the majority of patients.

In addition to the various printed tools, the master’s-level social workers use their assessment skills when they screen people from different cultures and who speak different languages, Giddens says. "Social workers already have finely honed assessment skills, which helps them see all patients as individuals. We have to be careful when we used the Culture Clues and other materials. While they give us general information, we have to be careful not to assume that every person in that culture is exactly the same," he points out.

Never make any assumptions

The first key to providing culturally sensitive care is to never make any assumptions, Giddens says. "I tell my staff to realize that everybody is going to have a different perspective, whether it seems obvious to us or not. This includes Caucasians as well. Not everybody from the same background or even the same family looks at things the same way," he adds.

At the University of Washington Medical Center, the social workers ask patients right up front for suggestions on how they want to be involved in their care and to get a better picture of their beliefs and practices. They ask how their particular culture deals with illness, who the family spokesperson is, and who should be present during treatment. "We tell them frankly that there are things that we don’t know about their culture and their beliefs and that we need to find out. We want to work with them to come up with a treatment plan, rather than just handing them a plan," Giddens says.

For instance, the social workers at University of Washington Medical Center spent a lot of time with the family of a South Pacific Island native who needed end-of-life care. "They didn’t understand our medical system, and it took a lot of time to explain about hospice care and continuing life support. We involved more family members that we would with many of our Caucasian families, and we needed the whole team to be there to help explain to the family what their options were and why the treatment was going in that direction," he says.

The sooner you can start the discussion and ask patients about their cultural beliefs, the easier it will be to provide them with the care they need, Giddens advises. "I tell my staff never to use a cookie-cutter approach. It takes more time in the beginning when you spend time finding out the specific beliefs and practices of each patient, but it saves stress and frustration later," he says.

The hospital has created patient & family advisory councils made up of patients and family members from various cultures who meet with staff advisors in the NICU, the inpatient cancer area, and the rehabilitation services area. They advise staff on how to improve the care and how to make decisions based on the understanding of all stakeholders. "They help us interpret the patient satisfaction surveys and advise on what we can do to improve the patient care experience," Garcia says.

Members of the councils can help staff see things from another point of view, she points out. For instance, a resident was discussing the case of a premature infant who was given a 1% chance to live and wondered why the mother wanted to continue treatment. "A woman spoke up and said that any mother would hold onto hope even with a small chance because at least there was a chance. It’s too easy to see things from our own lens and the resident, never having been a parent, didn’t understand," Garcia says.

The hospital maintains a pharmacy line where nurses and physicians can call to get more information about naturopathic herbs or other alternative medicines the patient may be taking.

"If it’s not medically unsafe, we encourage patients to participate in their cultural practices because of the mind-body aspects of healing. If something makes them feel comfortable and doesn’t interfere with care, it could help them get better," Garcia says.

She advises all hospital staff to be respectful of their patients’ other cultural beliefs and practices as long as they don’t negatively interfere with the care plan. "In reality, it takes a family and a community to help patients get better, whether it’s someone to help with wound dressing after discharge or just someone who makes them feel like they are cared for," Garcia says.

She cautions staff that the training module and the Culture Clues are just tools and should never be used to stereotype patients. "We caution them not to let their own cultural assumptions cloud their ability to truly understand what the preferences are for the patient and the family," Garcia says.

The hospital has moved from a largely contracted interpreter service to one in which almost 80% of the interpreters are in-house hospital employees. "It makes a significant difference. It’s much less expensive in the long run to hire employees than to use hourly interpreters. We have made the interpreters part of the team. They know the system, they have worked with our physicians and staff, and they can provide more information about cultural issues," Giddens says.

The hospitals forms, including advance directives, have been translated into the most requested languages. All new employees take a cultural competency quiz as part of their new employee evaluation. The social work department has included a cultural competency evaluation as part of its annual evaluation for several years. Now, all employees in the hospital participate in a cultural competency skills review on an annual basis. Cultural competency tools and programs are a part of employee orientation.

The hospital developed a self-directed educational tutorial, "Respect Through Understanding," that the staff can use to learn more about the types of patients and families they are likely to encounter. "This helps create awareness, not only of key cultures but what resources are available to support all staff," Garcia says.

Patients and families bring their cultural beliefs and practices with them, and these influence not only how they engage with providers but also how comfortable and safe they feel with the care plan, she reports. "One of the most important pieces of our work with patients and family members is to join them in creating a sense of hope. When we are tuned into someone’s religious and cultural practices, it allows us to be a better partner in building and sustaining hope," Garcia says.


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