How nurses, health care meet the challenge

by Susan Trossman, RN

It's one of the first lessons learned in nursing school: Treat the whole person and be open to differing beliefs about health and illness. Among the required reading often is a chapter on cultural differences.

But are nurses and their employers truly prepared to deliver quality care to all people in the United States -- a country that no longer is described as a melting pot but as a cultural salad?

Nurses' opinions on this issue vary, as do their employers' approaches to providing health care workers with the tools they need to care for diverse patient populations.

"The need for nurses to provide culturally sensitive care seems self-evident. We should be respectful and accommodating of different cultures, traditions and practices," said Meg Campbell, MSN, RN, CS, FAAN, a nurse practitioner at Detroit Receiving Hospital. "That's easy to say, but often difficult to do."

Neither Campbell, a Michigan Nurses Association member, nor Barbara Ott, PhD, RN, believe nurses and other health care providers are doing as good a job as they could be -- particularly in some communities where diversity has grown by leaps and bounds.

"As nurses, we've always taken care of diverse populations," said Ott, an associate professor at Villanova University College of Nursing and Pennsylvania State Nurses Association member. "And along the way, we've made adjustments in how we provide care for one or two cultures beyond Caucasian and African American -- such as Hmong in California or Navajo in the Southwest. Now we're seeing multiple cultures in hospitals where we didn't see them before, and it's making some staff uncomfortable with their ability to provide the care they want."

However Valerie Martin, RN, feels she and her co-workers are generally well-equipped to handle the needs of their culturally diverse patients. As a staff nurse on the inpatient rehabilitation unit at the University of Washington Medical Center (UWMC) in Seattle, a large part of her role is to provide spinal cord injury patients with information vital to their health.

"Most of my co-workers are veteran nurses," Martin said. "And I think you become more culturally sensitive as you gain experience working with diverse patients. You begin to know where the differences lie and how to work with them."

Charlotte Finnerty, RN, a staff nurse in the emergency room at Northside Medical Center in Youngstown, OH, says she can't assess how well nursing is doing when it comes to ensuring culturally sensitive care, because she believes it comes down to the individual nurse -- experienced or not.

"Some nurses are more open to diversity. Others are more shut off; they feel people should react the same, regardless of their backgrounds," said the Ohio Nurses Association (ONA) member. "I've always lived in a multicultural and economically diverse environment, so I learned early on how to deal with people according to their background."

Nurses who believe they generally do well attending to patients of varying cultures and lifestyles acknowledge they've made some missteps along the way -- an inevitable part of the learning process. They also know that new challenges are always around the corner.

Martin, for example, recalls working with an elderly Maya-Hispanic patient who needed a suppository and digital stimulation as part of his routine bowel program. Through the interpreter, she tried to explain to the patient what she was doing and believed he understood. Only later did she learn from the interpreter that the patient now questioned whether he was a homosexual.

"It just shows that you don't know how certain things are interpreted by people from a different culture," Martin said. "That's why a detailed explanation of how and why you are doing something is really important."

Ott added that providing culturally sensitive care goes beyond allowing a patient to make a decision that's counter to one's own beliefs. "It's also how you treat the patient and your mannerisms," she said.

She recalled an incident in which health care workers "allowed" a Jehovah's Witness to refuse blood, but not without first badgering him to change his decision.

"They were practically pummeling the patient with their own beliefs," Ott said.

Making assumptions also can affect providing appropriate patient care.

Gloria Ward, RN, PNP, who is employed by the Chicago Department of Public Health (CDPH), related an anecdote about a maternal-child health clinic where she worked. The clinic administrator believed staff was doing a good job serving clients, but could be more sensitive to the needs of lesbians. A workshop subsequently was held on site for the entire staff, including support staff, to improve services to this population.

"I just saw them as patients," said the Illinois Nurses Association (INA) member, who considers herself unbiased in the care she provides. "Before the workshop, I only addressed the parent and child. Now I see the parent, the child and the partner as a family unit. This has made me more aware of the many different types of non-traditional families that I care for and has raised my level of sensitivity, because sensitivity can sometimes get lost in the paperwork.

"But in general, I think that education and experience working in the community prepares nurses to be culturally alert and sensitive to the differences that clients bring."

Breaking the rules

Martin, like other nurses, has learned that being culturally sensitive requires, at times, adjusting "the rules" by which RNs and other health care workers operate.

In rehabilitation nursing, for example, a premium is placed on patients' regaining much of their independence by learning new ways to perform activities of daily living. But Martin said that in the Cambodian and other Asian cultures, it's not uncommon for families to want to make up for a patient's deficit by doing everything for him or her.

"Sometimes you have to let go of the goals you'd like people to reach," she said. "Patients might end up with fewer rehab skills, but that's what they and their families want."

ONA member Frank Stanovcak, RN, an assistant nurse manager at Northside Medical Center realized that imposing strict limits on the number of family members at the bedside can be counterproductive when working with certain cultures. As long as their presence doesn't interfere with patient care, a family member can serve as a great source of a patient's history, and in some cases, as a translator, he said.

Added Campbell, "It's the little things that make us culturally sensitive. But in health care, we tend to be rigid, for example, making people undress for an examination even when they don't have to."

Campbell and Ott both also pointed to how they've had to change their professional styles when working with people from other cultures.

Campbell said she stopped automatically trying to shake a Muslim man's hand when being introduced after she learned that it was unacceptable for a man to take the hand of a woman in such fashion.

Said Ott, "I use a lot of humor when I'm working as a clinician and with my students. But it doesn't work cross-culturally for many reasons. In China, for example, they expect you to act in a serious manner and with the authority they think you have."

Programs, solutions

UWMC's patient population is diverse: A look at demographics by ethnicity showed that 67 percent of its patients were Caucasian, including Russian and other Eastern European populations; 6 percent, African American; 5 percent, Asian; 3 percent, Hispanic; and 1 percent, Native American (18 percent were not identified by ethnicity), according to Catherine Broom, ARNP, CS, a psychosocial clinical nurse specialist and UWMC Magnet program coordinator.

(To attain Magnet status from the American Nurses Credentialing Center, an ANA subsidiary, facilities must demonstrate that they are sensitive to the unique and diverse needs of individuals and target populations, among other criteria.)

Behind English, the most predominant language spoken by UWMC patients was Russian, followed by Spanish, Vietnamese and then Chinese dialects. In fiscal year 2001, UWMC's department of interpreter services logged more than 21,000 in-person encounters and 5,500 phone encounters in 73 different languages or dialects.

"Because our population has become more diversified over the years, we recognized as an organization that to serve our population better, we needed to build our interpretive services and create other resources for staff," Broom said.

For example, UWMC holds seminars to build cultural awareness and has developed an educational resource called "Culture Clues." Available to staff online, Culture Clues provide details on specific cultures' perception of illness, such as how people deal with an illness; pattern of kinship and decision-making, such as whether a patient should be shielded from bad news; and comfort and touch, which includes information on eye contact, body language and modesty. Currently, Culture Clues are available on Albanian, Latino, Russian, Korean, Vietnamese, African American and Chinese cultures.

Staff also have access to "Ethno-Med" online, which has more detailed information on cultural beliefs related to medical care. And there are educational materials in different languages available to staff and patients on topics like diabetes, hypertension and preventing falls at home.

"We're also working on a project to assist nurses with patients on a moment-to-moment basis, such as language-communication cards that have a picture communicating certain needs or tasks like changing a dressing or needing to use the bathroom," Broom said.

In Ohio, Northside Medical Center held diversity training for all staff. One of the most helpful aspects of the training, according to Stanovcak, was understanding the different ways people present with pain.

It's often difficult to assess pain levels for Eastern Europeans, who like many older adults, can be very stoic, Stanovcak said. "They can be breaking into a sweat and saying, 'I'm OK, I'm OK.'"

In Chicago, Ward said the CDPH incorporates varying cultural practices and beliefs into staff development programs. And, the Hispanic Affairs, Gay and Lesbian and Refugee programs are a few examples of the strategies developed to address the needs of specific populations appropriately and sensitively. The department also recently formed a committee on diversity that's looking at how staff can better meet the needs of the populations they serve.

INA member Ruth Slaughter, MPH, RN, a director of public health nursing with the CDPH, is working with the University of Illinois to look at the initial preparation of nurses on providing culturally sensitive care, as well as continuing education programs.

"We're looking at diversity in recruitment, education and practice," Slaughter said. "Academia and practice have to work together to help nurses become more competent in how we provide care."

Campbell agrees. She believes standard coursework needs to be developed for nurses, and she wants to see more mentoring programs implemented.

"We also need to boost our ranks in terms of diversity, because working side-by-side with nurses from other cultures makes us more informed," Campbell said.

Overall, both she and Ott believe nurses should look at defining "culture" more broadly.

"We should look at someone's individual culture -- looking beyond the box that defines someone by religion or ethnicity," Campbell said. "Individual culture includes gender, age, sexual orientation, lifestyle and other factors. For instance, a young, homeless, gay person who uses IV drugs is culturally distinct from a recently retired grandmother even though both might be African American and Baptist. All of these attributes have to be considered rather than characterizing someone simply as 'Hispanic male' or 'white female.'"

She noted that providing culturally relevant care at end of life is particularly important. "What was culturally important -- their traditions, beliefs -- become powerfully important," she said.

Both Campbell and Ott believe that a solid strategy to ensuring patients receive culturally sensitive care centers on asking the patient this question: "Is there anything I need to know that will help me in providing care to you?"

Once nurses have asked that open-ended question, they can ask more detailed questions about rituals, such as whether the patient wants the bed to face East or wants to see a priest. Delving into people's cultural practices and beliefs ultimately can save nurses' time. For example, it would be important to know that someone other than the patient is the chief decision-maker when developing a plan of care or trying to get consent for a treatment.

Ott added that improving one's interpersonal skills can help nurses to understand, appreciate and accommodate cultural differences.

Finally, nurses say there is a big pay-off when working successfully with different cultures.

"You learn so much from working with diverse patients," Broom said. "And when you feel you've done a good job respecting people's cultural preferences and traditions and helping them get care that's meaningful to them -- that's a good thing. And it's a more satisfying nursing experience."

Susan Trossman is the senior reporter for The American Nurse.