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For other articles and previous issues click here. September 19, 2005 When
You Don’t Speak the Patient’s Language — Delivering
Care Despite Language and Cultural Barriers Communication is essential from the moment the patient walks into the department. From the first moment, that person is trying to convey his or her situation to healthcare personnel. When the patient does not speak English or subscribe to the beliefs of Western medicine, providing quality care can be a more difficult task. To improve that situation, hospitals across the country are employing interpreters, requiring diversity training, and changing the one-language, one-culture mentality. In 2003, the U.S. Census Bureau reported that 33.5 million (11.7%) of U.S. residents were born outside this country. Of those, more than 53% were born in Latin America. With such an upsurge in America’s already diverse population, the healthcare industry has realized the need to address multiculturalism and diversity awareness. Healthcare professionals understand that by tailoring care to the different cultures they serve, they provide better care. “There has always been a need for a cultural impact in healthcare and with the United States seeing a tangential growth in immigration from the 1990s, we must change the way we approach healthcare to provide the best care,” says Howard Ross, president of Cook Ross, a consulting and training firm in Silver Spring, Md. Finding better ways to communicate with the culturally diverse population is essential, he adds. There has been an explosion of diversity training and awareness in hospitals across the country. At the Albert Einstein Healthcare Network in Philadelphia, residents are required to complete a three-year cultural competence program, according to Harriet Bernstein, director of language and cultural services. Scripps Mercy Hospital in Chula Vista, Calif., has a cultural competency program that is designed to “improve cultural competency and awareness through education and professional development by ensuring access to quality interpretation services for limited-English-proficient patients,” explains Tanya McCann, Scripps’ cultural competency coordinator. Cook Ross has developed CultureVision, an extensive database that provides the “knowledge necessary for healthcare professionals to overcome the uncertainty associated with cultural differences. It enables them to care for people of varying backgrounds and assist, support, and facilitate the patient’s ability to regain or maintain the highest levels of independence and wellness,” according to the company Web site. Despite the programs and services offered by each of these organizations, they agree that there is a common edict, reflected in this statement by Ross: “Knowing what questions to ask is paramount. Realizing that each culture is different and has a particular system in which they prefer to be treated is far better than setting up stereotypes…” In addition, Elsa Batica, manager of the Cross Cultural Health Development Training program at Children’s Hospitals and Clinics in Minneapolis, says, “It is important for healthcare professionals to make the patient comfortable by fostering a partnership rather than establishing a power differential.” Keeping an open mind and owning up to any mistakes rather than blaming the non–English-speaking patient is imperative to establishing trust, she adds. Staff Interpreters At Scripps Mercy Hospital, the cultural competency program offers training and educational opportunities to Scripps health professionals and physicians. To entice the staff to participate, the hospital offers nurses continuing education units while physicians can earn continuing medical education units. The only current mandatory training teaches participants the importance of providing appropriate interpretation services and how to use the Cyracom phone system—a dual-phone translation service available 24 hours a day—when an interpreter is not available. “There is discussion and plans to incorporate cultural sensitivity and language training into overall Scripps and department orientations,” McCann says. “There is some discussion to include cultural sensitivity and language into job descriptions as well.” Despite the lack of mandatory training at Scripps, McCann says, “In cultural competency trainings it is emphasized that there is a ‘platinum rule.’ Rather than treating people the way we want to be treated, we treat our patients the way they want to be treated. They are the customers and we are here to serve their needs. This means accommodating their cultural and language preferences.” “Our bottom line is to serve our patients within their cultural preference,” says Albert Einstein’s Bernstein. “In doing so, we are providing good medical care, good supportive care, and we are establishing trust by communicating in their language and respecting the nuances of their culture.” To make this vision a reality, Albert Einstein employs nine staff interpreters fluent in Spanish, Korean, Russian, and Vietnamese. There are also an additional 50 employees who are trained as volunteer medical interpreters. Listening, Understanding, Accepting After conducting research, Ross and a colleague deduced that a significant number of Vietnamese women in labor were suffering from signs of dehydration. “We realized that altering the temperature of the water that was offered to a pregnant Vietnamese woman significantly reduced the signs of dehydration,” he says. By questioning why the woman was not drinking the water and finding out that in her culture cold foods are avoided during labor and delivery, the nurse would have offered water that was the appropriate temperature for the woman. “Something as simple as the temperature of water can make a huge difference in the quality of care that our now culturally diverse population receives,” Ross says. Outside Western Medicine In the early 1980s, the United States assisted a large Hmong population living in refugee camps in Thailand to come to this country. It is estimated that nearly 150,000 Hmong live in the United States with one-half of this population living in Minnesota, according to research by the Children’s Hospitals and Clinics of Minnesota Web site. Among Hmong medical traditions, there is a focus on traditional herbal treatments—both alone and as a complement to Western medical treatments. Additionally, Hmong have different concepts of illness than Western physicians. For that reason, healthcare professionals may have a difficult time gaining the confidence of Hmong patients to provide care, according to research. To both better serve and understand this growing population, Children’s Hospitals and Clinics of Minnesota offers an integrative medicine department to address the medical and social differences between the Hmong approach and Western medical care. Integrative medicine is “an approach that draws on a variety of healing traditions, blending the best of conventional and complementary therapies in a personalized plan that best fits each child and family,” according to the hospital Web site. With so many initiatives underway across the United States responding to the increasing numbers of non–English-speaking immigrants, it is important to recognize that everyone is different, Ross explains. “Realizing that diversity training and multiculturalism in healthcare is not just a fly-by-night proposition is crucial to the success of our healthcare system,” he says. Without the interpreters at Albert Einstein or the cultural competency program at Scripps, many patient groups would receive compromised healthcare. Looking at the numbers of people coming to the United States from around the globe, it is obvious that they hope for a better life for themselves and their loved ones. Multiculturalism and diversity training can help make this hope a reality. — Kim M. Norton is a freelance writer/journalist.
When working with interpreters, it is best to keep in mind the guidelines developed by cultural competency expert Robert W. Putsch III, MD, on the use of an interpreter: • Unless you are thoroughly effective and fluent in the target language, always use an interpreter. • Learn basic words and sentences in the target language; emphasize by repetition and speak slowly, not loudly. • Be patient. Careful interpretation often requires that long explanatory phrases be used. • Address the patient directly; do not direct commentary to or through the interpreter as if the patient does not exist. • Return to an issue if you suspect a problem and get a negative response. Be sure that the interpreter knows what you want. • Provide instructions in list format and have patients repeat their understanding of the medical therapy. • Use short questions and comments; avoid technical terminology and professional jargon such as “workup.” • Use language the interpreter can handle; avoid abstractions, idiomatic expressions, similes, and metaphors. • Plan what to say ahead of time. Do not confuse the interpreter by backing up, rephrasing, or hesitating. — Source: Putsch III RW. Cross-cultural communication. JAMA. 1985;254(23):3344-3348.
2. Begin by being more formal with patients who were born in another culture. In most countries, a greater distance between caregiver and patient is maintained through the relationship. Except when treating children or very young adults, it is best to use the patient’s last name when addressing him or her. 3. Do not be insulted if the patient fails to look you in the eye or ask questions about treatment. In many cultures, it is disrespectful to look directly at another person (especially one in authority) or make someone “lose face” by asking him or her questions. 4. Do not make any assumptions about the patient’s ideas about the ways to maintain health, cause of illness, or means to prevent or cure it. Adopt a line of questioning that will help determine the patient’s central beliefs about health/illness/illness prevention. 5. Allow the patient to be open and honest. Do not discount beliefs that are not held by Western biomedicine. Often, patients are afraid to tell Western caregivers they are visiting a folk healer or taking an alternative medicine concurrently with Western treatment because in the past they have experienced ridicule. 6. Do not discount the possible effects of belief in the supernatural effects on the patient’s health. If the patient believes the illness has been caused by embrujado (bewitchment), the evil eye, or punishment, the patient is not likely to take any responsibility for his or her cure. Belief in the supernatural may result in his or her failure to either follow medical advice or comply with the treatment plan. 7. Inquire indirectly about the patient’s belief in the supernatural or use of nontraditional cures. Say something like, “Many of my patients from ___ believe, do, or visit ___. Do you?” 8. Try to ascertain the value of involving the entire family in treatment. In many cultures, medical decisions are made by the immediate or extended family. If the family can be involved in the decision-making process and treatment plan, there is a greater likelihood of gaining the patient’s compliance with the course of treatment. 9. Be restrained in relating bad news or explaining in detail complications that may result from a particular course of treatment. “The need to know” is a unique American trait. In many cultures, placing oneself in the doctor’s hands represents an act of trust and desire to transfer the responsibility for treatment to the physician. Watch for and respect signs that the patient has learned as much as he or she is able to deal with. 10. Whenever possible, incorporate into the treatment plan the patient’s folk medication and folk beliefs that are not specifically contradicted. This will encourage the patient to develop trust in the treatment and will help assure that the treatment plan is followed. — Source: Salimbene S, Graczykowski JW. 10 Tips for Improving the Caregiver/Patient Relationship Across Cultures. When Two Cultures Meet: American Medicine and the Cultures of Diverse Patient Populations, Book 1, What Language Does our Patient Hurt In? An 8-Part Series of Practical Guides to the Care and Treatment of Patients from Other Cultures. Inter-Face International. Amherst, Mass: Amherst Educational Publishing; 1995:23-25. |
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