The Importance of Cultural Awareness in Patient Care

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By E’Louise Ondash, RN

Suzanne Dibble DNSc, RN, is reluctant to relate stories of nurses’ cultural ignorance because “it’s embarrassing,” she said.

As the number of immigrant and ethnic populations increase in the United States, it is important for nurses to understand how cultural beliefs affect the health care of their patients.

But with a little prodding, the professor emerita at the University of California, San Francisco tells this story that happened in a Colorado hospital: An older Navajo man was terminally ill and the family wanted to take him home to die. Unfortunately, the discharge process dragged on and, as the man was dying, his nephew broke the hospital window to "allow his uncle's spirit to escape," the staff found out later.

“They were the type of windows that didn't open,” Dibble said, "but if they'd known, they would've made other arrangements."

As the number of minority, immigrant and ethnic populations increase in the United States, it is important for nurses to understand how cultural beliefs affect the health and health care of these patients, said Juliene G. Lipson RN, PhD, FAAN, also professor emerita at UCSF.

“Although there are some nurses who are very skilled in using their considerable knowledge to give excellent culturally tailored care, the majority have difficulty with at least some cultural issues and may be uncomfortable in cross-cultural communication.”

That’s why Dibble and Lipson teamed up to co-edit the second edition of “Culture and Clinical Care” (UCSF Nursing Press; $33.95. For downloadable version, visit http://nurseweb.ucsf.edu/www/books.htm). This book features information on 35 ethnic groups, each chapter written by nurses who are familiar with the cultural practices.

Dibble offered another anecdote that illustrates why nurses should understand ethnic beliefs and practices: Some years ago, she was caring for an 8-year-old gypsy girl who was dying of cancer. About 60 family members gathered in the hospital parking lot to keep vigil. The staff couldn't figure out why, for the entire time the little girl had been a patient, neither she nor the family would eat the food the hospital provided.

“Gypsies have a belief about pollution,” Dibble said, “and unless they know how the food was prepared and if the dishes were carefully treated and washed, they will not eat. Everything would’ve been fine if we had given them paper plates and plastic utensils.”

The bottom line, she added, is that you “don’t assume anything. Check things out as you go along. If you notice that someone isn’t eating or that things aren’t going well, take a few minutes to figure out what the issues are. We use the acronym ASK, which stands for awareness with skill and knowledge.”

Being culturally aware is important because the provider-patient relationship “is built on trust,” explained Sharon Brangman, M.D., editor of "Doorway Thoughts,” a three-volume series published by the American Geriatrics Society to help clinicians care for older adults from minority ethnic groups ( www.americangeriatrics.org).

“Sometimes a lack of cultural sensitivity or cultural competency can lead the physician or other health professional to make incorrect assumptions that can have a negative impact on patient care.”

Brangman offers this anecdote to illustrate her point.

An elderly African American woman came to the office and all of the staff called her by her first name. This was upsetting to her because “it had connotations that went back to when she was a young woman in the south and worked as a domestic. People in that household, even the children, called her by her first name, which is a sign of disrespect, particularly among older African Americans. The health care team started off their relationship with her in a way that hampered the development of trust and she was reluctant to speak openly about her medical issues.”

Jane Delgado Ph.D., MS, of the National Alliance for Hispanic Health in Washington, D.C., doesn’t like the phrase “cultural competency.” Her preference is “cultural proficiency.”

“‘Competent’ means you think you understand,” she said. “‘Proficiency’ means you value the cultures. It’s the difference between being a short-order cook and being a chef. If you’re competent, you know your stuff, but application is what proficiency is about.”

Delgado also wants nurses to know that immigrants who don’t speak English are not lazy, uninterested or stubborn. Rather, “when you’re older, it’s hard to learn a second language. And just because you speak louder in English doesn’t mean they understand you. Yelling doesn’t help.”

Until recently, cultural awareness “has often been considered unimportant or ‘soft medicine’ since it is not the hard science that most health professionals are taught in school,” Brangman explained. However, “there is increasing awareness that a lack of cultural competence . . . does have an impact on the disparities in health care and disease that are seen in minority populations in this country.”

Understanding other cultures is both necessary and a good thing, Delgado reiterated, “because… it is the right thing to do as a nurse, it prevents misunderstandings and it results in folks willing to access follow-up care.”

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