Vol. 1 Issue 10
Culturally Sensitive Care
Strategies for meeting the needs of each individual patient, regardless of background
Nursing has always been considered the science of caring, with specific procedures and protocols carried out in consistent ways. In many healthcare settings, patients receive standardized forms of nursing care that are equally applied to patients of varying racial and ethnic backgrounds.
With the United States becoming increasingly multicultural, nurses must now rethink some of these standardized models. The needs of foreign-born patients can be significantly different from those of an American-born citizen. Through assessment and care planning that includes ethnic considerations, nurses can provide culturally sensitive care that better meets the needs of each individual patient, regardless of background.
Exploring Multicultural Issues
Recently, the Illinois Council on Long Term Care, a professional association representing 26,000 caregivers working in 210 nursing facilities, embarked on a groundbreaking research study to examine cultural issues in long-term care. Council researchers conducted in-depth interviews with nurses at 10 nursing homes that serve multicultural populations, asking them about their challenges and best practices.
To highlight the need for this study, the researchers obtained statistics from the Illinois Department of Public Health indicating that the state's nursing home population has been changing dramatically during the past 5 years. The number of white residents in Illinois nursing homes has declined each year, while the department's other measured populations black, Indian, Hispanic and Asian have increased on a yearly basis.1
Areas to Observe
The study's participants described a variety of issues that impact the provision of culturally sensitive care. The researchers grouped their insights into the following categories. Nurses may consider these observations as part of their care planning process.
Staffing Issues Nurses are hiring ethnically diverse staff members to serve the needs of their multicultural populations. Some facilities have begun placing help-wanted ads in ethnic newspapers and have made partnerships with ethnic organizations to educate immigrants about job opportunities.
In addition, they are recruiting doctors who represent foreign backgrounds. A group of Chicago nurses has incorporated translators into a nurse aide training program for participants who have difficulties with English. ESL (English as a second language) classes have begun appearing in facilities to help staff members who need additional language training.
Language Barriers By hiring a diverse staff for all shifts, facilities are providing translation services 24/7. Nurses have developed lists of staff and community translators that are shared with every department. In addition, facilities have developed communication books and posters that include English phrases, translations and the phonetics of how to pronounce these translations. One nursing home serving a variety of ethnicities has developed a CD-ROM of foreign phrases, with audio output, for use during staff inservices.
Nonverbal Communication Staff members receive training on utilizing culturally sensitive nonverbal communication. For instance, some Asian cultures are uncomfortable with too much eye contact. Touching and hugging can make some foreign citizens squeamish, including some Asian and Indian cultures. Certain hand signals can hold different meanings in other cultures, such as the "OK" sign used in the United States signifying "zero" for a Russian population. Another example: people from India often use their right hand for eating, while the left is used only for toileting and personal care. Thus, nurses should only pass medications to these individuals' right hands.
Nutritional Needs Several facilities are offering separate meal options for individuals from different cultures, prepared by chefs representing those countries. Some foreign citizens simply cannot stomach the American diet, experiencing gastrointestinal problems if required to eat American foods. Families may help by bringing in favorite food items, with facilities offering refrigerators and microwaves for meal preparation. Cultures may have specific Kosher laws to follow, including some Jewish and Muslim cultures. Nurses also should be aware of the perceived medicinal qualities of foods for different cultures, such as seaweed soup being viewed by many Koreans as good for cleansing the blood.
Nontraditional Methods for Healing Increasingly, nurses are including nontraditional methods for healing, such as massage therapy, acupuncture and t'ai chi into their patients' care plans. Nurses are attending educational forums on these non-Western healing methods to become familiar with these approaches and learn how to properly utilize outside experts in augmenting a patient's plan of nursing care.
Medication Issues Individuals from some cultures may want to include herbal medications into their plan of care. Additionally, there may be ethnic pharmacies patients may want to use, with medicine bottles imprinted with instructions in a foreign language. Nurses should be sensitive to the timing of passing medications, such as with Muslim residents who are saying prayers or fasting for Ramadan. Also, nurses should note that many Asian cultures do not drink cold beverages warm water should be available, when requested, for passing medications.
Spiritual Needs and Care Nurses should be particularly sensitive to patients' spiritual needs and incorporate them into daily care when appropriate. Some cultures utilize faith healers as part of their caregiving rituals, such as a medicine man used by some Native American populations. Some Asian and Latin American patients may want a religious shrine in their room to uphold their traditions. Facilities are using spiritual assessments to address patients' needs, with contacts made to religious leaders of many faiths to optimize care.
End-of-Life Care Some cultures may be very uncomfortable discussing advance directive wishes, with DNR orders and the use of g-tubes. Particular rituals may be necessary during end-of-life care, including prayers, offerings, chanting and the burning of incense. Nurses may find that throngs of family members and friends come to visit during a patient's last days, such as with many patients from Hispanic cultures. In addition, families from some cultures may wish to wash and prepare the body after death.
Decision-Making Different cultures have different beliefs regarding who should make healthcare decisions for the patient. In some Asian cultures, the eldest son may make these decisions. For a number of Hispanic cultures, the entire family wishes to be included in this process. Nurses should ask patients and families about their preferences.
Beliefs Regarding Illness Patients from different cultures may have unique explanations for why they are ill that go beyond a disease-specific medical model. These explanations may involve punishment from God, spells, spirits entering the body and food imbalances. Nurses should ask patients to describe in their own words why they feel they are experiencing medical symptoms.
Past Life Experiences Particularly for patients with dementia, past life experiences may resurface and affect care. For instance, a patient who survived the Holocaust may be fearful of showers, reliving traumatic experiences from the concentration camps. A patient who lived through the tumult of World War II may want to hide underneath the bed when hearing unexpected loud noises. Nurses should consider a patient's past life experiences when analyzing behaviors that seem unusual.
Nurses should not make the mistake of making ethnic stereotypes regarding care needs, such as believing everyone of a particular ethnicity will follow a certain practice. Every culture has incredible diversity and subcultures. Nurses should assess each patient as an individual. By learning about cultural preferences, nurses will become increasingly familiar with factors that could potentially impact patient care.
Through a proper clinical assessment that includes cultural factors, nurses can look at each person as an individual and determine caregiving strategies that uphold cultural traditions and beliefs. By becoming more sensitive to cultural issues, nurses can provide a higher quality of holistic care to patients of varying ethnic backgrounds, bringing comfort in many ways that patients and families can appreciate.
Here are some initial action steps nurses can take to provide culturally sensitive care:
• Include cultural questions regarding the care areas listed above in your nursing assessment process.
• Do some research about the cultures you serve through ethnic resources available on the Internet.
• Make contacts with ethnic community organizations. Many groups are very willing to help with volunteers, language services and ethnic programs to meet the needs of foreign-born patients.
• Develop a diversity committee made up of staff, patients and family members to discuss how your healthcare setting can better provide culturally sensitive care. Hold quarterly meetings to review your progress and make improvements.
1. Illinois Center for Health Statistics, Illinois Department of Public Health. (1997-2001). Long-term care facility profiles. Springfield, IL: Author.
Kevin M. Kavanaugh is director of public affairs and Susan Duda Gardiner is director of clinical services, Illinois Council on Long Term Care, Chicago.