TAN Issue: January/February 1998: Features: Nurses need to strengthen cultural competence for next century to ensure quality patient care

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by Michael Stewart, MA

Understanding patients' cultures
Facing patient prejudices
Overcoming language barriers
Useful Questions to Ask Patients

The number of people in cultural, ethnic and racial groups that have traditionally been labeled "minorities" in this country is growing at a rapid pace. As frontline providers of health care, nurses are the first and sometimes only contact these people have with the health care system. This makes it crucial that the profession develop a strong cultural competence in its approach to patient care.

"Inattention to cultural competence in patient care leads, at best, to sub-optimal patient outcomes and, at worst, to active harm," says Carla Serlin, PhD, RN, director of ANA's Ethnic/Racial Minority Fellowship Programs. "When we fail to address issues of difference such as language, ethnicity and race, our patients will have lower levels of compliance with care instructions and longer hospital stays."

Antonia Villarruel, PhD, RN, president of the National Association of Hispanic Nurses, says, "As individuals and as nurses, we need to recognize that diversity is now the norm. Encountering patients who may speak limited or no English will be commonplace."

Understanding patients' cultures

Serlin says a nurse "needs to discover what the illness and the interventions she's employing mean to the patient and what the patient is experiencing, so the patient will improve. This can be done best with questions. We do systems assessments, but we ask next to nothing about culture." (See "Useful Questions to Ask Patients.")

It's also important that nurses understand how the actual symptoms and prevalence rate of illnesses (including mental disorders -- see article, previous page) can manifest themselves differently across cultures, adds Serlin. "Blacks have higher-than-average rates of gastrointestinal cancers," she says, "as do Asian-Americans but not Asians living in Asia."

Because of unique cultural differences, ANA President Beverly L. Malone, PhD, RN, FAAN, says nurses should not adopt a color-blind mentality. "It's not a badge of honor. It means there's something wrong with the sight. Nurses need to see who the patients are. We want to see the whole person, including their color. People are uniquely different, and treatment decisions are uniquely different. Take the term "white." There's Italian-American, Irish-American and Polish-American. Again, we cannot fall back on, I treat patients all the same.'"

Facing patient prejudices

"I've had a patient ask for the nurse, and when I said I was his RN, his cardiac monitor began to dance," Serlin recalls. "It turned out he just couldn't deal with having a black nurse. I had the supervisor, who doubted me on this, check by using other, white nurses. He was much better. It wasn't appropriate to risk his health, which was very precarious, by putting him in a position where he had to confront his prejudices right at that moment."

Serlin advises a nurse who faces apparent patient prejudice to first double-check his or her own perceptions and biases about working with that patient. However, if the evidence of patient discomfort based on prejudice still seems strong, the nurse should then try to assess the potential for a real adverse impact on the patient's outcome.

"Of course, these are very sensitive issues," says Serlin."If things really seem out of kilter from an objective standpoint of signs of illness, it's not a bad idea for the nurse to consult her supervisor, as I did."

Overcoming language barriers

"Having access to the language of the patient and his or her community is critically important," says Malone. "How can you assess needs if you can't speak to someone? If you're in a Hispanic community, you need to speak Spanish. You need different cultural knowledge if you're in Texas working with Latinos from Mexico than you do if you're in Florida working with Latinos from Cuba.

"Schools of nursing should include language in the curriculum," Malone continues. "Hospitals and institutions should put together language programs like those for business people going overseas. Many times, we encounter patients who are desperate, in critical situations. If this language ability is important for business people, how much more so for nurses?"

Nurses would be well-advised to learn a foreign language, agrees Wendell Oderkirk, PhD, RN, associate professor at New Mexico State University in Las Cruces, a specialist in community health, and a member of the New Mexico Nurses Association. "Knowing something about Spanish gives me an entree with patients that a translator or interpreter wouldn't give. We can't depend on a kid to interpret for his or her parents. For one thing, the parent often won't give the kid information to pass along because some conditions are embarrassing."

Oderkirk stresses that it's important to encourage both people who are bilingual to join the nursing profession and Anglo, monolingual nurses to learn another language. "Thirty to 35 percent of our nursing students here in Las Cruces are bilingual, but we need to do more," he says. "The drop-out rate for Hispanic kids is higher than for Anglos, so it's harder to get them into college in the numbers we need."

As noted in the December 1, 1997, issue of Modern Healthcare, several standards of the Joint Commission on Accreditation of Healthcare Organizations guarantee language access to patients. In addition, the failure of health care providers to address language barriers also may violate Title VI of the Civil Rights Act of 1964. (For more on the legal ramifications of language barriers, see DiversityRx. The website offers links to organizations and resources on cross-cultural health care, general cross-cultural issues, minority health, migrant health, immigration and general health care.)

Issues of culture, economic class, ethnicity, language, race, sexual and gender orientation and age all play into the mix of attitudes and decisions that determine cultural competence. These attitudes influence nurse behaviors, not just toward patients, but toward one another. "It's a continuous loop," says Malone. "We can't ensure the best possible patient outcomes without considering cultural competence to be an integral part of holistic nursing care. Those positive outcomes come not just from appropriate work with patients, but with nursing colleagues as well. It's not something about which you can say, I've got it; I'm through now,' because it's not just learning about others, but about ourselves -- and that process just doesn't end."

Michael Stewart, MA, is senior public relations specialist at the American Nurses Association.

Useful Questions to Ask Patients

  • Were you born in this country?
  • What language do you speak at home?
  • Do you have any special dietary needs?
  • How are you handling this problem (your condition) at home?
  • Are there things that would be a comfort to you while you are here?