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The greatest challenge to providing care for a culturally diverse population, said Aroian and others, is the language barrier. The first step to treatment is talking with patients in order to find out what is bothering them-an all-but-impossible task if provider and patient cannot communicate.

"When there is a language barrier, it's hard for nurses and others to conduct even the most simple assessment of what's wrong," said Aroian, who has focused much of her academic work on the health care patterns of various ethnic groups within the United States.

To address language differences, hospitals and clinics across the country are hiring interpreters and seeking out nurses and doctors who speak the language of the more prominent minority groups in their communities. Some also sponsor on-the-job language training.

Nurses and staff members at St. Elizabeth of Hungary Clinic in Tucson, Ariz., for example, attend a four-week program in Mexico to help them master the fundamentals of Spanish more quickly. While participants must pay for the trip themselves, Donna Zazworsky, MS, RN, FAAN, director of community nursing for the clinic, said that most nurses view the program as crucial for dealing appropriately with the region's growing Mexican population.

"Not only do you have to communicate with your patients in order to help them," Zazworsky said, "but you have to be proficient enough to control the conversation and make sure that patients tell you what you need to know."

Ultimately, many health care providers try as much as possible to hire members of the larger minority groups they serve-and not just for common language purposes. Many health care providers say that most minorities are not comfortable in a hospital or clinic unless they are dealing with one of their own.

"If a Chinese person comes to our door and does not see someone Chinese sitting behind the front desk, they often turn around and leave," said Virginia Tong, who helps run the Sunset Park Family Health Center Network of Lutheran Medical Center in a largely Chinese section of Brooklyn, N.Y.

At Denver's Clinica de la Familia, charge nurse Margaret Salamanca said that most of the doctors and nurses are Hispanic. "We have some Spanish-speaking patients who just don't want to tell the whole truth to English-speaking physicians," she said. "It's all about creating a comfort zone for those we serve."

While perhaps less apparent than language difficulties, starkly contrasting viewpoints and customs regarding health care also make treating a culturally diverse population a challenge. The millions of men and women who immigrate to America bring with them a host of beliefs about illness and healing that often run counter to the tenets of Western medicine. The key to overcoming this obstacle, nurses and other health care professionals say, is balancing what's best for patients while respecting their views. In other words, be flexible.

"We have to put aside some of our discomfort and hesitation and meet them where they're at," Reinhardt said. "We certainly have to encourage the proper medical help, but as nurses, I think we have to value and pay attention to a person's cultural heritage in order to facilitate the best quality care."

Reinhardt points to several examples of this sensitivity in addition to the leeway she and her colleagues afforded the Iranian family regarding visiting hours. She described one instance in which the hospital staff allowed a Somali family to wash and care for the body of a deceased family member-as is the custom with some residents of that country.

She also recalled a time when the staff had to downplay a West African man's cancer diagnosis in order to spare his family much shame in its community. In this particular culture, Reinhardt said, cancer is viewed as a curse and so the family would not accept the diagnosis. The nurses and physicians thus had to refer to the man's affliction as an infection. "We couldn't be as up-front about it as we would with many Westerners, out of respect for their background," Reinhardt said.