Embracing Diversity
From language differences to divergent viewpoints and beliefs, health care teams around the country take on the challenge of providing medical help to patients from different cultures

By H. Cheever Griffin
December 18, 2002

As Carol Reinhardt, RN, recently entered the room of a new patient in the intensive care unit at Ohio State University Medical Center, the longtime nurse assumed the discussion she was about to have with family members would be like most others.

It wasn't. The patient was an Iranian man, and as Reinhardt began explaining his ailment to the loved ones gathered around his bed, she quickly encountered the unexpected. When she tried directing her discussion toward the man's wife and daughter, they lowered their heads and turned away.

It eventually dawned on Reinhardt that she was supposed to speak only to the man in the room-who in this case happened to be the patient's son-in-law.

Reinhardt then mentioned the hospital's visiting hours-and received a look from family members like she'd just asked them all to jump out of the nearest window. The son-in-law requested to see the nurse manager and explained that leaving sick loved ones alone for any amount of time was akin to abandoning them. "They had no comprehension of visiting hours," Reinhardt said. "It was something that was abhorrent to them."

The nursing team met with the family and quickly worked out a compromise: The visiting hours would stand, but be extended each day for family members of this particular patient. The impasse was solved, but not before it provided Reinhardt with yet another example of what she sees as a growing trend in her hospital and many others: an increasingly diverse patient population-with increasingly diverse needs.

Most researchers agree that the United States, long a destination of immigrants, continues to grow more culturally diverse. According to the U.S. Census Bureau, the number of foreign-born residents in the country jumped from roughly 19.8 million to a little more than 28 million between 1990 and 2000. What's more, experts predict that Caucasians, who now represent about 70 percent of the U.S. population, will account for barely more than 50 percent by the year 2050.

The country's growing number of newcomers, many of whom migrate from Latin America and Asia and in smaller numbers from throughout the world, come from all walks of life.

However, they share at least one thing in common with everyone else: They, too, need health care.

"This is something that every nurse needs to be aware of," Reinhardt said. "Our country is growing more and more diverse, and the people from these different cultures are finding their way to our doors."

When they get there, the going is often rough. Nurses around the country say that from language differences to divergent viewpoints and beliefs, providing medical help to patients from different cultures can be a mighty challenge. Nonetheless, it is a challenge that many hospitals and nursing staffs are attempting to meet as the populations they serve take on an increasingly international appearance.

"In years past, the medical community has largely just paid lip service to this matter," said Karen Aroian, Ph.D., RN, a professor with the college of nursing at Wayne State University in Detroit. "But it has now become a most pressing issue for health care providers."

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.

Salamanca added that one way to practice cultural sensitivity is to give patients your time and simply listen to them. She and other nurses say that Hispanic patients in particular like to spend time with their health care providers and that many of the older Hispanic people insist on expressing their own-often less than scientific-reasons for the onset of a particular ailment.

Salamanca, who is of Colombian and Chilean descent, recalled one elderly Hispanic patient who was certain that her cough was due to the large number of cockroaches that had temporarily infested her home.

"You have to be respectful of what they have to say," she said. "Obviously, you want to steer them to other ways of thinking, but you have to listen with a sympathetic ear because a lot of what they tell you stems from their beliefs. If you put them off, it only builds a wall."

Other examples of hospitals and clinics trying to accommodate the customs and beliefs of minority groups abound. One of the more dramatic examples comes from Zazworsky, who recalled that while working as a nurse at an Arizona hospital several years ago, she watched an elderly American Indian patient become extremely agitated in his bed. It turned out that the man's window faced a roof corner of the hospital on top of which sat a statue of an owl. According to the beliefs of his tribe, the owl signified death and thus the man believed he was going to die. Hospital officials eventually removed the statue.

One question that often arises is how can any nurse or doctor know all the customs and beliefs of the patients that come before them? It's not easy, say health care professionals. It takes years of interaction with members of different cultural groups as well as efforts on the part of hospitals and clinics to enlighten their employees about the ways of particular peoples.

At Sunset Park Family Health Center, for example, Tong oversees language and cultural training sessions, while Reinhardt said that the staff at Ohio State University Medical Center creates posters that describe the customs and beliefs of the many different groups that reside in the community.

Several books also address the subject. They analyze the health care beliefs of various cultural groups and, in essence, serve as a quick reference for all the dos and don'ts when providing care for foreign-born residents. Culture & Nursing Care: A Pocket Guide, for example, is a 300-plus-page pamphlet that describes everything from the death rituals of Haitians to the ways Russian women prefer to deliver babies. (Vaginal over cesarean-even if a baby is in breech position, physicians are expected to exhaust all measures to ensure a vaginal delivery.)

"It provides a way for nurses to approach patients from different cultures and help improve communication during what is often a time of great stress and transition," said Sue Dibble, DNSc, RN, professor of nursing at University of California, San Francisco, and co-author of the pamphlet.

Of course, many nurses add that there is more to properly treating patients from different cultures than just understanding their particular views on health care. It also helps to know aspects of their daily life.

"You want what you're doing to have an impact on these patients, and so you have to know a bit about how they live," Tong said.

As an example, she said that admonishing Chinese patients with hypertension about their use of salt is a well-intentioned but largely futile exercise. She explained that most Chinese people don't season their food the way Americans do. They use soy sauce, which is loaded with salt.

"If you don't know to address the issue of soy sauce with them, then you've lost the battle," Tong said. She added that the nurses and others at the Sunset Park Clinic are instructed to encourage their Chinese patients to eliminate soy sauce from their diet, or at least cut back on it.

It's the same with dairy products. Giving Chinese women prenatal care advice to eat plenty of cottage cheese and yogurt will most likely fall on deaf ears, Tong said. "They won't eat that stuff," she explained. "They prefer rice porridge, so you have to provide them recipes that contain more of the nutrients they need."

Many in the medical profession acknowledge that learning the health-related customs of various cultures-not to mention their everyday ways of life-comes largely from years of experience.

With the nation growing so diverse, however, the nursing field is taking steps to help its members gain this knowledge sooner rather than later. Aroian at Wayne State University said that where once the topic of cultural diversity and health care warranted perhaps a class period or two, it is now a full course at her nursing school and a number of others.

And whether it's four-week study trips to Mexico or language and cultural training classes on-site, more and more hospitals are working to give nurses the tools they need to provide the increasing number of ingredients in the national melting pot with the best health care possible.

Aroian said she applauds such efforts and suggests that-in the end-the best strategy is not simply to learn about a particular culture, but to show a willingness to embrace them all. "I tell nurses that if you are receptive to different peoples and genuinely curious about them, you'll develop the skills to address what they need."

Contact H. Cheever Griffin at cgcommunications@ameritech.net