MNA Member Author’s Book on Honoring Patient Preferences in Multicultural Context
By Anne Knights Rundle, RN, MS

Editor’s Note:   Anne Knights Rundle, a current MNA Leader Fellow from District 5,  is the senior editor of “Honoring Patient Preferences – A Guide to Complying With Multicultural Patient Requirements,” which has been released for publication by Jossey-Bass Publishers.  Co-editors on the project include Maria Caralho-Rawhi, LICSW, who works at Children’s Hospital, and Reverend Mary Redner Robinson, Director of Pastoral Care at Children’s Hospital.  Rundle has 10 years experience in health care, coordinating services to inner city and under-served Latino communities in the United States and South America. 

Below, she provides an abstract of the material covered in her book.  Rundle is also available to conduct workshops on the subject for health care provider groups.  For information on ordering the book, call 888-378-2537.  To learn more about a workshop, call Ms. Rundle at 617-332-9237 or email her at Palomitos@Yahoo.com.

Effective health care incorporates the cultural traditions and spiritual concerns of the patient and family.  The authors, staff at Children’s Hospital, Boston, have developed Honoring Patient Preferences to help providers improve relationships with patients and families who represent an increasingly diverse population. The guide offers basic information on the general characteristics and traditions of several cultural and religious groups.  It also contains information on resources, such as consultants, interpreter services and external agencies, and tips for meeting JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requirements.

While the guide’s objective is to acquaint providers with the traditions of other cultures, the authors urge them to first consider their own value systems since the providers’ own traditions, values, belief systems and biases may affect their care of a patient with different cultural norms.  In the United States, many providers are educated under the Western tradition, which promotes certain values about health and illness.  Usually, biological (or biomedical) information is of primary concern, sometimes excluding all other aspects.  For example, a provider with Western training may not appreciate a family’s reliance on a spiritual healer.  It is essential to remember that a patient’s and family’s perception and understanding of the origin and meaning of well being, illness and recovery can be major factors in the health care process.

Culture of the Health Care Provider
 Many of the providers at Children’s Hospital are Caucasian North Americans, with “Western” traditions.  While they are as diverse as any other ethnic group, there are some similarities in Western culture that sets members apart from other cultural groups.  For example, communication style among most Americans tends to be linear, direct and “to-the-point.” In other cultures, such as African, Asian and Latino, communication may be more narrative in form, and people may get to the point gradually.  While in Western culture, direct eye contact is a sign of respect and attentiveness, in other cultures it may be considered disrespectful or an affront.

In Western culture, people value the time-efficient behavior.  Time is “saved,” “lost,” or “wasted.”  It is very important to be “on time.”   Western thinking is often future-oriented.  People plan for the future in many aspects of their lives.  Believing that they, not fate, control the environment, they think they can determine the direction of many areas of their lives.  In many other cultures, time is present- or past-oriented.  Taking time to build personal relationships is much more important than being “on-time;” therefore, stopping to talk to a neighbor could be more important than arriving on time for a clinic appointment. 
 
While preventive medicine is an important aspect of health care in the United States, in many other countries it is not practiced.  For example, a Central American parent may not give preventive asthma medicine when the child is exhibiting symptoms at the moment. 

 Individualism and autonomy are highly valued in American culture.  People’s success is judged by their acquisition of possessions, degrees and titles.  Privacy is also very important.  In particular, religion and spirituality are private matters.  On the other hand, in many languages other than English, the word “privacy” does not exist except in the context of  “forced isolation.”  In most other cultures, society is group-oriented.   The welfare of the group, and cooperation rather than competition, are primary values in African, Arabic, Asian and Latino cultures.
 
Many people from non-Western cultures believe less in control over the future and more in the role of fate.  So while Americans tend to “plan and do,” focusing on tasks, members of other cultures may tend to “be a part of” and accept fate.
 When working with culturally or spiritually diverse patients and families, providers are encouraged to first understand their own cultural values and traditions and adjust their expectations accordingly. This chapter offers strategies for providers making an initial assessment of the cultural and spiritual needs of a patient and family. 

Purpose of the book
 This book is intended to help providers best meet the needs of their patients.  To maximize utilization of this resource, read all chapters.  Chapters 2 and 3 contain samples of general beliefs and practices of various cultural and religious groups.  While providers are encouraged to utilize this material to consider the traditions of the group, they are cautioned not to stereotype or to over-generalize or characterize all members of a cultural or ethnic group as alike.  Individuals of the same cultural group may not hold the same values, and their cultural values may or may not be factors in the illness experience.  Aspects to be considered in the assessment include: individual characteristics, socioeconomic status, race, education, age, sex, and the stages, conditions, and adjustment to the migration experience; and whether the immigrating family lived in a rural or urban area in their native country. 

 The samples are based on one particular hospital’s patient population.  Other hospitals will have different patient demographics, based on the organization’s geographic location.  This guide can be used as a template.  Using the sample templates, provided in chapter 4, hospitals can write informational material about cultural or religious groups in their patient population.  Chapter 5 contains information about the use of interpreter services and the aspects of a bilingual medical interview.  Chapter 6 provides tips for meeting the Joint Commission on Accreditation standards. 

Strategies for Providers
 The following information is intended for providers who are initiating a healthcare relationship with a patient or family.  While this information is useful for all families, it is especially helpful for providers who care for patients and families with cultural beliefs, spiritual traditions or languages that are unfamiliar to them.

Before Meeting with the Patient/Family
1. Understand your own cultural values and traditions.

2. Acquire basic knowledge of cultural values, health beliefs and nutrition practices of the patient and family.
 

During Conversation with the Patient/Family
1. Determine the level of fluency in English, and arrange for an interpreter if needed.

2. Ask how the patient/family prefers to be addressed.

3. Allow family members to choose seating for comfortable personal space and eye contact.

4. Avoid body language that may be offensive or misunderstood.

5. Speak directly to the client, even if you are using an interpreter.

6. Choose a speech rate and style that promotes understanding and demonstrates respect for the client.

7. Avoid slang, technical jargon and complex sentences.

8. Use open-ended questions or questions phrased in several ways to obtain information.
 

Questions to Ask
According to Kleinman, et al (1978), understanding someone’s cultural background assists in the development of an individualized, comprehensive plan of care.  Certain questions can help the provider establish a relationship and exchange important information with the family. The explanatory model of illness posits that a patient interprets and defines symptoms.  Using this dialogue, the provider helps the patient understand and communicate his or her feelings about the illness. Kleinman recommends the following sample questions.  Document the answer in the patient’s record.

1. What brings you here (to the hospital, clinic)?

2. What do you call your child’s (illness, problem)?

3. What do you think causes the (illness, problem)?

4. What have (doctors, nurses, other caregivers) done so far?  What have you, other family members done so far?

5. How has the illness affected your child’s life? 

6. How has it affected you and your family?

7. What worries you most about the illness and its treatment?

8. What would you like to happen today at the clinic/hospital? 
 

During Patient/Family Teaching

• Determine the patient/family’s reading ability before using written material in the teaching/learning process.
• Review client understanding and acceptance of recommendations.
• Adapt the plan of care as necessary to ensure optimal patient health.

Consultation on Cultural or Religious Issues
Staff in health care organizations may be available to provide consultation regarding cultural or religious issues.  Consultants offer knowledge of the culture by simply being a member of the culture and/or having extensive experience working with individuals from specific cultural or religious traditions.  They may be able to provide information about family structure and roles, health beliefs and practices, and immigration patterns and their impact on families.

Cultural Consultants
Consultants are skilled and trained in providing consultation to health care providers. The role of the consultant is:

• to provide factual information about the specific religious tradition and culture;
• to assist the team in identifying and discussing with the patient and family cultural traditions and health beliefs which may influence understanding of the diagnosis and care plan as well as future compliance with recommendations for care at home;
• to assist the team in incorporating knowledge of the patient and family culture into both their assessment and treatment plan; and 
• to assist the team in dealing with misunderstandings or conflicts which may arise in the patient, family and staff relationships due to cultural differences.

Interpreter Services 
Cultural consultation or cultural mediation is provided by trained interpreters as part of their role as a member of the health care team.  This teaching and consultative role is critical to effective interpreting. 

Pastoral Care
 Religious consultation or mediation is provided by hospital chaplains.  The chaplain can clarify spiritual concerns in the health care setting, and assist both provider and family in seeking a plan of care that is medically appropriate and sensitive to religious issues.

Other Members of the Health Care Team
Other staff members may share knowledge of the culture and health beliefs, which they have gained through being a member of that culture or through training.  This level of consultation is embedded in their professional roles. Cultural consultation is provided by a cadre of trained consultants who may be called upon for assistance when the team identifies a need for consultation from an individual outside the patient, family, or professional team. Many members of the Pastoral Care, Social Work, Psychiatric Nursing, Psychology and Psychiatry staff are trained to provide this level of consultation.  Begin by conferring with the pastoral care and/or mental health staff assigned to the unit or clinical program. 

External Consultants
 Experts outside of the health care organization may provide in-service education regarding specific cultures or may be asked to comment from their knowledge base in a range of case-based training situations. 

References
American Association of Retired Persons. “Appreciating Diversity: a Tool for Building Bridges.”  AARP Publications. 1996.
Kleinman, et al. “Culture, Illness and Care: Clinical Lessons From Anthropologic and Cross-Cultural Research.” Annals of Internal Medicine, 1978; 88: 251-258. 
“Cross-Cultural Counseling: A Guide for Nutrition and Health Counselors,” United States Department of Agriculture, FNS-250, 1986.