Briefly introduce a person you have recently cared for in your nursing practice. (Be sure not to include any identifying information that would be protected by HIPAA!) Discuss the person’s view of the cause of their health condition, the person’s health literacy, and the person’s identity on the continuum of privilege-disadvantage (Table 4 in the Lor article on p. 361). What was (or would be) your approach to care for him/her in a culturally competent way?

Briefly introduce a person you have recently cared for in your nursing practice. (Be sure not to include any identifying information that would be protected by HIPAA!) Discuss the person’s view of the cause of their health condition, the person’s health literacy, and the person’s identity on the continuum of privilege-disadvantage (Table 4 in the Lor article on p. 361). What was (or would be) your approach to care for him/her in a culturally competent way?

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

 

Online Materials & Resources

  1. Visit the CINAHL Complete under the A-to-Z Databases on the University Library’s website, locate and read the article below:
    • Lor, M., Crooks, N., & Tluczek, A. (2016). A proposed model of person-, family-, and culture-centered nursing care. Nursing Outlook64(4), 352–366.
      https://www.sciencedirect.com/science/article/abs/pii/S002965541630001X (Links to an external site.)
    • https://doi.org/10.1016/j.outlook.2016.02.006 (Links to an external site.)
  2. Read the article below:
    • Carteret, M. (2015, October). Reading Between the Head Nods | Dimensions of Culture. Retrieved from http://www.dimensionsofculture.com/2015/10/reading-between-the-head-nods/ (Links to an external site.)

      It is important for U.S. healthcare providers to understand some key aspects of how language and culture can affect interactions with patients and families who have come to this country from other cultures―especially recent immigrants and refugees. Providers may not be prepared for the high context communication style that is normal in many societies. A lack of awareness of how this manifests in conversations with patients can lead to misunderstandings. Providers may feel very confused by certain behaviors and frustrated by unclear conversational dynamics.

       

      LANGUAGE BARRIERS BETWEEN PROVIDERS AND PATIENTS

      Interactions between healthcare providers and their patients provide a great many opportunities to explore the challenges inherent in cross-cultural dialogue. The formation of a therapeutic relationship is especially difficult when parties cannot communicate directly, and it becomes even more complex when different culturally-based belief systems are involved. A competent interpreter can mediate these barriers by attending not only to the linguistic but also to the extra‐linguistic aspects of communication.

       

      MISSING EQUIVALENTS

      Perhaps the most obvious challenge that surfaces in communication between providers and their patients when they speak different languages is missing equivalents or ‘untranslatable’ words. Missing equivalents are an especially common problem in medical settings because so much medical terminology does not translate into other languages and health belief systems. For example, the concept of bacteria, a living physical organism that is invisible to the naked eye, is a concept that has no equivalent in many rural, non‐literate societies. To get the concept across, a trained medical interpreter will have to work with a provider to find ways to explain this concept which can not be easily demonstrated. Conversely, there are culturally-based concepts outside the scope of western medicine like evil eye or fright sickness also attributable to invisible forces―evil spirits. These challenge the scientific basis of western medical practice and are definitely missing any equivalents. Highly qualified medical interpreters help bridge the gaps in understanding where extra‐linguistic aspects of communication are involved.

       

      BEING ACCURATE VERSUS BEING POLITE

      Missing equivalents are often easily spotted. Two people communicating—or three if an interpreter is involved—will often recognize a gap in understanding due to looks of puzzlement, and queries such as “Sorry?” or “Beg your pardon?” What is much trickier to discern and solve are differences in the normal expectations people may hold about the way language should be used. In some cultures for example, being polite to the other person is more important than supplying objectively correct information1. One interesting study done between people living in England and Iran in the late 1970s provides a useful example. The study involved giving directions to foreigners. In Iran, which a high context culture, when asked for directions, the need to appear helpful and polite outweighed the importance of accurate information. In this middle-eastern collectivist culture, one out of five people in the study pointed the way to a place even if that place did not exist. In England, where people tend to be low context communicators like Americans and Canadians, nobody did this.To many westerners, this seems like dubious “helpfulness.”

      High context cultures tend to place a high value on interpersonal relationships and close-knit community. They also tend to preserve social hierarchy, and authority figures of any kind are treated with deference. Doctors are usually seen as educated experts of high status. Thus, patients want to please their doctors and a lot of head nodding and smiling may occur regardless of actual understanding or agreement with what the authority figure is saying.

       

      UNDERLYING MOTIVATIONS

      Sometimes, in cross-cultural medical encounters, patients who are high context communicators may be indirect about the real reason for their visit to a doctor’s office. It is not always easy to uncover an underlying motivation or secondary gain expected from a medical appointment. Unless proven otherwise, it might be prudent to assume not everything is being directly stated. Always confirm understanding, especially with respect to the desired outcome of the visit. The patient may be unsure about an American doctor’s reaction to—and willingness to approve—what he or she really wants.

      EXAMPLES COMMON WITH IMMIGRANTS AND REFUGEES

      • A patient visits a doctor for the I-693 green card physical exam, but says he has no problems. He does not want to reveal any health problems because he is afraid citizenship may be affected. (I-693 is the Report of Medical Examination and Vaccination Record Department of Security, U.S. Citizenship and Immigration Services.) 
      • A patient wants homecare or daycare benefits, so she goes to see the doctor complaining of back pain or headache or leg pain so she can get some medication. Any medication will do, because she has been taught that having medicines makes her more likely to get these services approved.
      • In family medicine, a lot of people visit their doctor because they need work or school excuses, especially because they work at tough jobs and/or jobs with poor vacation allowances. In order to get time off to attend a family wedding or funeral, for example, a patient might need proof of illness from a doctor. So the patient presents with complaints about pain, headaches, nausea. This happens much more with poor families. People with white collar jobs are usually allowed reasonable time off.

      INTERACTION SKILLS TO ASSURE BETTER COMMUNICATION

      Anticipate patients in cross-cultural encounters to want to please a doctor. Figuring out what a doctor wants to hear will be a top priority.

      • Ask open ended descriptive questions—avoid questions that can be answered with a “yes” or a head not. “Describe the pain you are having.” or “Tell me about when this headache started.”
      • Be prepared for people to answer by telling a story. The story in important!
      • Provide affirmations to encourage participation in conversation. Especially encourage questions.
      • Use reflective listening.
      • Provide summary statements to check for real understanding, including: “Is there anything else you needed my help with today? Or is there any other reason you have come to see me?”

      SUMMARY

      Cross-cultural interactions between providers and patients sometimes introduce a unique level of conversational complexity because people who are new to the U.S. healthcare system base their expectations on past experiences of health care experiences in other countries. They may also base their expectations of physicians and office visits on misinformation they have learned from members of their community or extended family. Being prepared for the likelihood of mismatched expectations, especially when meeting with a recent immigrant or refugee, is an indication of real preparedness and responsiveness in cross-cultural patient care.

       

      Resources

      1. Hofstede, G. Cultures Influences Second Edition. London, UK. Sage Publications. 2001
      2. Collett, P. & O’Shea, G. (1976) Pointing the way to a fictional place. A study of direction giving in Iran and England. European Journal of Social Psychology, 6, 447-458.