In certain geographic locations in the United States, healthcare systems are being visited by recent and second-generation immigrants who use culturally specific healthcare practices. Some come with folk remedies unfamiliar to nurses. Others may be distrustful of Western healthcare practices because their own view of health and illness is rooted in beliefs associated with imbalances in energy or in other important natural forces requiring special spiritual interventions. Some immigrants want to combine "their" remedies with "our" treatment recommendations. Often such practices add up to higher costs because more staff time is required to accomplish positive patient outcomes.

We are constantly reminded that home health nurses are expected to streamline their assessment skills, provide excellent care, monitor patient outcomes, and perform all activities cost effectively. In order to provide more with less, we need to be able to quickly establish a close-knit cooperative bond with all clients and their families, including those from cultures different than our own.

Several nursing experts have written about the importance of integrating transcultural nursing knowledge into our everyday practice. The most prominent nursing pioneer in this area was Madeline Leininger who wrote extensively on this subject (1988). Giger and Davidhizar later developed a detailed transcultural assessment model that included specific patient-centered cultural assessment topics (1995). In a recent issue of Home Healthcare Nurse, Narayan offered another excellent and comprehensive model for conducting a cross-cultural assessment (1997). This article presents a condensed cultural assessment tool. The tool requires less time to administer, but still enables the nurse to gather the most essential information necessary for thorough care planning.

To illustrate what can happen if a cross-cultural assessment is not performed, a real dilemma that happened in a hospital-based agency will be described. Following that example, the assessment tool will be presented, along with general indications and approaches to consider when preparing to do a cross-cultural assessment, and actual home health case study examples.

Chaos in One Setting

For several years, Mt. Zion Hospital and Medical Center in San Francisco served as one of the main care providers for the Russian Jewish emigre population. In the mid 1970s, 5000 additional emigres arrived. System-wide confusion broke out. Physicians and nurses were at a loss to understand what they were witnessing (Wheat, Brownstein, & Kvitash, 1983). Here is what happened:

1. New immigrants made a habit of arriving several days late for appointments yet demanded to be seen immediately. Others made dramatic entrances into the emergency room, feigning heart attacks and presenting with "near-death emergencies" that were anything but severe or emergent clinical situations.

2. When cared for in a routine manner by nurses and physicians, these patients complained about being "assaulted," ridiculed, and treated as second-class citizens.

3. If nurses or physicians mentioned diagnosis; tried to involve patients in decisions about treatments, tests, medications; or attempted to explain why an operation was needed; their efforts were met with extreme anxiety, providing proof to the Russians that care providers were incompetent.

4. Nurses were strongly criticized by very hostile patients and family members who claimed their care was "inferior" because the nurses refused to allow patients the proper amount of bed rest.

5. Nurses were placed in the awkward position of having to refuse tips offered by patients. These patients were insistent. They expected to pay extra for receiving pain medication on time, having bed linen changed, and receiving bed baths.

The Solution

The basic problem was that the Russian emigres' were not behaving like "usual" patients. Their "disturbing" behaviors were impacting the entire healthcare system. Nurses, physicians, hospital administrators, and patients were upset. To find a solution to this problem, outside consultation was called upon. With the help of the Jewish Welfare Federation, Mt. Zion administrators contracted with Russian translators to interview patients to learn more about these unusual patient behaviors. What was learned was most interesting.

Each patient behavior that Mt. Zion staff found disruptive was traced back to the "old country's" polyclinic systems. There, the polyclinics were extremely overcrowded and very poorly staffed. If a Russian needed care, he or she developed a special set of "survival skills" for that system. After details of the translators' findings were shared with Mt. Zion staff, nurses and physicians were more understanding and tolerant. They learned the following details.

The Russian Clinic System

In Russia, care is received through polyclinics that are only open a limited number of hours and manned by physicians and nurses who work fixed shifts. If a patient has not been seen by the time the clinic hours end, he or she must return the on following day. Under these circumstances, appointment schedules are never accurate and sometimes appointments are not kept at all. Therefore, a patient may intentionally decide to arrive late in order to save time. The Russians also knew they stood a much better chance of being seen if they presented with an acute illness.

The new emigres soon learned that Mt. Zion had a policy of quickly evaluating any ER patient presenting with chest pain. The Russians adapted to Mt. Zion's chest pain policy, used that information to their advantage, and presented with these "symptoms" in the ER.

Professional Behavior in Russia

The demeanor displayed by physicians and nurses in Russia varies from that in the U.S. In Russia, the approach to illness is serious and grave and nothing to smile about. If a care provider was friendly and smiling (as was often the case with Mt. Zion nurses and physicians), this was proof the provider was being disrespectful, did not care, was not serious, and was not assuming proper responsibility for the patient's care.

The age of U.S. care providers and their mode of dress also was perceived negatively. In Russia, age and wisdom are valued more than someone with recently acquired knowledge. Interns and residents were viewed as "less than" real physicians and were treated accordingly by the emigres. Distinct uniforms are worn by all healthcare workers in Russia and are associated with the image of the stern, capable, wise, seasoned care provider. Failing to wear a uniform meant the provider was a trainee and incompetent. Care provider/patient relationships are authoritarian in Russia. Wearing the proper uniform is seen as an integral part of this authoritarian image.

Patient Self-Care Issues

In the Russian caregiver/patient relationship, the patient expected to be told exactly what to do. Consequently, if a nurse or physician at Mt. Zion tried to involve the patient or family in decision-making options, the usual response from the emigre was one of shock and grave anxiety, and added to the emigre's belief that the caregiver was not competent.

Treatment Options

The most common treatment in Russia is plenty of bed rest. Illnesses we would treat in home care in the U.S. are treated in the hospital in Russia because extreme overcrowding in most homes does not allow for bed rest. In Russia, quality of care is judged by the length of time a patient is told to remain in bed. Minimum bed rest standards and hospital lengths of stay are well established and adhered to in the Russian system. Therefore, insisting that patients get up and be discharged as soon as possible conflicted with what every Russian knew to be "proper" care; the Russians expressed to the Mt. Zion staff their displeasure with this "inferior care."

Tipping

In Russia, it is common practice to tip hospital staff. Russian hospital staff are poorly paid; therefore, in order to get any attention or services, the patient pays a tip for routine care and services. The emigres were very confused when the Americans did not want their money.

Providing Culturally Competent Care-Sources of Help

The Mt. Zion experience is not unique. The issues raised were related to cultural differences in healthcare beliefs about "proper practice" and which services a health system "should" provide. Our system was not reacting in a way that was familiar to these patients from a different culture. In home care, culturally related misunderstandings usually occur on a case-by-case basis, seldom impacting an entire system. However, sorting through problem-solving approaches is sometimes more difficult in home settings because staff often work in semi-isolation, whereas in hospitals, other staff are present to share their observations and assessments.

When culturally related misunderstandings arise, seeking help is important, particularly if the home care nurse hopes to maintain a supportive, therapeutic relationship with the client.

Text Resources

Often help can be found in reference books and through community agencies providing translators and experts in a particular culture. Unfortunately, most books provide only a synopsis, using targeted information about the particular cultural group. Relying on such information is limiting because each group is clustered into "expected" patterns of behavior.

However, one very helpful and recent reference book for nurses is a pocket guide written by Lipson, Dibble, & Minarik (1996). The book highlights 24 cultures and presents the following information for each cultural group:

history of migration,

preferred term used by the people in that cultural group,

major language and dialects used,

verbal and nonverbal communication distinctions including orientation to time and how discussions about serious and/or terminal illnesses could be bridged,

specifics about activities of daily living (ADL),

food practices,

symptom management,

birth and death rituals,

decision making,

the structure of family relationships, and

any additional culturally specific information.

Help With Language

Language barriers add to the challenge of trying to provide culturally competent care. Calling in an interpreter (when one is accessible) is the usual course of action. However, the quality of information obtained through an interpreter may be inconsistent if the translator does not understand the meaning of complex medical information. Reliance on friends or family to interpret may be the only option available in home care.

In this situation, great care must be taken to explain complex medical information so that the interpreter understands what needs to be conveyed. In addition, it is often inappropriate for children to be responsible for communicating sensitive or complicated information to their elders. Care must also be taken when men are asked to translate for women or when the central family decision maker is also asked to be the translator because decisions made unilaterally by this person may be integrated into the context of the translation.

Cross Cultural Assessment: Indications, Approaches, and Assessment Questions

Before implementing a treatment plan, the nurse must first decide if conducting a cross-cultural assessment is indicated and then choose a specific approach to use. He or she will then be ready to ask the structured assessment questions. Asking these questions in the initial visit serves as a good starting point for establishing a bond between the nurse and patient. Once the clients' healthcare practices and beliefs are disclosed, the nurse and patient will be better able to partner in care planning.

General Approaches

Before asking the questions, the nurse should remember these general ways of approaching a cross-cultural assessment. Narayan refers to some of these as examples of "social etiquette" (1997, p. 665).

As "Westerners" we are bold and direct when asking questions. We also expect direct and complete answers. However, a more gentle approach is wise, proceeding discreetly about how direct to be. Many cultures are known to value small-talk and social chit-chat even in crisis situations. This indirect, tactful approach to intervention is comforting. If family members are present, ask the patient which member(s) of the family should be included in discussions about treatment. The family will appreciate this respect and attention from staff (F. Conway, personal communication, May, 1999)

In some cultures, talking around the illness may be more helpful and trust promoting than focusing directly on the illness. When family members speak, pay close attention to what is said and what is unspoken about the illness or condition. These observations will provide clues as to how best to proceed.

In some cultures words such as cancer, operation, terminal illness, and death are not used. In many Middle Eastern cultures, if death is pending, the mere mention of preparing for death is viewed as a serious breach in the nurse/client relationship. To speak of death is to admit that the situation is hopeless and is an unforgivable affront to God-the only Being capable of deciding one's fate (Lipson & Meleis, 1983).

Use the client and family's same words-repeating them for validation of meaning and context. Ask about words that are unclear.

Seek out experts in that specific culture for help.

When observing the family, the nurse will find it helpful to watch who "takes charge" in decision making or introduces new subjects for discussion. Nonverbal cues are not universal and can be misinterpreted. Even so, paying attention to these may be important (F. Conway, personal communication, May, 1999).

The patient and/or family may have already been victims of cultural stereotyping by others. Therefore, sensitivity about this possibility will also be beneficial.

A person's need for modesty varies greatly between cultures and between individuals in that culture. For example, in some cultures it is inappropriate for a patient to be uncovered or seen undressed in front of the nurse unless a designated family member is present. In another example, male patients might be shocked if asked by a female nurse to give a urine sample because doing so shows a lack of sensitivity and respect for the patient's modesty (F. Conway, personal communication, May, 1999).

Determining how important religion is to the client and family is vital. If religion plays a prominent role, the family may have built strong alliances with representatives from their faith; therefore, it would not be uncommon for these key individuals to be included in major healthcare decisions.

However, according to Lipson & Meleis (1983), in certain Middle Eastern cultures, clergy visitation should not even be mentioned for the terminally ill patient until a spokesperson of the family clearly requests one, because to "request a visit on behalf of the family violates the value of hope, 'interferes with God's plans,' and conveys an image of a health care system that 'gave up"' (p. 860).

The Assessment Questions

The specific cross-cultural assessment questions are offered by many authors, only a few of whom are mentioned here:Leininger, 1977; Kleinman, Eisenberg & Good, 1978; Tripp-Reiner, 1984; Giger & Davidhizar, 1995; Narayan, 1997. The questions presented in this tool are a synopsis of these well-known authors describing this subject.

Summary

In nursing, it is well known that establishing a successful nurse/client relationship depends on the nurse's ability to promote a bond of trust between them (Arnold & Boggs, 1995). A home care nurse working with a client from a different culture will need to be mindful and take the extra steps mentioned in this and other articles. Such steps will help promote this bond of trust and aid the nurse in providing more culturally competent care. However, because every person is unique, these same approaches and structured questions can be asked of all patients. To do so will enable the nurse to have a more complete understanding of each patient's health care beliefs, practices, and decision-making strategies.

As has been shown through the case studies presented, gaining a more thorough understanding of the patient and his/her family's health care beliefs is critical to achieving cost-effective and clinically positive outcomes. In each of the examples discussed, if these cultural assessments had not been performed, more nursing resources and longer-term service would have been required.

Indications for a Cross-Cultural Assessment

According to F. Conway, a cultural anthropologist, a cross-cultural assessment is indicated when any one of four situations occur (personal communication, May, 1999):

1. The client is clearly culturally different from the care provider (e.g., when a different language is spoken).

2. The client is from a different cultural background than the care provider and does not understand or seems to be dissatisfied.

3. There are difficulties with the family (e.g., if several members try to intervene in conducting inconsistent care approaches).

4. The client's nonadherence with the care plan becomes an issue and creates significant problems with his or her improvement.

Case Study No. 1

Situation

Mrs. N. and her family had recently immigrated from Cambodian. Mrs. N. had suffered from severe rheumatoid arthritis and was receiving Methotrexate injections at home. Home health staff could not communicate directly with her because of a language barrier, but they could and did rely on Mrs. N.'s son to translate. However, his command of English was limited and he was not knowledgeable about medical terminology or procedures. Over time, it was determined that Mrs. N. needed a hip replacement, and should to come into the clinic for preoperative visits and teaching. For reasons that were unclear at the time, Mrs. N. failed to keep her appointments.

Cross-Cultural Assessment Findings

In an effort to understand more about this patient and why she was failing to keep clinic appointments, with the help of her son, the cross-cultural assessment questions were asked. It was learned that because Mrs. N. was such a recent immigrant, having come from a very isolated, rural Cambodian farming community, she had no knowledge of surgery being used to treat a problem such as hers. She distrusted what the physicians wanted to do because she understood nothing about hip replacement surgery. In her rural community, surgery was performed only under dire, life-threatening circumstances.

Interventions

When this information became known, a meeting was held with Mrs. N., her son, key clinic staff, and the home health nurse. Mrs. N. and her son were helped to understand that while surgery of this nature was unknown to them, the procedure was frequently used to help arthritic patients and that staff anticipated a successful postsurgical outcome. Staff worked with the son to help him understand the necessary technical information so that he could properly translate information.

Outcome

Within a short time, the surgery was agreed to and scheduled. The home health nurse made a pre-op visit and later followed through with Mrs. N.'s home care. Mrs. N.'s progress and outcomes were significantly different because staff asked the right questions and were sensitive to cross-cultural needs.

Case Study No. 2

Situation

Following surgery, an elderly male Filipino patient diagnosed with dementia (Mr. L.) was referred to home health for wound care. His command of English was quite good; however, the patient was extremely upset and confused during the nurse's initial visit.

The family had no notion as to why their grandfather was so profoundly agitated. The nurse decided that another nurse should be assigned to follow the patient's progress. A different nurse was sent out on the next home visit. Once again, Mr. L. became increasingly disturbed, confused, and combative.

Cross-Cultural Assessment Findings

Among the cross-cultural assessment questions asked of the family was what they thought should be done and how Mr. L. should be treated. Family members were at a loss to understand, but were very concerned because the wound care was complex and they were not equipped to manage the care themselves. After a third nurse was turned away, the family and home health agency sat down to problem solve. No one was certain whether the ethnic background of the nurses was an issue for this patient; however, everyone present in the conference decided it was worth trying one final approach.

Intervention

A Filipino nurse was sent to care for Mr. L. and the atmosphere changed immediately. Mr. L. became significantly less agitated and home care resumed. Although his thoughts were still quite confused because of dementia, he was more at ease with this new nurse. It was later learned that when non-Filipino nurses came into the home, Mr. L. thought he was back in the jungles of the Philippines fighting in the second World War. The presence of a Caucasian face triggered Mr. L.'s combative reactions and heightened his confusion.

Outcome

In this instance, the nature of the problem was not directly related to differences in cross-cultural expectations. However, by being receptive to trying different approaches related to cross-cultural dynamics, the home health department and family were able to partner to resolve the crisis.

Cross-Cultural Assessment Tool

If the patient is an immigrant ask: How is this kind of illness is treated in that country?

How would you describe this problem you have? Or, is there someone else I should talk to?

What does this sickness do to you?

How long have you had the problem? Why has the problem happened to you?

Why do you think the problem began when it did?

What do you think is wrong, out of balance, or causing the problem?

What has been done so far?

What do you think will help your problem clear up? What should be done?

What does the family think should be done?

Apart from me (us), who else do you think can help you get better?

How serious do you think this situation/problem is?

Case Study No. 3

Situation

Mrs. T., an elderly Asian woman with diabetes mellitus was discharged to her home following a bilateral amputation. She spoke some English and most of the younger family members were fluent in English. The case manager making the initial home assessment found the woman and her family were having difficulty performing basic needs because of an unusual physical constraint.

In this home, as in many Asian homes, each family member slept on an individual mattress placed on the floor. Arranging for nursing care and accomplishing routine ADLs was an ordeal. Anyone caring for Mrs. T. was required to lift and transfer her from the floor to a chair, wheel chair, or couch, or care for her on the floor. Dressing changes were performed on the floor. The physical therapist was able to adapt and provide the necessary therapy on the floor as well. Mrs. T. was responding very slowly to rehab efforts and was not regaining her strength-chiefly because the plan of care was so difficult to implement.

Cross-Cultural Assessment Findings

One of the indications for using the cultural-assessment tool is when noncompliance with the care plan creates significant problems with patient improvement. The assessment questions were asked with that focus in mind. Prior to the assessment, the patient and family had firmly rejected bringing in a hospital bed. The information gathered from the assessment revealed that such a change would be seen as a serious breach of respect for their grandmother. They believed it would be disrespectful to ask her to move out of her traditional bed and into a strange one.

Intervention

After much discussion, the family and patient concluded that if a hospital bed was needed temporarily and could lead to faster recovery, they would be willing to try it. This transition occurred and rehabilitation progressed.

Outcome

The patient and family decided to keep the bed because daily care was made so much easier when performed from a bed versus the floor.

ACKNOWLEDGMENT

The authors thank Dr. Fred Conway, Lecturer in the Department of Anthropology, San Diego State University for his valuable assistance.

REFERENCES