Providing primary care to rural patients requires creativity, resourcefulness, and sensitivity. The NP's education in and exposure to cultural sensitivity can support delivery of care that is both patient-centered and ethnically-focused. Clinicians' knowledge about the cultural heritage of their constituency must include recognition of norms, beliefs, and practices. Knowledge of culture and its application often sets NP practice apart from other colleagues. Cultural knowledge is the provisional detail in delivering primary care that can make or break its acceptance. For example, knowing when an important amulet or type of healing ceremony is central to a patient's recovery enhances not only acceptance of allopathic treatment but its positive outcome as well.

Caring for a culturally diverse rural constituency requires a provider to be astute in shifting delivery strategies. Understanding the commonalities as well as differences in rural lifestyle, including health beliefs among different ethnic traditions, increases the likelihood that care prescriptions will be followed. It is not enough to make a blanket prescription for therapy as an analogue to medication, such as application of moist heat for 20 to 30 minutes four times a day for cellulitis. Unlike an office worker who may have a scheduled break time as well as access to a nearby hot water source to prepare a hot pack, a rural farmer out trapping in the winter woods will not likely have ready access to resources for following the therapy as ordered. Further, if the patient's norms and values are focused on winter trapping, not self-care, there is scant possibility that a provider's recommendation will change that patient's self-care response.

Assessing Core Beliefs

The rural practitioner must assess how the patient's core beliefs and patterns of response can be integrated into recommendations for care. I recently saw a patient whose needs fit this viewpoint. Mr. L. is a farm worker with type 2 diabetes and peripheral neuropathy. He was born and works in rural southern Quebec. Because his idiomatic knowledge of English is limited, and because my French is equally challenged, we typically communicate with simple words in French and English and gestures. In examining his right foot, I assessed an unusual callous deposition on the dorsum of the great toe. I knew why such a callous forms; a dairy worker may habitually attach milking machines via a deep crouch position. This position puts dorsal pressure on the bent foot's great toe, and is not an atypical stance in workers on small farms. Advising this patient to soak the foot in order to soften the callous conflicted with his practice of shaving it with a razor blade. I had to not only make a correct assessment of how his callous developed, but had to devise a tenable plan for treatment and future prevention.

In primary care practice, the provider must know about and respect different ethnic and cultural traditions and actively include them in a prescribed plan of care. One of my patients is an elderly Vermonter whose short-term memory is rapidly failing. He still lives alone, maintaining his lifelong practice of hunting, trapping, and ice fishing.

I recently set him up with Lifeline services. In completing my plan for managing his memory problems, I drilled him on what he should do if he fell and was unable to help himself (i.e., push the Lifeline button). I was concerned that his Lifeline would not be usable when he was out in the woods. His reply pulled me up short, making me see that my plan was just that- mine. He said, "If I want to go out and check my trap lines, I'm going to do it. And if I fall and cannot get this thing to work, then so be it."