T It’s all in the cards: By Tammy Killen, MSN, BSN, RN
he world has become much smaller, largely due to air travel and Internet services that connect people all over the globe. Migrating families no longer feel the pressure to assimilate to American culture, and many immigrants prefer to keep their cultures, specifically their language, alive in America. Challenges may
Determining cultural
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
arise when an immigrant with limited English proficiency seeks healthcare services. Language services have been added to help healthcare workers communicate with foreign-born patients.1 Some companies have 24/7 translation services that healthcare workers can call to communicate with patients through a translator.
Despite this progress, healthcare disparities remain an issue in America.2 A lack of cultural care is one of the reasons for differences in the treatment of patients, which means that increasing healthcare workers’ cultural competence is one way to improve patient satisfaction and reduce healthcare disparities.3,4 Appropriate language services
coupled with understanding and respect of a culture is necessary to create a good relationship with patients of different ethnicities. A cultural preference card can create a communication tool to help nurses provide the patient with cultural expectations during a hospitalization. This article is intended to provide information to help
preference information
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It’s all in the cards: Determining cultural preference information
healthcare providers care for patients who are culturally different from themselves. Nurses lacking sufficient cultural education may not focus on what’s important to the patient, which can negatively impact patient satisfaction and outcomes.
Healthcare disparity and cultural competence Healthcare disparities can be defined as a difference in healthcare availability, quality, and results, and disparities can be caused by many
members on what the culture is all about would help with “just in time” cultural education. One pair of researchers determined that cultural competence is defined as being aware of and incorporating these 12 community essentials (the foundation of all cultures) whenever possible: 1. Locale: Where’s the person from? (This is for informational purposes only.) 2. Communication: What’s the most common language spoken in the home?
Barriers such as language, food preferences, healthcare beliefs, and ethnic physical traits can impact the quality of care provided to a patient. factors, such as race, geographical region, language barriers, self-care behaviors, insurance coverage, and cultural behaviors.2 Improving the cultural competence of a community healthcare facility can help remove cultural barriers that may cause disparities in care. After reading about missed cultural opportunities in healthcare, we wanted to do something to help our hospital stand out. We wanted to meet the needs of our community no matter the person’s culture. We knew the only way we could meet cultural needs was to have something in front of us to remind us of what a particular culture preferred in terms of everyday living. Also, a quick handout for staff
3. Family roles: Who’s the one that makes healthcare decisions? 4. Work issues: Does economy play a role in healthcare? 5. Biocultural ecology: What types of ethnic issues may occur, such as race-specific diseases? 6. High-risk behaviors: Does this culture have practices detrimental to physical health? 7. Nutrition: What’s the meaning of food to this culture, and what’s the food choice at home? 8. Pregnancy and childbirth practices: What are the views on childbirth and pregnancy? Are there any customs that would make the patient uncomfortable if not performed? 9. Death rituals: What’s the view of death, preparation for burial,
44 December 2013 • Nursing Management
and bereavement practices for family? 10. Spirituality: What are the behaviors that give meaning to life, including prayer and faith? 11. Healthcare practices: How does this culture view health, sickness, medicine, and healing? 12. Healthcare practitioners: What type of healthcare provider does this culture normally seek? Preferences can include male or female physicians, NPs, pharmacists, and so on.3
Community culture Based on the 2010 U.S. Census American Community Survey, Bradley County, Tenn., where our hospital is located, has 14.8% American ancestry.5 The other population groups, in order of prominence, are: German, English, Irish, Hispanic, French, ScotchIrish, Dutch, Scottish, Italian, Polish, Asian, Sub-Saharan African, Swedish, Welsh, Swiss, Ukrainian, French Canadian, Greek, Hungarian, West Indian, Norwegian, Czech, Lithuanian, and Slovakian.6 At the beginning of this project, a simple questionnaire was given to nurse managers on seven units asking them to write down the top three ethnicities treated in the facility (listed in order of frequency). American (White) was the number one ethnicity chosen by all seven respondents. Six managers responded with Hispanic, and one person responded with Black. Five people responded Russian as the third most frequent ethnicity, and two others responded Indian and Asian. For the purpose of this project, the Hispanic (specifically, Mexican) and Russian populations were selected by nursing management as the most frequently treated patients. (See Figure 1.) www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1: A sample Mexican American cultural preference card (in English) Please circle your choices. Your nurse will discuss your choices with you and make a plan to honor as many of them as possible during your hospital stay. 1. Language preference:
English
2. Please refer to me as:
Mr.
Mrs.
3. Please direct information to:
me
husband
wife
mother
father
4. Breakfast food:
fruit
cheese
bread
eggs
sausage
5. Meal times: Lunch at: Evening meal at: Snacks: 6. Spiritual needs:
noon
Spanish Ms.
Miss.
use my first name
use my last name
brother
sister
bacon
early afternoon (2 p.m.)
5 p.m.
8 p.m.
midmorning
late evening
I usually pray at __________(time) I meditate at __________(time) I don’t need time for spiritual reflection.
7. I eat only cold foods when I have a fever or feel hot. 8. I eat only hot foods when I have pain, breathing problems, or feel cold. 9. If available, I would like my caregiver to be a:
male
female
doesn’t matter
Please write down any other cultural choices you may like to continue while you’re in the hospital. Your nurse will discuss your cultural care plan with you. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Provider awareness Barriers such as language, food preferences, healthcare beliefs, and ethnic physical traits can impact the quality of care provided to a patient.7 Our cultural preference worksheet provides the patient with an easy mechanism to select cultural customs for the healthcare provider to meet during a hospitalization. Many nurses care for patients from different cultures but don’t know what aspects of care create a quality hospital experience.8 The Joint Commission requires that healthcare providers ask patients about any cultural beliefs that may need to be addressed during their care.9 It has been observed, at my facility, that some staff members ask this question rapidly, which doesn’t give the patient ample time to think about what “cultural www.nursingmanagement.com
belief” might mean. Also, adequate time isn’t given to the patient to discuss options for cultural choices. The cultural preference card is a tool designed to give the patient a check box system to choose particular activities associated with his or her culture. Some of the choices are related to family structure, timing of meals, food preferences, and healthcare provider gender preference. Using the cultural preference card will help nurses know what part of the patient’s culture is important during hospitalization. A cultural care plan can be discussed between the patient and the healthcare provider.
Usage and follow-up We’re currently preparing to implement the cultural preference cards in our hospital. The following is an explanation of how the cards will
be used. The cards are created by staff members and cover the “Patient Rights” chapter of our Joint Commission workgroup. The information is retrieved from internet and textbook sources. Because many of our employees are of varied cultures, we check with our hospital staff members and make sure that the cultural information we’re using is correct and relevant to our community. The prepared cultural preference cards will be given to patients upon hospital admission. An area is provided on the cards for nurses or patients to add requests. A short synopsis of the culture is provided to the hospital staff to help with the understanding of cultural rituals and requests. The cultural preference card will act as a reminder to the staff members about the patient’s preference when it comes to food,
Nursing Management • December 2013 45
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It’s all in the cards: Determining cultural preference information
music, eye contact, gender of caregivers, who to talk to when discussing patient issues, and other culturally driven experiences. When the cultural preference card has been completed by the patient, the nurse will relay the information to each department as needed. Dietary staff members will receive
liked the culture synopsis handouts for the staff members and thought the tool would open up communication between patient and provider, and ultimately allow for greater cultural competency. To get nursing staff members excited about using the new preference cards, a cultural fair will be
Improving the cultural competence of a community healthcare facility can help remove cultural barriers that may cause disparities in care. the information on food preferences and meal times. Other ancillary departments will receive information such as provider gender preference and who’s considered the decisionmaking family member. Our hospital is currently introducing new computerized documenting systems, which means that these cards will eventually become electronic so that the information can be immediately and easily viewed by all departments caring for the patient. An oral presentation of the research and preference card idea was provided at a round table meeting. Each attendee (all managers) received a handout about Mexican and Russian culture. The preference cards for each culture were also supplied. An evaluation questionnaire was given to each attendee after the meeting. Twelve managers heard the presentation, and 11 questionnaires were returned. All of the nurse managers
presented to the staff. All hospital employees will be invited to share information on how to make sure care is culturally competent for our patients and visitors. Displays will be provided showing the use of the cultural preference cards. Scenarios will be presented about how to care for a patient by meeting his or her cultural expectations. There will also be a presentation on how a patient might feel if none of his or her cultural beliefs are allowed to be expressed while hospitalized. Each nursing unit in the hospital will implement the cultural preference cards as nurses complete the education.
On a winning streak Cultural awareness is defined as the self-awareness and critique of one’s own world view.10 Nurses can only care for a patient using their own world view unless they’ve been educated on other cultures. Using cultural information can help nurses create
46 December 2013 • Nursing Management
new ways of forming effective crosscultural relationships with patients. The cultural encounters of the nurse will allow an increase in the knowledge base about particular essentials for each culture. With every encounter, the nursing staff will grow more culturally competent. Working with one patient at a time, nurses can shrink the cultural divide; cultural competence is within our grasp. NM REFERENCES 1. Language Line Solutions. http://www. languageline.com. 2. Kersey-Matusiak G. Culturally competent care: are we there yet? Nursing. 2012; 42(2):49-52. 3. Purnell L, Paulanka B. Transcultural Health Care: A Culturally Competent Approach. 3rd ed. Philadelphia, PA: F.A. Davis Company; 2008. 4. Perry A, Potter P. Clinical Nursing Skills and Techniques. St. Louis, MO: Elsevier Mosby; 2006. 5. U.S. Census Bureau. Bradley County quick facts. http://quickfacts.census.gov/qfd/ states/47/47011.html. 6. U.S. Census Bureau. American fact finder. http://factfinder2.census.gov/faces/nav/ jsf/pages/index.xhtml. 7. Long TB. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102-108. 8. Bagchi AD, Af Ursin R, Leonard A. Assessing cultural perspectives on healthcare quality. J Immigr Minor Health. 2012; 14(1):175-182. 9. The Joint Commission. 2013 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2012. 10. Petroulias P, Groesbeck L, Wilson FL. Providing culturally competent care in home infusion nursing. J Infus Nurs. 2013;36(2):108-114. Tammy Killen is a nurse manager of Ambulatory Care Services at SkyRidge Medical Center in Cleveland, Tenn. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000437772.56144.8a
www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
he world has become much smaller, largely due to air travel and Internet services that connect people all over the globe. Migrating families no longer feel the pressure to assimilate to American culture, and many immigrants prefer to keep their cultures, specifically their language, alive in America. Challenges may
Determining cultural
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
arise when an immigrant with limited English proficiency seeks healthcare services. Language services have been added to help healthcare workers communicate with foreign-born patients.1 Some companies have 24/7 translation services that healthcare workers can call to communicate with patients through a translator.
Despite this progress, healthcare disparities remain an issue in America.2 A lack of cultural care is one of the reasons for differences in the treatment of patients, which means that increasing healthcare workers’ cultural competence is one way to improve patient satisfaction and reduce healthcare disparities.3,4 Appropriate language services
coupled with understanding and respect of a culture is necessary to create a good relationship with patients of different ethnicities. A cultural preference card can create a communication tool to help nurses provide the patient with cultural expectations during a hospitalization. This article is intended to provide information to help
preference information
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It’s all in the cards: Determining cultural preference information
healthcare providers care for patients who are culturally different from themselves. Nurses lacking sufficient cultural education may not focus on what’s important to the patient, which can negatively impact patient satisfaction and outcomes.
Healthcare disparity and cultural competence Healthcare disparities can be defined as a difference in healthcare availability, quality, and results, and disparities can be caused by many
members on what the culture is all about would help with “just in time” cultural education. One pair of researchers determined that cultural competence is defined as being aware of and incorporating these 12 community essentials (the foundation of all cultures) whenever possible: 1. Locale: Where’s the person from? (This is for informational purposes only.) 2. Communication: What’s the most common language spoken in the home?
Barriers such as language, food preferences, healthcare beliefs, and ethnic physical traits can impact the quality of care provided to a patient. factors, such as race, geographical region, language barriers, self-care behaviors, insurance coverage, and cultural behaviors.2 Improving the cultural competence of a community healthcare facility can help remove cultural barriers that may cause disparities in care. After reading about missed cultural opportunities in healthcare, we wanted to do something to help our hospital stand out. We wanted to meet the needs of our community no matter the person’s culture. We knew the only way we could meet cultural needs was to have something in front of us to remind us of what a particular culture preferred in terms of everyday living. Also, a quick handout for staff
3. Family roles: Who’s the one that makes healthcare decisions? 4. Work issues: Does economy play a role in healthcare? 5. Biocultural ecology: What types of ethnic issues may occur, such as race-specific diseases? 6. High-risk behaviors: Does this culture have practices detrimental to physical health? 7. Nutrition: What’s the meaning of food to this culture, and what’s the food choice at home? 8. Pregnancy and childbirth practices: What are the views on childbirth and pregnancy? Are there any customs that would make the patient uncomfortable if not performed? 9. Death rituals: What’s the view of death, preparation for burial,
44 December 2013 • Nursing Management
and bereavement practices for family? 10. Spirituality: What are the behaviors that give meaning to life, including prayer and faith? 11. Healthcare practices: How does this culture view health, sickness, medicine, and healing? 12. Healthcare practitioners: What type of healthcare provider does this culture normally seek? Preferences can include male or female physicians, NPs, pharmacists, and so on.3
Community culture Based on the 2010 U.S. Census American Community Survey, Bradley County, Tenn., where our hospital is located, has 14.8% American ancestry.5 The other population groups, in order of prominence, are: German, English, Irish, Hispanic, French, ScotchIrish, Dutch, Scottish, Italian, Polish, Asian, Sub-Saharan African, Swedish, Welsh, Swiss, Ukrainian, French Canadian, Greek, Hungarian, West Indian, Norwegian, Czech, Lithuanian, and Slovakian.6 At the beginning of this project, a simple questionnaire was given to nurse managers on seven units asking them to write down the top three ethnicities treated in the facility (listed in order of frequency). American (White) was the number one ethnicity chosen by all seven respondents. Six managers responded with Hispanic, and one person responded with Black. Five people responded Russian as the third most frequent ethnicity, and two others responded Indian and Asian. For the purpose of this project, the Hispanic (specifically, Mexican) and Russian populations were selected by nursing management as the most frequently treated patients. (See Figure 1.) www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1: A sample Mexican American cultural preference card (in English) Please circle your choices. Your nurse will discuss your choices with you and make a plan to honor as many of them as possible during your hospital stay. 1. Language preference:
English
2. Please refer to me as:
Mr.
Mrs.
3. Please direct information to:
me
husband
wife
mother
father
4. Breakfast food:
fruit
cheese
bread
eggs
sausage
5. Meal times: Lunch at: Evening meal at: Snacks: 6. Spiritual needs:
noon
Spanish Ms.
Miss.
use my first name
use my last name
brother
sister
bacon
early afternoon (2 p.m.)
5 p.m.
8 p.m.
midmorning
late evening
I usually pray at __________(time) I meditate at __________(time) I don’t need time for spiritual reflection.
7. I eat only cold foods when I have a fever or feel hot. 8. I eat only hot foods when I have pain, breathing problems, or feel cold. 9. If available, I would like my caregiver to be a:
male
female
doesn’t matter
Please write down any other cultural choices you may like to continue while you’re in the hospital. Your nurse will discuss your cultural care plan with you. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Provider awareness Barriers such as language, food preferences, healthcare beliefs, and ethnic physical traits can impact the quality of care provided to a patient.7 Our cultural preference worksheet provides the patient with an easy mechanism to select cultural customs for the healthcare provider to meet during a hospitalization. Many nurses care for patients from different cultures but don’t know what aspects of care create a quality hospital experience.8 The Joint Commission requires that healthcare providers ask patients about any cultural beliefs that may need to be addressed during their care.9 It has been observed, at my facility, that some staff members ask this question rapidly, which doesn’t give the patient ample time to think about what “cultural www.nursingmanagement.com
belief” might mean. Also, adequate time isn’t given to the patient to discuss options for cultural choices. The cultural preference card is a tool designed to give the patient a check box system to choose particular activities associated with his or her culture. Some of the choices are related to family structure, timing of meals, food preferences, and healthcare provider gender preference. Using the cultural preference card will help nurses know what part of the patient’s culture is important during hospitalization. A cultural care plan can be discussed between the patient and the healthcare provider.
Usage and follow-up We’re currently preparing to implement the cultural preference cards in our hospital. The following is an explanation of how the cards will
be used. The cards are created by staff members and cover the “Patient Rights” chapter of our Joint Commission workgroup. The information is retrieved from internet and textbook sources. Because many of our employees are of varied cultures, we check with our hospital staff members and make sure that the cultural information we’re using is correct and relevant to our community. The prepared cultural preference cards will be given to patients upon hospital admission. An area is provided on the cards for nurses or patients to add requests. A short synopsis of the culture is provided to the hospital staff to help with the understanding of cultural rituals and requests. The cultural preference card will act as a reminder to the staff members about the patient’s preference when it comes to food,
Nursing Management • December 2013 45
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It’s all in the cards: Determining cultural preference information
music, eye contact, gender of caregivers, who to talk to when discussing patient issues, and other culturally driven experiences. When the cultural preference card has been completed by the patient, the nurse will relay the information to each department as needed. Dietary staff members will receive
liked the culture synopsis handouts for the staff members and thought the tool would open up communication between patient and provider, and ultimately allow for greater cultural competency. To get nursing staff members excited about using the new preference cards, a cultural fair will be
Improving the cultural competence of a community healthcare facility can help remove cultural barriers that may cause disparities in care. the information on food preferences and meal times. Other ancillary departments will receive information such as provider gender preference and who’s considered the decisionmaking family member. Our hospital is currently introducing new computerized documenting systems, which means that these cards will eventually become electronic so that the information can be immediately and easily viewed by all departments caring for the patient. An oral presentation of the research and preference card idea was provided at a round table meeting. Each attendee (all managers) received a handout about Mexican and Russian culture. The preference cards for each culture were also supplied. An evaluation questionnaire was given to each attendee after the meeting. Twelve managers heard the presentation, and 11 questionnaires were returned. All of the nurse managers
presented to the staff. All hospital employees will be invited to share information on how to make sure care is culturally competent for our patients and visitors. Displays will be provided showing the use of the cultural preference cards. Scenarios will be presented about how to care for a patient by meeting his or her cultural expectations. There will also be a presentation on how a patient might feel if none of his or her cultural beliefs are allowed to be expressed while hospitalized. Each nursing unit in the hospital will implement the cultural preference cards as nurses complete the education.
On a winning streak Cultural awareness is defined as the self-awareness and critique of one’s own world view.10 Nurses can only care for a patient using their own world view unless they’ve been educated on other cultures. Using cultural information can help nurses create
46 December 2013 • Nursing Management
new ways of forming effective crosscultural relationships with patients. The cultural encounters of the nurse will allow an increase in the knowledge base about particular essentials for each culture. With every encounter, the nursing staff will grow more culturally competent. Working with one patient at a time, nurses can shrink the cultural divide; cultural competence is within our grasp. NM REFERENCES 1. Language Line Solutions. http://www. languageline.com. 2. Kersey-Matusiak G. Culturally competent care: are we there yet? Nursing. 2012; 42(2):49-52. 3. Purnell L, Paulanka B. Transcultural Health Care: A Culturally Competent Approach. 3rd ed. Philadelphia, PA: F.A. Davis Company; 2008. 4. Perry A, Potter P. Clinical Nursing Skills and Techniques. St. Louis, MO: Elsevier Mosby; 2006. 5. U.S. Census Bureau. Bradley County quick facts. http://quickfacts.census.gov/qfd/ states/47/47011.html. 6. U.S. Census Bureau. American fact finder. http://factfinder2.census.gov/faces/nav/ jsf/pages/index.xhtml. 7. Long TB. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102-108. 8. Bagchi AD, Af Ursin R, Leonard A. Assessing cultural perspectives on healthcare quality. J Immigr Minor Health. 2012; 14(1):175-182. 9. The Joint Commission. 2013 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2012. 10. Petroulias P, Groesbeck L, Wilson FL. Providing culturally competent care in home infusion nursing. J Infus Nurs. 2013;36(2):108-114. Tammy Killen is a nurse manager of Ambulatory Care Services at SkyRidge Medical Center in Cleveland, Tenn. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000437772.56144.8a
www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
