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You can overcome the cultural differences between you and your patients by tuning in to certain cultural customs and doing your "homework."

Perhaps you recently cared for a Spanish-speaking man whose daughter had to translate your take-home instructions. Or maybe it was a Caucasian woman who seemed confused by your lack of eye contact. In today's multicultural society, you're more and more likely to find yourself in situations like these, caring for patients whose cultural backgrounds differ from your own.

The possible legal pitfalls of such encounters are numerous. For instance, you might be held liable for damages as a result of treatment without informed consent if your patient didn't understand your explanation of her care.¹ Or, the culture gap could lead your patient to become confused and angry, making him--and even his family--predisposed to suing you if something goes awry with his care.

But cultural differences don't have to be a barrier to the delivery of good healthcare. Learning about the social customs and health beliefs of the patients you treat can improve your rapport with them. Be careful not to stereotype, though, since each patient is an individual. Instead, use this knowledge as a starting point to ask questions that can help you tailor your care for each patient.

You may need to adjust your cultural expectations, too, to open the lines of communication even further. For example, you may need to involve the family--which plays a central role in managing illness in many cultures--more directly in patient care rather than focusing on the patient alone.

Social do's and don'ts
When you first assess a patient, determine if she understands English and, if not, what language she's comfortable using. Even though she may speak English, she may communicate more clearly in her own language and prefer to use an interpreter. This person is likely to be a family member or friend, but can also be another healthcare provider. (This issue's Web Flash has tips on how to deal with a language barrier, as well as the consent issues of using an interpreter. Check it out at www.hpso.com.)

Once the lines of communication are open, you'll need to consider the patient's perception of the proper way to show respect and her attitudes toward things like touching and eye contact. If you're a respiratory therapist meeting a Vietnamese patient, for instance, keep in mind that in this culture, women do not shake hands. And, if you're an EMT examining a conscious Cambodian patient with possible head injuries, explain why you need to touch her head: In that culture, touching the head--which is considered the most important part of the body and the place where the spirit is found--is deemed an insult. A lack of eye contact, which might be viewed as embarrassment or passivity in Western society, is a sign of deference in many Asian cultures. Maintaining eye contact is considered ill-mannered and disrespectful.

To reduce the chances of miscommunication, consider the patient's reaction to your approach, explanations, and directions. Don't assume, for example, that a patient's behavior means she fully understands your instructions--or doesn't understand them at all. Many Vietnamese people smile often, regardless of their underlying emotion, so a smile cannot be automatically interpreted as agreement or comprehension.² On the other hand, a Native American patient may not respond when you first explain a treatment protocol. Taught to value the importance of silence, she may be taking the time to quietly digest the information you've given her.

A failure to ask questions may reflect the view--predominant in Asian cultures--that the healthcare provider is an authority, and that it is improper to challenge an expert. If you're a PT explaining a home exercise program, try to bridge such a gap by saying something like, "Can you demonstrate the exercises I've just described to you? I'd like to make sure I've explained them thoroughly."

The family's role
Many non-Western cultures, like those of the tiny African nation of Eritrea, feel strongly that the family, rather than the patient, be informed first of a diagnosis or poor prognosis.³ Other groups, like Native Americans and Hispanics, oftentimes believe that the family should be consulted before treatment begins.^4,5 Remember, though, that your first duty is to the patient and his right to confidentiality. Under the law, the patient has the right to make his own treatment decisions. If he wants to delegate that responsibility to a family member, you'll need to thoroughly document his decision per your facility's policies and procedures.

If the patient does defer to the traditional role of his family, you'll need to find out who needs to be involved in the decision-making process. Among Native Americans, for example, women are usually the family spokesperson.⁴ In contrast, the man often makes decisions in traditional Vietnamese families (though decision-making is more likely to be shared if a couple is "Westernized").² To gain a patient's compliance with a physical therapy regimen, for instance, it may be necessary to consult with the patient's spouse or parents first, depending on the culture you're dealing with and the patient's wishes.

Discovering healthcare beliefs
You'll also need to find out what healthcare practices the patient and his family follow. For example, a pharmacist needs to be extra diligent when filling a prescription for patients whose cultures, like those of Ethiopia and Cambodia, can be cavalier about the use of medication. These patients tend to expect a prescription for every illness, adjust the dosing regimen on their own, and share medications with family and friends. A pharmacist must emphasize to such a patient that he should not, for instance, stop taking his antihypertensive drug because his symptoms don't improve immediately. He'll also need to explain that the patient should not stop taking the medication once he "feels better," nor should he take fewer pills if he experiences side effects.

African-Americans, Hispanics, and Native Americans are among the many people who combine traditional medicine, like herbal remedies, with Western medicine to treat a wide variety of illnesses, including diabetes and hypertension. A pharmacist needs to ask a patient if she's used any herbal treatments and, if so, what effect they've had. He'll need to ask, too, if the patient's doctor knows she's using herbal therapy. If necessary, the pharmacist should explain how the herbal treatment interacts with, or counteracts, the prescribed medication. If it's harmless, the pharmacist should let the patient continue using it.

Do your homework
And finally, if you lack a basic knowledge about the culture of the patients you treat, educate yourself. Speak with social workers who deal with the groups most prevalent in your community and talk to colleagues who seem particularly adept at putting patients of different cultures at ease. Use them as resources to learn more about different cultures, and to pick up useful tips.

You might also want to conduct a literature search on caring for patients from different cultures. You can begin by looking up the sources listed below. (For more sources on cultural diversity, see the resources listed at the end of our Web Flash at www.hpso.com.) Be sure to contact your professional organization, as well.

By showing your sensitivity to cultural preferences and doing your "homework," you can ensure that your patients receive high quality care that's not compromised by cultural differences. And ultimately, that translates into good risk management.

REFERENCES

1.National Center for Cultural Competence. (1999). Policy brief 1. Washington,DC.Author.

2. LaBorde, Pamela. "Vietnamese Cultural Profile." Ethnic Medical Guide. 1996. http://healthlinks.washington.edu/clinical/ethnomed/vietnamesecp.html

3. "Eritrean Cultural Profile." Ethnic Medical Guide. 1995. http://healthlinks .washington.edu/clinical/ethnomed/eritrean.html (13 Oct. 1999).

4. "Health Beliefs and Practices: American Indian." Feb. 1998. http://www.amedpub .com/health/health/indian.html#current.

5. National Coalition of Hispanic Health and Human Services Organizations. (1998). Delivering culturally competent prenatal care. Washington, DC: Author.