Caring for Culturally Diverse Patients at Home
by Geri-Ann Galanti, Ph.D.
Published in Home Health Care Consultant, Vol. 6, No. 1, January 1999,
pages 33-34.
Caring for patients at home requires much more than knowledge of disease
processes. WHen home health care workers enter the home of a patient,
they are stepping into an entire social world; and when that patient
is from a culture that has customs that vary from those of the visiting
caregiver, the potential for problems increases dramatically. Caring
for culturally diverse patients is challenging because the rules of appropriate
behavior vary tremendously in and among cultures, based on education,
social class, length of time spent in the country, the degree to which
an individual interacts with members of his or her own culture versus
that of other cultures, and personality factors.
Many issues may arise when treating culturally diverse patients in their
homes. The following examples are generalizations; they do not apply
to everyone. It is hoped, however, that the information below will increase
awareness of what may be encountered when providing home health care
to members of different cultural and ethnic groups.
LANGUAGE
A common source of problems is language, the most significant being lack
of a common tongue. In such cases, interpreters are often used. However,
this can
also create cultural problems.
For example, most Asian cultures are extremely hierarchical, and it is viewed
as inappropriate for a young person to tell an older person what to
do. This may be particularly problematic when the home health care nurse
or worker tries to communicate with the patient. Because the eldest male
is at the top of the social hierarchy, insturctions to the patient may have
to be conveyed via that family member.
EYE CONTACT
Another aspect of communication which is a potential source of misunderstanding
is eye contact. In Anglo American culture,
eye contact is seen as an important component of direct and honest communication.
Avoidance
of eye contact is often interpreted as anything from a psychiatric symptom
to evidence of dissembling, or at least, of withholding information. Such
interpretations,
however, are likely to be incorrect, if the person who is avoiding eye contact
is Asian, Middle Eastern, Native American, or possibly Hispanic.
In Asian cultures, to look someone
directly in the eye implies equality. The lack of eye contact is used to
imply inequality in some situations. For example, a physician or a nurse
would be considered superior to a patient, as would a male to a female. Thus,
direct eye contact with a superior shows a lack of respect. Many Hispanics
will
also avoid direct eye contact as a
way of demonstrating respect, although Latin cultures lack the rigid hierarchy
common to most Asian cultures.
Among many Middle Eastern cultures, eye contact is avoided between men and
women out of propriety. Direct eye contact may be interpreted as sexually
suggestive,
and thus care is taken to avoid such implications. In many Native American
cultures, the eyes are believed to be the window to the soul. If you look
someone directly
in the eye, you could steal their soul. Or they could steal yours. In order
to avoid inadvertent soul loss/theft, eye contact may be avoided. Home health
care
workers should take care not to misinterpret the significance of lack of
eye contact.
GENDER
Gender issues can be another source of conflict. In the Muslim Arab culture
it is forbidden for a man to look at the body of a woman
to whom he is not married. The wise home health agency, recognizing
the importance
of sexual segregation in many Middle Eastern cultures, will try to send same-sex
providers to patients’ homes.
In many Middle Eastern cultures, it
is the role of the husband to protect his wife; to act as a buffer and intermediary
between her and the rest of the world. Most Middle Eastern women do not see
this
as sexist or oppressive; rather, they value the protection and care.
If a female home care worker senses that there is essential information that
is being
withheld due to the presence of the husband, she should insist on examining
her privately. Otherwise, it is best to respect the patient's culture.
TOUCHING
The issue of touching goes beyond gender. Although there is tremendous individual
variation regarding people's comfort level with being touched, there are
some cultural patterns. In Middle Eastern cultures, touching between members
of the opposite sex is to be avoided, especially touching of females by males.
This
is also true
in the orthodox Jewish religion . In general, Asians may not be like being
touched, and physical contact is relatively infrequent in most Asian
countries.
Although nursing care emphasizes the importance of touch, health care workers
must realize that this practice was developed in the context of Western nursing
culture, and may not be appropriate for all ethnic groups. Most Hispanic
patients, on the other hand, will probably feel quite comfortable with hands-on
care.
FOOD
Another issue that frequently
arises concerns food. In general, accepting
offered food in a patient’s home avoids insult.
The rules regarding how quickly you should accept
it vary; however, in an African American home, it should be accepted
immediately, especially
if the visitor is Anglo American. Given the long history of racial discrimination
in this country, a white person's refusal of food from
an Afrian American
may be interpreted as evidence of racism.
Iranians will expect food to be accepted on the second offer. The first time
it is offered is out of politeness; the second offer demonstrates sincerity.
Such a rule allows the maintenance of social propriety, even when one has
no extra food to share.
If the person offering food is Chinese, it is appropriate to accept on the
third offer. To accept sooner is seen as rude, although as with all cultures,
allowances
may be made for outsiders who are not always expected to know the “rules.” A
group of nurses from mainland China once said that one of the biggest problems
they had in the U.S. was that when they
politely
turned down offers of food, a second offer never came Many reported that
until they learned the American custom for accepting food, they were constantly
hungry.
PSYCHOSOCIAL CARE
Often, issues that arise are more complicated than cultural gestures. An
Anglo-American female patient, for example, insisted that her agency not
send her Filipino caregivers. After the second experience with a Filipino
caregiver, the patient complained to her agency that Filipinos are too cold
and reserved. This case actually raises two issues. Filipino nurses are often
perceived to be cold and unfriendly because,
in the Philippines,
nurses are trained only for technical nursing care. The psychosocial aspects
of nursing that are important in American culture, are seen as inappropriate
and intrusive in the Philippines.
In the United States, there is often no one but the nurse to take care of
the patient’s
psychosocial needs. The American patient who expects the health care
worker to show
personal interest may perceive a Filipino nurse --
who is trying to behave appropriately -- as cold and uncaring. Ideally,
health
care workers trained in other cultures should be given guidance and training
as to what is expected of someone in their position here. Too often, it is
assumed that the foreign worker will somehow, "just know what
to do."
The broader, complex issue raised by this example is that of racism.
It must be decided whether patient satisfaction is more important than attitudes
that promote racism. Generally, the solution is
to tell patients that the home health care agency has sent the best person
available for the job.
Suggested Reading:
Galanti, Geri-Ann. Caring for Patients from Different Cultures: Case
Studies from American Hospitals, 2nd edition. 1997. Philadelphia:
University of Pennsylvania
Press.
Giger, Joyce N. and Ruth E. Davidhizar. Transcultural Nursing. 1991. Chicago:
Mosby.
Lipson, Juliene G., Dibble, Suzanne L., and Pamela A. Minarik. Culture
and Nursing Care: A Pocket Guide. 1996. San Francisco: UCSF Nursing Press.
Narayan, Mary C. Cultural assessment in home healthcare. Home Healthcare
Nurse 1997; 15(10):663-670.
About the author:
Dr. Galanti is on the faculty of the UCLA School of Medicine’s
Doctoring Program; UCLA School of Nursing; Division of Nursing,
California State
University,
Dominguez
Hills; Department of Anthropology at California State University, Los Angeles.
