Azella C. Collins, MSN, RN, is the Second Vice-President of the National Black Nurses Association.
KEY WORDS : Cultural Competence; Cultural and linguistic competence
In 1975, I was a young energetic community health nurse armed with Orem’s theory, a desire to improve the health status of my patients, and a never ending thirst for increased knowledge. How could I fail?
One of my more difficult cases came when the agency for which I worked began receiving large numbers of referrals for Hispanics with diabetes. We didn’t have an Hispanic nurse on staff, and the patient was in the area I served. I purchased a book entitled, Spanish for Health Care Workers, sat in my car and looked up the Spanish words for nurse…syringe…medication…diet…..exercise…and tried to develop a plan for communicating with my new patient. I did not have a clear plan for teaching this 43 year old Hispanic women who had limited English proficiency, and in 1976 we did not have any Spanish teaching literature for diabetic patients. I went to a South Chicago Hospital and explained my plight to an assistant administrator, who helped me find staff who spoke Spanish. She agreed to translate for me over the phone. I was an excellent nurse but did not trust my ability to learn Spanish in 15 minutes.
I went to the home, met my patient, and asked, via pointing, hand signs and broken Spanish if it was okay to use the telephone. I called the hospital staff that had been volunteered to assist me and had her ask the patient if it was okay to use her as the translator. My patient agreed. It took more than two hours to complete a task that I would normally have completed in 45 minutes; I had to trust what I was being told.
During each visit, my patient always seemed anxious and on the verge of tears. I had to become strategic in my approach. I found myself smiling and nodding more, having the translator ask more open ended questions, stooping when I talked and motioned to her, and I also used a very soft voice when I was in her presence.
During the first two week period my patient’s blood sugars never normalized. She never shared what worried her with us. This question was posed in a mirad of ways. I filled her syringes; I observed her self administering insulin enough times to know that she properly administered the insulin. I knew what she was scheduled to eat because the translator and I had prepared the menus. Her breakfast was always prepared prior to insulin administration. She kept a list of the foods she ate times she ate, when and how long she exercised. All of this information was relayed to me by the translator.
The doctor increased the insulin by five units and told me to get ready to teach the patient how to adjust her insulin based on her blood sugars. I had nightmares at the thought of trying to explain the sliding scale concept to our translator, and I just did not trust my patient to comply. I did not have any evidence of non-adherence to the medication and dietary regime. But I intuitively knew something was not right.
The next day I thought to take the food lists over to the hospital and have another translator read them to me.
There was a difference in translation. I was now working with three Hispanic women, each from a very different culture. Long story short. My patient had told the first translator she understood what an 1,800 calorie ADA was….in reality she did not. My patient and the first translator did not consider avocados, sour cream, and cheese fats. There were not readily available Spanish teaching menu guides, and the preparation of something as simple as a taco varied from culture to culture. The second translator and her son typed and drew sample menus, with cooking instructions for me to use with this patient. I rearranged my schedule to coincide with her meal times so that I could observe her prepare meals.
The lessons learned from this patient are too numerous to detail in this article. Cultural competence is the ability to work effectively within the patient’s cultural context, which includes individual, family, and community cultural values, beliefs, and behaviors. There is a need for organizations and their staffs to respond with sensitivity to the linguistic and cultural needs of the patients served. During those few weeks, I learned that if I did not provide the appropriate services, in a way that was perceived as important by the patient, my patient might receive unnecessary insulin, experience increased stress, and quite possibly numerous adverse reactions.
Community health nurses (CHN) must understand their patient’s point of view; they must be creative in their approach as they invite their patients to share their needs and tell their story. The CHN must use a culturally based theory or model to guide their communication and assessment. Search the world wide web for resources on cultural competency. Today the CHN has access to mature practitioners who understand the importance of incorporating standards of practice for cultural competence into everyday demonstrable skills. Younger nurses may want to seek out a mature practitioner and develop a mentoring relationship.
This patient returned to Mexico during my fifth week of contact with her. I often wondered how she was adjusting to diabetes, if she was still on insulin, and whether she had conquered the changes in her lifestyle that were necessitated by diabetes. I was working an a Master’s degree in Psychiatric Nursing during this time and used this patient experience as one of my antecedents on the importance of quality care to patients with limited English proficiency. In 1976 culturally competent care had not yet become a buzz phrase. It would be 25 years before health care professionals developed consensus on what constitutes cultural and linguistic competence.
From 1976 to 1983 I utilized a mélange of notes collected over the years to care for patients whose culture and language was different than mine. Those notes consisted of the needs and preferences including home remedies for patients which I had to work with whenever I left the comforts of providing nursing care in the inner-city of Chicago. My cultural heritage and the heritage of patients I cared for, both inner city and Hispanic, were different in how we implemented what we believed, however; the end point - achieving and maintaining a high quality of life - was the same for each culture.
Our population is becoming more diverse each day. Culture and language are driving forces in how health care services are delivered and perceived. Today’s nurses have access to numerous resources where directions on implementing culturally competent care can be obtained and today’s nurses must be prepared to care for a more diverse population as we work to eliminate health care disparities.
Camphina-Bacote, J. (2003) Many faces: Addressing diversity in health care. Online Journal of Nursing. 8(1)
U. S. Department of health and Human Services, Office of Minority Health (2001). National standards for culturally and linguistically appropriate service in health care. Final report.