Cultural Competence Q&A

Gihan ElGindy, RN, MSN

Imagine for a moment that you are a patient in a hospital that is unable to meet your special dietary needs. What are you going to do? Would you sign out against medical advice and go to another health care facility that can accommodate your requirements, even if its medical care is not known as the best?

The health care profession, like any other profession, has been forced to adopt customer-oriented service models. Logically, the best customer service model is to provide whatever is necessary to please every customer. In reality, of course, this model presents many challenges within the health care environment because of the many restrictions and contingencies, such as time, hospital policies, patient privacy and legal factors.

One of the biggest “customer service” challenges for nurses and other care providers is being able to meet the unique needs of patients from a wide variety of cultural, ethnic and religious backgrounds. Applying the adopted customer-oriented model within the context of nursing requires advanced assessment and validation skills whenever caring for our “customers” (patients). With this notion in mind, care providers are expected to be sensitive, open, flexible and able to meet these unique “customer” needs as appropriately as possible and at all times. Remember, cultural needs are not a luxury; they are a necessity and a part of the basic patient’s bill of rights.

Performing dietary assessments is one key area where nurses must develop cultural competency skills. Being knowledgeable about the dietary needs of different cultures and religions—including preferences, customs and restrictions—and how they may impact a patient’s care plan is essential to providing customer-oriented patient care. The following recommendations for conducting a dietary cultural assessment can guide nurses in reaching the desirable level of cultural sensitivity.  

The art of asking the right questions—rather than making assumptions based on preconceived notions or stereotypes about various cultural, ethnic or religious groups—is the key to conducting a culturally competent dietary assessment. Here are some considerations to keep in mind.

• Remember that each patient is a unique individual. Just because a certain culture, ethnicity or religion has dietary traditions or guidelines, that doesn’t necessarily mean that every person who is a member of that group adheres to them. Nurses must determine whether the patient follows his/her cultural guidelines, and if so, to what extent. E.g., does he/she follow the guidelines strictly or liberally? When dealing with immigrant populations, special attention must be paid to issues such as length of time the person has been living in the United States, whether the person is first or second generation, and degree of assimilation into the American and/or other cultures.
• Understand the significance of patients’ personal food habits and preferences in relation to cultural norms. For example, just as buttering the bread is an essential habit for Americans, so is cooking with soy sauce—which is high in sodium—in many Asian cultures. Asking Asian renal or heart patients not to use soy sauce in cooking is like asking Americans not to butter their bread. However, asking them to switch from regular soy sauce to a low-sodium brand of soy sauce can decrease their total salt intake by half. 
• When asking about foods the patient eats, keep in mind that patients who are recent immigrants to the U.S. may not be familiar with American food names or dishes. This problem can be solved by using pictures of foods. I cite this example based on my own personal experience: When I first emigrated to the America from Egypt, I felt no need to learn the American names of food until I had to study them in order to pass my NCLEX-RN® examination!
• Investigate whether the patient’s dietary restriction is a cultural norm, a personal preference or a religious mandate. This is a vital element when serving meals and different food items.  For example: for Muslims, who religiously are not allowed to eat pork or any part of the pig cannot eat from any dish or food utensils used or touched pork and pork products.  It is considered a contaminated item and they expect to eat from a new clean dish and utensils that are completely free from any pork or pig traces.  This restriction is true for Muslims as well as other faiths such as Judaism, Mormon, Hinduism, and vegetarians. 
• Being very specific when asking about a main belief system such as Christianity. This is not enough; investigate more about the uniqueness within this belief system such as Seven Day Adventist, Mormon, Jehovah’s Witness, etc.  For Example; an insulin diabetic patient needs few snacks per day, which is quiet normal to many Christians.  For some Seven Day Adventist believers; they are dominantly pure vegetarians, it may be more appropriate for the care provider to suggest dividing the three main meals into five or six small ones rather than suggesting eating snacks between meals. Eating between meals is not a favorable habit for some Seven Day Adventist believers. 
• Inquiring about special habits or religious practices desired to be performed before/after a meal and/or any food item.  Facilitating such desires or practices can positively impact on the level of the patient’s compliance with the prescribed plan of care including any dietary restrictions and enhance health recovery.

Folk Practitioners or Corandero Practices 

Asking about the prescribed pharmacological/herbal treatments and visits to the folk practitioners need to be an essential part of our assessments.  Being aware of the existing combination is a safety issue for both the patient and the care providers.  In fact, we need to acknowledge the hidden competition of the Folk Practitioners existence in almost every culture, including the US.  He/she is an experienced person in prescribing effective herbal treatments, home remedies, dietary management, etc. that are easy to follow and are quite inexpensive. The folk practitioner has almost a treatment for every illness, sickness, and/or all different kinds of health problems.  Their repeated home visits for the sick are one of their key strategies for gaining great success among the poor, elderly, lonely, and the disabled population.

For example, physicians prescribe expensive nitroglycerin sublingual tablets for Anginal pain that usually expires within 6 month contrasting the Corandero/Folk Practitioners who prescribe peppermint oil that never expires and costs only a few dollars.  Applying a few peppermint oil drops in the mouth has a very close vasodilatation effect on the body.  Of course the elderly, no insurance, and limited income populations will select the peppermint regime especially if it can manage their condition effectively.  Another factor for the folk practitioner’s success is teaching their patients effective complementary dietary practices such as drinking very light tea with plenty of natural mint leaves.  The constant effect of the mint leaves on the blood vessels may easily keep some patient populations free from chest pain.    

Whenever discovering the mix of the non-traditional and pharmacological medications, that are widely spread lately, it is very serious to ask the patients to continue or stop taking this combination.  Especially if we do not know that much about these practices for the following reasons:

• Keeping in mind that the patient has already made a conscious decision to take such therapy or combination of therapies.
• What is being used may be a placebo to sooth the emotional status with no medical significant effect.
• The patient may already stop taking the traditional pharmacological medications and is currently only using something that has a very similar effect to the prescribed pharmacological medication. 
• The patient is combining both therapies because one of them is not enough or not effective for the current health condition.
• The patient is experiencing current side effect of one or both therapies without realizing the significance of them.   

Conducting further physical and psychological assessment evaluating the effect of each therapy on the current health condition is a must before altering or stopping any of these therapies.  Logically and scientifically, if assessment reveals a healthy condition, regardless of what is being used currently, it means that it must be working right for that patient or illness and why not keeping it and wisely ask for more frequent assessment visits as needed.

The best approach in similar cases is to continue dietary/herbal cultural assessment focusing on the following issues to reach a safe, sound, and legal decision:

• the current use, action, side effects, and the length of use.
• any possible addiction effect whether physical or emotional, and assess the current addiction signs and/or symptoms if they exist.
• the current combining: prescribed pharmacological medication, herbal, and the folk treatment.
• the current health condition while using or not using this combination.

Because there is no equivalent of FDA approval for most of these folk remedies, ask the patients for any documents or sources of information to gain in depth of information for any unfamiliar herbs, un-known therapies, and/or non-traditional ones.  If nothing is available in English, there are many herbal and non-traditional books available in the public libraries, different bookstores, and university’s libraries that teach cross cultural programs. Internet searches may also be performed to reach countless English websites.  Also, we need to accept that the patient is a source of such information whether documented or not. He/she is the one who knows most about these therapies and why he/she decided to try it/them.

Editor’s Note: Minority Nurse’s cultural competence expert, Gihan ElGindy, RN, MSN, is an internationally recognized authority on cross-cultural issues in nursing. Her advice column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace.