As a Certified Registered Nurse Anesthetist (CRNA), I have to interface and plan anesthetics for this diverse group of patients. Not only must CRNAs take into consideration age, weight, assessment of health issues, airway and anesthetic plan but also the linguistic and cultural issues that influence each patient's directed care management.
Removing Language Barriers
After checking the anesthesia machine and preparing emergency and anesthetic drugs, nurse anesthetists or nurse anesthesia students must conduct an interview and assessment of their patients before moving them to the operating room. During the interview, they may find there is a language barrier. There will be patients where English is a second language and/or patients with limited English proficiency. It is imperative that each patient, regardless of the language barrier, is fully informed regarding his or her anesthesia.
Nurse anesthetists should always avoid using patients' bilingual children, family members and friends as translators. Using these familiar people as interpreters seems like a quick fix, but they dilute the interaction at best or misinterpret in the worse case scenario. Patient privacy should be foremost in securing anesthesia consent.
The best form of communication with a patient with limited English proficiency is the Language Line Service that can be found in most hospitals. After completing the necessary preparations for anesthetizing the patient, nurse anesthesia providers should locate the nearest Language Line telephone.
Not every patient room has this special telephone, and it is important to physically move it from the nursing station into the room if necessary. For example, when I was the Chief Nurse Anesthetist at South Jersey Healthcare System, if a Mexican immigrant patient with no English capability was in labor, I would ask the charge nurse for the Language Line telephone, which was retrieved from the nurse's station and taken into the patient's room.
This special telephone has two receivers. Only the anesthesia provider and the patient are on the telephone, simultaneously speaking with a trained interpreter. The anesthesia provider gives the operator the account number and requests the preferred language from the patient. The Language Line translates over 180 languages.
When interviewing patients via the Language Line telephone, it is best to ask short questions in terms of allergies, last meal, previous surgeries and anesthesia, health issues and the preferred anesthetic plan. Nurse anesthetists should make sure that the last question they ask their patient via translator is "Do you have any questions regarding your anesthesia?"
The Language Line operator identifies his or herself as a number, not by his or her own name. It is important to capture the identifier number on the anesthesia consent form to ensure that the Language Line was the best form of communication used prior to scheduled or emergency surgery.
The anesthesia consent at South Jersey Healthcare System had an English and Spanish version. The patient would sign the Spanish side, where the Language Line operator's number was clearly written, along with the anesthesia provider's name, the signature of a witness like a registered nurse and the date and time.
I have observed several cultural trends in my years as a nurse anesthetist. For example, the Hispanic/Latino patient typically has a great deal of supportive family members who will come to visit or accompany the patient. This does not necessarily affect my work; however, some culture-specific customs do.
One cultural issue I have encountered concerns the Asian patient population, particularly aged patients. A cultural norm that needs to be acknowledged by anesthesia providers is the "coining" of Southeast Asian patients. This practice involves applying hot oil to the back and torso, then rubbing a coin or the edge of a spoon on the skin until circular or linear marks are embedded. Anesthesia providers typically auscultate patients' lungs and/or perform regional anesthesia. CRNAs may see these marks on a patient's back when giving spinal epidurals and not know what they are. It is important to recognize this practice before administering anesthesia and not misinterpret it as elder abuse or any other form of abuse.
Another cultural issue for nurse anesthetists is taking care of Muslim and Orthodox Jewish patients, especially women. These groups are similar in their treatment of married women, and couples tend to be concerned with female patients' exposure to males in the operating room. Muslim and Orthodox Jewish patients may insist on wearing the hijab or a simple scarf or wig while in public. They will often ask for only female providers in the operating room, if staffing permits. It is important to relay to these patients and their husbands that their modesty as a patient will remain intact as much as possible, including covering windows in the operating room. CRNAs must communicate with male surgeons not to enter the room until the patient has been properly identified, put to sleep by a female CRNA and draped by the OR technician. Only after the surgeon exits should window coverings be removed. The patient should be covered with blankets as she is transferred to the PACU.
Lastly, another cultural group of patients that should be acknowledged are women from Africa, the Middle East and other regions practicing female genital mutilation (FGM). According to the World Health Organization, 100–140 million girls and women have undergone the cultural indoctrination of FGM. Typically, girls age 7–10 will go through this process, where the external genitalia are partially or totally removed, often with crude instruments (not sterilized) and under no anesthesia. The repercussions are wide, from infection to vaginal birthing issues to psychological problems as adults. Women from these cultures who reside in the United States will require anesthesia services for cesarean sections and major genital reconstructive surgery. Nurse anesthetists should be aware of this practice and how it will impact their work.
Again, with the changing demographics of the United States, our patient population will dictate new ways of approaching their anesthetic plan. We must treat each person regardless of ethnicity, language barrier or imposed societal cultural norm in the same manner as we do with our family members, neighbors and friends... with the utmost respect and dedication to our anesthetic practice.