Last summer, The Joint Commission’s culturally and linguistically competent patient-centered communication standards became part of the hospital accreditation process. One year later, what difference are they making?
In 2009, Minority Nurse published a Vital Signs story that asked: “Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care?” What prompted that question was The Joint Commission’s announcement that it was developing a set of standards that would incorporate the provision of culturally competent patient-centered care into the national requirements for hospital accreditation.
They’ve been a long time coming, but on July 1, 2012, these new and revised standards for patient-centered communication officially became part of the overall accreditation decision. The standards—which are published in a free downloadable implementation guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals—require health care organizations to, among other things:
Identify and effectively meet the oral and written communication needs of all patients, including those with limited English proficiency, hearing or visual impairments, and low health literacy;
Use highly qualified interpreters and translators, rather than untrained individuals, family members, or bilingual staff;
Document patients’ language and communication needs in their medical records.
Plus, the standards include two provisions designed to create a more equitable environment for lesbian, gay, bisexual, and transgender (LGBT) patients and their loved ones. One requires hospitals to prohibit discrimination based on sexual orientation and expression of gender identity. The other provides equal hospital visitation rights for same-sex domestic partners by allowing “a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.”
As all nurses know, Joint Commission accreditation reviews are something hospitals take seriously. One year later (or two years in the case of the LGBT standards, which took effect in July 2011 to align with the Centers for Medicare & Medicaid Services’ 2011 visitation rights regulations1), what effect have the patient-centered communication standards had? Are they helping hospitals do a better job of serving culturally diverse patients’ needs? And more importantly, are they starting to make any difference in improving minority health outcomes?
Too Soon to Know
The answer is: It’s still too early to tell.
“We’ve been trying to do some analysis of the scoring data and the requirements for improvement that we’ve seen since last July,” says Christina Cordero, PhD, MPH, associate project director, Department of Standards and Survey Methods, at The Joint Commission. “These data have been somewhat limited because of the time frame. But we’re planning to [look at] that information to see how frequently these issues are being scored, what kinds of situations and comments are coming up on survey, and what our surveyors are seeing on-site.”
In the meantime, anecdotal evidence suggests that most hospitals are at least trying to make sure they’re implementing the standards correctly. For instance, says Cordero, who helped develop the patient-centered communication standards and the Roadmap for Hospitals, The Joint Commission has been fielding many questions about how to implement standard RC.02.01.01, EP 28, which requires hospitals to include patients’ race and ethnicity in their medical records.
“Most of these inquiries have focused on what categories and question formats hospitals should use to collect that information from patients,” she explains. “For example, should they ask about race and ethnicity together in one question or in two separate questions? We responded by publishing FAQ documents on our website to help hospitals implement a data collection system that works for them.”
As for identifying areas where improvement may be needed, The Joint Commission’s initial analysis of data from surveyor site visits seems to indicate that hospitals are finding some of the standards harder to comply with than others.
“The one standard that has been coming up most frequently on-site over the last few months is PC.02.01.21, identification of patients’ language and communication needs during the provision of care, treatment, and services,” Cordero reports. “This may mean that hospitals are struggling more with that issue. Our surveyors are looking at not just the documentation of communication needs but what hospitals are doing to identify and address those needs.”
Is It Enough?
Minority health advocates are also keeping an eye on what The Joint Commission’s evaluation of the standards’ early years will reveal.
“I hope there will be a systematic examination of the outcomes and the impact on the quality of patient care,” says Cora Muñoz, PhD, RN, co-author of the book Transcultural Communication in Nursing. “But the fact that there are now two external bodies that require this—the Office of Minority Health [which developed the Culturally and Linguistically Appropriate Services (CLAS) standards in 20002] and now The Joint Commission—is a step in the right direction.”
Hector Vargas, JD, Executive Director of GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay & Lesbian Medical Association) feels that the patient-centered communication standards are “just one piece of a larger picture of progress we’ve seen over the last few years. These standards, the CMS hospital visitation rules, the [2011] Institute of Medicine report [The Health of LGBT People: Building a Foundation for Better Understanding], Healthy People 2020—which for the first time includes specific LGBT health goals—and the Affordable Care Act have all made a difference in how hospitals are addressing the needs of LGBT patients.”
But some transcultural nursing leaders, such as Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CNS, CTN-A, FAAN, President and Founder of Transcultural C.A.R.E. Associates in Cincinnati, argue that simply having culturally sensitive accreditation standards—or even federal government mandates—in place is not enough. Unless these requirements are vigorously enforced, she believes, there’s no guarantee that hospitals will act on them.
Vargas agrees. “The policies are there at the macro level,” he says, “but we really have to rely on the professionals in the hospitals—nurses in particular, but all members of the health care team—to make sure those policies are enforced.”
Nurses as Communication Champions
What can nurses do to help ensure that their institutions are complying with the standards on an ongoing basis—not just when Joint Commission surveyors show up? Muñoz, who is professor emeritus and an adjunct professor at Capital University School of Nursing, asserts that nurses must be leaders in a constant dialogue about the crucial role culturally competent communication plays in planning and delivering the best possible care for every patient.
“When nurses have a patient who needs language assistance, they must demand that the patient gets those [interpretation] services,” Muñoz adds. “As patient advocates, they should not settle for just getting by, or using family members [as interpreters] when it is convenient. That is not acceptable.”
Laura Hein, PhD, RN, an assistant professor at the University of South Carolina College of Nursing and a member of GLMA’s board of directors, gives two reasons why it’s important for nurses to be involved in championing the standards’ LGBT-inclusive provisions. “One is patient protection and advocacy. The other is to protect the rights of their [LGBT] colleagues, whether they themselves are LGBT-identified or not.” However, she cautions, “If they’re working in a state, or a hospital, that is not accepting of LGBT people, it’s a little trickier for them to be an advocate without endangering their own employment.”
Even though the impact of the patient-centered communication standards is still a work in progress, Muñoz emphasizes that progress is the key word. “At least we have the standards now; we didn’t have them before,” she says. “We’re moving forward. I wish we could move faster. But we’re moving.”
References
U.S. Department of Health and Human Services, “Medicare Finalizes New Rules to Require Equal Visitation Rights for All Hospital Patients,” November 17, 2010, www.hhs.gov/news/press/2010pres/11/20101117a.html, accessed March 26, 2013.
U.S. Department of Health and Human Services, Office of Minority Health, “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15, accessed March 25, 2013.
The logo for the Kahuawake Schools Diabetes Prevention Project in Quebec uses a medicine wheel diagram to illustrate the concept that “healthy eating habits and daily physical activity can prevent diabetes.”
“Americans Indians and Alaska Natives feel very strongly about traditional beliefs because they define who we are. Many of us were born and raised in environments where these teachings are passed down. It is not a matter of simply keeping these values and practices alive; it’s a cultural necessity.”
Is this a traditional medicine man speaking? No, it’s a modern-day nurse—Lillian Tom-Orme, PhD, MPH, RN, FAAN, research assistant professor at the Health Research Center, Department of Family and Preventive Medicine, at the University of Utah in Salt Lake City. A member of the Navajo (Diné) Nation, she is also president-elect of the National Alaska Native American Indian Nurses Association (NANAINA).
Who better to understand the significance of traditional American Indian or Alaska Native health care treatments than a nurse who shares the same beliefs, or at least understands them? In areas with large indigenous populations, such as reservations, there is great demand for culturally sensitive nurses who respect and honor native beliefs. In fact, the Indian Health Service, the principal federal health care provider for Indian people, gives preferential treatment to hiring health professionals who are of American Indian or Alaska Native descent. In addition, some tribes own and operate their own health care facilities.
Following American Indian and Alaska Native health care rituals not only keeps the traditions alive, but also provides comfort to patients who believe in and practice them. Even when native patients trust modern health care techniques, traditional treatment methods may offer an additional sense of security.
Common Beliefs
Although traditions vary from tribe to tribe, and even among members of the same tribe who live in different regions, there are basic Indian beliefs about health that extend beyond tribal boundaries. Perhaps the most common is the importance of prayer for maintaining health and treating illness.
“Prayers are emphasized as a part of daily life,” comments immediate NANAINA Past President Bette Keltner, PhD, RN, FAAN, dean of the Georgetown University School of Nursing in Washington, D.C., and a member of the Cherokee tribe. “In some tribes, it is inappropriate to pray for oneself—the beneficiary of prayers will be another person. This practice emphasizes how important family and community is in American Indian culture, because you cannot pray in isolation.”
Similarly, American Indian and Alaska Native cultures revere elders. People of advanced age are viewed as special because of their life experiences and wisdom. They often serve as counselors to communities and are the proponents of tradition because of their direct ties with the past. American Indians and Alaska Natives also consider their entire tribe as an extended family.
One of the most important members of a tribe is the medicine man or woman. Although patients of Indian descent may visit a modern health care clinic regularly and even spend time in the hospital when necessary, many also want to be seen and treated by a traditional healer.
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However, many patients do not realize they have the right to use traditional medicine in a hospital setting—a cultural communication gap that American Indian and Alaska Native nurses can help fill.
“Some older patients don’t ask to see medicine men, so nurses should offer to contact one for them,” suggests Dottie Whipple, LPN, a member of the Dakota/Lower Sioux tribe who works for the IHS in Martin, S.D. “When I worked in [a health care facility in] northern Minnesota, we were able to bring in a medicine man or someone to pray with the patients.”
Natural remedies, such as herbs and roots, also play an important part in the healing process. Many American Indians or Alaska Natives drink teas brewed from herbs to maintain good health or to treat ailments. Spending time in sweat lodges is another popular practice, especially for treating drug or alcohol abuse; the heated environment and the sweating are believed to purify the body. Ironically, tobacco is often used in healing ceremonies because it is viewed as a gift from the earth that can cleanse the environment and is a medium of communication with the Great Spirit.
Minority nurses who share this cultural heritage not only have the advantage of being aware that Indian patients may be using these treatments, they also may be able to help patients use these remedies in combination with modern health treatments.
Another widespread Indian health belief that is finding its way into modern health care practice is the medicine wheel or circle of life—a diagram of a hoop or circle divided into four sections, representing mental, physical, emotional and spiritual principles. The number four itself is considered sacred in Indian culture, as there are four primary laws of creation—Life, Unity, Equality and Eternity—as well as four directions and four seasons. Other medicine wheels are based on the four traditional forces of nature: Earth (sustenance), Wind (momentum), Fire (energy) and Water (cleansing).
Because the medicine wheel combines several aspects of life, doctors and nurses who work in American Indian or Alaska Native communities are increasingly using medicine wheels to develop culturally competent health care education and treatment programs. For example, Vera Franklin, CADC, executive director of the Ahalaya Native Care Center in Oklahoma, uses a “recovery medicine wheel” to counsel chemically addicted patients living with AIDS. The Kahnawake Schools Diabetes Prevention Project, which serves a Mohawk community near Montreal, Canada, is one of several successful programs that use the circle of life to teach healthy lifestyle habits.
There are a number of common beliefs surrounding death as well. Indian nurses who understand these beliefs can comfort and communicate with their patients more effectively than nurses without this cultural awareness. According to Erna Johnson, RN, director of nursing at Parker Indian Hospital in Parker, Ariz., and a member of the Quechan tribe, one Navajo belief is that when people die at home, their spirits remain in the home; therefore, many patients choose to die in the hospital. Tom-Orme adds that Diné women who view the hospital as a place to die may choose not to give birth there.
Johnson notes that one Pima belief that is shared by several other tribes is that any body part that is removed during life, such as by amputation, must be put back with the body when a person dies. Otherwise, the person will go on to the afterlife incomplete. In Papago (Tohono O’odham) culture, when a person dies, the family bathes the body and combs his or her hair. All hair that comes out in the brush or on the floor must be bound and placed with the body so the spirits will take the deceased person with them.
Complementary Care
Today’s American Indian and Alaska Native nurses often combine traditional remedies with modern health care treatments, giving their native patients the best of both cultural worlds.
“I combine traditional and modern treatments for my own care and for others, too,” Whipple says. “When my husband gets a cold, he takes cold medicine; I eat my [medicinal] berries. Our reservation was very small, but I grew up with all the ceremonies, and my dad used herbs. I didn’t go to the doctor very often.”
However, just being of American Indian or Alaska Native descent doesn’t necessarily qualify a nurse to make decisions about using traditional remedies or to know how to combine them with modern treatments, Keltner cautions. Making the correct choice requires nurses to consider several factors, including their own capabilities.
“Nurses must assess the patient’s needs and recognize that some conditions require certain treatments; for example, appendicitis might require surgery. On the other hand, some conditions could be complemented with traditional healing methods to foster recovery,” Keltner explains. “In those cases, an Indian nurse must evaluate whether to refer the patient to a traditional healer or whether she is capable of providing the healing herself.”
The former NANAINA president goes on to emphasize that health is a cycle—a person may experience illness and then have a period of good health. She says that American Indian and Alaska Native nurses are “keenly aware of the spiritual aspects of health and illness” and understand that spirituality can “facilitate good health.”
When traditional healers are allowed to work in a hospital setting, they must be given the space and tools they need to do their jobs. Johnson, who spent a long time working with the Tohono O’odham tribe in Arizona, recalls that at the hospital where she worked, there was a room set aside for healing rituals. The hospital staff removed all the oxygen tanks from the room so that the medicine man could light candles for his rituals.
“It makes sense that we incorporate these [traditional] values into our practice,” Tom-Orme says. “A friend of mine put this very nicely when he said that, ‘as native professionals, we have to understand that traditional medicine works from within to the outside.’ Modern medicine, in contrast, works from the outside inward as we ingest medication into our bodies.”
Getting the Point Across
Because linguistic competence is an important aspect of providing culturally competent care to ethnic minority patients, American Indian and Alaska Native nurses who speak the native languages of their patients are in high demand. Most health care facilities located on or near reservations, or in areas with large Indian populations, employ a number of nurses and other personnel who can translate for patients.
“When an American Indian is very ill, that person may revert back to his or her native language, even if that language is not used very often,” Whipple explains.
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On a deeper level, getting patients to understand the medical consequences of their actions poses a challenge for nurses. Lifestyles and traditions that have been handed down from generation to generation—such as the traditional use of tobacco—factor into a number of prevalent health problems among American Indians. At the same time, many illnesses that are serious concerns in Indian communities, such as diabetes, high blood pressure and cancer, are relatively new to this population, because they were brought to this country by immigrants from Europe. In fact, Indian languages don’t even have a word for “diabetes” or “cancer.”
“This is why we are struggling with the problem of diabetes in our communities,” Tom-Orme comments. “Nurses must take into consideration the broader framework to explain diabetes and other chronic and persistent health problems. Indian people are now beginning to discuss these issues in public forums. The Navajo Nation is trying to standardize the diabetes ‘language’ so that we are all speaking about the diabetes pathology and health concepts the same way, to avoid misunderstanding and to improve outcomes.”
One way that American Indian and Alaska Native nurses are able to educate their patients to prevent and treat illness is by showing genuine interest in the community’s health. On many reservations, community educators and outreach programs have proven to be effective in getting patients and their families to comply with prescribed care. The Indian Health Service and other health organizations have established successful programs in which nurses or other caregivers visit patients’ homes.
“I see a lot of denial, especially in people with diabetes,” Whipple says. “At the IHS, we have outreach programs that continue to follow up with patients. We send letters or make home visits. A lot of patients finally become convinced that [health care] is important because someone cares enough about them to keep coming back.”
Blending old traditions and new techniques into an effective health care practice is a challenge even for nurses who are intimately familiar with American Indian beliefs. For nurses who have not grown up in this cultural environment, college and nursing school programs can help familiarize them with native beliefs—but Keltner warns that such information does not prepare nurses to provide traditional Indian remedies.
“One of the risks is that in an already-crowded nursing curriculum, students will only get an overview or survey,” she explains. “That does not give you the knowledge to go out and practice those methods. Nevertheless, nursing should be an interactive and personal profession. There’s no way to ignore the responsibility of learning about other cultures.”
With so much of their culture having been destroyed, lost or assimilated into other cultures, it’s no wonder that American Indians and Alaska Natives want to hold on to their traditional health care practices and beliefs. Nurses who can integrate these beliefs effectively into their modern practice are not only helping their patients to stay healthy but are also helping to preserve an important part of the past.
Editor’s Note: Meet Minority Nurse’s cultural competence expert: Gihan ElGindy, RN, MSN, 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.
Death and dying is a universal human experience throughout the globe. Yet human beings’ beliefs, feelings and practices in regard to this experience vary widely between different religions and cultures. As nurses, it is amazing how much we need to learn in order to incorporate sensitivity to unique religious and/or cultural needs into our daily practice. For patients from diverse cultures, quality of care means culturally appropriate care. We need to remember that dying is difficult enough; no one needs to undergo additional stress or suffering as a result of cultural misunderstanding.
As we all learn in nursing school, the patient is the focus of our care. Therefore, patients–and their families–from cultures we may not be familiar with should be viewed as a source of knowledge about their special religious/cultural needs and norms. In many cases, accommodating these needs in a hospital setting is not that difficult, but it definitely requires creativity and just a few extra minutes of our time.
Often, just being aware of our own perceptions and religious/cultural practices, and possessing a degree of openness toward other individuals’ unique needs, is more than enough to lead our basic common sense in caring competently for dying patients from diverse cultural backgrounds during this difficult time.
However, we must resist the temptation to make generalizations or assumptions that all individuals from the same cultural, ethnic or religious background are exactly alike. Within many ethnic populations, such as Hispanics/Latinos, there is a great deal of diversity in terms of cultural practices, geographic origin, etc. Above all, it’s important to realize whether you are dealing with recent immigrants to the U.S. or with first- or second-generation individuals.
Q: As an ICU nurse, I care for dying patients every shift. Often when there is a Hispanic or Latino patient dying or deteriorating, I have to face a crowd of family and friends all day, regardless of the visible visiting hours sign, posted in Spanish. The frustration is mutual. In addition, sometimes the families request to place a special food item in a special location next to the patient’s bed. I know how much this item must mean to them but many of our inflexible unit policies do not promote such practices. What is the best approach to resolve this issue?–Mary John, RN
A: Yes, it is true that America’s health care facilities have many inflexible polices that do not allow much room for promoting diverse cultural/religious rituals or practices. This is a conflict that we nurses face every day and need to work on through ongoing dialog. It can often be difficult to accommodate a patient’s wishes without changing these old, dry polices that ignore many individuals’ needs, even during their last minutes of life.
In the situation you have described, to fully understand these families’ requests we need to understand their culture, too. Hispanics/Latinos are predominantly Christians, yet they encompass varied cultural backgrounds and traditions. Sometimes when a Hispanic/Latino person is sick or dying, close family members such as the spouse, children, parents, etc. may all sit in a circle around a carefully selected food item, such as a fruit dish, placed in the middle of the room. They may spend most of the night praying and conducting special religious practices around this fruit dish. As a result, it becomes a holy dish that holds a great religious significance; the family believes that the holy object can assist their sick or dying loved one. At the end of the night, the family carries the holy fruit dish to the nurse or other care providers, expecting their full compliance in placing it next to the patient to facilitate healing, recovery or a peaceful death.
A simple discussion with the family explaining hospital and unit policies will usually lead nowhere. To please everyone and maintain a positive environment–including compliance with unit policies–the best approach is to place the holy fruit dish or food item in a sealed plastic bag, placing it exactly as the family specifies and explaining to them the perishable item’s time limitation depending on fermentation status and weather conditions. Allowing the item to remain in place for several hours–such as only eight, 10 or 24 hours–will be very much appreciated and calming to everyone. It is very important to remember to ask the family what they want you to do with this item when the time is over.
Q: I recently encountered my first Jehovah’s Witness patient, a child who was dying from a simple bleeding condition. It was very painful to watch his parents repeatedly refusing a blood transfusion that could easily save the boy’s life. Then I heard the physician trying to obtain a court order that would enable him to act as the child’s guardian so he could administer the needed blood transfusion. What a relief, he was able to save the child’s life. But I still do not fully understand why the parents were so angry. Will you kindly explain this, and why they were refusing a simple treatment that has saved millions of lives? –B.B., Kansas.
A: It is very hard and often very painful for care providers to have to watch the process of slow death, or to do nothing for a dying patient whom they think they can save. Many times, we tend to forget that there is a limit to our role and that we need to realize and accept this.
To help you understand why this young patient’s parents were so resistant to the child being given a blood transfusion, let me first explain the significance of blood in the Jehovah’s Witness faith. Jehovah’s Witnesses believe blood is sacred, representing life. Because of the Bible’s command to “keep abstaining from. . .blood,” their religion prohibits the ingestion of blood and the transfusion of blood and/or blood products. Some artificial blood products may be permissible but never natural human blood or its byproducts.
Often, Jehovah’s Witnesses who require medical or surgical treatment will request the use of nonblood alternatives. To be a culturally competent care provider means recognizing that adult patients have a right to make this choice. Therefore, obtaining the patient’s clear written permission before performing any auto-transfusion procedure is the safest practice for both the provider and the receiver. Failure to do so constitutes violating the patient’s bill of rights and can lead to litigation or legal actions. However, under U.S. law, providing care to a Jehovah’s Witness patient who is a minor (as in the case you describe) differs from caring for a Jehovah’s Witness adult. For minors, the physician can obtain a court order allowing administration of blood or blood products against the parents’ will if he or she knows the procedure can and will save the child’s life. The reason behind the physician’s action is to protect the minor’s life until he/she becomes an adult and can make his/her own faith decision. Of course, when physicians take this action it is not surprising that care providers, especially nurses, will face angry parents.
In future, to resolve this issue easily and safely for everyone, it would be helpful for you to learn about the bloodless treatment alternatives that are available for Jehovah’s Witness patients. If the facility where you work is unable to provide these alternatives, be aware of the health care centers in your area that are specialized and authorized to manage Jehovah’s Witness patients. Contacting the Witnesses’ Hospital Liaison Committee in your area to obtain more information on bloodless treatment options, patient transfers and/or consultation can also be very helpful. This service is available 24 hours a day, seven days a week.
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Q: I had a dying Muslim patient. I tried to provide her with spiritual support but instead I made her upset. I told her, innocently, that I would call the priest for her. Her tears and facial expressions were alarming enough to send a message of pain. Will you please explain what went wrong? In the future, how can I provide appropriate assistance to Muslims patients who are dying?–Linda
A: Before answering your questions, I need to explain an Islamic concept/principal first. In Islam there is no religious figure, such as a priest or rabbi, through which one communicates with Allah (God) on one’s deathbed. Muslims communicate directly with Allah anytime and anywhere as they wish. In other words, they don’t need a human religious figure to act as a spiritual “middleman.” Nor do they need to give confession to absolve their sins before they die.
Secondly, while it was culturally inappropriate in itself to offer to send a Catholic priest to comfort a Muslim patient, what really made this patient upset was probably that she perceived your action as a message that she was about to die. After death, Islam, like many other religions, requires conducting a prayer for the dead, asking for Allah’s mercy and forgiveness before burial takes place. This prayer may be performed by an Imam–a respected member of the community who, through his memorizing of the Quran (Muslim holy book), leads prayers–or by a Shiekh, or Islamic Scholar, who is a knowledgeable person who spent most of his life studying Islam and usually earns a PhD degree in Islamic Shariah (or “Islamic Laws Jurisprudence”). Therefore, even if you had offered to call an Imam or Shiekh instead of a priest, the patient would probably still have been upset, because she would have interpreted this as meaning that her death was imminent.
In the future, the most culturally appropriate way to assist a dying Muslim patient is to offer them the Quran and to facilitate their prayers.
