A matter of understanding

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A matter of understanding

How one facility meets its patient ­population's unique cultural needs

After reading this article, you will be able to:

  • Describe the unique regional challenges this organization faces when working toward cultural sensitivity and awareness
  • Identify hard-to-reach groups in terms of training and orientation
  • Describe how eye contact factors into communication with patients at the facility
  • Discuss programs specifically designed to combat wellness issues related to cultural dietary habits
  • Describe the knowledge and expertise required from a patient advocate at the facility


Cultural awareness has risen to the top of healthcare development and concerns in recent years. Ensuring that patients' needs are met, that they understand the ­education given to them, that appropriate translation services are provided-all of these components and more must be built into a facility's plans to provide the ­highest-quality care possible.

There is frequent discussion about big city ­hospitals faced with the challenge of finding translators or ­translation services for the dozens of languages spoken on their campuses, or how to prepare ­nursing staff for the wide range of ­cultures they may encounter in a given day.

But what about those facilities that are embedded in a unique ­culture? Or the hospitals that must adopt a ­singular ­understanding to meet the needs of a very ­specific ­patient population?

For that story, let's travel to the Four Corners region in New Mexico.


Four Corners

Northern Navajo Medical Center (NNMC) is in the heart of the Navajo reservation spanning New Mexico, Utah, Arizona, and Colorado. Situated in the Four Corners region, NNMC has patients arrive from all four adjoining states. But that's not the most unique challenge the ­organization faces.

"We're smack-dab in the middle of the ­Navajo ­culture," says Kathy Mosley, BSN, CPMSM, CPCS, medical staff and performance improvement coordinator.

While cultural sensitivity and awareness is now mandated by Joint Commission standards, when you are embedded in the local culture, your ­organization needs to tackle it regardless of whether a regulator or accrediting body tells you to do so, she says.

"It's mandated, but it's always been of huge importance to us," says Mosley.

Cultural awareness starts at orientation. All staff ­undergo a rigorous training and orientation process, both administrative and clinical.

One issue that presents a challenge is locum tenens. "We don't have an organized medical staff orientation. [Rather] there is a clinical orientation they have to go through with the nurses," says Mosley. "New physicians get a concentrated version of it."


Outsider's perspective

Mosley herself came to NNMC as an outsider and found the transition eye-opening.

"During orientation when I first arrived, they had ­pictures to help identify bubonic plague," she says. "I didn't think they were serious. But my sister, who had been working here for some time before me, said yes, there is still the plague on the reservation."

The weeklong training includes a day of ­general ­orientation that is foundational to all duties at the ­hospital, with discussions with the CEO and risk managers.

From there it's split into clinical and administrative training.

Some of the general things taught during that initial orientation include key differences in communication to ensure that staff are reading the right signals from the patient population, whether speaking with the patient, a family member, or a guest.

Eye contact, for example, was something Mosley describes as a ­challenging cultural shift.

"When I talk to people, I'm very into eye contact," she says. "I learned that culturally, the Navajo don't ­necessarily look you in the eye. You don't have direct eye contact when you speak."

As a nurse, Mosley would try to teach or explain something to a patient or family member, and that ­person would look at the floor or a wall. At first, it left her confused whether they were paying attention to her.

"But they were," Mosley says.

This trait is less prevalent with the younger generations, she says, but it is still something to be aware of when engaging in communication with older patients.

Also of particular concern among the older generation-though not exclusive to them-was the ­culturally appropriate way to discuss illness and death.

"When you talk to the patients, you don't talk directly about, for example, a cancer diagnosis," says Mosley. "You talk to them about it in the third person-such as, if someone were to have this cancer, this is the treatment they would undergo."

To discuss the illness directly-you have X cancer, you will need X treatment-is considered bad luck. "There is a belief that discussing the illness is to take it on," says Mosley.

Younger staff members seem to adapt to the cultural sensitivity requirements most easily, particularly new nurses.

"They are fresh out of school, exuberant and ready to start their new job," says Mosley. "With the ­shortage in nurses a few years ago we had a proctoring and ­mentoring program which was particularly interesting-they seemed to adapt to the culture very well."

Staff members who come to NNMC know that the ­majority of the patients will be from a Navajo ­background, and that they must adapt to the ­organization's and region's culture to perform their jobs effectively.


Beyond beliefs

Another cultural shock for Mosley when she first ­arrived was the living conditions in the more rural parts of the reservation.

"I was used to working up in Montana, where you discharge someone and you gave them some supplies and instructions," she says.

But there are parts of the reservation without ­running water or electricity, meaning that some of the basics of post-discharge care are impossible without additional help.

"You don't simply give the patient dressing changes for a leg ulcer-you give them all the supplies, including bottled water," she says.

And then there is the issue of family.

"Part of the Navajo culture is that they are very ­family oriented," says Mosley. "Many times if there is a sick grandparent, you aren't just dealing with the immediate family-you are dealing with the entire extended family. Everyone shows up to support them."

This can be helpful as there is always someone who can help translate and communicate with the extended family. But NNMC has also adopted a medical translation program employing several trained translators.

"Before anyone can be used as a translator for ­patient complaints, interviewing the family, or helping a ­physician with discharge instructions, they need to be trained in this program," says Mosley.

This is particularly important when it comes to translating ­medical ­instructions. There are nuances within the ­Navajo language, says Mosley, where the wrong ­inflection can change the meaning of the entire statement.

"This is especially possible with medical terms," she says. "There isn't an equal word for everything in the English language. You might need an entire phrase to explain one word."

This can slow the process down, and NNMC must be prepared to help physicians, who might be impatient to take the next step in treatment or have concerns about time-sensitive decisions.

"A lot of times physicians might be in a hurry and want to grab a family member to translate, but it's just not adequate," says Mosley.


Dietary concerns

In order to be respectful of the local culture and ­maintain patient satisfaction, NNMC has incorporated specific dietary staples into its food service.

"It's a bit informal," says Mosley. "The policy doesn't say OB will do this, dietary will do that. It says we will be culturally sensitive."

Rather than making a wholesale decision, the facility uses traditional blue corn when it can in place of more traditional oatmeal or cream of wheat, and incorporates mutton into meal choices.

But meeting cultural sensitivity needs at the same time as providing sound dietary advice is sometimes a delicate balance.

"Diabetes and obesity is such a problem in this area, and it is challenging to help patients focus on what they can and can't change," says Mosley.

Key staff members have taken responsibility for ­creating diabetes education and prevention programs. If a patient is newly diagnosed with diabetes, he or she is placed on a list for the program, which is headed up by the ­organization's chief of internal medicine.

"The epidemic frustrated [the chief of internal ­medicine] enough that she developed this quick ­access clinic," says Mosley. "Everyone who is diagnosed is ­encouraged to visit the clinic, where they can get a glucose monitor and strips" to help monitor their blood sugar.

This culture- and condition-specific clinic has the full support of the entire facility, as the complications of diabetes affects every department, from family medicine to podiatry. A local retailer has even helped the hospital create an incentive program with gift certificates to help promote healthy behavior.

Other healthcare providers have worked hard to ­combat the prevalence of obesity in the region by ­­creating a "Just Move It" program to promote exercise.

"They've set up exercise areas throughout the ­community to promote physical activity," says Mosley.

The hospital has established health stations to take blood pressure, do fingersticks, and provide water for community members trying to increase their activity levels.

"There is a focus on kids to keep them active," says Mosley. "And then the kids will drag their parents out."

While programs to promote healthy behavior help, it is also necessary to understand the cultural factors that cause such high rates of obesity and diabetes. Traditional foods like mutton and fry bread are high in fat content, for example, and traditionally there is a belief that to be overweight is to be healthy. It's also more expensive to eat healthier-not just on the reservation, but across the country.

"It frustrated me when I first got here, the thought that a chunky baby is a healthy baby," says Mosley.

The best approach has been a combination of cultural awareness and education.

"Education is the center of everything," says Mosley.


The advocate

A discussion about cultural sensitivity and awareness cannot be complete without discussing NNMC's use of a patient advocate. The original person filling this role was a longtime nurse who had worked in patient and nursing education. Her time spent in the community and working with patients had earned her the respect of the community both in and out of the hospital.

"What she said held a lot of weight," says Mosley.

The nurse essentially created a niche for herself as a patient advocate by having the right combination of education, cultural knowledge, and language skills. When she left the organization, it was ­determined that the role would not be limited to someone with a nursing background. Another staff member, who had worked on the administrative end of the ­mental health department, stepped forward. She was also rooted in the community, fluent in Navajo, and very culturally aware. She did not have the clinical ­expertise of her predecessor, so in order to ­complement her cultural and translation skills, the quality department-made up almost entirely of staff with a clinical background-partnered with the new patient advocate to ensure she had the right clinical skills as well.

"Our patient advocate is crucial to handling ­patient complaints," says Mosley. "She really can allay concerns and fears, and calm and defuse situations."

Back in her risk management days before coming to NNMC, Mosley says, she and her colleagues would see that it was rarely the "bad" physicians who drew complaints-it was the rude ones. An offensive comment was more likely to be reported than a clinical ­complaint-a good indication of just how important cultural sensitivity is in every hospital.

"We have established a really strong structure and baseline," says Mosley. "Our physicians are accustomed to the culture. When someone is in the ICU, there will probably be a family meeting where they will work with our patient advocate-this is a huge benefit. She speaks Navajo, helps interpret, and is aware of cultural beliefs. She is the physician's right arm."