Caring for patients at home requires much more than knowledge of disease processes. When home health care workers enter the home of a patient, they are stepping into an entire social world; and when that patient is from a culture that has customs that vary from those of the visiting caregiver, the potential for problems increases dramatically. Caring for culturally diverse patients is challenging because the rules of appropriate behavior vary tremendously in and among cultures, based on education, social class, length of time spent in the country, the degree to which an individual interacts with members of his or her own culture versus that of other cultures, and personality factors.
Many issues may arise when treating culturally diverse patients in their homes. The following examples are generalizations; they do not apply to everyone. It is hoped, however, that the information below will increase awareness of what may be encountered when providing home health care to members of different cultural and ethnic groups.
A common source of problems is language, the most significant being lack of a common tongue. In such cases, interpreters are often used. However, this can also create cultural problems.
For example, most Asian cultures are extremely hierarchical, and it is viewed as inappropriate for a young person to tell an older person what to do. This may be particularly problematic when the home health care nurse or worker tries to communicate with the patient. Because the eldest male is at the top of the social hierarchy, instructions to the patient may have to be conveyed via that family member.
Another aspect of communication which is a potential source of misunderstanding is eye contact. In Anglo American culture, eye contact is seen as an important component of direct and honest communication. Avoidance of eye contact is often interpreted as anything from a psychiatric symptom to evidence of dissembling, or at least, of withholding information. Such interpretations, however, are likely to be incorrect, if the person who is avoiding eye contact is Asian, Middle Eastern, Native American, or possibly Hispanic.
In Asian cultures, to look someone directly in the eye implies equality. The lack of eye contact is used to imply inequality in some situations. For example, a physician or a nurse would be considered superior to a patient, as would a male to a female. Thus, direct eye contact with a superior shows a lack of respect. Many Hispanics will also avoid direct eye contact as a way of demonstrating respect, although Latin cultures lack the rigid hierarchy common to most Asian cultures.
Among many Middle Eastern cultures, eye contact is avoided between men and women out of propriety. Direct eye contact may be interpreted as sexually suggestive, and thus care is taken to avoid such implications. In many Native American cultures, the eyes are believed to be the window to the soul. If you look someone directly in the eye, you could steal their soul. Or they could steal yours. In order to avoid inadvertent soul loss/theft, eye contact may be avoided. Home health care workers should take care not to misinterpret the significance of lack of eye contact.
Gender issues can be another source of conflict. In the Muslim Arab culture it is forbidden for a man to look at the body of a woman to whom he is not married. The wise home health agency, recognizing the importance of sexual segregation in many Middle Eastern cultures, will try to send same-sex providers to patients' homes.
In many Middle Eastern cultures, it is the role of the husband to protect his wife; to act as a buffer and intermediary between her and the rest of the world. Most Middle Eastern women do not see this as sexist or oppressive; rather, they value the protection and care.
If a female home care worker senses that there is essential information that is being withheld due to the presence of the husband, she should insist on examining her privately. Otherwise, it is best to respect the patient's culture.
The issue of touching goes beyond gender. Although there is tremendous individual variation regarding people's comfort level with being touched, there are some cultural patterns. In Middle Eastern cultures, touching between members of the opposite sex is to be avoided, especially touching of females by males. This is also true in the orthodox Jewish religion . In general, Asians may not be like being touched, and physical contact is relatively infrequent in most Asian countries. Although nursing care emphasizes the importance of touch, health care workers must realize that this practice was developed in the context of Western nursing culture, and may not be appropriate for all ethnic groups. Most Hispanic patients, on the other hand, will probably feel quite comfortable with hands-on care.
Another issue that frequently arises concerns food. In general, accepting offered food in a patient's home avoids insult. The rules regarding how quickly you should accept it vary; however, in an African American home, it should be accepted immediately, especially if the visitor is Anglo American. Given the long history of racial discrimination in this country, a white person's refusal of food from an African American may be interpreted as evidence of racism.
Iranians will expect food to be accepted on the second offer. The first time it is offered is out of politeness; the second offer demonstrates sincerity. Such a rule allows the maintenance of social propriety, even when one has no extra food to share.
If the person offering food is Chinese, it is appropriate to accept on the third offer. To accept sooner is seen as rude, although as with all cultures, allowances may be made for outsiders who are not always expected to know the rules. A group of nurses from mainland China once said that one of the biggest problems they had in the U.S. was that when they politely turned down offers of food, a second offer never came Many reported that until they learned the American custom for accepting food, they were constantly hungry.
Often, issues that arise are more complicated than cultural gestures. An Anglo-American female patient, for example, insisted that her agency not send her Filipino caregivers. After the second experience with a Filipino caregiver, the patient complained to her agency that Filipinos are too cold and reserved. This case actually raises two issues. Filipino nurses are often perceived to be cold and unfriendly because, in the Philippines, nurses are trained only for technical nursing care. The psychosocial aspects of nursing that are important in American culture, are seen as inappropriate and intrusive in the Philippines.
In the United States, there is often no one but the nurse to take care of the patient's psychosocial needs. The American patient who expects the health care worker to show personal interest may perceive a Filipino nurse -- who is trying to behave appropriately -- as cold and uncaring. Ideally, health care workers trained in other cultures should be given guidance and training as to what is expected of someone in their position here. Too often, it is assumed that the foreign worker will somehow, "just know what to do."
The broader, complex issue raised by this example is that of racism. It must be decided whether patient satisfaction is more important than attitudes that promote racism. Generally, the solution is to tell patients that the home health care agency has sent the best person available for the job.