Increased Cultural Diversity among Nurses and Patients in Health Setting

 
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Introduction
Cultural diversity is becoming an important issue in the healthcare system. According to Egede (2006) culture can be defined as integrated patterns of human behaviors including thoughts, communication, language, customs, beliefs, values, and actions. In non-medical disciplines, culture is defined as shared and learned values, beliefs and ways of life of a particular group that are transmitted from one generation to another and affects the ways of thinking and actions of the people. Therefore, culture is a variable for racial and ethnic differences encountered in the delivery of health services. The experience of the nurses on caring for culturally diverse patients has been shown to positively or negatively affect their care for the patients due to the attitudes and pre-formed opinion (Cioffi, 2005). The cultural diversity among nurses has been shown to results in issues such as communication problems, education problems and lack of patients’ satisfaction that have negatively impacted on the health outcomes. Therefore, the aim of this paper is to critically explore communication problem as a resultant issue arising from patient and nurses cultural diversity and make recommendations for alleviating the challenges associated with communication problems for practice improvement.
Resultant Issues: Communication Problems
Effective communication between patients and health care workers is essential for delivery of safe and quality care. The relation between patients and nurses is based on good communication where both parties fully understand one another. This always results in adherence to the medications, patient satisfaction and better health outcome (Wynia & Osborn, 2010). However, cultural misunderstandings between patients interfere with effective communication between the patients and the nurses thereby contributing to poor quality of care and patient dissatisfaction (Almutairi & McCarthy, 2012).
Studies have also shows that patient cultural diversity results in poor communication between the patient and nurses thereby leading to a poor health outcome. Halligan (2006) reported that critical care nurses had difficulty in communicating with patients due to cultural differences with resultant in language barriers. Halligan (2006) considered this differences as a major barrier for good patient-nurse relationship causing poor quality of care. According to Schyve (2007), cultural differences have been associated with language differences as well. One’s culture is believed to affect an understanding of a sentence and the perception of the world. As a result, cultural diversity may promote negative attitude associated with a cultural stereotype which is a significant barrier to effective communication between the patient and health care workers.
In the professional organizational perspective, cultural diversity as a barrier to effective communication is viewed as a problem that affects the communication among the nurses themselves and care delivery to the patients. Research has shown that nurses experience communication problem is cross-cultural encounters with their fellow nurses, especially in situations that they do not have a common language (Jirwe, Gerrish, & Emami, 2010). Similarly, nurses also experience the same communication difficulties when interacting with culturally diverse patients. For instance, nurses have reported communication problems with immigrant patients and patients from cultures different from the nurse’s (Jirwe et al., 2010). Therefore, cultural diversity as a barrier to effective communication in the professional organizational perspective is viewed in two ways. First, a problem that affects communication between nurses and nurses or nurses and other health care workers. Secondly, a problem that affects communication between nurses and patients or between patients and other health care workers. Either way, lack of effective communication results in poor care delivery and patient dissatisfaction.
In the ethico-legal perspective, nurses like other healthcare personnel are required to be culturally and linguistically competent in order to address the problem of communication in healthcare. According to Singleton & Krause (2010), nurses are ethically required to seek the consent of the patient before any medical procedure or treatment is initiated. In cases of communication problem, there is an ethical problem due to cultural language barrier for effective communication. However, nurses are in ideal position to facilitate the interconnections between patient culture, language, and health literacy in order to improve health outcome in culturally diverse patients. Kourkouta and Papathanasiou (2014) argues that nurses are ethically and legally required to devote their time to patient communication with the necessary confidentiality. Therefore, this means that all nurses must properly understand their patients and initiate the strategies of effective communication. In this perspective, communication problems is viewed as an issue of cultural diversity is viewed as a problem affecting the ethical requirements of a nurse.
Lack of clear communication as a resultant problem of cultural diversity is now an issue in healthcare because of the numerous problems associated with it and the increasing number of patients from diverse cultural backgrounds. In the United States, for instance, the cultural face of the patient is changing with the US Census Bureau reporting that in every three people, one comes from an ethnicity other than non-Hispanic white (Cang-Wong, Murphy, & Adelman, 2009). The American population is composed of people of different cultural background such as whites, Asians, blacks, American Indians, Alaska Natives, Native Hawaiian and other races (Cang-Wong et al., 2009). The trend is the same in Australia where cultural diversity has been reported to be a significant feature of the healthcare system in the country affecting the quality of nursing care (Chenowethm, Jeon, Goff, & Burke, 2006). The patient population in Australia is made up of between Indigenous and non-Indigenous Australians with disparities in healthcare system depending on these two cultural backgrounds (Nguyen, 2008). Despite the increasing patient cultural diversity, the diversity among nurses has not kept up with the population. In numerous health care facilities, the nurses do not reflect the demographic characteristics of the general population (Chang & Kelly, 2007). Although the nurses are educated on cultural sensitivity, lack of ethnic diversity among them poses a challenge for the provision of holistic care to the diverse group of patients (Cang-Wong et al., 2009). One of the major challenges in this case is lack of clear communication between the nurses and the patients. However, cultural diversity among the nurses may also pose communication challenges among the nurses themselves (Tucker, Marsiske, Rice, Nielson, & Herman, 2011).
Cultural diversity among the nurses and patient cultural diversity which results in communication problems among the nurses themselves and between patient and nurses have been shown to cause poor health outcomes. For instance, lack of clear communication has been associated with medication errors (O’Daniel & Rosenstein, 2008), patient dissatisfaction (Almutairi, 2015), and increased length of hospital stay (Agarwal, Sands, & Schneider, 2010).
Patient Dissatisfaction
Patient satisfaction is a factor which is negatively affected by poor communication between nurses and patients due to cultural differences. Indeed, studies have demonstrated that proper patient communication improves patient satisfaction with nursing care. For instance, Uitterhoeve et al. (2009) reported that nurses’ cue-responding behavior as determined by their communication with the patients significantly improved the measures of patient satisfaction. Similarly, a systematic literature review by Fleischer, Berg, Zimmermann, Wüste and Behrens (2009) also established that effective communication is an important factor in establishing a therapeutic relationship between the patient and the nurse which in turn improves patient satisfaction. Patient satisfaction has also been associated with effective communication between nurses and other healthcare professionals (McGilton, Robinson, Boscart, & Spanjevic, 2006). McGilton, Robinson, Boscart and Spanjevic (2006) investigated the effect of communication enhancement intervention for health care workers on patient satisfaction and found that some patients were satisfied with the care delivery. The results of these studies demonstrate that patient satisfaction is directly dependent on effective and proper nurse-to-patient communication and effective communication among the healthcare workers. Therefore, it is deductive that cultural diversity which results in communication problems causes patient dissatisfaction with nursing care.
Medical Errors
Effective communication is significant in establishing the medication requirement as well as the previous history of a patient. Additionally, proper communication among nurses and other healthcare workers ensures the minimization of medication errors. In cases of cultural diversity resulting in difficulties in communication, nurses are not able to proper evaluate the patients in order to retrieve their past medication history (O’Daniel & Rosenstein, 2008). In addition, nurses are face communication challenges in communicating with other nurses or health care workers. The culturally-driven communication challenges have been shown to result in increased medication errors which can cause detrimental effects to the patients. This is because lack of communication creates an environment in which medication errors can occur (O’Daniel & Rosenstein, 2008). Cultural differences may also interfere with communication regarding patient medication when the patients cross-regional health care levels. A study by Frydenberg and Brekke (2012) explored the effects of inadequate communication on patient’s medication errors on admission. The research established found 50 medication errors with half of these errors being attributed to lack of clear communication from previous healthcare facilities. Out of these, 27 errors were found to be potentially harmful to the patient. Another study by Kazaoka Ohtsuka, Ueno and Mori (2007) investigated the impact of communication problems in nursing systems in cases of medication requests between nurses. The results of this study showed that nurses have a communication problem which influenced by the relationship in the workplace in the team nursing system resulting in medication errors. Some of these communication errors are caused by the cultural diversity among the nursing staffs. According to Khairat and Gong (2010), failures in clinical communication, which can be caused in part by cultural diversity, has been shown to increase the number of medication errors in hospitals. Therefore, the results of these studies show that communication problems associated with cultural diversity can significantly cause harmful medication errors in healthcare settings
Increased Length of Hospital Stay
According to Gruenberg et al. (2006), lack of clear communication between the patients or their caretakers and the nurses or other health care workers have been associated with increased hospital stay. Some cases of the lack of clear communication have been associated with communication barriers arising from cultural diversity of the patients and their caretakers. Agarwal, Sands and Schneider (2010) conducted a study to investigate the economic impact of communication inefficiencies in hospitals. The study found that the communication problems accounted for the annual loss of $12 billion with 53% of this loss attributed to increased length of hospital study. The findings of this study show that ineffective communication which can be caused by the cultural diversity among the patients, nurses or other health care workers increases the length of hospital stay for a patient resulting in the economic burden. In this perspective, cultural diversity is an economic problem to both the patient and the hospital.
Recommendations
This is scientific evidence showing that cultural diversity results in issues such as lack of clear communication between patients and nurses, among nurses or between nurses and other healthcare practitioners. There is also evidence to demonstrate that the communication problems results in patient dissatisfaction, medication errors, increased length of hospital stay and general poor quality nursing services. Therefore, nurses play a significant role in addressing cross-cultural communication barriers experienced during practice. According to Schyve (2007), effective communication should take into consideration cultural differences among other factors in order to ensure effective communication. It is therefore recommended that nurses should continually develop and assess their ability to practice cultural self-awareness in order to recognize their cultural assumptions and biases (Purnell & Paulanka, 2008; Racher & Annis, 2007). These requirements are part of cultural competence assessment which all healthcare workers including nurses are required to meet. However, self-assessment on cultural awareness or health literacy is not part of routine nursing practice currently (Singleton & Krause, 2010). Therefore, there is a need for nurses to include cultural competence self-assessment tools that incorporate health literacy into their daily practice.
Secondly, nurses should use patient assessment tools that can efficiently collect information regarding the cultural beliefs of the patient as well as the language that they understand. Currently, studies have reported the use of “gut feelings as a clinician” to assess the health literacy of the patient (Schlichting et al., 2007). However, this assessment tool is influenced by unconscious biases making it imprecise (Singleton & Krause, 2010). Therefore, better literacy and cultural assessment tools are necessary for accurately collecting the cultural beliefs and literacy level of the patient to promote effective communication. Nurses need to collaborate with other healthcare practitioners in developing and using the tool to collect the information. Thirdly, nurses can serve as the advocates for motivating the healthcare organizations to address patient-communication barriers. According to Singleton and Krause (2010), nurses are the best group of healthcare workers to be such advocates for describing the negative effect of the communication problems on patient safety and health outcomes. The nurses are also well-qualified to forms for the patients and education materials which are necessary for addressing the cultural concerns of the patients.
Conclusion
Cultural diversity is now a trend in the healthcare system because of the increasing diversity of the patient population and multi-cultural health care staff. The cultural diversity has complicated communication between patients and nurses, among nurses or between nurses and other healthcare practitioners. Research has established that these communication problems results in patient dissatisfaction, medication errors, increased the length of hospital stay and general poor quality nursing services. Therefore, nurses should continually develop and assess their ability to practice cultural self-awareness in order to recognize their cultural assumptions and biases necessary for effective communication. Nurses should also use patient assessment tools that can efficiently collect information regarding the cultural beliefs of the patient as well as the language that they understand. Finally, nurses can serve as the advocates for motivating the healthcare organizations to address patient-communication barriers. Cultural competence should be met by all the healthcare workers, and further research is needed to establish the effect of cultural diversity on health outcomes.
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