Illness is Illness in Any Language: Nursing at a Multicultural Hospital
About five years ago, the hospital where I worked, St. David’s in Austin, Texas, came up with a cultural sensitivity package for employees. It was a printed list of points to be aware of when caring for patients from various cultural backgrounds. Previously, when in doubt about an obviously non-white or non-African-American patient, the staff usually labeled them "Hispanic." That seemed to be the default category.
Ever since the day an elderly Cambodian woman was transferred to my unit with paperwork describing her as Hispanic, I recognized the need for this kind of education. However, in the hospital’s earnest but clumsy efforts at enlightenment, kindergarten stereotypes prevailed. The printed guidelines were good for a laugh, if nothing else. Mexican-Americans, they said, liked spicy foods and believed certain dishes helped cure various illnesses. Women from India were modest. Asian patients didn’t always say what they meant, and might smile and nod even when they disagreed.
"Get a load of this!" said Shirley, a fellow Canadian. "Canadians are reserved, polite, and don’t like to be touched. Please! What else did they get wrong?"
"I Can Say 'Pain' in Six Languages"
My thoughts flew back to my time at Mount Sinai Hospital in Toronto, Canada, which made me realize I already had a lot of credits in multicultural awareness.
Mount Sinai, an excellent teaching facility affiliated with the University of Toronto’s medical school, was multiculturalism central. At least 50 percent of its patients did not speak English as a first language. Toronto’s three million people hail from all over the world; an estimated 60 percent of its population was born abroad. At one point in the late ’90s, the United Nations named the city the most ethnically diverse on the planet. The same could apply to the Southland today.
How many hospitals retain a full-time Chinese interpreter? Mount Sinai had one, plus lists of on-call interpreters—many from the largely Portuguese cleaning staff, the Asian food service workers, and the West Indian security staff. Patients spoke Korean, Ukrainian, Polish, Portuguese, Greek, Italian, Pakistani dialects, and Iranian Farsi. Interestingly, hospital signage was entirely in English, though on every floor, at any given moment, employees and visitors could be found who were multilingual. Inevitably, communication challenges meant that nurses picked up snippets of foreign phrases.
"I can say ‘pain’ in six languages," bragged Karen, a seasoned Mount Sinai nurse.
Learning about the relatively exotic backgrounds of most of my patients more than compensated for the strains involved in leaping cultural boundaries. And strains there were.
"I smell something burning," muttered Karen one evening. "Oh, no!" she sputtered, "This is unbelievable. They’ve got to stop right now!"
An East Indian family sat on the floor of a four-bed room, busily stirring aromatic spices into the dish they were cooking on a small Hibachi grill. The four-bed rooms were airier and more spacious than the semi-private rooms, but there were limits to the activities permitted in them. As a startled patient peered around his curtain at the scene, Karen called a nurse who spoke Gujerati to interpret, since the family huddling near their relative’s bed spoke little English.
I remember a lovely Somali woman who sought treatment for a painful eye condition. On the day she was admitted, a female Somalian friend stayed with her to help translate the admission forms. This was only partly successful, however, since the friend didn’t know what diabetes meant.
Successful immigrant professionals in Toronto often flew their elderly relatives to Canada for medical care since they could afford to. This led to interesting scenarios. Since few of these patients spoke English, I could have written a manual on body language communication by the time I left Mount Sinai. I once obligingly tried to pour water over an elderly Sikh’s hands in a sort of morning cleansing ritual he seemed to indicate was necessary. I did my best, but his disgusted expression told me he thought I was a total klutz.
A pale Turkish woman recovering from gallbladder surgery frantically flipped through her Turkish-English dictionary as I grabbed a basin so she could throw up. Just in time, too. She was still trying to find the English word for nausea.
And at the height of the Gulf War, a handsome Iraqi-Canadian, who looked like Omar Sharif, appeared at the nurses’ station one evening. He was an engineer who had flown his aged father over for eye surgery. The patient was comfortable and doing fine post-op. I told the son that visiting hours ended at 8:30 a.m., but he could come back at 11:00 a.m. the next day.
He fixed pleading dark eyes on me and begged me to let him stay overnight at his father’s bedside. I explained that since his father had a roommate, this was impossible. However, I bent the rules and let him stay until late evening, telling him he could come back at 9 a.m. The irony of an Iraqi immigrant’s father receiving excellent care at a Jewish hospital while Iraq was pounding Israel with bombs was exquisite, though consistent with ethical medical treatment.
Sometimes the information families provided was sketchy at best. A Greek family grew tired of waiting to have their ancient grandmother admitted and abandoned her in her room. Left alone, she couldn’t communicate since she spoke no English. At that time, my Greek consisted of a few words I’d picked up randomly, such as kukla, or doll—not much help. I called the family at home but reached only a 16-year-old grandson. A laborious three-way conversation ensued, featuring such highlights as, "Please ask your grandmother if she has any allergies."
But families could also be helpful A Pakistani woman in her thirties had brought her mother-in-law over to live with the family, and now the older woman needed surgery. The daughter-in-law wrote out the words phonetically in her mother-in-law’s language for pain, water, and bathroom and taped them to the bedside table to facilitate communication.
"Maybe now she will go to English classes," the daughter-in-law remarked. "She baby-sits the children while we work, and needs to be able to give clear directions to the house in an emergency. We’ve been trying to get her to go to night school classes. It’s high time after two years."
Cultural Responses to Childbirth and Illness
Culture affects how patients react. Among immigrant patients, the less affluent were often more stoical and less demanding than the more prosperous. One of the first obstetrics cases I helped with as a student nurse was a young Portuguese woman who didn’t speak English and was about to have her first child. Though an older woman active in her community brought her to the hospital and sat with her, the patient’s husband never put in an appearance during her quietly endured, 20-hour labor. The reason? He was at home with a slight cold.
Patients’ expectations could also be at variance with North American reality. I was once assigned to the newborn nursery, where it was assumed that the mothers would take over most of their infants’ care, wheeling bassinets back and forth between their rooms and the nursery. A Middle Eastern patient stayed in her bed and refused to lift a finger. Many of the nurses frowned judgmentally on her behavior.
"She won’t get up and help because at home she wouldn’t be expected to," said an experienced nurse who had worked abroad. This made sense. In many cultures, women who have just given birth are cared for and waited on for up to 40 days.
A nurse from a middle-class background in Chile was amazed that, in North America, new mothers almost seem to compete to see how quickly they can bounce back to their pre-pregnancy routines. I privately called the desire to immediately return to normal "feminist macho" behavior, as though giving birth were nothing special, like recovering from a cold.
"In my country, the neighbors would be bringing me food and visiting every day for a month!" she said.
Respecting patients’ cultural and religious practices was integral to working at Mount Sinai, but sometimes it was easier said than done.
"I’m sorry, I didn’t hear you," I apologized to a retired rabbi as I turned toward his bed. Far from asking me a question, as I had thought, he was chanting aloud, wrapped in a prayer shawl. I retreated quickly. But this faux pas paled in comparison to the time I complimented an older woman on the bead necklace she was holding, only to realize too late it was a rosary. She took it well.
At Mount Sinai, the rules precluded patients wearing any jewelry to surgery. But just try explaining to an 85-year-old Albanian woman that the gold hoop earrings she had worn for 70 years had to come off. Realizing they were embedded in her skin, we put pieces of tape over them instead, although what this accomplished was debatable. Getting her to remove her underwear was an even greater challenge.
Although many Mount Sinai patients had moved mountains—of paperwork, at least—to immigrate to Canada, this didn’t mean they instantly assumed new identities. On the contrary, they re-created old battles and ethnic conflicts in their new country. The Turks disliked the Greeks, who did not care for the Macedonians. Poles and Russians re-fought World War II.
Where Are You From?
I loved figuring out where patients originally came from by studying their names. I correctly pegged a chic, middle-aged woman as Haitian. She was a bank executive. I learned that Caribbean-English accents vary from island to island and that someone from Barbados, for instance, can always identify a native of St. Kitts.
I remember an elderly patient called Sophie. Blind and disoriented, she was rail-thin and would not eat. When aides tried to feed her, she flailed her arms and constantly shrieked Yiddish phrases that sounded like curses. A picture of her as a lovely young woman hung above her bed. She was wearing a fashionable black dress, posed elegantly in a doorway somewhere in Eastern Europe. The photo reminded us that the Sophie we knew was a mere remnant of the true Sophie.
We tried everything, but it often took half an hour to coax her to accept a few spoonfuls of food. Only her elderly brother, a retired physician who visited daily, could calm her down. But he was an eccentric and preoccupied man who refused to translate her words for us.
"What’s she saying?" we asked often, to no avail. Shaking his head, he would try to interest her in a spoonful of soup or a bite of toast.
Jodie, a junior resident, often bore the brunt of Sophie’s screams and curses. Her grandfather spoke Yiddish, so one evening when things were unusually quiet on the unit we persuaded her to call him and ask what he thought Sophie was saying.
"Hi, Grandpa," Jodie began, "What? Am I in practice yet? Well, not exactly. I’m still in school. I beg your pardon? When am I going to start making some money? It doesn’t quite work that way, Grandpa . . ."
Eventually, she found out what Sophie was saying, and it wasn’t pretty.
"He says it means ‘I’ll tear your nose and eyes out!’" Jodie relayed. Oh well, we didn’t expect compliments.
On the basis of my sketchy high school Spanish, I was called to the Emergency Room more than once to translate for a Latin American family, but I could have used a crash course in Mandarin, Portuguese or Ukrainian. What greatly helped in day-to-day patient care was the fact that many of the nurses came from the Philippines, Hong Kong, India or the Caribbean and could relate to the patients’ disparate cultures. Since many of the residents and doctors were also foreign-born, often from Russia or Israel, it wasn’t uncommon for them to converse with patients in several languages, or with one patient in a mixture of dialects.
Sometimes all it takes is a role reversal to develop empathy. In my case, it happened when my husband collapsed and was hospitalized during a vacation in Portugal. Neither of us spoke more than a few words of the language. We were fortunate that his doctors—though not the nurses—spoke English. Though he recovered quickly, our sense of helplessness and vulnerability took longer to shake off.
Hospitalization is always a crisis—even more so when it happens in a new country where a patient may not fully understand the language or the cultural values. As our society becomes more multiethnic, we nurses have learned the importance of recognizing cultural differences and becoming informed about them. Communication is vital, not only to ensure that patients get optimum care, but also to allay the anxieties that are an inevitable part of the hospital experience.
Diane Barnet is an RN and a legal nurse consultant. She has written for the Los Angeles Times, Backpacker, American Careers. Her book, What You Need to Know About Hospitals was published by Crossing Press, Santa Cruz, in 1998.
This article is from workingnurse.com.