Volume 26, Issue 3, June 2019, Pages 383-391  https://doi.org/10.1016/j.colegn.2018.09.007Get rights and content Limited guidance exists on culturally sensitive communication related to interactions between clinicians, patients and families. To explore the concept of culturally sensitive communication and identify clinical practice implications and knowledge gaps related to culturally sensitive communication in healthcare. A concept analysis was undertaken, using Walker and Avant’s (2011) framework which comprises eight consecutive steps to explore the concept and clinical practice implications. A systematic literature search was undertaken to identify papers published between January 1, 1995 and December 20, 2017, leading to the inclusion of 37 relevant research papers in the concept analysis. Based on the research literature, examples of model, borderline and contrary cases of culturally sensitive communication were developed. Three major uses of culturally sensitive communication were identified, including understanding one’s own culture, open and sensitive communication, and strategies to collaborate with the patient and family for optimal patient care. An awareness of one’s own cultural beliefs, values, attitudes and practices was identified as an essential first step before learning about other cultures. This awareness includes being sensitive and adaptive to individual cultural differences and relies on clinician self-understanding and reflection. Strategies to collaborate with the patient and family for patient care include respectful and supportive clinician interactions with the family that enable a collaborative approach to care. This concept analysis aids understanding of culturally sensitive communication, the benefits and challenges associated with its use, and clinical practice implications.
Internet Citation: Research Protocol: Improving Cultural Competence to Reduce Health Disparities for Priority Populations. Content last reviewed December 2019. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
The need for culturally safe, patient-centered care to improve health outcomes is growing as healthcare professionals provide care to our increasingly multicultural society. A practitioner’s cultural competence—the ability to understand and interact effectively with people from other cultures—is critically important in helping to eliminate health disparities and social disadvantages for all patients, regardless of their ethnicity or race. Clinicians must be able to understand how each patient’s sociocultural background affects health beliefs and behavior. By understanding the patient’s social determinants of health, practitioners are better able to care for multicultural populations. A number of tools are available to help practitioners screen for social determinants of health. In its Family Practice Management, the American Academy of Family Physicians, provides “A Practical Approach to Screening for Social Determinants of Health.” Health LiteracyHealth literacy is also a social determinant of care that can affect practices. People from all age, race, income, and education levels are challenged by an inability to obtain, process, and understand the basic health information and services needed to make appropriate health decisions and to follow instructions for treatment. The AHRQ Health Literacy Universal Precautions Toolkit provides guidance to help practitioners promote better understanding by all patients. Consider the following scenario involving health literacy: A married 32-year-old Middle Eastern female with uterine fibroids presented at the office of a gynecologist. After years of infertility and pain, a hysterectomy was recommended. The patient spoke English moderately well but with a heavy accent. She declined offers of an interpreter and for a translation of the surgical consent form. Eight weeks posthysterectomy, the patient asked the physician how soon she could expect to become pregnant.
Addressing the ProblemThe Doctors Company’s closed claims studies have shown that inadequate provider-patient communication frequently contributes to patient noncompliance, poor patient outcomes, and litigation. In multicultural and minority populations, communication factors may play an even larger role because of the behavioral, cognitive, linguistic, contextual, and cultural barriers that must be overcome. Research has shown that services for minorities can be improved by removing language and cultural barriers. When cultures and languages create barriers, clinicians are unable to deliver the care they have been trained to provide. Culturally competent care depends on resolving systemic and individual cultural differences that can create conflicts and misunderstandings. If the provider is unable to elicit patient information and negotiate appropriate care, negative health consequences may occur. Traditionally, training in cross-cultural medicine has focused on providing a list of common health beliefs, behaviors, and key “dos and don’ts.” This approach, which does not consider acculturation and socioeconomic status, can lead to stereotyping. An alternative approach, first proposed by Drs. Carrillo, Green, and Betancourt in 1999, helps clinicians elicit a patient’s beliefs and preferences in order to identify and address the patient’s concepts, concerns, and expectations. This communication model is called ESFT: Explanatory model of health and illness, Social and environmental factors, Fears and concerns, and Therapeutic contracting.1 Case ExampleConsider this scenario with an example of the ESFT approach: A 62-year-old Dominican patient presented with hypertension. In the past two years, she had been seen by several physicians, had multiple tests to rule out any underlying etiology, and tried a variety of medications to control her blood pressure. Despite these efforts, her blood pressure remained poorly controlled. The patient, whose primary language was Spanish, had limited English skills but refused an interpreter at all clinic appointments. It appeared that the patient was nonadherent with taking the antihypertension medicine—taking it only periodically when she felt tense or stressed. Further inquiry by the physician revealed that the patient was illiterate and did not understand the complex medication regimen she had been given. The physician was able to explore the patient’s explanatory model for hypertension using the ESFT approach. The patient strongly believed that her hypertension was episodic and related to stress. She didn’t take her daily antihypertension medication because it didn’t fit her explanatory model. The physician was able to reach a compromise by explaining that, although her blood pressure goes up during stressful times, her arteries are under stress all the time, even though she didn’t feel it. Taking medications daily would relieve the arterial stress but would not help with her emotionally stressful episodes. The physician was able to negotiate with the patient to add relaxation techniques to her daily routine. Bias and EthnocentricityBiases affect how we view and care for individuals. They are the attitudes or internalized stereotypes that can affect healthcare professionals’ perceptions, actions, and decisions in an unconscious manner that often contribute to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics.2 All of us come from different backgrounds and tend to see the world from our own perspective. Failing to recognize or respect the views of others can manifest itself in a form of bias known as ethnocentricity. Ethnocentricity may take the form of explicit bias such as xenophobia, overt racism, or religious bias. Explicit bias occurs at a conscious level, but when the individual is not aware of the bias, it is implicit bias. Bias can result in a lack of cultural competence evidenced by failure to consider the terminology, comfort care, and remedies implemented by persons from a culture other than that of the healthcare provider. What You Can DoConsider the following strategies to address cultural diversity challenges in your practice: Listen to the patient’s perception of the problem. Explain your perception of the problem. Acknowledge and discuss differences and similarities. Recommend treatment. Negotiate treatment.
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Why is it important for a healthcare provider to be aware and sensitive to cultural diversity?
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