Patient Education: Addressing Cultural Diversity and Health Literacy Issues

Authors and Disclosures

Margaret Chang, MN, RN, is a Nurse Consultant, Urologic and Transcultural Nursing, San Diego, CA.

Ann E. Kelly, MSN, APRN, BC, is a Faculty Member at National University, Department of Nursing, San Diego, CA, and the Past Coordinator of Patient Education, San Diego Veteran Affairs Healthcare System, San Diego, CA.

Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.

Sidebar: A Case Presentation -- Health Literacy and Cultural Diversity

Introduction

The following case was presented in a weekly interdisciplinary unit conference. Staff members were concerned about meeting the needs of this complex patient who required an interpreter for discharge instruction, about the short notice for discharge, and about safety and hygiene issues related to squatting on the toilet.

Clinical Interaction

Mr. T, a 78-year-old Asian male, was admitted to the hospital for acute urinary retention and congestive heart failure. A Foley catheter was inserted to relieve the urinary retention, and the patient was placed on bed rest. Later during staff rounds, Mr. T's nurse was shocked and distressed to find Mr. T in his room squatting on the toilet seat trying to move his bowels. The nurse scolded Mr. T for getting out of bed without assistance and for squatting on the toilet seat instead of sitting.

Mr. T remained in the hospital overnight and was discharged home about 5:00 p.m. the next day with his Foley catheter still indwelling. He was sent home with new prescriptions for furosemide twice daily, digoxin once daily, and potassium once daily. As part of the discharge teaching, catheter care was demonstrated to the patient and discharge medication instructions were discussed. The patient's daughter in-law acted as translator. The family all nodded their heads and smiled; everyone appeared to understand the instructions and signed off the discharge paper as understood.

Results of Clinical Interaction

Mr. T lives with his wife, who is 75 years old, his son, and his daughter in-law. His son's job requires that he travel frequently to other countries. A home health nurse visited Mr. T the day after he was discharged from the hospital. The nurse found Mr. T lying in bed with his full urinary drainage bag on the floor. The drainage bag had not been emptied since Mr. T left the hospital. Mr. T. had taken his furosemide at breakfast and again at lunchtime since that is what he understood twice a day to mean.

Clinical Implications

Toileting: Squatting for elimination. In many Asian and African countries, squatting toilets are the norm. The muscles used in squatting differ from those used in sitting on a western toilet for defecation. Sikirov (1987) reported that squatting is healthier for the pelvic floor muscle and that squatting affords many advantages for the body even at the present time. Especially when traveling in Africa and many Asian countries, there may be a hole in the floor that requires an individual to squat in the public toilets even in five-star hotels and restaurants.

In Mr. T's situation, less straining and energy were required for him to squat than to sit on the western toilet. In the aforementioned situation, the nursing staff could have checked on him and provided privacy for him, as long as they deemed that he was in a safe situation. There are no cleanliness issues in using the squatting position providing the seat is in the upright position.

Low health literacy: Medications. Mr. T took furosemide two times as instructed, once at breakfast and once at lunchtime. The question arises as to whether he was instructed on the exact times his medications should be taken. As a consequence of taking his medication incorrectly, he could have become dehydrated and lowered his potassium, which can lead to digoxin toxicity. Prior to discharge, a thorough discussion and written handout (in simple terms with universal signs to facilitate understanding in any language) as to when his medication should be taken might have avoided this problem.

It cannot be assumed that someone understands what is being said because they nod and sign a sheet of paper. Recently reported in the news, a Spanish-speaking patient was seen in the emergency department of his local hospital because he followed the directions on his medication label to take his diuretic and beta blocker "once" a day. In Spanish "once" means 11; he took 22 pills (amednews.com, 2004).

Language issues. English is the second language for Mr. T and his family. When English is the second language, individuals may have more difficulty speaking and understanding English during times of stress and illness. During a health crisis, family members frequently are asked to act as interpreters. In some cultures, it is inappropriate to discuss personal, health-related information with someone younger and/or of the opposite gender. This could have been the situation for Mr. T. when his daughter-in-law was used as the interpreter for his discharge instructions. It would have been more appropriate to get an official interpreter.

Patient teaching. Nurses often learn of a patient's discharge with only a few hours notice and are not given adequate time to ensure that the patient can manage self-care safely. Patients need to know what self-care activities are most important in their personal situations. Detailed instructions regarding medication use should be reviewed and written out for each patient.

Patient needs assessment. A patient needs assessment should include evaluation of the patient and family's knowledge, beliefs, attitudes, and skills for self-care. When time and energy are limited, the nurse needs to know what learning must be achieved for survival and how best to achieve this (Rankin, Stallings, & London, 2005). Examples of survival behaviors for Mr. T and his family include:

• The ability to demonstrate appropriate catheter care, which would include emptying the urinary drainage bag. Changing the urinary drainage bag could be addressed later by the home health nurse.
  
  

• How to care for the catheter and genital area. What and when to report any change in this area.
  
  

• When to take his medications and the potential side effects of each medication. How and when to contact medical assistance if adverse side effects occur.

Cultural behavior. Mr. T and his family nodded their heads, smiled, seemed to understand the instructions and signed off the discharge instruction sheet. These behaviors could be related to Mr. T's cultural values. He did not want the nurse or himself to "lose face" (Chang, 1995). It is important to know what the patient truly understood. Providing patients with a visual and hands-on demonstration and taking the extra step of asking the patient to return the demonstration better ensures understanding. When asking patients to demonstrate, the nurse might phrase the request as, "Can you show me how you are going to do this when you get home? I want to make sure I was clear and that I covered all the steps." This technique places the responsibility of education on the nurse rather than only on the patient.

It is noteworthy that Mr. T's Foley drainage bag was completely full and had not been emptied since he came home from the hospital because he did not want his daughter-in-law to empty the urinary drainage bag. This is a cultural issue related to gender, family relationships, and the sick role. In this situation the home health nurse could assess the wife's ability to manage the task. She could probably teach the wife to empty the urinary drainage bag. Continued home health care could be provided and should include contacting the physician facilitating the removal of the urethral catheter.

Conclusion

Cultural sensitivity/awareness would have helped Mr. T and his nurses with the following:

• Squatting to eliminate can be safe and is common in African and Asian countries.
  
  

• Utilizing an appropriate interpreter
  
  

• Taking his medications safely and effectively.

The patient education evaluation technique of return demonstration would have addressed the issues of saving face and health literacy needs as well as measuring the skill attainment of emptying the urinary drainage bag.

References

1. amednews.com. (2004, May 10). Health literacy. Help your patients understand directions. Retrieved January 12, 2007, from www.ama-assn.org/amednews

2. Chang, M.K. (1995). Bridging the cultural gap. Urologic Nursing, 15(4), 123-126.

3. Rankin, S.H., Stallings, K.D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia: Lippincott, Williams & Wilkins.

4. Sikirov, B.A. (1987). Management of hemorrhoids. A new approach. Israel Journal of Medical Sciences, 7(23), 284-286.