Educating Invasive Cardiac Patients from Multicultural Backgrounds

In modern healthcare facilities, there is a growing need to establish cultural competency in order to deliver excellent care to patients from different cultures. This paper focuses on the methods employed to assess, educate and medically manage cardiac patients from different cultures at the authors’ allied health duty stations. The method of patient assessment is explained in detail, and patients are educated regarding their medical care from the preprocedural through the postprocedural processes. Many patients who enter the healthcare system come from different cultures and hold different values. The methodology discussed in this paper is an example of standardized medical care provided to all cardiac patients who undergo an invasive cardiac procedure at Emory University Hospital in Atlanta, Georgia, as well as at other facilities where the authors are presently employed or were formerly employed. In the early 1980s, as managed care began to evolve, patient education, which involves informing the patient about his/her illness along with a better understanding about wellness, became more important to the needs of patients seeking medical care. Trusting relationships between patients and physicians, nurses and other healthcare professionals began to be established. Many medical facilities implemented policies and procedures regarding patient care standards that specified how patients would be educated about their medical conditions and their goals for healing and returning to as normal a daily lifestyle as possible. Third-party medical insurance carriers influenced this process as well. They mandated that medical personnel become involved not only in providing high-quality patient care, but in educating patients as a preventative measure. Achieving these new patient education goals required the development of standards that would help to change patients’ attitudes, knowledge and skills and that would result in improved health.¹ The new standards of care, or pathways of care, include the development of checklists that are designed to assist patients in becoming involved in their medical management program, become knowledgeable about their medical issues, and focus on personal goals such as abandoning unhealthy behaviors that will hinder their recovery.² According to the typical new patient education program, caregivers are assigned to review the pathways of care with the patient. The purpose of this dialogue between the caregiver and the patient is to enhance the patient’s and the caregiver’s knowledge regarding the patient’s current state of health and to develop an understanding of the patient’s psychosocial history. Many centers have developed questionnaires with input from various medical facilities. The questions are formulated according to a standard format so that physicians, nurses and other allied healthcare professionals are able to ask the same questions during a patient’s admission or pre-admission visit. These questionnaires serve to initiate the process of altering patients’ unhealthy behaviors and to promote wellness. Typical questions focus on the patient’s medical history and their psychosocial history.² If permitted by the patient, family members are also included in the questionnaire, which is written in simple, laymen’s terms. Patients from different cultures are an important consideration in any patient education program. There has been a considerable influx of people from different cultures in Georgia and in the United States as a whole. The resulting cultural diversity in the U.S. patient population has altered the attitudes of professional medical personnel in terms of the value of teachable moments, which can empower patients to make decisions about their health and wellness.¹ The effective education of the patient from a different culture seeks to provide the patients with sufficient information about his/her health and lifestyle. The healthcare provider needs to master the skill of extracting information from the patient of a different culture in terms of the patient’s needs and possible learning barriers. Also, the healthcare provider must offer concise counseling, make use of written, audiovisual and data-based patient education materials, and provide ongoing education for each admission.¹ To start with, a health and psychosocial history should be completed. If a language barrier exists, an interpreter should be sought. If one is not readily available, a capable family member could be asked to interpret for the patient. If the patient is male, it is best to have a brother or older son do the interpreting. With female patients, the opposite is preferable. In many cultures, men are more at ease discussing health issues with other men, as it helps to avoid any moral or value issues that may arise if a woman were present. Healthcare providers must be sensitive to the cultural beliefs and practices of all patients in order to ensure that communication is effective and that quality care is delivered. During the assessment stage, it is essential to establish trust between the patient, his family and the healthcare professional. The healthcare professional should be able to recognize where the patient fits within his family. This requires understanding the culture-specific norms governing the structure of marriage, the organization of the family, the authority in the family, the residence of the family, and the inheritance in the family.³ While the patient’s medical history is noted and his physical assessment is underway, the caregiver must determine if the patient is part of an elementary kinship unit, a nuclear family or a conjugal family system.³ If the patient belongs to a kinship-type family unit and is alone, it is helpful to determine if there are any children living in the area. If not, then the patient’s ability to understand what he’s being taught by the caregiver will be diminished, especially if the patient is elderly. Sometimes patients arrive for their procedures with their spouse, children, parents, grandparents, aunts, uncles and cousins in tow.³ Dealing with a large, consanguine family system such as this poses many challenges for the healthcare interviewer because each relative may attempt to contribute to the assessment in his or her own way. And to complicate matters further, the patient may ask each member of the extended familial to contribute information about his health history. In such cases, the healthcare professional must determine if the patient exercises authority within his kinship unit. If a female spouse answers all the questions, then it can be assumed that she has authority.³ If the male demonstrates control, then it can be assumed that he has the upper hand. After determining the patient’s sociocultural characteristics, it is time for the healthcare interviewer to ascertain the nature of the patient’s social system. During this brief assessment, economic, educational and other relevant information is noted.³ For instance, if a new cardiac medication is available, it is necessary to determine if the patient afford the monthly cost. If the patient has no medical insurance, will an inferior, but cheaper, medication have to be prescribed? How can a healthcare management system provide adequate care for those who lack a formal education and come from a different culture? After all, the goal of modern healthcare in the United States is to return patients to health and to educate them about maintaining good health. This challenge requires teaching at the patient’s level of understanding. If the caregiver cannot accomplish this, then the anticipated result will likely not be realized. During an educational session, the patient’s belief system becomes very important because his spiritual beliefs and values are crucial factors in his ability to achieve the desired degree of wellness.³ If the patient trusts the caregiver’s education, then his positive values will govern his desire to do the best he can for himself. After all, the spiritual wellbeing of any person includes courage, faith, hope, optimism and happiness. If a patient is able to share his ethical values with his family members, then they too can be guided through life’s challenges.³ The general patient interview process begins, if needed, with the assistance of a skilled interpreter. A thorough, basic assessment is accomplished by asking questions⁴ such as those shown in the first sidebar entitled Medical Assessment Questionnaire for Patients of Different Cultures. The information obtained from these questions will serve to develop an attitude of understanding, empathy, patience, respect, and, most importantly, trust between the patient and the caregiver. Once trust is established, pertinent questions about the patient’s overall health and psychosocial history can be completed.² The second sidebar entitled General Health and Psychosocial Health History Questionnaire for Patients of Different Cultures shows the types of questions that may be asked.⁵ After a patient completes the questionnaire, an attending physician reviews the patient’s self-history and then explains, in nontechnical language, all aspects of the prescribed procedure and any complications that could occur. In some facilities, the review may be completed by cardiology fellows, nurse practitioners or physicians’ assistants. In addition, the team members explain any alternative treatments that could be administered to make a diagnosis. The patient is then asked to sign an informed consent for the recommended diagnostic or interventional procedure.² During this stage, an action plan that encompasses the knowledge and concerns about the procedure, along with desired outcomes, are once again discussed with the patient. Additional teaching and discharge plans are completed through the use of procedural videos, written materials or verbal explanation. At this point, a nutrition evaluation with a licensed dietician may be prescribed, as well as a recommendation to attend smoking cessation classes, if applicable. Cardiac patients who have a history of myocardial ischemia, myocardial infarction, coronary artery disease and/or previous percutaneous coronary intervention (PCI) are encouraged to attend a cardiac rehabilitation program.⁶ Other tests conducted during the pre-procedure work-up should include an electrocardiogram, blood work that includes a basic chemistry profile, CBC, cholesterol level, lipid profile, cardiac enzyme panel, a PT reading, if a patient has been on warfarin, or a PTT reading if heparin has been used. Next, the patient is prepared for the procedure. Lab results and medication orders are verified with the physicians. Since ionized contrast media can induce renal failure, diabetics are screened for the use of metformin, which is excreted through the renal bodies. If the patient has not discontinued metformin in the preceding 48 hours, the attending physician is notified. The patient is instructed to fast (n.p.o.) from midnight.⁶ Most importantly, the physician’s assessment, along with a signed, informed consent from the patient and the pre-procedure assessment are completed in the presence of family members, if such is approved by the patient. Healthcare professionals must continue to be sensitive to the patient’s sociocultural characteristics throughout the patient’s hospital stay so as to optimize the education, care and wellbeing of the patient. The patient is next transported to the cardiac catheterization suite for his procedure. It is essential that the cardiac catheterization laboratory staff assume the responsibility for continuing the patient’s education once he arrives in the lab. During the procedure set-up, the cardiac catheterization team should complete an intraprocedure questionnaire that focuses on patient care throughout the procedure. (This part of the assessment, however, will not be covered in this article.) Finally, a program geared toward patients from different cultures should focus on the desired outcome at discharge.⁶ The patient should be taught new coping strategies that will allow him to overcome denial and arrive at an attitude of acceptance if severe heart disease has been diagnosed. Successful patient education requires frank discussions with the family members and cooperation with the patient. Also invaluable for a successful outcome is emotional closeness between the patient and his family, faith, trust, honesty and dependability. Ideally, a well-implemented education program for patients from different cultural backgrounds will lead the patient and his family to a new understanding of his health issues and the plan for healing and wellness. Further patient teaching and discharge planning are completed by the physicians, nurses and allied healthcare workers assigned to the patient. Prior to discharge, patients should be able to verbalize an understanding of the recommended self-care that will reduce postprocedure complications (recurrent angina, bleeding, swelling in the groin). Other items6 that the patient should understand and be able to discuss include: 1. Risk factor modifications, including the use of blood pressure control medication, cholesterol-lowering medication and platelet inhibitors. 2. Management of self-care guidelines and future medical follow-up (the follow-up appointment should be made at this time). 3. Medications and side effects (to be explained by the pharmacist). 4. Procedure results. 5. Self-management and actions to take if signs and symptoms return (angina, arm pain, jaw pain, leg or foot pain). 6. How the patient’s culture, ethnicity and/or religion may affect his ability to alter his diet. After these factors are discussed, the patient’s anxiety level should be evaluated to determine if his ability to achieve compliance might be hampered. Further assessment ensures that patients are not discharged if they are experiencing chest discomfort, groin pain, extremity numbness or extreme back pain. In conclusion, the aim of this paper was to focus on how interventional cardiology patients from different cultures should be assessed, educated and managed. Patients from different cultural backgrounds who speak different languages and hold different beliefs require sensitivity, awareness and additional effort on the part of healthcare professionals if they are to receive quality medical care. All patients should be asked to answer standardized questions in order to ensure consistent, standardized medical care, but the patient from a different culture needs additional cooperative efforts of physicians and healthcare providers in order to receive the same quality of care offered other patients. The effective implementation of a program focused on treating patients from different cultures requires the following actions:⁷ 1. Assessments of allied healthcare employees’ knowledge of the needs, beliefs, expectations and practices of patients from different cultures. 2. Budget allowances for staff education and training on how to care for patients from different cultures. 3. Creation of a diverse, educated healthcare team that is capable of meeting the basic, as well as the complex, needs of these groups of patients. 4. Establishment of a skilled pool of interpreters. 5. Development of relationships with ethnic groups in the community, as well as with product and equipment vendors who are culturally sensitive. 6. Continual review of the diversity practices of the center when quality improvement compliance studies are conducted. 7. Development of cultural competency evaluations of staff members that encompass administratively tailored and standardized policies. Finally, and most importantly, it is essential for healthcare professionals to look beyond the factual medical record of the patient from a different culture to arrive at an understanding about the patient’s cultural beliefs and practices. This requires that staff members be adequately educated about cultural sensitivity issues, that they show empathy, perceptiveness and a helpful attitude toward establishing dialogue with the patient.⁸ In doing so, the healthcare provider will be better able to develop an appropriate medical regimen that encompasses the patient’s cultural beliefs about medicine, healing and wellness.

1. American Academy of Family Physicians. (2000, October 1). AAFP core education guidelines: Patient education. Retrieved March 5, 2005, from www.google.com: http://www.aafp.org/afp/20001001/core.html.

2. Hale D. An Invitation To Health (10th ed.) Belmont, California: Thomson-Wadsworth, 2003.

3. Olson DH, DeFrain J. Marriages and Families Intimacy, Diversity, and Strengths (4th ed.) Boston, Massachusetts: McGraw-Hill, 2000.

4. University of Michigan Healthcare System. Patient education: cultural competency. Retrieved March 7, 2005, from http://www.med.umich.edu/pteeducation/ cultcomm2.htm

5. Emory Healthcare/Emory Hospitals. (2001). Assessment: Patient self-history

6. Emory Healthcare/Emory Hospitals. (2001). Cardiac Cath/Angioplasty: Clinical Pathway.

7. Quander L. Cultural competence within your organization. Retrieved March 6, 2005, from http://www.dhh.stste.la.us/ LaMHA/Cultural_competence.htm.

8. Anderson K. The challenges delivering culturally competent health care. ASRT Scanner 2005;37:11-19.