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By: Marcia Carteret, M.Ed – Senior Instructor, Department of Pediatrics, University of Colorado School of Medicine

Demographic trends across the United States indicate a growing need for better cross-cultural communication skills among healthcare professionals. This short guide will introduce key ideas and concepts for interacting with patients and their families from diverse cultural and language backgrounds.

Demographic Trends Driving the Need for Enhanced Communication Skills:

• It is projected that 72% of the U.S. population growth over the next 20 years will come from immigrants or the children of immigrants.
• By the year 2050, the U.S. population will be 438 million, up from 296 million in 2005. Nearly 82% of the increase will be due to immigrants and their U.S. born children.
• Nearly one in five Americans (19%) will be an immigrant in 2050, compared with one in eight (12%) in 2005.
• The Latino population, already the nation’s largest minority group, will triple in size and account for most of the nation’s population growth between 2005 and 2050. Latinos will make up 29% of the U.S. population by the year 2050.
• All these assumptions are built on recent trends. It is important to note that these trends can change. All population projections have inherent uncertainties as they can be affected by changes in behavior, by new immigration policies, or by other events.

(Statistics come from U.S. Census Bureau, Population Division. http://www.census.gov/people/)

Key Cross-cultural Communication concepts for ems professionals:

The following key concepts and related suggestions for communication with patients and families from other cultures are highly situation-specific. Good communication takes practice. In an emergency situation, some of the suggested communications for patients and families will actually fall to someone other than a member of the ambulance team. For example, communication responsibility might fall to a police officer who is tasked with explaining the location of the hospital after the ambulance has already left. Some of this communication might fall to the firefighters who may be the first to arrive on scene. In situations where there is time for an EMT or Paramedic to utilize these suggested approaches to cross-cultural interaction, the improved communication with patients and families will optimize the success of the professionals working in emergency and nonemergency ground ambulance services.

Key Concept 1: The Triple Threat

Be aware of the “triple threat” to healthcare communication. Increasing numbers of people served by EMS professionals will have:

1. Limited English proficiency
2. Limited understanding of western medicine and the US healthcare system
3. Low health literacy – 90 million “mainstream” Americans do not understand basic health information. Both language and cultural barriers add to this significant healthcare communication challenges.

Source: http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx

Key Concept 2: American Culture is Based on Individualism

In the United States, each individual is guaranteed certain fundamental rights that do not exist in all countries. Our healthcare system is based on the rights of the individual patient. The Patient Self-Determination Act (PSDA) of 1990 guarantees a person’s right to all information needed to make informed decisions about medical care. Every patient has the right to accept or refuse medical or surgical treatment. Similarly, HIPPA specifies legal rights to confidentiality, integrity, and availability of protected health information. It is very important to understand that not all cultures value individual rights in the same way. Some patients and their families will not understand the concept of privacy between family members. For example, parents may expect access to all health information regarding children of any age – even adult children. They may also anticipate having the ability to make decisions for any family member and may not understand that the consent of the patient is critical in our healthcare system.

Key Concept 3: Expect Multigenerational Households

Be aware that grandparents, aunts, uncles, and cousins may be living under the same roof with the patient needing care. In this setting, it may be difficult to determine who the key decision-maker is. It is important to note that even when the patient is coherent, he or she may not be the one who does most of the talking. Remember that unlike other cultures, American culture is highly individualistic and each person of legal age desires to speak for themselves.  For some patients coming from different cultures, the family may work as a group to make a decision. For example, the male figure may be expected to do most of the communicating with healthcare professionals making some women unaccustomed to communicating in certain situations.

Demonstrate awareness of family dynamics by asking respectful questions

This will help bring coherence to any conversation between the emergency responder and other persons at the scene. Below you will find sample questions that focus on respect and clarity. You will notice that the questions also show respect for privacy between family members and between families and outsiders. These are very general examples.

1. Determine which family members are present at the scene. Clarify the relationships and the direct involvement with the patient:
2. Are you family of this person?
3. Are you the wife/mother/grandmother/father?
4. Ask adult patients who are coherent:
5. Who can help you make decisions right now? (Clarify the relationship of any person the patient indicates.)
6. Is it OK if I talk to your father/brother/mother/wife, etc.?(When the patient is an adult.)
7. Your son has agreed that you can speak for him. (This clarifies the patient’s consent with the family member(s) involved.)
8. If the patient is not coherent, then ask:
9. Who here is family?
10. Who will be speaking for this man/woman etc.

Be aware that a family member or friend may want to speak for the patient but may not be the proper person. Always clarify. Some families are very careful about privacy outside the immediate family. Shame is a powerful influence in many traditional cultures. Families do not want to be embarrassed in front of their community.

When attempting to establish level of consciousness by directly eliciting information from the patient, simply explain that the patient must answer for himself/herself. This should help reduce the answering of questions by family members and bystanders.

Key Concept 4: Clarify, Explain, Reassure

With so many different services responding to one call, people who are still learning to function in U.S. mainstream society cannot be expected understand the role of an EMT or Paramedic. Explain your professional role using simple language. For example, you could say, “I am not a doctor. I am an emergency medical professional. I have come to help because someone called 911. I will take this person who is hurt/sick to the hospital safely.”

Remember the following when trying to clarify, explain and reassure:

• Use simple familiar words. For example, “Stabilize” is a complex word, even though it might be the best word to describe what you do for a patient in an emergency. “Help” is a better word to use in many circumstances.
• Use short sentences.
• Be clear when you are asking a question or giving instruction: “Have you taken any medication?” or “Show me where it hurts.” Long questions or statements with multiple thoughts can be hard to understand. Avoid sentences like this, “It looks like you are having a reaction so I need to know if you have taken any medication that made you feel sick.”

It is possible that some people will be very concerned about a member of their family being transported in an ambulance alone. Remember that expectations are based on our past experiences. This may be the first time that the patient and their family have been served by emergency responders. Be prepared to explain your role clearly and concisely to help ease any anxiety.

In non-emergency situations, if there is time for explanation, be sure key family members understand where the patient is being taken. Imagine a scenario where the ambulance has left and no one at the scene actually understood where the patient was taken for medical attention. This is disconcerting for all families no matter what their cultural background.

If one additional person is able to ride along in the ambulance, explain this to the patient and whoever seems to be the key decision-maker. If the patient is a child, you will likely be explaining this to a parent or other primary caregiver. In any case, the choice of who will ride in an ambulance might be culturally-based. It might be less acceptable for a woman to ride along. Perhaps a father or oldest male sibling would be the appropriate choice. The only way you would know is to ask. You might face situations where you need to refuse to allow another person to ride along on the way to the ER. This is perfectly okay and normal.  Simply say, “I can’t let you ride with us. It is a rule.”

Trust, Shame, Privacy

Individuals from some cultures may view illness as a personal family matter and dislike help from EMS personnel. People may act suspicious or even seem passive about what is going on. A passive demeanor is often a subtle way of indicating trust issues. Remember that recent immigrants are caught between cultures as they learn to function fully in society. This leads to contradictory beliefs and behaviors that can indeed be confusing. Nowhere is this more evident than in healthcare interactions. People may need help, but they may not trust the person who comes to help them.

Modesty Concerns

Cultural expectations about modesty are important to consider when working with any culture.  Examination by a healthcare provider of the opposite gender can create conflict. Gauge the severity of the situation. In a life threatening situation there isn’t time for careful conversation. In less threatening situations, explain what you need to do.  You could say, “To help you, I must examine your lower abdomen. It is important. Is that OK?” Ask the patient first, and clarify with any parent, spouse, or family member who is present. The question shows respect no matter what culture a person comes from. Also, ask any bystanders to please give the patient privacy. Again, the immediate situation will dictate what is realistic.

Expressions of Pain are Affected by Cultural Norms

Individuals in some cultures remain stoic, even in the presence of severe pain. Others wail when only slightly uncomfortable. Many Americans will expect immediate relief from pain. People from other cultures may view pain as necessary and be less likely to treat it with medication. These variations in the expression of pain can prove difficult for an EMS professional who is attempting to assess and manage pain. Also, while the 1-10 pain scale is useful for gauging pain relief for a patient who is familiar with such a ranking system, it may not make sense to every patient.

Language Barriers

Interpreters

It is important to ask if anybody speaks English. Ask if it is possible for a specific person who speaks English to act as an interpreter in the situation. Preferably the interpreter will be a family member who is approved by the patient. Be careful using children of any age as interpreters. In an emergency situation, a child of reasonable age can interpret very basic information, but they should never speak for the family or patient. Families from more traditional cultures place importance on generational hierarchy. You don’t want a child to get in trouble for stepping out of his place or for saying something that upsets an adult. Furthermore, a child might misunderstand the limits of personal responsibility in the situation. If a family member were to die in the hospital, a child who interpreted for medical professionals might feel somehow responsible.

Head Nods and Agreement

In an emergency situation, it is absolutely necessary for EMS to act with authority. An EMS Professional must demonstrate the ability to stabilize difficult situations under time pressure. In many cultures it is important to appear agreeable when talking with authority figures. People from some cultures may nod their heads and say “yes, yes, yes…” but actually not understand what they are agreeing to. This leads to inaccurate patient information or medical histories when the EMT or Paramedic is interviewing and assessing the situation. It is necessary to confirm comprehension. Ask concise clarifying questions. Reassure people who might be afraid to communicate.

Eye Contact

An EMT or Paramedic will often be perceived as an authority figure by people from more traditional cultures. If a person is avoiding eye contact while listening to you or while answering questions, be aware that in some cultures direct eye contact with an authority figure is very rude. In trying to be respectful, people may avoid eye contact. Do not mistakenly categorize this behavior as disrespect, dishonesty, or evasiveness.

Silence

Silence may be the only response a person can muster if he or she is frightened. Silence might also be a way of showing respect, similar to avoiding eye contact. Being thoughtful about answering a question shows humility and real effort in giving the best answer. Unfortunately, silence is often mistakenly interpreted as a sign of disrespect. It can be helpful to say, “I need your help. Please try to answer my questions. Your answers help me help you.” Also, try not to rush patients and their families to provide an immediate answer. At times, EMS professionals allow very little time between questions and begin talking before the other person is able to answer.

Reverting to Native Language

Bilingual patients may revert to their native language in times of stress. This should not be seen as manipulative or uncooperative. Calmly ask the person, “Can you speak in English? Please try English.” If the person does not speak any English, this will at least help them realize you can’t understand.

Conclusion:

Enhanced cross-cultural communication skills are necessary for all professionals working in emergency and nonemergency ground ambulance services. As first-responders, EMTs and Paramedics are often working in high stakes situations where communication is already a challenge. No matter which culture an emergency professional is interacting with, the key to good communication is asking good questions and phrasing all dialogue in simple sentences. EMS professionals should always be clear that a question is being asked or that a statement of information is being made. Asking for clarification is essential.

Establishing relationships between people at the scene is also very important. EMTs and Paramedics will find that enhanced communication skills will not only improve cross-cultural interactions, but these skills will improve outcomes with all patients and their families.