Kapiolani
Community College Horizons 2003
Kapiolani
Community College
Horizons 2003
INTRODUCTION
Hawaii is a melting pot of different cultures. Each culture comes with its own
set of unique beliefs, traditions, and practices. Each culture’s beliefs
play important roles in how healthcare decisions are made, how treatment is
accepted or rejected and who ultimately has the final say with such decisions.
Since a variety of cultures are treated in hospitals in Hawai‘i, a healthcare
provider must address subjects such as family loyalties, religious affiliations,
obligations and their beliefs in supernatural forces when caring for patients
and their families. As a healthcare provider who cares for patients with strong
traditional cultural beliefs, I have noticed that each culture has beliefs which
could possibly restrict us from providing what every hospital should strive
for, the best healthcare possible. Especially in Hawai‘i, a healthcare
provider must approach each patient differently.
METHODOLOGY
As a healthcare provider in a dialysis center in Hawai‘i I treat many
patients of different cultural backgrounds three times a week. Although the
observations discussed in this paper were made throughout the semester, I have
seen these trends for the past four years in the five different dialysis units
I have worked at. In the time I have worked in culturally diverse environments,
cultural relativism is strongly promoted and ethnocentrism is avoided at all
costs. Anything negative discussed is purely due to the fact that it makes providing
healthcare more difficult.
In a hospital community, in this case Saint Francis Medical Center, there are
many strict privacy policies. The data obtained for this field study is based
on observations of patterns of behavior as not much detail can be given about
the subjects. Interactions between dialysis patients of Samoan, Filipino, Chinese,
Japanese, Hawaiian, and Caucasian descent and their healthcare providers (doctors,
nurses, patient care technicians, dietitians and social workers) have been analyzed.
These interactions are only a few examples of how traditional cultural beliefs
constrict healthcare.
ANALYSIS AND DISCUSSION
FILIPINO PATIENTS
A traditional Filipino’s healthcare practices in Hawai‘i come from
many cultures, including Indian, Chinese, Arabian, Spanish, Mexican and American
because of their presence in the Philippines throughout history. Sociolinguists
have determined there are eight major languages and seventy-five different dialects.
Apparently a traditional Filipino person has a very strong sense of family loyalty
to immediate and extended family members. Also, Filipinos hold strong bonds
to both matrilineal and patrilineal lineages that are continuously maintained
by reciprocity, insuring many people for support. Extended family members are
therefore part of the basic unit of the Philippine society.
Healthcare providers notice that when being cared for, Filipinos are very observant
and sensitive to the tone and manner of a speaker. For example, a patient resisted
healthcare when he took offense to the tone of voice of a healthcare technician
who tried to provide care and advice about the dialysis treatment the patient
was receiving. Communication between the employee and the patient broke down
as tempers rose. Soon after, against the advice of the nurses and her physician,
the patient refused treatment and asked for it to be terminated for the rest
of the day, resulting in inadequate dialysis treatment. Later that afternoon
harassing phone calls were made by her family members accusing the hospital
of not providing the care that she needed.
During the patient’s next visit, family members brought the patient in
with harassing attitudes towards all of the employees. Eventually the problem
was resolved by having the family members meet with the supervisor and hospital
security. The whole incident created difficulties that unnecessarily involved
more individuals than needed and took away the opportunity to provide efficient
as well as adequate care. Although this was a negative incident for the hospital,
it does show how important family loyalty is within the Filipino culture.
Filipino patients, if not antagonized, tend to be too polite and will not disagree
with elders and authority figures such as doctors or nurses. When I was assessing
one of the patients, he told me that he had chest pains the night before. The
nurse in charge came over to further assess the patient and he denied such pain.
I overheard the conversation and warned the patient it would best for his health
if he informed the nurse of the absolute truth about his previous condition.
Filipino patients, wanting to be polite, often withhold such vital information
from nurses or doctors. Eventually, he did listen and told the nurse the details
about his pain but only after strong persuasion.
In another incident, a Filipino patient informed me that she had some difficulty
breathing. Oxygen was provided for her during her dialysis treatment. Midway
through her treatment her nephrologist arrived at the unit to check on his patients.
The oxygen provided made it obvious this particular patient had some difficulty
breathing. Her physician asked her if she knew what was causing her difficulty
breathing and whether it was mild or severe. Forgetting that she had a nasal
cannula attached to her, this elderly Filipino patient denied any discomfort
or difficulty breathing. Again, being far too polite for fear of offending her
physician, the patient withheld information. In major disbelief the angry physician
pointed at the nasal cannula and asked her what it was for. The patient laughed
and with some hesitation proceeded to tell him the truth.
Many Filipinos strongly believe in both modern medicine and folk or herbal medicine.
Patients will take both at the same time in hopes of a miraculous cure. It is
known that mixing medications is quite dangerous and in an extreme case, could
cause death. This is also possible when mixing both modern and herbal medicine.
There have been no recorded incidents of this happening at this hospital; but
even after patients are educated about these risks, they resume mixing herbal
medicines with modern ones because of their strong cultural beliefs.
With so many Filipino dialects, communication becomes difficult. Many times
when a Filipino health-care provider tries to communicate with a Filipino patient,
there is still difficulty communicating because they speak different dialects.
Patient frustration becomes evident. Workers are not expected to learn different
languages, and this makes it difficult for an employee of another culture to
communicate with the patient about his or her health.
CHINESE PATIENTS
One reason healthcare is difficult with patients of the Chinese culture is that
they do not like being touched. This makes physical assessments difficult for
the healthcare provider and uncomfortable for the patient. In dialysis, it is
important to physically check a patient for edema (swelling) around limbs, especially
the feet, and to listen for fluid within their lungs using a stethoscope. Chinese
patients tend to pull away when a worker proceeds to touch them. Swelling is
a sign of fluid build up which threatens a patient’s health, but more
specifically the patient’s heart. If edema is present, a patient’s
dialysis treatment must be amended, according to how much swelling there is.
To determine what kinds of amendments should be made, a patient care technician
needs to determine how much swelling there is by pressing a thumb against the
swollen limb to feel how soft the tissue is and how deep an indentation is caused
by this pressure. Many patients of the Chinese culture are hesitant to let an
employee do this. One patient always has swollen feet, but never lets anyone
execute the proper edema assessments. Instead, he presses on his feet himself
and tells us to just look at it. Visually. it is helpful. but providing care
is hindered because we are unable to feel how soft his tissue is and how deep
the indentation is, for a more accurate assessment.
Another way dialysis patients are checked for fluid buildup is having the patient
lie in a supine position, while we use our fingers to apply pressure to a patient’s
jugular neck vein and visually check how distended the neck vein is. Many Chinese
patients ask workers to bypass this assessment and move on to the next assessment.
On one occasion a physician moved in close to a Chinese patient to perform a
neck distention assessment. To the surprise of the physician, the patient pushed
the his arm away. There was a short discussion between the patient and the physician
who later decided to avoid this assessment on this patient. This is another
example of culture prohibiting healthcare.
A third assessment Chinese patients are very uncomfortable undergoing is having
a patient care technician listen to a patient’s lungs with a stethoscope.
It is one last way to check for fluid build up. When fluid is accumulating,
it also builds up in the lungs and causes a crackling sound when a patient breathes.
One can also check a patient’s heart sounds for irregularities and heart
rate during this time. It has been observed that many Chinese patients rush
themselves through this assessment to minimize time of physical contact. There
is a Chinese patient who has employees listen to his heart and lungs while he
holds the stethoscope on the appropriate sites. Healthcare is not completely
restricted but the Chinese culture does affect how it is provided to the patient.
In the Chinese culture health is maintained by balancing the Yin and Yang. Food
is believed to be very important in maintaining this balance. This belief is
a great threat to the health of a patient on dialysis. While on dialysis a patient
is asked to follow a strict diet and to abstain from many foods and drinks,
such as certain fruits, vegetables and dairy products. It becomes a major dilemma
that Chinese patients, as well as all other dialysis patients, must deal with
for the rest of their lives as they receive dialysis treatment. Results of laboratory
blood tests done on many Chinese patients expose blood levels of certain chemicals
that indicate improper diet practices. When questioned by dietitians, patients
admit to not surrendering their traditional cultural diets because they are
still attempting to balance Yin and Yang.
There are quite a few Chinese patients who refuse to surrender to the diet.
They continue eating as if they were not on dialysis and ignore the warnings
from all healthcare providers. Through time I have seen each of these patient’s
health deteriorate, although slowly, much quicker than any of the other patient
on dialysis. Patients receive dialysis treatments to correct any chemical imbalances
that the kidneys are no longer able to correct. By ignoring the prescribed diet
a continuous chemical imbalance is created and dialysis treatment is increased
to compensate for this imbalance. Therefore, the dilemma is between the cultural
belief of preserving balance between Yin and Yang or maintaining chemical balance
within one’s body through dialysis and a proper diet. Both cannot be accomplished
without compromise.
JAPANESE PATIENTS
Traditional Japanese culture reinforces a social code whose first rule of conduct
is “Do not make waves.” This creates a situation where patients
do not inform nurses or patient care technicians about their health problems.
Gaman is a Japanese term meaning self-control and the ability to endure or tolerate
pain and deny any personal suffering. Traditional Japanese patients restrain
from discussing difficulties they are having with their health. Another Japanese
term, Haji, refers to shame, something that should be avoided at all costs.
It not only reflects on the individual but also the individual’s family
and family name. Japanese see admitting to difficulties or pain as a sign of
weakness and not maintaining gaman. If they do, haji is exhibited and the image
of one’s self and one’s family name is viewed with lower status.
At the end of dialysis treatment a patient is usually hypotensive (has a lower
than normal blood pressure). This poses a threat to a patient’s health
because first of all he or she feels weak. The patient is at risk of blacking
out when standing up, or if not in the unit, soon after while the patient is
driving home. Now, not only is the patient is at risk but other drivers are
as well. Secondly, having a low blood pressure puts dialysis patients at risk
of clotting their grafts or fistulas (both are surgically created to provide
access to a person’s circulatory system with the use of needles specifically
for dialysis patients). If a graft or fistula becomes clotted there is no access
for dialysis to a patient’s circulatory system. Treatment cannot be given
until further surgery is done to either repair it or a new access is created.
It is mandatory that a patient be allowed to leave only if his or her blood
pressure is at or above the approved level with a systolic pressure of at least
100.
Many older male Japanese dialysis patients fall below this limit but deny any
light headedness which is an indication of low blood pressure. The pride that
accompanies gaman puts the blame on the machine; claims are made that they are
inaccurate and Japanese patients refuse to surrender to the idea their health
is delicate in order to avoid haji. Promoting gaman only hurts Japanese patients
because the necessary treatments and education for further prevention are avoided
or not provided, further complicating their health. One must choose between
self, familial and cultural pride and being oblivious to their pains or succombing
to pride and putting their health first.
NATIVE HAWAIIAN PATIENTS
Health statistics for Native Hawaiians are pretty grim. Hawaiians have the shortest
life expectancy of any ethnic group in Hawai‘i. The incidence of chronic
diseases like diabetes and heart disease is higher for Hawaiians than for any
other ethnic group in the state. This is supported by the fact that there are
so many Hawaiian dialysis patients. A common coping method used by Hawaiian
patients to solve problems is to avoid or deny of problems all together. With
Hawaiians come a laid back attitude towards everything including trying to understand
their health problems and educating themselves about their condition. Hawaiians
believe the problem will go away if they ignore it long enough. No action is
taken against the illness until the situation becomes extreme. This explains
why there are so many dialysis patients in the first place. Initial precautions
are therefore not taken that could help restore a patient’s health sooner.
Dialysis patients usually are unable to urinate and must restrict their fluid
intake. If not regulated, fluid builds up in the body and this constant build
up weakens one’s heart over time. Excess fluid creates great pressure
around the heart. Initially, while trying to pump with this added pressure,
the heart muscle builds up to a greater size. Later, the heart muscle weakens
over time because of the constant need to remove large amounts of fluid from
a patient during dialysis treatment. The heart is continuously being overworked
trying to maintain a constant blood pressure since pressure is changing while
fluid is being removed. A great analogy of this is blowing into a balloon and
releasing the air over and over. The air represents the pressure created by
fluid in a patient and the balloon is the heart. If done repeatedly the elasticity
of the balloon eventually wears down and becomes weak. This is exactly what
happens to the heart over time.
Hawaiian patients, with their laid back attitudes, put little effort into regulating
their fluid intake. It is normal to see Hawaiian patients having large amounts
of fluid removed during every dialysis treatment. There are many Hawaiian patients
who end up with heart problems because of this ignorance. Now, these patients
not only deal with dialysis but also their frail hearts. A great example of
this is a Hawaiian patient who needed a pacemaker implanted. For many years
he was warned by physicians, nurses, patient care technicians, dietitians and
social workers about the dangers of consuming too much liquid and was advised
that he should limit fluid intake. He ignored the warnings and continued his
everyday life as usual, drinking anything and everything he wanted. Eventually
his heart weakened resulting in a life threatening pulse rate and blood pressure.
The patient went through an urgent surgery to have a pacemaker implanted. Since
then his health has improved drastically, and he is now being told to use the
same precautions that he ignored for many years. Although he knows what it could
result in he is still ignoring such advice and continuing to consume fluids
the way he has always done so, in excess. Over time this ignorance will catch
up with him again and this time will more than likely result in death.
JEHOVAH’S WITNESS PATIENTS
There are a few Hawaiian and Samoan Jehovah’s Witness patients. One belief
that they hold dealing with healthcare is refusal of blood transfusion because
it is against their religion to have someone else’s blood cells transfused
into them. This becomes a problem especially with dialysis patients since they
often have a low hematocrit (lower than normal percentage of red blood cells
in the body). Usually, patients are given medications to help replenish this
loss but when the percentage falls drastically, a physician orders a blood transfusion
to be given during treatment. An expensive blood transfusion will raise a patient’s
hematocrit immediately. Hawaiian and Samoan Jehovah’s Witness patients
refuse the blood transfusion because of their religious beliefs. With a low
hematocrit comes weakness that could cause one to black out and create difficulty
breathing. This not only affects patients during dialysis treatment but also
during all daily activities up until the patient’s hematocrit reaches
a safer percentage.
SAMOAN PATIENTS
Elderly Samoans enjoy the respect of their family and the community. They are
a source of wisdom and knowledge. It is ones duty to care for elders and be
obedient and humble. There is a strong sense of family and all family members
are expected to be present at major life occasions such as the birth of a child,
wedding or a funeral. The church is also important in helping to support, adjust
and retain a sense of community. In return a Samoan individual dedicates a lot
of his or her time towards the church. Many citizens of Samoa travel to Hawaii
to receive advanced care and with them these Samoan patients bring their strong
cultural beliefs.
A great amount of physical space, especially the area in front of an adult,
should be given to a Samoan individual. If this space is intruded upon, Samoans
takes it as a sign of disrespect. Body language is also very important to be
aware of with Samoan people. It is considered rude to talk while standing. This
puts all healthcare providers in a difficult situation when they need to approach
a Samoan patient. Dialysis patients are in a supine position during dialysis
treatments, and when an employee approaches a patient, this individual cannot
help but invade the patient’s personal space. First an employee needs
to look down on a patient, because the patient is lying flat. Second, employees
usually stand in front of the patient in order to monitor a patient and note
observations in the patient’s chart throughout the treatment. Third, when
speaking to a patient, the healthcare provider sits down next to the patients
but usually moves in close to the patient because there are many other patients
around that are asleep who do not want to be disturbed. In all three situations
it is very easy to offend a Samoan patient and have these actions taken as a
sign of disrespect. This makes treating Samoan patients, especially patients
who have just arrived from Samoa, difficult because they become less cooperative
with staff and in sometimes display their anger. Social workers must then intervene
and inform Samoan patients that actions taken by healthcare providers are strictly
to provide them with proper care and in no way meant to disrespect or dishonor
them.
One’s family and religion are first priority to a Samoan individual and
is so important that a Samoan puts his or her family and church before his own
health. Samoans believe being sick results in attention to the illness and this
attention may prevent one’s participation in family, church or social
activities. Thus, the illness and treatment for it is usually ignored during
important family events so that the patient can participate in them, and in
some cases, allow normal daily activity to continue. This has been noticed with
many Samoan patients who cancel or forget about their appointment for dialysis
treatment.
There is one Samoan patient who often cancels his weekend appointment just to
take his family to the beach for the whole day.
In the Samoan culture the idea of preventive health care practices is not well
established. Dialysis patients are on strict diets that prevent them from becoming
ill; and when they do get sick, they are put on medications to assist their
weakened immune systems. Samoan patients have a difficult time maintaining the
strict dialysis diet. Family gatherings and church events involve a lot of food
that dialysis patients are not allowed to eat. Not eating the food offered to
them makes a Samoan individual feel like they are disrespecting the providers
of the food, the celebrant of the event as well as everyone at these celebrations.
As a sign of respect to everyone patients ignore preventative care practices
and these restricted foods are eaten.
Another example of ignoring preventive care practices is when a patient who
missed an appointment for dialysis treatment is provided the opportunity to
make up the missed treatment but declines, putting his health at further risk.
These make up appointments are crucial in maintaining the health of a dialysis
patient and prevents it from deteriorating even further. But because treatments
take away from time they would rather spend with family, very little effort
is made by Samoan patients to reschedule a follow up appointment and the treatment
is skipped all together.
CAUCASIANS
Caucasians in Hawai‘i represent a diverse regional and ethnic background.
Although they are grouped together, it is understood that each ethnic group
brings with them, their own culture, values and tradition. Some of the following
observations may relate to some of the ethnic groups under the Caucasian classification.
if not the group as a whole. Independence and self assertion are two basic values
of Caucasians and may pose a problem when dealing with healthcare. It has been
observed that due to the higher level of education of a typical Caucasian dialysis
patient, these patients tend to self diagnose their illnesses. This results
in self medication with over-the-counter drugs without consulting with their
physician, nurse or pharmacist as to whether it is safe to use with the many
other medications a normal dialysis patient uses. As discussed earlier mixing
medications can result in a dangerous, and possibly fatal, situation. Self assertion
and independence causes Caucasian patients to dodge proper education and information
about the situation they are putting themselves in.
Vacationing patients are closely monitored during dialysis treatment. While
in Hawai‘i they are introduced to many types of foods without thorough
education about the complications these foods cause to all dialysis patients.
This brings the need for changes to be made to their prescribed dialysis treatment
while they are still vacationing. Nurses immediately contact the patient’s
representative physician while in Hawai‘i and changes are then made.
Physicians trust nurses to inform them of any situation where they think a physician
would want to make any amendments to a patient’s current prescribed dialysis
treatment. Usually these changes are then made without patients ever seeing
their physician. This is a tremendous problem for Caucasian patients (mostly
with visitors) who believe nurses only provide physical care and if any changes
are made to their treatment, they should be informed of these changes by their
physicians directly because physicians are the only ones with control over their
diagnosis and treatment. Caucasian patients do not believe that nurses should
be able to represent the voices of their physicians. Nurses are not given much
trust or respect during these types of situations. Therefore, these patients
often ask to contact by their physician by phone. If they are unable to speak
to their physician, they ask that no changes be made until they are able to.
This only delays the proper treatment that a Caucasian patient should be receiving.
CONCLUSION
Hawaii is one of the most racially diverse places in the world; there really
is no majority and everyone is a minority. With this brings many cultural beliefs
interacting with each other especially in crowded areas where everyone is in
close proximity with one another. Often these interactions among Hawai‘i
residents, immigrants and vacationers of Filipino, Chinese, Japanese, Hawaiian,
Samoan, and Caucasian descent bring conflict of beliefs and makes relating with
one another difficult. The many cultural differences in hospitals around Hawai‘i
results in one thing, whatever the reason it may be: difficulty providing the
best care possible for each patient. Lack of understanding between cultures
and the break down of communication prevents necessary information from being
conveyed between the patient and the healthcare provider and vise versa. The
information provided is not completely understood or plainly ignored. Therefore,
the proper treatments, such as dialysis, become difficult to manage and the
regulation of adequate care each patient needs must take many factors into account
before suitable treatment can be offered and preventative care can be practiced.
Hopefully, through continuous education and through time these traditions will
be modified by modernization, as well as enculturation of each others’
ethnic backgrounds. This is especially critical with those who have just moved
to Hawai‘i and still cling to their strong cultural values and beliefs.
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