What happens when medical treatment and religion collide?
Transcultural nursing addresses the growing need for multicultural awareness in healthcare.
By Doug Childers

At first, the doctors thought they were facing a problem created by a language barrier. Their patient, a pregnant Muslim woman of Arab descent, was refusing to have an amniocentesis performed, although the results of a quad screening, which looks for prenatal neurological problems, was abnormal. An amniocentesis would almost certainly indicate neurological problems, if the fetus had any, but the woman adamantly rejected the doctors' arguments.

That's when the doctors turned to Rose Khalifa, RN, BSN. Khalifa is president of the National American Arab Nurses Association.

"I was brought in as a translator," Khalifa said. "It wasn't a language problem, though."

Khalifa soon discovered that the patient's religious beliefs precluded her having an abortion, even if the amniocentesis revealed that her baby would be born with significant neurological problems.

"She wasn't willing to choose an abortion, so why go through the risks inherent in the procedure" - which included miscarriage - "if it didn't help? The patient was happy I came in and explained the situation," Khalifa said.

With Khalifa's help, the doctors finally understood their patient's reason for rejecting their proposal, and they didn't perform the amniocentesis. Happily, the baby turned out to be perfectly healthy.

Judith A. Lewis, Ph.D., RNC, FAAN, a professor at Virginia Commonwealth University 's school of nursing, recalls a similar case in which a Nigerian woman refused to have a Caesarean section performed on her because her belief system dictated that only vaginal births were acceptable.

"I think the doctors thought she was a weird tribal freak, but I was there with students, and we spent a lot of time talking about how frightened the couple must have been by the intimidation they got from U.S. doctors," Dr. Lewis said. "If I remember correctly, the husband was a doctoral student, so they certainly weren't educationally deprived."

The couple successfully refused surgery, and the woman delivered a healthy baby vaginally.

Dr. Lewis also remembers a troubling situation in 1978 in which medical professionals insisted on giving blood transfusions to a Jehovah's Witness, despite her religion's opposition to them.

In all three cases, medical professionals found themselves at odds with the patient over the course of treatment because they either did not understand or appreciate the patient's cultural and spiritual needs. It's a dilemma which many medical professionals are facing, as the American population grows more ethnically and spiritually diverse.

Today, treating the patient, rather than the disease, may mean knowing the patient's religion or understanding the belief systems tied to her ethnicity. Nurses, acting as intermediaries between the patient and the medical profession, are at the heart of the issue. And as a part of the growing field of transcultural nursing, they may play a key role in enriching the interaction between the patient and the medical staff.

"We're trying to say when you encounter people who don't look like you, you have to discover if there's a disconnect between what you're saying and what they're hearing," said Sheryl Garland, MHA, vice president for community outreach for VCU Health Systems and administrative director of the VCU Center on Health Disparities. "Medical professionals have to be sensitive to wherever that person is coming from, in terms of their religion, ethnicity and economic background."

Some of the spiritual and ethnic issues that doctors and nurses face are fairly straightforward, and dealing with them to the satisfaction of both the patient and medical professionals can be successfully planned in advance. As Khalifa points out, Muslims will often need providers of the same sex (this is especially true for women in labor).

Likewise, dietary restrictions placed on patients by their cultural or spiritual beliefs can be accommodated by a dietician who works within the patient's guidelines to ensure that the dietary needs placed on her by her medical treatment are met.

The ways different religions approach death are also critically important, and a proper understanding of them can help facilitate communication between the patient and medical professionals. As an example, Dr. Lewis points out that "Most Jews refuse post-mortem examinations, and would need to consult with a rabbi before allowing an autopsy."

Simply communicating with a patient may require advance planning. VCU, for example, partners with CyraCom, a national company that helps health-care providers communicate with patients in more than 150 languages.

"A couple years ago, we noticed there was a patient population from an area in Mexico that speaks a dialect called Mixteco," Garland said. "For some reason, there's a growing population of Mixteco speakers in Richmond . The only other place we know about a similar population growth is in San Francisco ."

The University of California , San Francisco , has a Mixteco dictionary which helps VCU medical staff with translation, and CyraCom has a translator who helps, as well.

"A large percentage of that population is illiterate, so translating our documents means they can't read it," Garland said. "Access to a translator is more important for us."

As many medical professionals are now discovering, nurses have been quietly practicing transcultural nursing for some time now.

"Two years ago, a group of representatives from health professions at VCU came together because they wanted to talk about getting information about cultural competency," Garland said. "They found the school of nursing was doing it for over five years. It was the nurses telling us where all the resources were. Health-care professionals can learn a lot from nurses."

Khalifa argues that transcultural nursing "has to be a core part of the normal protocol of all programs," and today, it is indeed entering the official curriculum in both medical and nursing schools more widely.

Dr. Lewis has added an assignment in the undergraduate women's health course she teaches, for example, "where students have to examine a culture or ethnic group other than their own, describe the world view, issues related to birth, death, prenatal and postpartum care, infant care, and any other women's health issue such as contraception and abortion."

Dr. Lewis dedicates class time to discussing their findings.

Khalifa stresses that "Nursing schools need to make sure they get the experiences in the backgrounds they'll be facing. Experience is a great memory aid, and it helps facilitate more permanent knowledge. It's better than reading to attain the task. Reading doesn't drive the message."

Nurses who are currently working in the medical field may find turning for help from their colleagues to be beneficial. "Your colleagues will see you have an intent to learn from the community, and it builds bridges between you and your colleagues," Khalifa said.

Having a diverse nursing staff helps foster rapport - "there's a silent understanding" between a nurse and a patient when they share religious or cultural background, Khalifa says. "In health care, trust is a huge element. Every patient is understood as a human being you seek to understand. It's not necessary to have the same ethnicity or religion, though. It's having a neutral position when you care for patients."

Garland also says it is helpful "to have access to a university setting and ask for assistance, especially if the university has an academic medical center." She points to VCU Health System's Community Health Education Center as a great example.

"It's a partnership between the hospital and the university library," she said. "It's a center inside our library. We have a medical librarian on staff who provides medical support to those looking for resources on various medical issues. You can also e-mail the librarian with questions, and within 24 hours, she'll respond. It's open to the community. So connections to a university opens doors."

Conferences are also great places to gain knowledge. The VCU Center on Health Disparities is holding a conference on Nov. 16 and 17 about Latino cultures and beliefs and how they affect medical professionals who provide health care in the Latino population. (For more information on the Latino Health Summit, call (804) 828-5414 or send e-mail to cmehelp@vcu.edu.)

So far, the medical profession is responding positively, but the understanding still isn't universal.

"My honest opinion is that those of us who are members of ethnic minority groups and/or are sensitized to the issues do a pretty good job," Dr. Lewis said. "It's the people who think they are sensitive and are not and who don't recognize a problem who will never change."