Introduction to Case Studies

CASE STUDIES

INTRODUCTION TO CASE STUDIES Every NM staff person is required to complete two case studies, one on the Latino culture and the other on the African American culture. For each cultural group, there is a clinical and non-clinical case study. Staff will be able to determine within the online training program which case studies they should complete based on their NM role (job). If anyone has questions about which to do, they have been directed to ask their manager for help. The four case studies are similar to situations that have occurred at NM in the recent past. Each case study is presented in vignettes (short stories) with accompanying questions. Within each vignette, a cultural issue(s) arose and impacted the care of the patient. The questions get at the heart of that issue and will require the learner to search the CultureVision tool to find the answers. Staff can print out hard copies of the two studies that are appropriate for them based on their NM role or they will be able to pick up hard copies from their manager. The staff person should read through each case study in its entirety and then open up the CultureVision tool on NM Connect to find and write down the answers for each case study’s questions. When reading the case studies, staff should focus on the interactions that occurred between the patient and staff person or between staff, not be on the clinical details. Managers will need to tell staff when they need to complete the case studies (set the deadline). Staff must then bring their completed case studies to a unit/department based discussion on cultural competence led by their manager. In that discussion staff and their manager will talk about the importance of cultural competence to NM, the answers to the two case studies, and how the lessons learned apply to their unit/department.

Northwestern Memorial March 2008 1 FINAL CLINICAL CASE STUDY – LATINO PATIENT (On green paper) IMPORTANT: Hints are provided that help you narrow your search for the answers in CultureVision. The sections or pages listed after Hint: mean the answer is found in at least one of these sections or pages. It may be found in more than one. Vignette 1 A 26 year old Latino female patient, who was 32 weeks pregnant and in pain, presented to OB triage as directed by her OB physician. She and her husband had immigrated to Chicago within the past year. She and her husband had difficulty speaking with the customer service representative at the triage desk. The customer service rep. told them to have a seat in the waiting area and they did. The couple noticed it did not seem to be a busy time in the triage area and many other families after them were going into the OB triage exam room area. After sitting for two hours, another customer representative noticed them and asked them why they were there.

1. What caused the breakdown in spoken communication between the couple and the first customer service representative? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Language and Communication>Nonverbal Communication section Answer: Language barrier. (CV: Language and Communication > Oral Communication)

2. What percentage of Latinos in the US has limited English language skills? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Language and Communication > Nonverbal Communication section Answer: About 50% of Latinos in the US speak limited English or not at all. Because of a lack of Latino doctors and limited funding for translation, Latinos with limited English skills often have difficulty communicating with healthcare providers. (CV: Language & Communication > Oral Communication)

3. What should the first customer service representative have done differently when she saw the couple had trouble speaking English? Hint: Think of what would have been better questions for the customer service representative to ask the couple. Answer: Ask the couple what language they speak at home. If not English, would they like assistance with their speaking (need an interpreter?)? Would they like an interpreter—if they say yes, call Language Line or use the in house interpreter in Prentice. (CV: Click Questions to Ask button and look under Language section)

4. Why did the couple continue to wait so long for medical attention –why didn’t they ask the reason for the long wait? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Family Traditions > Decision Making section Northwestern Memorial March 2008 2 FINAL Answer: Latinos regard healthcare providers ‘and support staff’ with much respect and view them as authority figures. They may be resistant to question healthcare professionals because they want to avoid conflict. ‘They do not question authority.’ (CV: Language & Communication > Oral Communication)

Vignette 2 The patient was then admitted to Labor and Delivery room after a two hour wait in OB Triage. As the nurse started to speak to the patient with an interpreter, she noticed that the patient would grimace intermittently. The nurse learned that the patient was in significant pain (6 on the pain scale of 10).

5. What are some of the cultural issues around the treatment of pain in Latino patients? Hint: Refer to in CultureVision: Treatment Issues > Treatment of Pain section, Concept of Health section, OR Labor, Birth & Aftercare > Pregnancy Care section Answer: Evidence shows there is more under-treatment of pain among Hispanics than Caucasians. Language barriers often exist between Hispanic patients and healthcare workers. Latinos are more likely to focus on the emotional component of pain and describe it as suffering. Some Latinos use moaning as a way to reduce the pain they are feeling. (CV: Treatment Issues > Treatment of Pain) Additional Discussion Question for Manager to Ask Staff: • What could the nurse have asked the patient to help her with her pain? Answer: Would you like something to help relieve the pain once you and your baby are being monitored?

Vignette 3 The woman went into full labor in the L&D room and during that time, her husband left the room and her mother and mother in-law arrived and insisted they needed to be present during the childbirth to the doctor and nurse.

6. Why did the husband leave his wife during childbirth and instead the mother and mother in-law want to be present? Hint: Refer to in CultureVision: Labor, Birth & After Care > Labor Practices section, Concept of Health section, OR Labor, Birth & Aftercare > Role of Father during Birth section Answer: The husband was following the practice in the Latino culture of the husband not being present during the childbirth. Since he is a recent immigrant, he is not following the more Westernized practice of the husband/partner being present during childbirth. This tradition also includes the mother and mother in-law being present instead. (CV: either Labor, Birth & Aftercare > Role of Father during Birth OR Labor, Birth & After Care > Labor Practices) Additional Discussion Point for Manager to Share with Staff:

Northwestern Memorial March 2008 3 FINAL • Other cultures, such as the Korean and Filipino cultures, also believe the laboring woman’s mother or mother in-law attends during labor rather than the husband.

Vignette 4 After childbirth, the patient was transferred to a post partum floor and continued to have difficulty communicating with staff. The nurse and patient care technician attempted to give the patient some icy cold water to drink and the patient refused. The nurse became concerned the patient may become dehydrated.

7. Why did the patient refuse the icy cold water? Hint: Refer to in CultureVision: Labor, Birth & Aftercare > Birth Recuperation section, Concept of Health section, OR Labor, Birth & Aftercare > Labor Practices section. Answer: ‘Some’ Latino cultures view illnesses, treatments, and foods as having “hot” or “cold” properties. Cold diseases or conditions are generally characterized by vasoconstriction and low metabolic rate and include menstrual cramps, coryza (rhinitis), pneumonia, and some gastro- intestinal problems (empacho). Hot diseases or conditions are characterized by vasodilation and high metabolic rate, such as in pregnancy, hypertension, diabetes, and acid indigestion. (CV: Concept of Health) During the 6-week post-partum period (a cold state), cold foods are also avoided due to the belief that they will impede the emptying of blood from the uterus and birth canal. The new mother will also avoid acidic and spicy foods during this time to avoid excessive blood flow or cramping. Heat is also restored by physical confinement of the postpartum mother to protect her from the cold. (CV: Labor, Birth & Aftercare > Birth Recuperation)

During childbirth, heat is thought to be lost (creating a “cold” state) and some foods and medications are sometimes seen as potentially dangerous and avoided. A woman who has just delivered may prefer to be given a hot drink and covered to help her regain heat. (CV: Labor, Birth & Aftercare > Labor Practices) Additional Discussion Point for Manager to Share with Staff: • Many other cultures, such as most Asian cultures, also view illnesses, treatments, and foods as having “hot” or “cold” properties. They believe too that the post partum period is a “cold” period and cold foods need to be avoided and warm drinks given. Additional Discussion Question for Manager to Ask Staff: • What should the caregivers have asked the patient? Answer: “What can we do for you during your stay here at NM?” More answers: CV: Click Questions to Ask button and look under Ask Perinatal Health Practices section: What food and drinks do you prefer during your pregnancy? And after you deliver the baby? What else can we do to help you feel strong after your delivery? Is there anything we can do to make this time easier?

Northwestern Memorial March 2008 4 FINAL CLINICAL CASE STUDY – AFRICAN AMERICAN PATIENT (On green paper) IMPORTANT: Hints are provided that help you narrow your search for the answers in CultureVision. The sections or pages listed after Hint: mean the answer is found in at least one of these sections or pages. It may be found in more than one. Vignette 1 An 81 year old African American woman presented to the ED complaining of a headache. She has had the headache for the past five days. Her eyes were closed and to assess her level of consciousness, the nurse, who was very busy that day, said “Mary—what is the problem? What do you need?” The patient opened her eyes, looked straight at the nurse, and then turned her head. She wouldn’t respond to the nurse.

1. Why didn’t the patient respond to the nurse? Hint: Refer to in CultureVision: Language & Communication > Oral Communication section OR Family Traditions > Family Structure & Relationships section AND think about how anyone would like to be addressed. Answer: In the ‘African American’ culture, family bonds and respect for elders is extremely important. Elders are thought of as a source of wisdom. They expect and receive a great deal of respect. Respect for elderly would suggest that the nurse address her more formally as Mrs. Smith out of respect and common courtesy. (CV: Family Traditions > Family Structure & Relationships)

Engaging in social conversation (in conjunction with health topics) with African American patients during healthcare-related interactions is viewed as warm and caring. Practitioners that are too task-oriented or time-focused may be seen as inconsiderate or rude. African American patients want to get to know you before disclosing personal information”. So the nurse should introduce herself/himself first, and then ask questions. (CV: Language & Communication > Oral Communication) Additional Discussion Question for Manager to Ask Staff: • What should the nurse have first asked the patient before addressing the patient? Answer: “How would you like me to address you?” (CV: Click Questions to Ask button and look under Personal Background, Ethnic Affiliation, and Acculturation section)

Vignette 2 The doctor arrived and asked the patient about her headache. She indicated she has had the headache for the past five days and she has had trouble sleeping. The doctor noticed that her pain score was 8 on a scale of 10 and she asked Mrs. Smith if the pain has been that severe over the past five days. Mrs. Smith answered yes. The doctor asked the patient why she didn’t come to the hospital sooner. They could have helped her relieve her pain.

Northwestern Memorial March 2008 5 FINAL 2. What is one possible reason for the patient not coming sooner to the hospital? She does have transportation readily available and is covered under Medicare. Hint: Refer to in CultureVision: Concept of Health section, Health Promotion > Disease Prevention section, OR Illness Related Issues > Attitudes about Physical Illness section

Answer: It is important to be aware of the potential for mistrust of institutionalized systems of care among African Americans, as they may be seen as "white." It may be necessary to spend more time establishing trust. (CV: Health Promotion > Disease Prevention)

African Americans often have an external locus of control concerning their health. What happens depends on God, doctors or simply, “it was meant to be.” The outcome is beyond their control. This view, shared by many older African Americans, may appear fatalistic to some, but may more correctly reflect an attitude of acceptance. (CV: Concept of Health) Many, older African Americans can sometimes have what appears to be a fatalistic attitude towards pain or death. • A more accurate description would be an acceptance of pain and death. • Older African Americans might refuse pain medication or treatments, or decide not to visit a doctor, because they see illness and death as something that is inevitable (CV: Illness Related Issues > Attitudes about Physical Illness)

Vignette 3 The patient underwent a brain CT scan and returned to the ED. The patient was admitted to a medical unit for observation. The transporter took her to her room. Upon leaving the room, the transporter said, “I will pray for you.” The patient became somewhat upset and uncomfortable.

3. Why did the transporter assume the patient was religious and would be comforted by his statement? Hint: Refer to in CultureVision: African American introductory page, Illness- Related Issues > Attitudes About Physical Illness section, OR Beliefs, Religion & Spirituality > Beliefs/Practices That May Affect Healthcare Decisions section Answer: The transporter assumed the patient was religious because she was an African American and the church often occupies a central place in the lives of African Americans. Public health practitioners, researchers, and policy makers recognize this role and are increasingly using the church to access African Americans for health improvement efforts. (CV: Beliefs, Religion & Spirituality > Beliefs/Practices That May Affect Healthcare Decisions) Another statement in CultureVision about African Americans that would support the transporter making the assumption the patient was religious is Community, religion/spirituality, and family are the most important aspects of Black/African American culture. (CV: African American introductory page) Additional Discussion Point for Manager to Share with Staff: • Do not make assumptions about any person’s religious beliefs or practices based on their culture. In this particular case, the patient was an atheist and that is why she became upset with the transporter’s comment.

Northwestern Memorial March 2008 6 FINAL Additional Discussion Question for Manager to Ask Staff: • What are some more appropriate comments the transporter could have said to the patient to offer comfort? Answer: Statements that are neutral and not of a religious nature. For example, “Take care.” “I hope you feel better soon.” etc. Vignette 4 When the patient was admitted to the medical unit the doctor ordered some other tests on the patient to determine if she had any other underlying illnesses.

4. What are some of the chronic diseases affecting African Americans today? Hint: Refer to in CultureVision: Illness-Related Issues > Common Health Problems section, Concepts of Health section, OR Illness-Related Issues > Health Disparities section Answer: Chronic disease has had an enormous effect on African Americans. Diabetes mellitus (Type II Diabetes) is among the most serious health problems facing African Americans. African Americans have the highest rates of cancers and mortality of any racial or ethnic group in the country. As of 2002, there were 3.4 million African Americans with asthma, the highest percentage of any racial or ethnic group. African American women are much more likely to develop systemic lupus erythematosus. African American women have the highest number of TB cases. (CV: Illness-Related Issues > Common Health Problems AND Illness-Related Issues > Health Disparities)

Vignette 5 The patient was required to stay an additional two days and had difficulty with keeping her headache pain under control with prescribe “as needed” medication. Whenever she asked for medication for her headache, the nurse waited another 30 minutes before bringing the medicine to her.

5. Do you think there is a bias in healthcare for giving African Americans pain medication? Provide a reason for your answer? Hint: Refer to in CultureVision: Treatment Issues > Treatment of Pain section, Treatment Issues > Ethnopharmacology section, OR Concept of Health section Answer: African American and ‘Latino’ patients are routinely under-treated for pain during emergency room visits. The pain of a disproportionately high number of minority patients is mismanaged after surgeries and cancer treatments. These results remain the same, even when economic status and insurance rates are taken into account. African American and ‘Latino’ patients have greater difficulty than Caucasian patients in obtaining pain medications that have been prescribed to them. In many cases, urban pharmacies do not stock any opiates. There are multiple instances of patients having to wait for hours for their prescribed medicines. (CV: Treatment Issues > Treatment of Pain)

Additional Discussion Question for Manager to Ask Staff: • Do you think there are instances where you might have a bias in giving pain medication?

Northwestern Memorial March 2008 7 FINAL NON-CLINICAL CASE STUDY – LATINO PATIENT (On orange paper) IMPORTANT: Hints are provided that help you narrow your search for the answers in CultureVision. The sections or pages listed after Hint: mean the answer is found in at least one of these sections or pages. It may be found in more than one. Vignette 1 A 26 year old Latino female patient, who was 32 weeks pregnant and in pain, presented to OB Triage as directed by her OB physician. She and her husband had immigrated to Chicago within the past year. She and her husband had difficulty speaking with the customer service representative at the triage desk. The customer service rep. told them to have a seat in the waiting area and they did. The couple noticed it did not seem to be a busy time in the triage area and many other families after them were going into the OB triage exam room area. After sitting for two hours, another customer service representative asked them why they were there.

1. What caused the breakdown in communication between the couple and the first customer service representative? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Language and Communication > Nonverbal Communication section Answer: Language barrier. (CV: Language and Communication > Oral Communication)

2. What percentage of Latinos in the US has limited English skills? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Language and Communication > Nonverbal Communication section Answer: About 50% of Latinos in the US speak limited English or not at all. Because of a lack of Latino doctors and limited funding for translation, Latinos with limited English skills often have difficulty communicating with healthcare providers. (CV: Language & Communication > Oral Communication)

3. What should the first customer service representative have done differently when she saw the couple had trouble speaking English? Hint: Think of what would have been better questions for the customer service representative to ask Answer: Ask the couple what language they speak at home. If not English, would they like assistance with their speaking (need an interpreter?)? Would they like an interpreter—if they say yes, call Language Line or use the in house interpreter in Prentice. (CV: Click Questions to Ask button and look under Language section)

4. Why did the couple continue to wait so long for medical attention –why didn’t they ask the reason for the long wait? Hint: Refer to in CultureVision: Concept of Health section, Language and Communication > Oral Communication section, OR Family Traditions > Decision Making section Northwestern Memorial March 2008 8 FINAL Answer: Latinos regard healthcare providers ‘and support staff’ with much respect and view them as authority figures. They may be resistant to question healthcare professionals because they want to avoid conflict. ‘They do not question authority.’ (CV: Language & Communication > Oral Communication)

Vignette 2 The patient was then admitted to Labor and Delivery room after a two hour wait in OB Triage. The transporter had trouble assisting her from the wheelchair to her bed. She seemed to be in a great deal of discomfort since she was moaning loudly. The transporter asked her if she needed a nurse and she looked at him blankly and told him she was OK. He was surprised of her response since he thought she was in intense pain.

5. Why did the patient exhibit signs of being in intense pain when she really wasn’t? Hint: Refer to in CultureVision: Treatment Issues > Treatment of Pain section, Concept of Health section, OR Labor, Birth & Aftercare > Pregnancy Care section Answer: Latinos are more likely to focus on the emotional component of pain and describe it as suffering. Some Latinos use moaning as a way to reduce the pain they are feeling. (CV: Treatment Issues > Treatment of Pain) Additional Discussion Question for Manager to Ask Staff: • Was it OK for the transporter to ask the patient if she was in pain? Answer: Yes, it was OK that the transporter asked the patient the question. Whenever you are in doubt about a patient’s condition, behavior, culture, etc., it is better to ask questions rather than assume anything. Also by asking questions, you are showing your concern and interest in helping the patient.

Vignette 3 The patient after giving birth was transferred to a post partum room and she continued to have difficulty communicating with staff. A Latino patient care technician (PCT) caring for the patient noticed a food service hostess coming down the hall carrying a food tray with spaghetti for her patient. The PCT looked at the food tray and stated the patient wasn’t going to eat that and walked away. The food hostess was taken aback and thought the PCT’s comment meant the food was not appetizing. The food hostess reported the PCT’s comment back to her manager and this manager called the PCT’s manager to report the PCT’s inappropriate comment and behavior.

6. Why would the Latino PCT tell the food service hostess the Latino patient would not eat the food on the tray? Hint: Refer to in CultureVision: Labor, Birth & Aftercare > Birth Recuperation section, Diet & Nutrition > Usual Diet, Customs, & Patterns section, OR Concept of Health section Answer: “For many Latino cultures during the 6-week post-partum period (a cold state), cold foods are avoided due to the belief that they will impede the emptying of blood from the uterus

Northwestern Memorial March 2008 9 FINAL and birth canal. The new mother will also avoid acidic and spicy foods during this time to avoid excessive blood flow or cramping. Heat is also restored by physical confinement of the postpartum mother to protect her from the cold. A woman who has just delivered may also prefer to be given a hot drink to help her regain heat. (CV: Labor, Birth & Aftercare > Birth Recuperation)

7. What should have the food service hostess asked the patient? Answer: “What can we do for you during your stay here at the hospital? What food and drinks do you prefer during your pregnancy? And after you deliver the baby? What else can we do to help you feel strong after your delivery? Is there anything we can do to make this time easier? More answers: Click the Questions to Ask button and look under the Perinatal Health Practices section. Additional Point for Manager to Share with Staff: • Many other cultures, such as most Asian cultures, also view illnesses, treatments, and foods as having “hot” or “cold” properties. They believe too that the post partum period is a “cold” period and cold foods need to be avoided and warm drinks given. Additional Discussion Question for Manager to Ask Staff: • How could the communication be improved between the two coworkers (food service hostess and PCT in this case study)? • Answer: The PCT should have explained her comment to the food service hostess and if the PCT didn’t do this immediately, the food service hostess should have asked the PCT what she meant. They need to keep the lines of communication between them open and clear.

Northwestern Memorial March 2008 10 FINAL