Developing a Transcultural Patient Care Web Site

JOURNAL De Ruiter, Larsen OF TRASCULTURAL / A PATIENT CARE NURSING WEB SITE / January 2002

Developing a Transcultural Patient Care Web Site HANS-PETER DE RUITER, BSN, RN KAREN E. LARSEN, MA, MBA Mayo Clinic

The development of a transcultural Web site created by a multidiscplinary committee in a large medical center is described. The purpose of this Web site is to give direct patient caregivers immediate, around-the-clock access to various types of transcultural information that can serve as an aid in the provision of culturally competent care. This article outlines the steps to developing the Web site and provides a description of the types of informational resources available on it.

THE NEED FOR A TRANSCULTURAL PATIENT CARE WEB SITE With an increasing number of culturally diverse patients entering hospitals and other health care facilities today, nurses and other health professionals need to expand their knowledge about different cultural and religious practices to provide good patient care. Leininger (1996) stated that clinical nurses “remain handicapped with limited knowledge and skills to provide culturally competent and responsible cultural care” (p. 28). She elaborated that “hospital staff often experience cultural shock when a strange or unknown cultural group arrives in their institution” (p. 29) and that “in the future, one can anticipate that hospitals and community health agencies will require that all health personnel be knowledgeable and skilled in transcultural health services” (p. 31). The need for nurses and other health care professionals at our medical center to learn about different countries, cultures, languages, and religions has been recognized for quite some time. A multidisciplinary group called the Transcultural Patient Care Committee (TPCC) was developed in the early 1990s with a charge to explore cultural beliefs and heritage,

increase caregivers’ knowledge about culturally specific needs of patients, develop caregivers’ multicultural assessment skills, and apply research related to these areas to clinical practice (Severson, Leinonen, Matt-Hensrud, & Ruegg, 1999). One result of the efforts of this group was the development of a manual titled The Transcultural Patient Care Resource Manual. The manual was placed on all hospital nursing units and contained various types of information including one-page leaflets on various countries and cultural groups; contact information for various institutional departments providing assistance with transcultural caring such as nurse discharge planners, chaplains, interpreters, and social workers; a cultural assessment guide; and a book on transcultural care. It soon became apparent that the print-based manuals were difficult to keep current and expensive to duplicate and distribute to all nursing units. At the same time, the Internet’s World Wide Web was developing, and the TPCC recognized that delivering the manual’s information via the Web would offer wider and more cost-effective institutional access with the added benefit of making more and different types of information available. Thus, a Web work group comprised of TPCC members and a Web development specialist from the Nursing Department was formed with the goal of developing a Transcultural Patient Care (TPC) Web site. The purpose of this article is to describe the development of this Web site and the resources available on it. PLANNING THE TRANSCULTURAL PATIENT CARE WEB SITE The steps to planning the Transcultural Patient Care Web site were identified and carried out by the Web work group with assistance from members of the TPCC.

Journal of Transcultural Nursing, Vol. 13 No. 1, January 2002 61-67 © 2002 Sage Publications

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JOURNAL OF TRASCULTURAL NURSING / January 2002

FIGURE 1.

The Transcultural Patient Care Web Site’s Main Page.

Step 1: Identifying the Purpose and Structure of the Web Site and Its Location on the Institution’s Intranet

Purpose. The Web site’s purpose is similar to the purpose of the original paper manuals. Our goal for the Web site is to provide direct patient caregivers with easy access to current, clear, basic, high-quality information that can assist them in providing culturally competent care. Structure. The TPC Web site’s main page (illustrated in Figure 1) is divided into eight topic areas, five on the right side of the screen and three on the left. In addition, the main TPC page identifies a contact person for the transcultural pages, a link to that person’s e-mail account, the date that the site was last reviewed, and a statement to health care professionals that the site is only a tool to assist them in caring for transcultural patients and families. Intranet location. The site was initially located on the Nursing Department’s Web site due to the fact that technical assistance was available from that department that enabled the group to bring up and maintain the site in a timely manner. However, TPCC members felt it should be a resource that could be easily accessed by all health care providers and not be seen as a resource just for nurses. This prompted TPCC members to pursue moving the site to a higher, more visible location on the institution’s Intranet. TPCC members met with representatives from the institution’s Intranet work group, who supported this plan. Links to the TPC Web site are now located under the following categories on our Intranet: Practice, Departments/Groups, Resources, and Quality of Care. In addition, links to the Web site are located on the Nursing Department’s Web site under Practice, Resources, and Links. Step 2: Identifying the Content to Place on the Web Site

Because a goal for the TPC work group was to convert as much as possible the print manual to an online resource, the

FIGURE 2.

Example of an Online User Evaluation Form.

materials contained within the manual were examined to determine which could easily be converted from print to online. The contact information for those departments within the institution that deal with transcultural issues and the cultural assessment guide were easily loaded onto the Web site. The one-page leaflets and the book were not converted due to publishers’ copyright restrictions for these materials. Various internally produced print and Web resources not in the print manual were identified or developed by TPCC members to place on the TPC Web site. This includes onepage leaflets on various ethnic and religious groups, foreign language phrase cards with common phrases used in patient care areas, listings of institutional classes offered on transcultural issues, and links to full-text patient education brochures in foreign languages developed by our Patient and Health Education Department. Various Internet Web sites related to transcultural topics, such as the World Factbook produced by the Central Intelligence Agency (CIA), Foreign Embassies in Washington, D.C., and EthnoMed, were identified, described, and linked to on the site. Step 3: Developing Procedures for Keeping the Web Site Current and Useful

TPCC members recognize the need for keeping the Web site’s content current, accurate, helpful, and changing. Procedures were developed to have TPCC members review the internally produced content on an annual basis; the Web site’s links are checked monthly, and new content is added as it is produced or identified and then reviewed by TPCC members. Feedback is encouraged from users of the site. Users’ suggestions for improving the site and comments regarding its content and usefulness can be made online by completing the

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De Ruiter, Larsen / A PATIENT CARE WEB SITE

FIGURE 4. FIGURE 3.

Example of a Portion of a Religious Transcultural Fact Sheet.

online evaluation forms available throughout the Web site. An example of the evaluation form for the Foreign Language Phrase Cards is illustrated in Figure 2. THE CONTENT OF THE TRANSCULTURAL PATIENT CARE WEB SITE As mentioned previously, the main page (Figure 1) of the TPC Web site is divided into a total of eight categories described as follows. Category 1: Information About Countries, Ethnic Groups, Religious Groups, and Special Populations

Nurses frequently have questions regarding specific cultural and religious customs that can affect the care they provide. They may need information on such topics as the endof-life rituals for the Islamic patient, the family’s role in caring for the patient from Somalia, or the dietary practices of the Jewish patient. This section of the site provides brief, basic information on selected countries, ethnic groups, religions, and special populations. The Web site links users to the CIA World Factbook (http://www.odci.gov/cia/publications/ factbook/) for general information about every country in the world. In addition, for selected countries, TPCC members have supplemented the CIA information with specific information that assists with patient care issues such as information regarding a country’s family structure, religious and spirituality issues, dietary practices, and health and wellness beliefs. Also included in this part of the site are fact sheets developed by TPCC members on the ethnic groups, religious groups, and special populations most frequently encountered

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Example of a Portion of the Bosnian Foreign Language Phrase Card.

at our medical center. A portion of the Islamic fact sheet is shown in Figure 3. Category 2: Communicating With the Non-EnglishSpeaking Patient/Family

This part of the Web site describes how medical center interpreters can be accessed and how they should be used. There is also a description of resources available to assist in working with interpreters. In addition, Category 2 includes links to TPCC-developed foreign language phrase cards. Each phrase card consists of a list of phrases commonly used in the health care setting, in both English and in selected foreign languages, including Arabic, Bosnian, Cambodian, Laotian, Somalian, Spanish, and Vietnamese. Figure 4 illustrates a portion of the Bosnian/ Croation/Serbian phrase sheet. The phrases are arranged into the following five categories: (a) personal greetings/information; (b) assessment/admission history; (c) hospital directions/daily care, which includes both staff member and patient requests; (d) physical examination/medical procedures; and (e) pain management/physical assessment. These sheets can be printed out on every patient care unit. Their use is not a substitute for an interpreter, but they can be used when a very basic question needs to be asked and an interpreter is not available. Category 3: Cultural Assessment Guide

The purpose of the Cultural Assessment Guide is to assist nurses and other health care professionals in completing the patient chart and developing the patient’s plan of care. The guide contains information on the importance of doing a cultural assessment and illustrates through a question-andanswer approach the various factors needing to be addressed

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JOURNAL OF TRASCULTURAL NURSING / January 2002

FIGURE 5.

A Portion of the Cultural Assessment Guide.

when doing one. These factors are listed in Figure 5, where a portion of the guide is illustrated. Category 4: Nutritional Assessment Tool/Resources

Nutritional assessment and information tools are designed to be completed by the non-English-language-speaking patient with the assistance of the nurse. Nurses access the Web site, select the appropriate language, print the tool, and share it with the patient. The tool includes questions related to general nutrition and diet such as the presence of food allergies, the quality of appetite, any weight loss or gain, and swallowing problems. After answering the questions, the patient is asked to select foods for their meals during their hospital stay. Figure 6 illustrates a portion of the Spanish nutrition tool.

FIGURE 6.

A Portion of the Spanish Nutrition Information Tool.

FIGURE 7.

A Portion of a Patient Education Pamphlet: English and Somali Versions.

Category 5: Patient Education Database

A link to an internally produced database containing institutionally approved patient education materials is made available for users. Included in the database are patient education materials in various languages, including Arabic, Spanish, Laotian, Vietnamese, Somali, Cambodian, and Hmong. To use the database, the health care professional simply clicks on a link to the database, selects the language and topic needed, and searches the database. Most of the foreign language pamphlets are available full-text in Adobe Acrobat’s Portable Document Format (PDF) and can be printed by the nurse on the nursing unit. A portion of the English and Somali versions of a patient education pamphlet is shown in Figure 7. The publications are also available from the institution’s warehouse should multiple or color copies be needed. Category 6: Department Resources

Category 6, shown in Figure 8, is titled Department Resources and provides a list of departments, classes, and other

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reviewed by TPCC members to ensure their continuing usefulness and the accuracy of their content. A Web site evaluation tool was developed and is used by reviewers when evaluating Web sites for inclusion on the site. The tool is comprised of 12 questions that assist reviewers in evaluating a Web site’s authority, content, currency, and usability. Some of the Web sites the TPCC’s members have found helpful are listed in Table 1. FUTURE OF THE TRANSCULTURAL PATIENT CARE WEB SITE FIGURE 8.

The Department Resources Page.

resources within the organization that can assist with caring for the transcultural patient, including the following: • Discharge planning coordinators assist with the dismissal of international and other patients. • The international section links users to information on medical center interpreters and other personnel that provide support for the international patient. • The medical social services department, nutrition services, and patient and health education center pages contain contact information and hours of availability for these departments. • The patient and visitor libraries link takes users to the patients’ libraries Web site where they can find information about hours of operation, e-mail for patients, databases of library materials, and links to Internet Web sites for patients. • Religious support for the international patient identifies inhouse contacts for various religions, including the Jewish and Hindu faiths. • The telecommunications page describes how health care professionals obtain special communications equipment for deaf and sight-impaired patients.

A representative from each of the aforementioned areas has been appointed and is accountable for the accuracy and currency of the information on their portion of the Web site. Representatives review and update their pages annually. Category 7: Classes

This section includes listings of the institution’s transcultural classes that are held periodically for all employees, including Resources for Communicating With Non-EnglishSpeaking Patients, Cultural Awareness: The Somali Culture, and Valuing Diversity in Our Communities. The list is updated regularly to ensure the accuracy of the information.

The future offers us many challenges and opportunities. One challenge is to continue to add content as it is developed in-house or becomes commercially available. We recognize our need to develop more summary sheets on various ethnic groups, religions, and special populations. In addition, we plan to develop additional diet and nutrition information sheets. We realize that developing materials in-house is not always cost-effective or efficient, so TPCC members continue to look for materials available to purchase. For example, we are currently studying gaining access to the Web version of CultureGrams (www.culturegrams.com), cultural information sheets for various countries. We also hope to eventually provide links to current, full-text journal articles dealing with transcultural topics found within library databases. A continuing challenge for us is to inform medical center employees about the site. Obviously, the site is of little use if people are unaware of it or unable to easily access and use it. TPCC members have accomplished this in part by holding demonstrations of the Web site at lunchtime brown-bag sessions and by writing newsletter articles about the site in medical center publications. We need to explore other methods of publicizing the site and training people to use it. With the fast growth of the Internet and information technology, staying on top of what information is available and the validity of this information is challenging. We feel that a collaborative model involving various health care professionals including nurses, social workers, dietitians, interpreters, librarians, and computer specialists is essential to identify and make available high-quality, useful transcultural information. Looking to the future, we see the delivery of transcultural information via the Web to be efficient and effective. It gives nurses and other health care professionals immediate access to important information that serves to enhance their patient care.

Category 8: Internet Transcultural Web Sites

A list of Internet Web sites dealing with various transcultural topics is maintained on the TPC site. These sites are

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JOURNAL OF TRASCULTURAL NURSING / January 2002 TABLE 1 Selected Transcultural Internet Web Sites

Resource

Address

General country/government information CIA World Factbook

Foreign Embassies in Washington, D.C.

http://www.odci.gov/cia/ publications/factbook/

Governments on the WWW

http://www.embassy.org/ embassies/index.html http://www.gksoft.com/govt/

U.S. Bureau of Consular Affairs

http://travel.state.gov/

Transcultural health sites Cross-cultural resources—Transcultural, multicultural, cultural competency EthnoMed: Ethnic medicine guide

http://medicine.ucsf.edu/ resources/guidelines/ culture.html http://www.ethnomed.org

Healthweb: Minority health

http://healthweb.org/browse.cfm? subjectid=53

MEDLINEplus health information

http://medlineplus.gov

Online diabetes resources: Non-English Web sites Transcultural and multicultural health links

http://www.mendosa.com/ nonengl.htm http://www.iun.edu/~libemb/ trannurs/trannurs.htm

General cultural sites Arab Datanet Librarians’ index to the internet

http://arabdatanet.com http://lii.org/

Telephone directories on the Web

http://www.teldir.com/

The Worldwide Holiday and Festival Site

http://www.HolidayFestival.com/

Content

Current information about countries around the world. Includes a map and information about geography, people, government, economy, communications, transportation, military, and transnational issues. Produced by the U.S. Central Intelligence Agency. Includes addresses, telephone numbers, e-mail, and Web addresses for foreign embassies located in Washington, D.C. Governmental institutions on the Web, includes parliaments, ministries, offices, law courts, embassies, city councils, and public broadcasting corporations. Contains more than 17,000 entries from 220 countries and territories as of December 2000. Information for Americans traveling abroad. Consular Information Sheets are available for every country of the world including such information as the location of the U.S. embassy or consulate in the country, health conditions, minor political disturbances, unusual currency and entry regulations, security information, and drug penalties. A lengthy list of Web sites compiled by the Department of Medicine at the University of California at San Francisco. EthnoMed, sponsored by the Harborview Medical Center at the University of Washington in Seattle, contains information about cultural beliefs and medical issues pertinent to the health care of recent immigrants to Seattle. Includes cultural profiles for Somalians, Cambodians, Vietnamese, and others. Evaluated sites dealing with general aspects of minority health and links to sites for specific groups such as African Americans, Asian Americans, Hispanic Americans, and Native Americans. Produced by the National Library of Medicine. Includes links to Web sites dealing with health issues for various ethnic groups and special populations including African Americans, Asian Americans, Hispanic Americans, Native Americans, gays and lesbians, and seniors. Descriptions of and links to Web pages dealing with diabetes in languages other than English. Links to general resources dealing with transcultural health; religious groups, including Amish, Jehovah Witness, and Islam; ethnic groups, including Hmong, Thai, and Cambodian; and special populations, including women, gays, lesbians, and bisexuals. Links to various Arab-related Web sites. A list of Web sites organized by subject with links to the best sites in each subject area. Includes links to sites dealing with world cultures, religions, and holidays. An index of online phone books with links to yellow pages, white pages, business directories, e-mail addresses, and fax listings from around the world. Find information about and dates for various religious and countryspecific holidays.

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REFERENCES Leininger, M. (1996). Founder’s focus: Transcultural nursing administration: An imperative worldwide. Journal of Transcultural Nursing, 8, 2833. Severson, M. A., Leinonen, S. J., Matt-Hensrud, N. N., & Ruegg, J. A. (1999). Transcultural patient care committee: Actualizing concepts and developing skills. Journal for Nurses in Staff Development, 15, 141-147.

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celsior College at Albany, New York. His clinical interests include medical nursing and transcultural patient care. Karen E. Larsen is a librarian in the Mayo Clinic Libraries at the Mayo Clinic. She received her MA in library science from the University of Minnesota at Minneapolis. Her clinical interests include being an information specialist in the subject areas of nursing and health care management.

Hans-Peter de Ruiter is a nurse manager in the Department of Nursing at the Mayo Clinic. He received his BS in nursing from Ex-

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