Learning Outcomes
By the end of this section, you should be able to:
- 23.5.1 Identify factors that affect communication with clients from diverse backgrounds.
- 23.5.2 Compare and contrast communication patterns in high- and low-context cultures.
- 23.5.3 Explain the effects of low health literacy on health outcomes.
- 23.5.4 Use effective communication strategies with clients with low literacy and low health literacy.
Cultural and linguistic competence refers to the ability of health care professionals and health care organizations to understand and respond effectively to the cultural and linguistic needs clients bring to the health care encounter. Like cultural competence, linguistic competence exists along a continuum and is not based on comprehensive knowledge. Linguistic competence enables nurses to care for clients with limited English proficiency. It involves providing these clients easily accessible and culturally appropriate language services, both written and oral. It also requires an awareness of how verbal, nonverbal, and written messages may vary across cultures. Nurses who understand the relationship between communication and cultural identity can adapt their communication to meet each client’s needs and preferences. This adaptation includes being mindful of a client’s communication preferences and cues and trying to understand and respect them.
Linguistically competent care begins with assessment. The first step is to identify the client’s primary language, by asking either the client, a family member, or another individual who is familiar with the client’s language. If the client does not speak the same language as the health care provider, the nurse must use a certified medical interpreter to facilitate communication (see Working with Translated Materials and Interpreters). When communicating with clients with limited English proficiency, nurses need to use clear and simple language, avoid medical jargon and technical terms, and give the client ample time to express themselves and to ask questions.
The Office of Minority Health (n.d.) has developed standards that provide information, resources, and continuing education opportunities for health care professionals to learn about culturally and linguistically appropriate services (CLAS). CLAS emphasizes the importance of tailoring health care services to an individual’s culture and language preferences, respecting and responding to the health needs and preferences of all individuals to achieve health equity, and ensuring that everyone has access to high-quality care.
Differences in Communication Styles
Cultural variations in communication can significantly affect how health care professionals and clients interact and how individuals understand and interpret messages. Nurses need to understand how communication styles differ across cultures. By adapting their communication to align with the client’s preferences, nurses can avoid potential misunderstandings and communicate more effectively with clients from different backgrounds.
Tone, volume, and speed of speech vary among cultures. Loud, fast, and expressive speech is customary for some individuals, whereas others may perceive it as rude or aggressive. Clients from some cultures may consider it rude or disrespectful to make eye contact while speaking to a health care provider, whereas others may consider it a sign of attentiveness and respect. In some cultures, low facial expressiveness is considered typical, whereas other cultures may view it as indicating a lack of interest or even resistance. Culture can also influence the level of emotional expressiveness considered appropriate in social interactions. Some clients may be more open about discussing their feelings and expressing emotions, whereas others may consider it inappropriate to show strong emotions in public or to discuss their health with people who are not close friends or family. As always, it is important to follow the client’s cues in order to provide culturally and linguistically responsive care.
Cultural differences in communication can impact the way that people understand and interpret messages. For example, in high-context cultures, such as those found in Latin American and Asian countries, communication tends to be more subtle and rely more on nonverbal cues and context. Words alone may not convey the full meaning of a message, so nurses should consider the context and relationships between people when communicating. In addition, it may be considered rude or disrespectful to be overly direct, particularly when discussing negative or embarrassing topics; instead, these cultures may use more subtle and implicit language, with a focus on harmony and the interpersonal relationship. In contrast, in low-context cultures, such as those found in North America and Northern Europe, people tend to be more direct in their communication, using clear and explicit language.
In some cultures, communication is more oriented toward the self, whereas in others it is more focused on other people. This difference can be seen in the way people use “I” statements versus third-person language and plural pronouns. In the United States, where the dominant cultural norm is individualistic, people tend to speak in terms of their own experiences and preferences. In contrast, many other cultural groups are more collectivistic, meaning they prioritize the needs and perspectives of the group or community over those of the individual. For members of these cultures, it may be more common to speak in the third person and to use plural pronouns, such as “we” or “they,” rather than “I.”
Health Literacy
Health literacy—the ability to access, understand, and use health information and services to make informed decisions about one’s health—ensures that individuals are empowered to take positive actions to improve their health and well-being. Individuals who are health literate can understand and use health-related information and services. Health literacy enables people to read and comprehend medical instructions and labels, follow a treatment plan, and communicate effectively with health care providers, all of which can lead to better health outcomes. Health literacy can also reduce health care costs by preventing unnecessary hospitalizations and other costly interventions. Additionally, health literacy is important for reducing health disparities and promoting health equity.
Research has demonstrated that health literacy can have numerous positive impacts on health care (Shahid et al., 2022). Health literacy increases the use of preventive health care, reduces unnecessary emergency department visits and preventable hospital stays and readmissions, decreases medication errors, and assists clients in better managing chronic conditions such as diabetes, high cholesterol, hypertension, and HIV. Moreover, it can increase client satisfaction, improve overall health outcomes, and enhance client safety, and it results in greater cost savings for the health care system (McDonald & Shenkman, 2018).
Healthy People 2030
Increasing the Health Literacy of the U.S. Population
One overarching goal of Healthy People 2030 is to remove health disparities and improve health literacy in all people (ODPHP, n.d.-a). Health literacy is the ability to access, understand, and use health information and services to make informed decisions about one’s health. Healthy People 2030 identifies health literacy as being vital to reaching all Healthy People 2030 objectives. However, health information can be difficult to understand, especially in those with limited English proficiency. Healthy People 2030 has expanded its definition of health literacy to emphasize not only things individuals can do to improve health literacy but also the role that organizations play in helping individuals find, comprehend, and use health information and services to participate in decisions about their care. This new definition goes beyond simply ensuring that individuals understand health information: It focuses on the individual’s ability to use this information to make well-informed choices.
Low literacy refers to the inability to read, write, and comprehend basic information. It is a widespread issue; an estimated 21 percent of adults in the United States have low literacy levels (U.S. Department of Education, 2019). Individuals with low literacy have limited ability to access information, learn new skills, and fully participate in society. Low literacy is often linked to other socioeconomic factors, such as poverty, low education levels, and limited access to health care. It can negatively impact health outcomes because those with low literacy may struggle to understand health information, follow treatment plans, and manage their own health.
Effectively communicating with clients with low health literacy involves using plain, nonmedical language; speaking clearly and slowly; and being specific and concrete, avoiding vague or subjective terms such as “not well” and “a few.” Common words one would use to explain medical information to friends or family, such as “stomach” or “belly” instead of “abdomen,” are appropriate. Nurses should pay attention to the words clients use to describe their illness and then use those words in conversation. Showing a client how to do something, such as performing an exercise or taking medicine, may be clearer than verbal explanations.