Therapy

June 2007

nsider
The professional's guide to products and career opportunities
TM

Increasing your
cultural competency
Managing pain after total
joint replacement surgery
Assessing the
bilingual client
 Therapy

It takes a team
June
2007

nsider
The professional's guide to products and career opportunities
TM

2 How to control pain and

improve functionality after
To paraphrase the African proverb “It takes a whole village to raise a child,” in total joint replacement
health care “It takes a whole team to help patients reach their potential.” surgery
We’re part of teams our entire lives, from our first, often clumsy, efforts at By Matt Tovornik, PT, and Yvonne
sports as toddlers to our professional work as adults. The therapy team includes D’Arcy, CRNP, CNS, MS
physical therapists (PTs), occupational therapists (OTs), and speech-language Total joint replacement surgery is
pathologists (SLPs). Members of each discipline bring a unique perspective to among the most painful of surgeries.
patient care, creating a synergy that often leads to better outcomes. Here’s how you can help your patients
We are recognizing the importance of that synergy with a new title for this postoperatively minimize pain and op-
publication—Therapy Insider. Within its pages, we’ll bring you information timize function.
you can use in your practice and delve into common issues all therapists face.
The first common issue we explore is cultural competence, an essential skill 6 Cultural competency
for therapists. Our country’s population is increasingly diverse, and the article benefits patients, therapists
on page 6 provides tips on how you can be more effective with patients of dif- By Cynthia Saver, RN, MS
ferent cultures and provides resources for further information. Understanding a patient’s culture is
This article ties into our first article for SLPs, which is on how to improve key to promoting a healthy working re-
your assessment of bilingual clients with communication disorders (page 10). lationship. Learn what you can do to
The author provides a four-step process to apply in practice. increase your cultural competency.
This issue also includes an article on pain management for patients who’ve had
total joint replacement surgery. 10 Improve your assess-
Therapy Insider is a comprehensive journal for all therapists, and we’d like ment of bilingual clients
to bring our readers articles about how therapists are working together. with communication
If you have an idea for a story or are interested in writing, contact me at disorders
Cynthia.Laufenberg@wolterskluwer.com. By Li-Rong Lilly Cheng, PhD
Sometimes we’re so busy we don’t take the time to thank our team mem- Assessing bilingual clients can be a
bers. We hope you’ll take a few minutes to acknowledge the stellar efforts of daunting challenge. Find out how to
your fellow members on the therapy team. improve your assessment skills by in-
Cynthia A. Laufenberg creasing your understanding of a
Senior Editor client’s culture.
Therapy Insider

EDITORIAL STAFF EXECUTIVE STAFF

EXECUTIVE PUBLISHER Theresa M. Steltzer Betsy Jones, Executive Vice-President and General
SENIOR EDITOR Cynthia A. Laufenberg Manager, Journals
EDITOR Cynthia Saver, RN, MS Matthew Cahill, Executive Vice-President for Publishing,
MANAGING EDITOR, PRODUCTION Erika Fedell Journals
COPY EDITOR Alina Nardone Ray Thibodeau, Vice President, Advertising Sales
DESIGN DIRECTOR Edward W. Rosanio Therapy Insider is published by Lippincott Williams &
Wilkins, 323 Norristown Road, Suite 200, Ambler, PA
COMPOSITION SYSTEMS SPECIALISTS Robert A. Nanni, Janice Rodan 19002-2758. © 2007 by Lippincott Williams & Wilkins. All
DIRECTOR, JOURNALS PRODUCTION Karyn Crislip world rights reserved. Reproduction in whole or part by
any means whatsoever without written permission of the
PRODUCTION MANAGER Linda Generale publisher is prohibited by law. Subscription information:
ADVERTISING SALES STAFF No charge to those served.
Paula Gould 570-223-6640, Customer service: Address all orders for copies to Therapy
Insider, 323 Norristown Road, Suite 200, Ambler, PA
e-mail: paula.gould@wolterskluwer.com
19002-2758. Phone: 215-646-8700.
Kristi Kenning 1-800-967-3400, 303-279-3012,
e-mail: kristi.kenning@wolterskluwer.com
Kelley Russell 1-800-846-1700,
e-mail: kkrlrp@aol.com

June 2007 1 Therapy Insider

How to control pain and improve
functionality after
total joint replacement surgery
By Matt Tovornik, PT, and Yvonne D’Arcy, CRNP, CNS, MS
T
Total joint replacements (TJRs), especially total knee re-
placements, are among the most painful surgeries. In a
preoperative survey of 20 TJR patients at Suburban
Hospital in Bethesda, Maryland, most indicated that they
expected to have high levels of postoperative pain; post-
operatively, this proved to be the case. Pain management
in TJR patients is complicated by their age, increased
number of comorbidities, and their general deconditioned
status before surgery.
Despite the pain, TJR surgery is often the best treatment
option for some patients, such as those with advanced os-
teoarthritis. Surgery not only lessens the pain from their
condition, but also increases functionality. So, effectively
managing postoperative pain is essential for helping pa-
tients achieve the best possible functional outcome.
In this article, we’ll look at several pain management
options that exist for these patients, including patient-
controlled analgesia (PCA), epidural analgesia, intermit-
tent intravenous (I.V.) injections of pain medications, and
oral pain medication, both extended-release and short-act-
ing formulations. One option that’s usually off limits is
nonselective nonsteroidal anti-inflammatory drugs, such
as naproxen or ibuprofen, because they can prolong bleed-
ing time. Also, keep in mind that any pain management
option must be combined with effective assessment tech-
niques before and during therapy sessions.
Pump away the pain
The PCA pump is a good choice for postoperative pain
management in TJR patients. The surgeon prescribes pain
medication, such as morphine, hydromorphone (Dilau-
did), or fentanyl, which is delivered I.V. through an infu-
sion pump at the bedside. Patients push a button to receive
Therapy Insider
a dose of medication from the pump if their pain level in-
creases. Continuous or basal rates, which deliver a set
amount of medication each hour, are no longer recom-
mended with PCA because they contribute little to pain re-
lief and carry the risk of overdose or oversedation.1,2 An
added benefit of PCA is that patients commonly feel more
satisfied with their pain relief when they use a PCA pump.
They can get pain relief when they need it without waiting
for pain medication, and they can choose when and how
often they use the medication, although a lock-out system is
in place so patients can’t overmedicate themselves.
On the local front
Using local anesthetic for pain relief, either alone, as in a
continuous femoral blockade, or combined with an opioid
delivered through an epidural catheter, is another option
for pain control after TJR. Epidural catheters can be placed
before surgery, used during the operative procedure, and
then continued for postoperative pain relief. The length of
time the catheters can be used is limited, however, because
most TJR patients are started on anticoagulants after surg-
ery, putting them at risk for an epidural hematoma. The pa-
tient’s international normalized ratio or prothrombin time
should be monitored closely while the catheter is in place.
More recently, continuous femoral blockade using an
On-Q PainBuster has become popular for pain control
(see About the On-Q PainBuster).
Progressing to oral medications
Oral medications are started when patients no longer need
the PCA pump or epidural or I.V. pain medications. These
medications should be offered regularly for the first few
days to promote more consistent pain relief.
2 June 2007
 Patients who’ve been using pain medication regularly
before surgery may require extended-release pain medica- About the ON-Q PainBuster
tion such as oxycodone (OxyContin) or morphine sulfate
extended-release capsules (Kadian, Avinza). For most pa-
tients, shorter-acting combination pain medications, such
as oxycodone and acetaminophen (Percocet) or hydroco-
done and acetaminophen (Vicodin, Lortab) may be suffi-
cient to adequately control pain.
Next, let’s look at what role physical and occupational
therapists can play in minimizing pain while optimizing
function in TJR patients.

Pain assessment
Once the health care provider has ordered rehabilitation
for the TJR patient, physical therapists (PTs) and occupa-
tional therapists (OTs) should assess the patient’s pain
level; social history; home environment; discharge needs;
goals; and functional, gait, and strength status. Establishing
a pain level baseline is important for gauging pain toler-
ance and response to activity, such as range of motion
(ROM) exercises. It’s best to use a pain rating scale of 0 to
10 (0 = no pain and 10 = maximal pain) to assess the pain
level. Check for pain at rest and with movement, and then
document the findings at the initial evaluation and after
each subsequent session to maintain a running record of
postoperative pain. A documentation sheet where these re-
The ON-Q PainBuster catheter is placed during surgery at the site of
sults are recorded helps track how the patient is tolerating
the femoral nerve. The catheter has a soaker hose type of perfora-
the therapy.
tion along the end of it, which allows a local anesthetic, such as
bupivacaine, to flow directly over the nerve. The result is a dramatic
On the move reduction in pain. The local anesthetic is contained in a ball-shaped
As the PT begins to mobilize the postoperative TJR patient reservoir and flows at a preset rate, either 5 mL or 10 mL per hour.
with transfer, gait training, and ROM exercises, the results The medication usually lasts for 48 hours postoperatively. Although
of the pain rating scale will be used during therapy to mod- the pain sensation is decreased, most patients have no trouble tol-
ulate the intensity of the sessions. Transfers and gait train- erating the local anesthetic and can participate fully in physical
ing with an assistive device, such as a walker or crutches, are therapy.
essential to facilitating independent mobility and allowing Photo courtesy of I-Flow Corporation, Lake Forest, Calif.
for a safe discharge home or to further rehabilitation.
The OT plays a key role in determining what type of de-
vices the patient will need for activities of daily living. The In addition, cold therapy can be applied locally to the
OT is involved in helping the patient transfer from bed to postoperative joint to decrease pain. The patient should be
chair in the early postoperative period to ensure that this educated on the benefits of cold therapy and routines for
can be done safely. Mobility training helps ensure safe use of cold packs in managing postoperative pain.
functional mobility. Movement also increases blood flow,
facilitates flexibility of all joints and, in turn, helps decrease Camp out
postoperative pain levels. Even before surgery, PTs and OTs play an important role
Remember that activity of any type, especially physical in educating patients about what to expect concerning ac-
or occupational therapy, can dramatically increase pain. tivity level after surgery. Many hospitals have developed
Make sure the patient has been premedicated 30 minutes Joint Schools or Joint Camps—patients come to the hospi-
before therapy or that he or she is using PCA with a drug tal before their surgery to see what their new joint will look
that delivers quick onset of relief. This is the best method like, and to hear from the staff who will care for them post-
to relieve the dynamic pain of movement. operatively.

Therapy Insider 4 June 2007

 At these sessions, exercises can be demonstrated or in-
structional sheets can be handed out to patients so they can
see what type of activity is expected. The PT and OT can
explain the postoperative exercise regimen and the need to
be comfortable enough to tolerate the activity after surgery.
This is the time to stress the benefits of early mobilization
in the plan of care for rehabilitation. It’s an opportunity for
the staff to meet patients and make an initial assessment
about what level of care will be needed in the rehabilitation
period. Some patients with good baseline functioning and
home support may be able to go directly home after
surgery with home physical therapy services. Other pa-
tients who are more deconditioned and have less home
support may need a short stay in a rehabilitation center be-
fore going home.
Most Joint Schools or Joint Camps have a set schedule
for therapy sessions that take place in a large gym area
where the whole group of joint patients can interact and
watch each other progress. This group process is important
in encouraging the patients to follow the plan of care for
participating in both physical and occupational therapy.
June 2007
Many patients report that they’re very satisfied and en-
couraged by the group therapy sessions and their interac-
tions with the PTs and OTs.
Easing the pain
Although postoperative pain control can be difficult in TJR
patients, the benefits of good pain management on early
mobilization is tremendous. The expert assessment skills of
PTs and OTs can help patients understand how to move
more efficiently and with less pain, contributing signifi-
cantly to the overall success of the surgical experience. ■
References
1. American Pain Society. Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain, 5th edition. Glenview,
Ill., American Pain Society, 2003.
2. D’Arcy Y. Treating pain after a total joint replacement. Nursing
2006. 36(5):26-28, May 2006.
Matt Tovornik, PT, is division director, physical medicine and
rehabilitation and orthopedic service, and Yvonne D’Arcy, CRNP,
CNS, MS, is pain and palliative care nurse practitioner, at
Suburban Hospital, Bethesda, Md.
5 Therapy Insider
Cultural competency
benefits patients, therapists
By Cynthia Saver, RN, MS
T
Too often, cultural competence is thought of as something
that’s “nice to achieve.” But it’s essential to optimal care.
Your ability to deliver culturally competent care can affect
everything from your patient’s access to health care to
whether he or she shows up for appointments.
“You need to have a broad understanding of how to in-
teract with many different cultures,” says Erin Shilling, PT,
a physical therapist at UCLA Medical Center in Los Ange-
les. She notes that connecting with patients promotes a
working relationship and makes them more likely to re-
turn for follow-up visits.
Culture is important
The diversity of the U.S. population continues to grow.
Unfortunately, disparity in health care among ethnic
groups is growing too. According to the most recent cen-
sus data, people of color are less likely to be insured than
whites, which can be partly explained by differences in
income and types of employment. Latinos, African-
Americans, Asians, and American Indian/Alaska Natives
are less likely to have a regular source of medical care and
less likely to have visited a health care provider in the past
year than whites.
One reason for this lack of access may be health care
providers’ insensitivity to patients’ cultural needs, which
may result from a lack of knowledge of culturally based
health beliefs and practices (see How cultural beliefs can
affect health care) or perceived lack of time. Yet, not tak-
ing time to learn about a patient’s culture deprives you
of a growth experience and a deeper connection with
the patient. Shilling’s parents are from different cul-
tures, and she cares for patients with a wide range of
cultures at UCLA. She finds comfort in knowing that
“it’s possible for people of many cultures to interact
positively.”
So, how can you deliver culturally competent care that
benefits you, your patients, and your patients’ families?
Let’s find out what steps you can take.
Therapy Insider
Seek to understand
Experts agree that the single most important tactic for
working with people of different cultures is understanding
their values in the following areas:
• Health care beliefs. “Try to understand your patient’s
culture and how it affects his or her approach to health
care in general, and physical or occupational therapy
specifically,” advises Awilda Haskins, PT, EdD. As an as-
sociate professor of physical therapy at Florida Interna-
tional University, Haskins has a diverse student body and
is accustomed to working with patients and families of
different cultural heritages.
Be alert for a mismatch between your own and your pa-
tient’s beliefs. For example, Americans pride themselves on
independence and may not value older adults as much as
many other cultures. “In some cultures, elders are pam-
pered and not allowed to exert themselves when they are
sick,” says Haskins, who cites African, Asian, and Hispanic
cultures as examples. This outlook can be frustrating for
the therapist eager to achieve optimal independence in a
limited time frame.
Culture can even affect preferences for complementary
How cultural beliefs can affect
health care
• Hispanics may believe in a bilongo, or hex, which requires consult-
ing with a healer.
• Many African cultures believe in the “evil eye,” so patients of
African descent may be upset by direct comments of praise.
• During Ramadan, Muslims fast from sunrise to sunset; this includes
abstaining from pharmaceuticals.
• Traditional Navajo medicine includes chanting, prayer, sand paint-
ing, dancing, and herbs.
• Pacific Islanders believe health has four components: spiritual, psy-
chological, physical, and the relationship with family.
Source: The Provider’s Guide to Quality & Culture Web site. http://
erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=
English. Accessed May 3, 2007.
6 June 2007
therapy. For example, some experts have noticed that
Americans use yoga and massage, while Hispanics may
prefer herbal remedies.
Keep in mind that you may need to take more time to
explain the role of physical, occupational, or speech ther-
apy. In his essay on culture and occupational therapy,
Michael Iwama, PhD, OT, noted that many nonwesterners
find occupational therapy difficult to understand and inte-
grate with their cultural views.
• Family involvement. The family’s role in care varies con-
siderably by culture. “We are a very individualistic society,
so we tend to deal with a patient one-on-one,” says Hask-
ins. “We sometimes don’t remember to include family.”
Shilling says, “Even in Europe, we see high cohesiveness of
family, with people living with their families until they are
in their 30s and getting married.”
Ask patients how much help they expect—and want—
from their family, and involve the family based on those
preferences. Asking first is especially important given Health
Insurance Portability and Accountability Act regulations
that restrict discussion of a patient’s condition with family
members unless he or she has given permission, points out
Jo Ann Gardner, PT, MBA, corporate rehabilitation director
for Greystone HCM in Tampa, Florida. It may take time to
work out family involvement, but it’s well worth the effort
and can help avoid misunderstandings down the road.
• Gender roles. In cultures with strong machismo values,
women are more likely to be primary caregivers, which
may affect goals for patients in the home setting. “Our
goals need to be eye-to-eye with the patient,” says Shilling.
If a male patient never prepared meals or did the laundry
at home, these would be unlikely therapy goals. And, if a
culture values the mother as “caregiver,” watch for in-
creased stress when the mother is the patient.
Gender can even affect basic communication. Haskins
notes that in the Haitian Creole culture, the husband may
speak for the wife, so you’d want to ask the wife if her spouse
needed to be present when discussing the treatment plan.
• Time. Culture often plays a role in how time is perceived,
which can create problems for therapists faced with a lim-
ited number of visits. The patient may not understand the
therapist’s timeline.
Nidhi Mahendra, PhD, CCC-SLP, assistant professor at
California State University, East Bay, uses the example of
“clock” versus “event” time. “If you think a visit is sched-
uled for 20 minutes, you’re on clock time,” she says.
“Event time means you believe the visit ends when the pa-
tient’s needs are taken care of.” Those from a culture with
the perspective of event time may become upset when the
number of allotted visits end before their needs are met. “It
helps to explain the situation in the beginning,” says Ma-
June 2007
Eight questions for assessment
These questions, developed by Arthur Kleinman, MD, a professor of
medical anthropology at Harvard Medical School, Cambridge,
Massachusetts, will help you evaluate a culturally diverse population.
1. What do you call the problem?
2. What do you think has caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does?
5. How severe is the sickness? Will it have a short or long course?
6. What kind of treatment do you think you (or the patient, if asking a
family member) should receive? What are the most important
results you hope to receive from this treatment?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness?
hendra, who is a member of the California Speech-Lan-
guage-Hearing Association’s Diversity Committee.
Caution: Assume nothing
There’s a fine line between understanding and generaliz-
ing, or worse, stereotyping. Learn about cultures, but pay
attention to individual differences instead of taking a cook-
book approach. “Hispanics in the United States come from
all over the world, including Cuba, Colombia, Venezuela,
and Mexico,” says Haskins. “There are geographic varia-
tions and variations among individuals.” The patient’s
level of acculturation depends on how recently he or she
immigrated and his or her social structure. Patients based
in a community of a single culture, for instance, are likely
to have had less exposure to American culture. In addition,
remember that patients may also come from a blended cul-
tural heritage, expanding their cultural influences.
A therapist may mistakenly think, “I don’t need to worry
about the patient’s culture. I can just treat the person the
way I would want to be treated. I’ll be fair.” However,
Haskins explains that what is “fair” varies by culture. For
example, white people expect to arrive at their appoint-
ment time and be seen. However, in some cultures (His-
panic, for example), first come, first served is the norm,
which could create conflict if you don’t explain the sched-
uling process ahead of time.
Also, don’t assume that patients aren’t adhering to a
treatment regimen through disinterest; always consider
the possible impact of culture. For example, an American
Indian patient may not return for treatment because the
therapist didn’t acknowledge the value of traditional
healing interventions. Cambodians may use coining (rub-
bing the skin with the side of a coin), which can cause
bruises. The therapist may incorrectly believe that the pa-
tient is a victim of abuse or isn’t taking care of the injured
area.
7 Therapy Insider
Tools and resources
Your attitude can play a large role in promoting cultural
competency, says Sabrina Salvant, EdD, OTR/L, assistant
professor of clinical occupational therapy at Columbia
University, New York. She emphasizes a thorough assess-
ment for patients of all cultures. “Look at the chart for gen-
eral information, such as contraindications to therapy,
then put it aside. Go in with a clear mind and without any
preconceived notions,” Salvant advises. Learn what the pa-
tient values and what he or she hopes to achieve through
therapy. Taking this time up front will help you create a
client-centered treatment plan and avoid wasted time from
lack of adherence to the treatment plan.
To help with this process, the therapy evaluation form
should include an area for cultural assessment. Another
tool is a list of eight questions developed by Arthur Klein-
man, MD, a professor of medical anthropology at Harvard
Medical School, Cambridge, Massachusetts (see Eight
questions for assessment). Although the term “sickness”
may need to be modified for patients undergoing therapy,
the questions still provide a good reference for defining
the patient’s beliefs.
To evaluate pain in pediatric patients, you can turn to the
appropriate Oucher scale, which is available in Hispanic,
African-American, and Caucasian versions. This picture
scale consists of a series of faces that reflect increasing levels
of “hurt.” Each face is assigned a numeric value that’s used
to track the level of pain over time. Another option is the
Wong-Baker FACES Pain Rating Scale, which uses cartoon
faces instead of photographs. Each face is assigned a num-
ber and a brief description of the “hurt.” Instructions for
the scale have been translated into many languages, includ-
ing Spanish, French, Japanese, and Vietnamese.
Don’t forget to ask about education, religion, type of
work, complementary medicine, and support systems, as
you would for all patients. Your assessment may reveal key
information. For example, members of some cultures may
practice voodoo and be skeptical of western medicine (see
Resources for cultural competency for more information).
Cultural preparation
Identify the most common cultures you encounter and
learn more about them by viewing movies, seeking out fa-
vorite foods and, if you have the opportunity, visiting the
country. Also, try to place yourself in situations in which
you encounter different cultures. Salvant says, “The more
information you have is key, and the more you place your-
self in different cultural situations, the more you’ll learn.
Otherwise you’re a spectator in life.”
Don’t forget to consider your experiences, positive and
negative, with other cultures to see how they’ve affected
Therapy Insider
Resources for cultural competency
Web sites
American Physical Therapy Association, http://www.apta.org
American Occupational Therapy Association, http://www.aota.org
American Speech-Language-Hearing Association - Office of
Multicultural Affairs,
http://www.asha.org/about/leadership-projects/multicultural
California Speech Language Hearing Association - Diversity Issues
Committee, http://www.csha.org/diversity.htm
The Henry J. Kaiser Family Foundation,
http://www.kff.org/minorityhealth/index.cfm
The Office of Minority Health, http://www.omhrc.gov
National Center for Cultural Competence,
http://gucchd.georgetown.edu/nccc
Oucher! http://www.oucher.org
The Provider’s Guide to Quality & Culture,
http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=
provider&language=English
Think Cultural Health, http://www.thinkculturalhealth.org
Articles and books
Iwama MK. Revisiting culture in occupational therapy: A meaningful
endeavor. OTJR. 24(1):2, 2004.
Lattanzi JB, Purnell LD. Developing Cultural Competence in Physical
Therapy Practice. Philadelphia, Pa., FA Davis, 2005.
Royeen M, Crabtree JL. Culture in Rehabilitation: From Competency
to Proficiency. Upper Saddle River, N.J., Prentice Hall, 2005.
your attitudes. “Look within yourself,” adds Shilling. “Say,
‘I’m going to treat everyone with empathy and compas-
sion.’” You may want to take a self-assessment quiz such
as the one available on The Provider’s Guide to Quality &
Culture Web site (see Resources for cultural competency).
Once you’ve looked internally, take a look around the
waiting and treatment areas where you work. Is the envi-
ronment inviting to people of different cultures? Haskins
recommends providing consumer magazines in different
languages and hanging artwork that reflects the cultures
of the patients you treat. A painting by Diego Rivera or
Frida Kahlo, for example, might be preferable to one by
Norman Rockwell if your patients are primarily of Mexi-
can heritage.
When learning about different cultures, include nonver-
bal as well as verbal behavior. For example, Muslim
women may avoid eye contact because modesty is impor-
tant, and you shouldn’t interpret it as evasiveness.
Most of all, don’t let fear of making a mistake stop you
from reaching out to patients of different cultures. If you
offend someone, acknowledge the mistake and learn
from it.
8 June 2007
Language barriers
Perhaps the most challenging part of being culturally com-
petent is overcoming language barriers. Your facility
should have a list of translators for patients who can’t
speak English. When using an interpreter, be sure to look
at the patient, not the interpreter. Speak in a normal tone
of voice, pausing every few sentences to allow the inter-
preter to translate.
While it may be tempting to use family members to
translate, don’t do it; this violates the 2000 guideline from
the Office of Civil Rights. If a patient speaks a less com-
mon language such as Hungarian, though, you may need
to ask a family member to temporarily translate until a
translator can be located. Shilling, who recently worked
with a patient from Hong Kong, adds that translators
may not be able to be present for every therapy session in
its entirety, so she emphasizes the need to “show not tell.”
“I turn up the volume by gestures and body language.
Demonstration is always important, but particularly in
these cases,” she says.
June 2007
Patient education
Mahendra says it’s important to have patient education
handouts translated into different languages. They can be
part of other internal resources, such as a binder or flip
chart with common phrases in different languages. “This
helps build rapport quickly,” she says.
Reading level isn’t a cultural issue, but it’s worth re-
membering that many consumers read at or below a fifth
grade level, so it’s important to assess the patient’s literacy
to make sure you can provide appropriate material. “You
might want to rely more on videos, drawings, and illustra-
tions that transcend literacy barriers,” Haskins says.
Lifelong learning
Although you can never totally learn about a culture, it’s
worth making the effort to ensure that patients receive the
care they need. Reading a single book or taking one tutor-
ial isn’t enough. As Salvant says, “Becoming culturally
competent is a lifelong endeavor.” ■
Cynthia Saver, RN, MS, is president of CLS Development, Inc., in
Columbia, Md.
9 Therapy Insider
Improve your assessment of bilingual
clients with communication disorders
By Li-Rong Lilly Cheng, PhD
T
The increasing diversity of clients with communication
disorders requires speech-language pathologists (SLPs) to
acquire greater cultural intelligence—the understanding
of a client’s values, social structure, and linguistic her-
itage.
Cultural intelligence is particularly important when
assessing the client who is bilingual: It contributes to un-
derstanding the true meaning of messages and the com-
municative intents of individuals.
Three types of support
To improve our assessment of bilingual clients, we need
three types of support:
Best practices. When working with bilingual or multi-
cultural clients and families, we must be inquisitive diag-
nosticians, adopting methods that have proven effective
and creating innovative strategies to solve our problems.
We need to use a range of tools to decode the meaning of
verbal, nonverbal, and sociocultural messages.
Cultural competency. We must go beyond interpret-
ing the superficial linguistic meaning of the messages we
receive from culturally and linguistically diverse clients
and decode the cultural implications embedded in the
meaning of the messages. Information on cultural com-
petency can be found at the American Speech-Language-
Hearing Association (ASHA) Web site (http:// www.
asha.org/about/Leadership-projects/multicultural) and
the National Faculty Center at The University of Arizona
(http://nfc.arizona.edu).
Knowledge of bilingualism. SLPs must understand the
nature of bilingualism. Goldstein (2004), Grosjean
(1982), and others have provided useful information
about living with two languages and the development of
bilingualism in children. Another important issue in
bilingualism is the use of interpreters.
A protocol for clinical practice
The following protocol can help you better assess linguis-
tically diverse clients and develop effective interventions.
Therapy Insider
Step 1. Use the SWOT method to assess strengths,
weaknesses, opportunities, and threats:
Strengths. Find a client’s cognitive, social, and commu-
nication strengths.
Weaknesses. Locate the weak points in the client’s over-
all cognitive development and communication patterns
and in her natural and social support system.
Opportunities. Check on optimal learning opportunities.
Threats. Find ways to prevent further challenges and
make certain there’s an accurate diagnosis, thus avoiding
the threat of an incorrect or untimely diagnosis.
Step 2. Use the RIOT approach to assess the client:
Review all relevant background information, including
family history.
Interview individuals who are close to the client.
Observe patterns of behavior and interactions in multi-
ple settings.
Test the client using culturally fair methods.
Step 3. Analyze the data collected.
Step 4. Develop intervention strategies based on the
data, as well as a plan to evaluate their effectiveness.
Learning from cultures
The United States is a nation with many immigrants, mi-
grants, and refugees. As SLPs, we need to be knowledge-
able about different cultures and open to learning from
our diverse populations.
RESOURCES
Cheng L. Lessons from The Da Vinci Code: Working with bilingual/
multicultural children and families. The ASHA Leader Online.
September 26, 2006.
Goldstein BA, ed. Bilingual Language Development & Disorders in
Spanish-English Speakers. Baltimore, Md., Brookes Publishing
Co., 2004.
Grosjean F. Life with Two Languages: An Introduction to Bilingual-
ism. Cambridge, Mass., Harvard University Press, 1982.
Li-Rong Lilly Cheng, PhD, is professor of speech language in the
School of Speech, Language and Hearing Sciences, San Diego
State University, San Diego, Calif.
10 June 2007