Activity 4: Intercultural communication principles
If you have not already completed the PCC4U module Communicating with people with life-limiting illnesses, please go to this module now and review the key principles for communication in palliative care.
Intercultural communication shares information between people of different cultures where language, nationality, ethnicity, values and customs differ. Communication between people from different cultures can be challenging due to possible misunderstanding of words and phrases. Some cultures rely more on behaviours rather than words and phrases than others. This requires health professionals to consider alternative strategies to verbal or written communication. 
When communicating with a person from a culturally and linguistically diverse background where English is their second language, some additional considerations are listed below. Whilst communicating in ways which would not be considered patronising or disrespectful, consider the following:
- who is present
- being aware of gender and age implications
- asking the person about their understanding of the situation
- avoiding jargon and acronyms used in the workplace
- describing medical terminology
- using visual aids to support understanding
- slowing down your body language and speech
- using plain language
- repeating important information
- addressing things, one at a time
- asking the person about their worries or concerns
- asking the person their thoughts/understanding of the situation.
Observe the tone of voice and nonverbal gestures used, as words account for only a portion of communication. Some cultures convey messages largely through body movements, gestures, posture, tone of voice and expressions. The use of silence, eye contact, touch, space and distance can all have different meanings and significance within a culture.  For this reason it is important to use a number of sources of observation to confirm the person’s understanding, as well as asking the person.
Showing compassion, kindness and respect for cultural differences to a person and their family will foster trust and open communication. 
Working with interpreters
People who speak little or no English require a medical interpreter to convey a prognosis and information for health professionals. Trained interpreters are used to speak to medical staff and understand some of the medical terms used.  They can also assist the health care professional to understand the person’s wishes and questions, especially when completing an advance care plan. 
Medical interpreters providing face-to-face, video conferencing or over the phone interpretation is available through services in Australia.
Not all interpreters will have skills in conveying bad news. Information can be altered or poor prognosis not interpreted at all in delivering messages. Confidentiality can also be an issue where they are a part of a small community or they know the person and their family. 
It is not uncommon for a person to request that someone they know act as interpreter. It is advisable however, that where possible family and friends are not used as interpreters as they may feel constrained or uncomfortable at the nature of the discussion. Where a medical interpreter is not available, questions should be asked to determine the person most suitable to interpret. Children should not be used as interpreters as they may misunderstand what is being said which could be harmful to them.  Asking a person who has not been professionally trained as a medical interpreter can cause:
- inaccuracies in information given due to lack of knowledge relating to medical concepts and terminology
- altered or distorted information being portrayed and suppression of information possibly related to ‘truth telling’
- breach of confidentiality
- invalid consent. 
Professional medical interpreters should be present when information is given or required from a person whose English is their second language, including:
- during admission, assessments and development of management plans
- explaining procedures, medical information and medication
- consenting for operations, procedures, treatments and research
- identifying correct person, procedure and procedure site
- giving prognostic information and bad news
- during family meetings and case conferences. 
When engaging an interpreter to assist with communication, consider the following principles when holding the meeting:
- informing the interpreter service of the nature of the meeting, gender and/or age preference, especially if sensitive matters will be discussed and brief information on the person’s condition
- speaking with the interpreter prior to the meeting to gauge their understanding of the terminology and concepts that will be mentioned during the conversation
- allowing time for the interpreter to briefly meet with the person and their family prior to the meeting
- using plain language when discussing care, for example a phrase such as “you may want to spend time with your family now” can be confusing and may be lost in translation
- including everyone one involved in the conversation rather than only looking at the interpreter
- avoiding long speech segments and highly technical language
- clarifying information with the interpreter regularly throughout the conversation
- asking the person and their family about their understanding and thoughts on new information and allowing time for a response
- allowing time at the end of the meeting for any questions or concerns to be raised
- offering counselling or debriefing to the interpreter after the meeting if the nature of the conversation was particularly distressing. [6, 9, 10]
Cue cards can be useful when communicating basic terms and concepts with people who have trouble communicating in English. Terms such as pain, toilet, drink, happy and sad can be conveyed on a cue card with an image and a word. A wide range of medical cue cards are available on the Eastern Health website.  Take care to ensure these cue cards are able to be read and understood by people who may have visual or cognitive impairments.
Brochures and resources containing information in languages specific to the person with a life-limiting condition can be useful to assist with care and for educational purposes. Multilingual resources with information on palliative/end-of-life care, symptoms and management are available on the Palliative Care Australia website.  Short videos relating to palliative care spoken in Greek, Italian and Cantonese are available on the CareSearch website. 
However cultural competence respects the diversity within cultural groups, and supports an approach to care that seeks to understand and respond to individuals within the context of their culture.
- Novinger, T. (2001). Intercultural communication: a practical guide. Austin, Texas: University of Texas Press.
- Huang, M., Yates, P., & Prior, D. (2009). Accommodating the Diverse Cultural Needs of Cancer Patients and Their Families in Palliative Care. Cancer Nursing, 32(1), 12-21.
- Sharma, R. K., & Dy, S. M. (2011). Cross-Cultural Communication and Use of the Family Meeting in Palliative Care. American Journal of Hospice and Palliative Medicine, 28(6), 437-444.
- CareSearch. (2012). Multicultural. Clinical Evidence. Retrieved September 11, 2013, from www.caresearch.com.au/caresearch/tabid/229/Default.aspx
- Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., & Normand, J. (2003). Culturally competent healthcare systems: A systematic review. American Journal of Preventive Medicine, 24(3), 68-79.
- Broom, A., Good, P., Kirby, E., & Lwin, Z. (2013). Negotiating palliative care in the context of culturally and linguistically diverse patients. Internal Medicine Journal, 43(9), 1043-1046.
- Queensland Health. (2012). Literature review: Best practice multicultural policy implementation. Retrieved from www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-080-att-b.pdf
- Ministry of Health NSW. (2006). Interpreters - Standard Procedures for Working with Health Care Interpreters. Policy Directive Retrieved from www0.health.nsw.gov.au/policies/pd/2006/pdf/PD2006_053.pdf
- Butow, P. N., Sze, M., Eisenbruch, M., Bell, M. L., Aldridge, L. J., Abdo, S., Tanious, M., Dong, S., Iedema, R., Vardy, J., Hui, R., Boyle, F., Liauw, W., & Goldstein, D. (2013). Should culture affect practice? A comparison of prognostic discussions in consultations with immigrant versus native-born cancer patients. Patient Education and Counseling, 92(2), 246-252.
- Australian Institute of Interpreters & Translators (AUSIT). (2007). AUSIT Guidelines for Health Professionals Working with Interpreters. Retrieved from http://ausit.org/AUSIT/Documents/Guidelines_For_Health_Professionals.pdf
- Hiruy, K., & Mwanri, L. (2013). End-of-life experiences and expectations of Africans in Australia: Cultural implications for palliative and hospice care. Nursing Ethics (Online). Retrieved from http://nej.sagepub.com/content/early/2013/03/04/0969733012475252.abstract
- Palliative Care Australia. (2012). Multilingual resources. Resources. Retrieved September 11, 2013, from www.palliativecare.org.au/6Old/MultilingualResources.aspx
Activity 4: Intercultural communication principles
- Consider the principles when communicating with a person whose second language is English. Outline strategies you would use to:
(a) say good morning and ask how they are feeling
(b) explain how and why vital signs are taken
(c) explain the goals of palliative care as opposed to active treatment
(d) explain an Advanced Health Directive order.
- Consider a scenario that requires an interpreter to be involved. What information would you give to the interpreter prior to commencing the interview with the person with a life-limiting condition?