A goal of Healthy People 2020 is to increase the percentage of satisfactory communication skills between individuals and healthcare providers (U.S. Department of Health & Human Services, 2019). In the past few years, mandates for effective patient–provider communication have been issued by accrediting agencies across the medical continuum (The Joint Commission, 2020). Therefore, communication becomes a significant role function.
As immigrants enter the United States and seek to access the healthcare system, a need exists to prepare nonnatives for the cultural challenges, including communication with healthcare providers and nurses. One tool for improving intercultural communication is role-play; this article describes the use of role-play to teach intercultural communication and bridge the gap between healthcare professionals and Muslim women.
In 2020, approximately 1.9 billion Muslims accounted for 24% of the world population (World Population Review, 2020). As many individuals from predominantly Muslim countries are often refugees or asylum seekers, the number of Muslim immigrants in the United States has increased (Mohamed, 2018). Cultural transition is important for refugees; however, Muslim women who attempt to balance new liberties in this Western culture while maintaining established culture ideals and gender roles experience challenges (Connor et al., 2016). Due to lack of autonomy in decision making, many Muslim women are vulnerable, and intercultural interaction appears to be one obstacle to Muslim women receiving healthcare (Seeger, 2015).
Building a solid patient–provider rapport contributes to better healthcare experiences as well as alleviates anxiety and enhances patients' engagement in healthcare decisions (Dang et al., 2017). Furthermore, a variety of communication skills, such as those showing respect for a patient's beliefs, affect the level of trust between patients and healthcare staff (Hashim, 2017). If trust is not present, patients may withhold information that could affect clinical decision making and health outcomes. As Blackstone et al. (2015) found people who speak a nonnative language are communication-vulnerable, so consideration of their lack of proficiency in reading and writing of the English language is important. Strategies to enhance communication with patients, especially nonnatives, is essential.
As a teaching strategy, role-play has the potential to aid Muslim women as well as providers within the North American healthcare system. Role-play has been used as an effective communication teaching strategy (Taylor et al., 2018), for example, with English as a second language (ESL) students (Abdul-Rahman & Maarof, 2018; Nhongo et al., 2017). Doyle-Moss et al. (2018) showed that nursing students who learned role-playing to communicate with ESL students considered the learning experience as positive for preparation of real-life interactive situations.
Among the fundamental communication dimensions of interaction is patient-care provider concordance or the ability of both parties to have alike conclusions about contexts related to the interaction (Nordness & Beukelman, 2017). Effective communication between healthcare professionals and patients is associated with improved outcomes and satisfaction (Chandra et al., 2018). To accurately provide a perspective, the patient should be able to effectively communicate his/her needs, concerns, and preferences. However, both sides of the healthcare interaction must be participatory and communicate knowledgeably to achieve the best outcomes. Overall, D'Agostino et al. (2017) noted that role-playing can successfully increase patients' participation in healthcare interactions.
The Muslim faith incorporates numerous traditions with diverse views related to illness and health. Consequently, delivering care to Muslim patients is often difficult for non-Muslim healthcare workers (Attum et al., 2020). During mission trips, the author held conversations that revealed some of the challenges encountered by Muslims when accessing and utilizing the United States' healthcare system. Stories behind the hesitancy of the Muslim population seeking medical assistance were particularly enlightening. The information shared through the stories opened doors for the disclosure of concerns associated with visits to healthcare settings. Accounts of confusion and of misunderstandings related to personal and family members' experiences were articulated. Some factors identified as barriers follow:
- lack of communication between provider and patient
- differing background of healthcare providers
- assumption of availability of a specific gender as a provider
- lack of satisfaction with the use and clarity of the provider's language
- use of medical and technical terms by the provider
- deficiency in answering questions.
According to the World Affairs Council of Houston (n.d.), “The transmission of knowledge, history and experience in West Africa was mainly through the oral tradition and performance rather than on written texts” (p. 1). Thus, this author concluded that the incorporation of drama into real-life situations could be used to lessen stressful situations encountered in the healthcare setting by these Muslims.
Communicating with Muslim women in a healthcare setting requires awareness of the following points: The hijab (scarf or veil), and the chador or burqa (fabric that covers from head to toe) worn by a Muslim woman symbolizes her devotion to her Islamic faith and is also an expression of her modesty. Modesty must be preserved during examinations.
- In some sects, it is unlawful for Muslim women to go out in public without a male relative. This male escort may also be present for clinical visits.
- Muslim women are typically prohibited from making direct eye contact with any male other than their husbands.
- Verbal and/or written instructions recommending a well-balanced diet should not include the consumption of pork. Muslims consider the eating of any hoofed animal as unclean.
- Patients seen during Ramadan (a month-long holiday of fasting and prayer) may not follow healthcare instructions to drink plenty of liquids throughout the day and to eat three meals daily.
ROLE-PLAYING AS A LEARNING ACTIVITY
The learning activity originated from the author's previous experience as a family nurse practitioner and the observation of other clinicians, recognizing insufficient cultural knowledge related to caring for Muslim women. As the focus of Madeleine Leininger's Theory of Culture Care Diversity and Universality (2008) is for nursing care to have beneficial meaning and health outcomes for individuals of different cultural backgrounds, the theory was used as the framework for the learning activity. The guidance of the theory afforded the provision of culturally congruent nursing care through a cognitively based assistive approach tailored to the values, beliefs, and lifestyles of Muslim women. In the end, Muslim women gained a communication tool to assist them in seeking and receiving healthcare in a culturally meaningful way in the United States.
Several Muslim women who voiced a lack of proficiency in understanding the English language but not in speaking it asked the author to assist them in communicating with healthcare providers in the United States healthcare system. A role-play activity was chosen to meet this request. The “Almost-Real Life” role-play guidelines suggested by Rao and Stupans (2012) were used to develop the learning activity for the women. This type of role-play allows participants to develop their skills in a realistic, yet protected setting. No cost or payment for participating in the activity occurred and involvement was voluntary.
The role-play activity was implemented at a West African Center in a large metropolitan city in the northeast United States. Dressed in traditional West African attire, the women sat in folding chairs complemented by individual tray tables. During the interactions, the women served as the patients and the author acted the role of the provider. Because one of the Muslim women had a slightly better command of the English language, she served as an interpreter for the other women as needed. The activity focused on overcoming the language barrier by preparing these nonnatives for interactions associated with common illnesses.
For the activity, the women chose imaginary complaints that would require a healthcare visit. Some of the potential ailments were common to both men and women in all cultures. One scenario began with a cough associated with a common cold. A volunteer agreed to enact the role of a patient with the imaginary chief complaint. The author asked questions like those routinely asked in a medical setting. This afforded the women an opportunity to practice responding in a familiar, nonthreatening environment.
As the encounter proceeded, the other women listened and observed the interactions, gleaning skills useful for their healthcare encounters. In addition to preparing the women to answer anticipated questions in the healthcare setting, the provider's expectations during a medical encounter were discussed. When unfamiliar words were identified, the women wrote the information on notebook paper. Following the activity, the meanings and contexts for the words were reviewed. Insights about unspoken thoughts, feelings, and attitudes, which often affect healthcare decisions and outcomes, were explored. An example of a role-play conversation follows:
Provider: “Hello. I am the nurse practitioner who will be seeing you. What brings you in today and how may I help you?”
Patient: (Smiled shyly before she answers) “I am coughing.”
Provider: “Ok, you have a cough. How long have you had your cough?”
Patient: (Appears more serious as if she wants to give the appropriate answer) “For a long time.”
Provider: “What do you mean by a long time? Tell me how many days you've had your cough and if you have had a fever or anything else going on?”
Patient: “I have had my cough for seven days, but I have not had a fever. Nothing else is wrong.”
Provider: “When and how much do you cough?”
Patient: “I cough every day even when I am trying to sleep.”
Provider: “Describe your cough to me? Is it dry? (demonstrates a dry cough) “Or does it seem as if you need to cough something up?”
Patient: “I need to cough something up.”
Provider: “What things have you done to try to get rid of your cough?”
Patient: “I drank ginger tea; it helped some.”
Provider: “What other things helped your cough and what seemed to make your cough worse?”
Patient: I ate ginger candy and it helped too, but nothing makes it worse.”
Provider: “Thank you. You did a great job answering my questions and pretending to be sick.
(Volunteer smiles broadly). If you were being seen in a real office, the provider would now perform an examination. Once the provider determined how to treat your cough, you would receive instructions before leaving the visit.”
In a group setting, certain healthcare topics may have caused embarrassment. Therefore, sensitive complaints, such as female-related concerns, were discussed in private settings and not as a part of the group's role-play activity. Emphasis was placed on teaching the women to become familiar with their bodies to improve recognition of issues. For example, instructions on how to perform a breast self-examination were provided. In order to be respectful of culture and privacy, the women remained completely dressed as the procedure was demonstrated. (See Sidebar: Health Insights About Muslims.) The nurse practitioner highlighted the benefits of the women's ability to complete the exam within the privacy of their homes. The women were taught to look for abnormalities such as the development of a lump, discharge other than breast milk, swelling of the breast, skin irritation or dimpling, and nipple abnormalities (such as pain, redness, scaliness, or inversion). The importance was reiterated of contacting their provider immediately for any of the findings.
Special attention was given to ensure the information given was not rushed and that comfort level of the subject matter was adequate. Nonverbal behavior was observed closely when waiting for permission to continue the learning activity. The women were very attentive, often nodding their heads to confirm comprehension. At times, a soft clicking sound was heard from their throats which also indicated understanding. All the women appeared to understand regardless of culture that females need private time to discuss “women-only issues.” In the end, based upon observations, the role-play activity seemed effective in reducing anxiety and increasing comfort in this group of Muslim women.
Nonnatives who move to the United States experience many challenges associated with adjustment to a different culture. Often, a visit for medical care requires the navigation of a challenging healthcare system. Christians have the opportunity to implement this directive: “Each of you should use whatever gift you have received to serve others, as faithful stewards of God's grace in its various forms” (1 Peter 4:10, NIV). Therefore, the nurse practitioner's gift of knowledge related to role-play was useful to assist nonnatives in gaining effective communication skills that transcend cultural barriers. The technique was effective in training individuals to evaluate their own communication skills to identify their weaknesses and make the necessary corrections, subsequently increasing self-confidence. The role-play equipped nonnative women with the knowledge of some expectations in the healthcare system. In turn, the activity assisted them in the acquisition of a sense of peace while being seen by a provider for a health concern. Overall, the positive encounters led to the development of a relationship of trust with healthcare professionals throughout the United States healthcare system.
IMPLICATIONS FOR NURSING PRACTICE
Providers and nurses should be able to communicate successfully with patients in order to achieve desirable outcomes. Effective information exchange ensures that concerns are elicited and explored. However, conflicting beliefs can affect healthcare through competing therapies, fear of the healthcare system, or distrust of prescribed therapies. As nonnatives have the potential of experiencing language-discrepant interactions, healthcare staff must be aware of the need to adjust in communication when caring for these patients. As role-play is one of several ways to provide context-bound communication skills training to decrease language barriers (Cox & Li, 2020), incorporating role-play to improve communication with nonnatives allows views from different perspectives to shape assessments and subsequent treatments. Strengthening the patient–provider relationship through the role-play training model reduces cultural and linguistic barriers, which ultimately could result in better healthcare outcomes in nonnatives.
The increasing diversity in North America brings opportunities and challenges for healthcare providers, nurses, and systems to deliver culturally competent services. A culturally competent healthcare system could improve outcomes and quality of care as well as influence the elimination of racial and ethnic health disparities. Delivering high-quality care for nonnatives requires an understanding of the differences in cultural and spiritual values. For years, healthcare providers have been educated on these variations in multiple populations of people. An emphasis has been placed on maintaining professionalism and delivering care while being culturally sensitive and competent related to the patient's beliefs. Nurses and other healthcare professionals have the added responsibility of having at least a basic understanding of various viewpoints such as privacy, touch restriction, and ideas of modesty. Furthermore, a provider or nurse must recognize his/her feelings and behavior toward those outside their own culture in order to be effective in providing care. Displaying an awareness of different cultural practices can facilitate comfort and effective patient expressions of health concerns during healthcare encounters. Despite differences in health practice ideas of wellness and even beliefs associated with religion, nurses have a responsibility to provide care that positively impacts the lives of their patients throughout the continuum of care. In the end, based upon observations, the role-play activity appeared effective and positive in reducing anxiety and increasing comfort in this group of Muslim women.
Sidebar: Health Insights About Muslims
Islam, the faith system followed by Muslims, is the third largest religion in the United States and continues to grow through immigration and conversion. African Americans comprise about 20% of this nation's Muslim population; most are converts to Islam (Mohamed, 2018).
Due to religious beliefs and modesty, the best healthcare practice is for Muslim clients to have a provider of the same gender. In general, Muslims limit eye contact with persons of another gender. Providers should refrain from extending a hand for a handshake or otherwise touching Muslim clients unless necessary.
During a physical exam, a healthcare provider can show respect by asking for the least amount of clothing to be removed, and to inform the patient about each step of a procedure or exam before proceeding. During history taking, specifically ask about the use of herbs and supplements, as these are commonly used.
According to Attum et al. (2020), the Islamic faith has a high regard for health and considers care of one's health a religious duty. Additionally, Muslim individuals believe that sickness, suffering, and dying are a test from God (Attum et al., 2020).
Ingesting alcohol and pork or any pork- or alcohol-containing food, supplement, or medication is prohibited, including gelatin and possibly magnesium stearate.
Ramadan, the month of fasting from food and liquids from sunrise to sundown, means that patients with diabetes need extra attention. Attum et al. (2020) suggest healthcare staff recommend that these individuals eat just before dawn and right after sundown to regulate their glucose and medication. Education about the signs and management of hypoglycemia is necessary. Breaking the fast is allowed in the Muslim faith if a person becomes severely hypoglycemic (Attum et al., 2020), and the chronically sick and the elderly who are not able to fast can forego fasting.
Unlike the North America culture where individualism is prominent, Muslims are highly family-oriented, and the extended family is a strong element of support. Expect that family members will be consulted and discuss medical needs and decisions as a group. Nurses and providers who consider the family unit in communication, planning, and treatment decisions will have better success.
—Karen Schmidt, BA, RN, JCN Contributing Editor
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