Meeting the Challenge: Patient Education in a Diverse America
Fran London MS, RN 

Journal for Nurses in Staff Development
November/December 2008 
Volume 24 Number 6
Pages 283 - 285

As our patient populations become more culturally diverse, it becomes more important to meet the challenge. This article shows how to provide culturally competent patient education by beginning assessment with the 8 Kleinman questions that elicit the patient's explanatory model. It then describes the skills needed to apply the principles of patient-centered care to individualize teaching to the needs, values, and priorities of the patient.

In the article "A Growing Challenge: Patient Education in a Diverse America," McHenry (2007) pointed out that patient education is a vital part of nursing practice, but the inability to provide consistent culturally sensitive patient care to minority populations has most certainly contributed to disparities in health and health care. McHenry concluded that "becoming culturally competent nursing professionals is not a simple task" (p. 87) and that "simply learning about facts about different cultures does not necessarily deem individuals 'culturally competent'" (p. 88). The Office of Minority Health (2007) agreed. Its Web site urges everyone to think about cultural health because healthcare systems need to accommodate increasingly diverse patient populations and cultural competence is a matter of national concern.

So what can move nurses toward cultural competence? What skills do nurses need to provide culturally sensitive care, specifically relating to patient education? McHenry (2007) suggested that case study discussions and games can be mechanisms for building cultural competence. But is there a quicker, more direct way to get there?

The core skills necessary for cultural competence are not new to nurses: listening, observation, empathy, and providing an individualized therapeutic response (as in patient-centered care). These are the same skills necessary to provide efficient and effective patient and family education. This article describes the skills and knowledge that the nursing student or staff nurse needs to provide culturally competent patient and family education.

Starting with an open attitude, cultural competence can be learned through experience at the bedside, during normal care activities. The key tool has been available for nearly 30 years: the Kleinman questions (Kleinman, Eisenberg, & Good, 1978). These questions facilitate the application of a nurse's core skills (listening, observation, and empathy) to assess the patient's cultural needs.


Kleinman et al. (1978) proposed eight questions that a healthcare provider could comfortably ask a patient of a different culture. This means that the healthcare provider does not have to know about the patient's culture but can specifically find out how that culture is reflected in the expression and understanding of the patient's symptoms and illness.

The eight Kleinman questions are the following:

1. What do you think caused the problem?
2. Why do you think it happened when it did?
3. What do you think your sickness does to you? How does it work?
4. How severe is your sickness? Will it have a short course?
5. What kind of treatment do you think you should receive?
6. What are the most important results you hope to receive from this treatment?
7. What are the chief problems your sickness has caused for you?
8. What do you fear most about your sickness? (Kleinman et al., 1978, p. 256)

Once the nurse understands how the patient views the illness, it becomes much easier to individualize care. Information, treatments, and education relating to self-care skills can then be presented within the patient's framework. This patient-centered approach demonstrates respect and minimizes the misunderstandings that arise when a nurse's assumptions are untested.


These eight questions can be presented to the staff in an inservice class and provided on laminated cards that attach to staff badge holders. Instructions include the following:

These are open-ended questions. Incorporate them into conversation into the admission interview and early in the admission, as appropriate. You do not have to ask them all. You do not have to ask them all at one time. These questions are appropriate for all patients, not only for members of minority groups.
If English is not the patient's primary language, even if he or she speaks English, consider using an interpreter. The patient's cultural views may best be expressed and communicated in the language of the culture.
Deeply listen to the responses without judgment. Remember that you are asking these questions to learn the patient's view. If the patient comes from a different culture, religion, or socioeconomic group than you, you may not accurately anticipate what you will hear. Some of the answers may be surprising, shocking, or confusing. Ask for clarification or detail as necessary and appropriate.
Remember that this is the assessment conversation, so at this time, do not correct what you perceive as wrong answers or misperceptions. If you do, it could prevent the patient from being willing to reveal more of his or her point of view, and you need that information to better individualize care. You may answer questions, but do not actively teach at this stage.
Accept that some of Kleinman's questions may not work for all patients. For example, when a patient is asked, "What kind of treatment do you think you should receive?" he or she may respond, "Why are you asking me? That's up to the doctor! Doesn't he know what he's doing?" A way to handle this reaction is to explain that some people come to the physician already believing that they need a specific medicine or surgery. This question is meant to elicit those beliefs.
Document significant findings from this assessment in the patient's chart to share with the rest of the healthcare team. The better that all the team members understand the patient's point of view, the more likely the team can provide patient-centered care.

Discuss the practical application of these questions. Inservice attendees may practice by asking one another these questions. The person role-playing the patient can choose to be a former patient or someone else he or she knows and answer as that person would have. Then, the staff can discuss how interventions may be modified to accommodate the patient's point of view.

It may help to offer nursing students and nurses anecdotes that provide concrete examples, such as those in Fadiman (1997). This book describes what happened when the healthcare providers did not understand the point of view of the patient and family and how, if these Kleinman questions had been asked, the outcomes may have been better.

Active listening is the first step to providing culturally sensitive care, and the Kleinman questions provide basic understanding of the patient's explanatory model. The next step is to learn how to use this information to individualize care and patient education. Consider the Web site of the Office of Minority Health at . This site includes articles and cultural health news and culturally competent nursing modules for independent, online learning at no charge.


The primary purposes of patient education are to ensure informed consent and to promote self-care skills that improve health outcomes. Historically, patient education was based on the assumption that self-care behaviors change when patients receive medical information.

In patient-centered care, in contrast, patients are seen as the experts of their life experiences relating to health and are respected as knowledgeable partners. In this model, healthcare providers and patients negotiate, collaborate, and plan actions that are acceptable to both. They discuss values and priorities and jointly make decisions for treatment management. In patient-centered care, the healthcare provider and the patient find a common ground and come to a mutual understanding. The degrees of collaboration range from the situation when the healthcare provider acts as counselor, helping the patient make decisions, to the situation when the healthcare provider provides information and encourages the patient to explore his or her values and make a decision that best suits his or her situation.

Providing patient-centered care requires not just listening skills but also the professional ability to negotiate decisions. In patient-centered care, the entire interdisciplinary healthcare team needs to understand the patient's point of view, values, and priorities and collaborate on the negotiation. Team members need to coach one another through the process of exploring with the patient what is best for him or her. When interventions are tailored to the patient, with the patient, many of the challenges that create noncompliance are eliminated.

To ensure that the patient clearly understands the teaching and can apply the information, it is essential to evaluate the patient's understanding (London, 1999). This can be done through "teach back," which is having the patient explain in his or her own words what was just learned, or through return demonstration, where the patient shows what he or she will do.


Patient education is most efficient and effective when teaching involves the learner and is individualized to the learner's needs, including cultural factors. Asking the assessment questions developed by Kleinman involves the patient and provides nurses with the information to individualize care and patient education. If, at any point in the process, the interaction becomes frustrating, return to assessment. Frustration is a sign that individualization needs refinement. Ask more open-ended questions to find out how to better tailor interventions to meet the patient's needs.


Evaluating the ability of a nursing student or staff nurse to individualize patient education by taking cultural considerations into account can only be accomplished by demonstrating skill. The student's or nurse's assessment should be reflected in the documentation of patient teaching as well as a description of how teaching was individualized based on the information gained from the patient. Another method of evaluation is to ask the student or nurse to describe the assessment process with a specific patient and explain how the teaching was then individualized. However, because this is valuable information to share with the rest of the healthcare team, true competence should be held to the standard of sharing through documentation.


Becoming a culturally competent nursing professional is, indeed, not a simple task. It is a process. First, one must be a competent nurse with listening, observation, and empathy skills who uses evidence on which to base his or her practice. Then, this evidence must be considered in light of the patient's concerns and preferences (Melnyk & Fineout-Overholt, 2005). Kleinman's questions enable the nurse to begin a conversation to elicit the patient's explanatory model. From there, the negotiation begins in the framework of patient-centered care, including patient education that is individualized to the needs and preferences of the patient. Ultimately, the only way to move from a theoretical transcultural framework to the functional provision of culturally competent care is to practice it. Fortunately, the patient-centered care model allows the nurse to come to the relationship without assumptions and prior knowledge of the patient's culture. It allows for conversation, mutual exploration, errors and corrections, and negotiations. The nurse does not have to be an expert at determining the best interventions but must know how to collaborate with the patient to find them. That is culturally competent patient education.


Fadiman, A. (1997). The spirit catches you and you fall down: Among child, her American doctors, and the collision of two cultures. New York: The Noonday Press. [Context Link]

Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258. [Context Link]

London, F. (1999). No time to teach? A nurse's guide to patient and family education. Philadelphia: Lippincott Williams & Wilkins. [Context Link]

McHenry, D. M. (2007). A growing challenge: Patient education in a diverse America. Journal for Nurses in Staff Development, 23(2), 83-88. [Context Link]

Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins. [Context Link]

Office of Minority Health. (2007). Think cultural health. Retrieved May 19, 2007, from [Context Link]