Stages of Grief
Dr. Elisabeth Kübler-Ross devoted much of her life to the study of the dying process and working with dying patients. She divided the grief process into five stages that she believes all persons go through (Table 5-7). It is helpful to understand these stages when attempting to help the dying patient. Although these stages relate to death, they can also relate to other losses, such as loss of body organs, health, marriage, or family members. People move between these phases, but not necessarily in a linear fashion.
As the time of death approaches, some of the earlier stages may be repeated. For example, patients who cannot care for themselves may become angry. The critical point to remember when assisting a dying patient is that the grieving period is a normal part of the dying process. The goal is for the patient to eventually accept the loss.
It is also important to understand that family and friends of the patient may be going through the stages of grief at a different pace than the patient. Although the patient may have reached the stage of acceptance, others who love that person may still be in denial, angry, bargaining to gain time, or depressed. You can be most helpful by being as sensitive as possible to the states of emotion of all those who are dealing with that person’s death.
Diverse Patient Populations
As a medical assistant, you will come in contact with people from many different cultures. A culture consists of the values, beliefs, attitudes, and customs shared by a group of people and passed on through the generations. Behaviors exhibited by the members of a culture are based on their beliefs and values. Health care beliefs may differ widely from those you are accustomed to. As you come in contact with people from cultures other than your own, be aware that diversity can create its own barriers to effective communication. To break through these barriers, you must be tolerant in attitude and treat each patient with respect, dignity, and understanding.
It will also be important for you to be aware of your nonverbal communication and that of the patient. As you research the different cultures in your area, you must learn how nonverbal communication varies across the cultures.
You must determine if eye contact should be direct or indirect. Not having proper eye placement can interfere with the communication process.
Facial expressions can show a variety of emotions, such as sadness, anger, confusion, and happiness. Facial expressions can also differ from culture to culture. A smile does not always mean kindliness or friendliness; it may also be a sign of fear. It will be important to determine what different facial expressions mean.
Hand gestures also vary across cultures. Some gestures that are accepted in U.S. culture are considered inappropriate in others. It is very important for you to understand the appropriate gestures to use for a particular culture.
Each culture has unique aspects related to medical care. You should be familiar with cultural practices and risk factors for the cultures that are served by the physician practice. Patients from some cultures, such the Haitian culture, believe in magic, so it may take time to build rapport and trust with them. People from other cultures, such as the Amish, may not carry insurance, and thus may prefer to pay cash toward medical bills. In cultures that value large families, such as many Appalachian communities, infertility may carry a stigma. Arabs have been shown to have difficulty metabolizing antiarrhythmics, antidepressants, betablockers, neuroleptics, and opioid agents, so they may experience elevated blood levels and adverse effects when customary dosages are prescribed. Chinese immigrants have an increased incidence of hepatitis B and tuberculosis. Cuban Americans have a high rate of coronary heart disease, hypertension, obesity, type 2 diabetes, and depression. Jewish patients have a higher rate of the genetic disorders called Gaucher’s disease and Tay-Sachs disease.
**TABLE 5-7 | Dr. Elisabeth Kübler-Ross’s Five Stages of Grief
Denial A refusal to believe that dying is taking place. In this stage, the patient (or family member) may need time to adjust to the reality of approaching death. This stage cannot be hurried.
Anger At this stage, the patient may be angry at everyone and may express this intense anger at God, family, and even health care professionals. The patient may take this anger out on the closest person. Usually this is a family member. In reality, the patient is angry about dying.
Bargaining The third stage of grief involves attempting to gain time by making promises in return. The patient may bargain with God. The patient may also indicate a need to talk at this stage.
Depression This stage is marked with a deep sadness over the loss of health, independence, and eventually life. There is an additional sadness of leaving loved ones behind. The grieving patient may become withdrawn.
Acceptance The acceptance stage is characterized by a sense of peace and calm. The patient may make comments such as “I have no regrets. I’m ready to die.” It is better to let the patient talk and not make denial statements such as “Don’t talk like that. You’re not going to die.”
Bias, Prejudice, and Stereotyping
Bias, prejudice, and stereotyping are barriers to effective communication that directly relate to cultural diversity. As discussed previously, culture is defined as the values, attitudes, and behaviors particular to a group of people.
Bias is an unfair preference for or dislike of something. A bias prevents forming an impartial opinion of someone or something. Prejudice is a preformed and unfavorable belief or attitude toward a certain culture or group with little or no information about the culture or group. Stereotyping is an idea people hold about the characteristics of a group. These ideas may be true of some members of the group but are unfairly applied to everyone in the group, or they may simply be untrue. Stereotypes are usually negative.
Ethnicity is a classification of people based on a group they are part of. They may be people of the same national origin or the same race or the same religion. People from the same ethnic background are likely to share similar traditions, beliefs, and language.
Race is a classification of people based on their physical or biological characteristics, such as skin color, shape of eyes, hair type, bone structure, or facial features. Race is often used to classify people unfairly and unjustly in a negative way.
People who are ethnocentric believe that their cultural background is better than any other. This leads to prejudice, prejudging, and stereotyping, which can negatively impact communication and the acceptance of others.
As a medical assistant, to avoid these negative behaviors, you should adhere to the following behaviors:
- Be aware of your own beliefs.
- Learn as much as possible about other cultures, races, and nationalities.
- Be sensitive to the feelings of others.
- Evaluate information before accepting it as a belief.
- Avoid ethnic jokes.
- Be open to differences.
- When unsure of a patient’s cultural beliefs, ask the patient to help you understand.
Language
A patient who speaks a language other than English is at a disadvantage when trying to obtain health care in the United States. Imagine, for a minute, how you would feel if you were traveling in a foreign country and had an accident that required you to go to the hospital. If you did not speak the language in that country, you might not understand anyone in the hospital, and the health care practices also might be very different from what you are accustomed to at home. Your feelings of fear, frustration, and confusion would be increased if you had no one to act as an interpreter. It will help you to be more tolerant if you imagine yourself in the position of the patient who does not speak English or does not speak it well.
You will encounter patients and other health care workers who speak a wide variety of languages. Speakers of Spanish are the second-largest language group, after English speakers, in the United States today. It would be helpful for you to learn a few phrases and some simple words in Spanish to help communicate with Spanish-speaking patients and coworkers. The same is true for patients who speak other languages. If at all possible, when a patient is not completely comfortable with English, you should get someone to interpret for the patient. Perhaps a fellow worker or family member could help. For patients with a limited ability to understand English, speak slowly and clearly (not louder), using simple words or phrases. Smiling and other positive nonverbal cues are helpful. You might try to demonstrate or act out what you want the patient to do. Use pictures, if they are available, to help relay messages, or make a clear drawing to get your point across.
When you are talking to a patient for whom English is not the primary language, use simple and common words. Avoid using medical terms if possible. You should never use slang. It is important for you to determine if the patient understands you. Sometimes patients who do not understand English pretend to understand so as not to seem impolite.
Procedure 5-4 will help you role-play interacting with a patient who does not speak English well.
***PRCOEDURE 5-4 Communicating with a Patient When There Is a Language Barrier
Communicating with a Patient When There Is a Language Barrier
Equipment and Supplies Pen or pencil; paper
Method
- Choose a classmate.
- Select a quiet part of the classroom to conduct the procedure.
- Determine who will be the medical assistant and who will be the patient.
- Have the student acting the part of the patient pretend to speak very little English.
- Be calm, respectful, and considerate (Figure A).
- Use simple and common words.
- Avoid using medical terms.
- Never use slang.
- Pay attention to your eye contact, facial expressions, and hand gestures.
- Make the patient feel as comfortable as possible. Note: In a real-life situation, if a staff member who speaks the patient’s language is available, offer to have that staff member translate the conversation if that would make the patient feel more comfortable.
- Document the interaction in the patient chart.
Charting Example
9/30/YY 8:05 a.m. Patient states that he speaks little English. Gave patient handout in Spanish after demonstrating procedure to the patient in the office. C. Glidewell, CMA (AAMA)
Figure A A medical assistant must be prepared to work with a patient who does not speak English.
Diverse Viewpoints
People from other cultures have different views and customs relating to health care delivery. Your views and customs may not be better than theirs, just different. Patients may have different views about the causes of illness, the treatments, and the behavior expected of the health care provider. In some cultures, illness is thought to be caused by winds or other forces, blood being too thick or thin, or the ill will of others. The best way to learn about the views of someone from another culture is to ask them.
You may not always be successful in encouraging patients from a different culture to relate their symptoms and signs to you. Patients may feel that talking about physical pain is a sign of weakness, or they may be forbidden to mention psychologic problems or to mention certain parts of the body or bodily functions. One of the duties of the medical assistant is to help ensure that the patient complies with the treatment physicians prescribe, whether it is in the form of medication or therapy or diagnostic examinations. It may be necessary to ask for assistance from a family member who understands the issues and can communicate more easily. Table 5-8 lists some diverse cultural traditions.
Religious Diversity
There are many religious beliefs and practices that may affect the interaction and communication between the health care provider and the patient. The medical assistant must become familiar with the various beliefs and practices associated with the religions adhered to by patients. Many religious communities exist in the United States, including Jehovah’s Witnesses, Christian Scientists, Orthodox Jews, Mormons (Church of Jesus Christ of Latter-Day Saints), and Amish. These religious groups may have varying beliefs about immunizations, blood transfusion and organ donation, childbirth and fertility, dietary restrictions, and the overall approach to health care delivery. There are also religious holidays that must be observed, so in scheduling appointments, be careful to respect the patient who is unable to accept an appointment on the date of a religious holiday or special observance.
**TABLE 5-8 | Cultural Traditions in Health Care
Country/Cultural Group Sick Care Practices Health Care Beliefs Family Role in Care China Holistic and traditional; includes acupuncture, herbal medicine Upset in body energy causes disease. Stigma is attached to mental illness. Health promotion is important. Family takes care of the sick, even in hospital.
Former Soviet Union Holistic, folk, and Western medical practices Health promotion is important. Acute sick care is practiced; rehabilitation is not stressed. Family members provide care in hospital: bathing, feeding, changing linens. Philippines Health promotion is important. Mental illness is a disgrace. Evil cast from the eyes of another can cause illness. Family may give hospital care. Children feel obligated to care for elderly. Vietnam Health care practices contain magical and religious components. Eastern and herbal medicine are important. Selfcare and self-medication are used to treat illness. Only acute sick care is permitted. Health is believed to come from the restoration of yin and yang and hot and cold balance. Patient care is a family responsibility. Hispanic/Latino Health care involves belief in God and fate. Good health may be luck. Believe transgressions or sins may contribute to illness. Natural and supernatural worlds exist, and body and soul are inseparable. Holistic practices are well accepted. Family is integral part of the health care process. They are involved in the decision making as to care and treatment of the patient. Native American Health care involves belief in religious and spiritual traditions. Rely on Mother Earth for remedies and healing powers. There must be harmony between the body, mind, and spirit. Family members, especially elders, are critical to the care of patient. Tribal leader may be consulted for advice in treatment.
Gender and Sexual Orientation
Sexual orientation describes what gender someone is sexually and romantically attracted to. A straight person is attracted to people of the opposite sex. Lesbians are women attracted to other women. Gays are men attracted to other men. Bisexual people are attracted to both males and females. Transgender people are those who identify with the opposite gender from what they were born with—from male to female or from female to male. Some transgender people undergo sex change surgery to physically change their sex organs.
You cannot determine a person’s sexual orientation by the way they look, or their job, or hobbies. The only way to know is if they tell you. Homophobia is fear and hatred of lesbian and gay people; biphobia is fear and hatred of bisexual people. Regardless of a medical assistant’s personal opinions or personal sexual orientation, patients of all sexual orientations should be treated the same.
Socioeconomic Status
A person’s socioeconomic status refers to individual and family social status based on income, education, and occupation. Researchers generally classify socioeconomic status as low, middle, or high. Medical assistants work with patients of every socioeconomic status and must be careful not to make assumptions about a person’s status or health based on appearance, speech, or other factors. Statistics show that low income and education are strong predictors of many physical and mental health problems, including respiratory viruses, arthritis, coronary disease, and schizophrenia. These might be because of environmental conditions, such as the workplace or housing situation, or they might be a causal factor. For example, mental illnesses can be the root cause of many socioeconomic problems. Medical problems and disabilities can prevent someone from working, thus causing them to lose health insurance coverage; then, high medical bills can use up a person’s financial resources, including their home that they once thought was secure.
Likewise, medical assistants should not assume that a person is well-off financially or treat those who are any differently. Do not treat a wealthy person rudely simply because they are wealthy; neither should you give them preferential treatment compared with other patients.
Lifestyle Choices
The phrase lifestyle choices refers to the decisions people make about how they live and behave. It can include choices such as where they live, who they live with, what they eat, how they exercise, moral and ethical standards, use of illegal substances, and political preferences. Never treat patients differently because of their choices, even if you do not personally agree with them. When choices affect a person’s health, provide patient education as directed by the physician. For example, a medical assistant who is an exercise enthusiast should not just randomly start telling an overweight person that they are living an unhealthy lifestyle and should eat differently or exercise more. When the patient is seen for a weight-related condition, such as cardiovascular disease or diabetes, and the physician has asked you to provide education, give the patient the appropriate brochures and instructions according to office policy, and document the education in the patient’s chart.
INTRAOFFICE COMMUNICATION
The goal in the medical office should be to establish a sense of rapport—an environment of cooperation—with patients, coworkers, supervisors, and vendors. To create this cooperative environment, all the communication skills we have examined in this chapter must be put to use.
**Professionalism Cultural Considerations
Many cultures, particularly some ethnic and some religious groups, have strong opinions regarding mental health disorders. In fact, some Asian cultures view the idea of mental illness as a flaw or weakness in a person’s character. Those who follow Scientology often strongly oppose psychology, psychiatry, and medications as a means for treating mental illness or depression. Some religious sects believe that mental illness is a form of demon possession or spiritual attack. These varying views regarding psychology and mental health have an impact on the way a patient receives treatment. Above all else, it is your responsibility to be the advocate for the patient and to place the patient’s wishes and beliefs above your own.
Establishing Trust
To communicate effectively in the health care environment and in everyday life, you must establish trust in your relationships and use integrity when relating to others. Integrity means being honest and demonstrating moral principles— doing the right thing even when no one is watching. Being open, honest, and firm in your convictions, presenting a professional image, and using positive body language help create a positive environment.
Some of the most difficult communication problems occur with other staff members (Figure 5-14).
Good staff communication depends on positive and respectful interactions. A thoughtless or condescending comment can cause permanent damage to a relationship. To be condescending is to adopt a superior attitude and act as though you are better or smarter than someone else. Withdrawing from the group, feeling angry and hurt, and discussing other staff members behind their backs cause office morale to suffer. Using assertive (positive) behavior with fellow staff means that you assert your own needs without threatening theirs. For instance, if it is your turn to have a holiday off and you have been scheduled to work, it is better to state, “I’m sorry, but I can’t work that day. Because I worked overtime on the last holiday, I have made plans for this one.” An aggressive (negative) statement, such as “It’s not fair; I always have to work on holidays and the others don’t,” would imply that favoritism or special treatment has been shown to some staff members and might cause the supervisor to become defensive.
Rapport and Team Building A positive attitude can make the difference between keeping and losing a job. A positive attitude is easier to project if you are happy in your work. The work group you are part of is an important factor in your attitude. Work groups must become a cohesive team. To do this, some degree of socializing is beneficial. Discussions with other staff members about hobbies, travel, sports, family, and friends help to establish trust and understanding. Of course, such discussions need to take place at times and in ways that do not interfere with work.
Gossip is unnecessary, unprofessional, and often results in a negative conversation, usually about someone who is not present. The medical assistant must learn to recognize gossip and not participate in it. Gossip can be extremely hurtful and is destructive to the cooperation needed in the medical facility.
Staffing arrangements are as varied as the types of medical practices. The solo practice with its staff of one; the multiphysician practice with a variety of staff, including an office manager; and the clinic with many registered nurses (RNs) and other types of allied health care workers are only a few of the types of practices in which the medical assistant may work. Whatever the staffing arrangements, the physician or office manager must be clear about the chain of command and convey to the employees the process for following the chain of command. In the solo office with one medical assistant, problems rarely arise. However, in larger practices, the health care professional with most seniority is often the unofficial office manager. This person may not be the most qualified staff member, the most multiskilled, or the most accomplished manager. Friction among coworkers is often a problem in many of these larger practices. To avoid this problem, clearly defined areas of responsibility and authority should be established. An office policies and procedures manual can help resolve conflict about authority and responsibility.
**PROFESSIONALISM The WORKPLACE
Communication is crucial in the workplace. You must communicate well with your patients and also with your peers and supervisors. Be sure to be sensitive and empathetic with your workmates. They, too, may have had a stressful day. When a patient dies, staff members are affected. Take time to support your peers and supervisors, too, with empathetic communication.