Nursing & Care Open Access Journal
Volume 1 Issue 2 - 2016
The Applicability of a Cultural Community Assessment on Delivering Triple Aim Care in an Acute Care Hospital
Melodie Cannon1* and Clara Tsang2
1Faculty of Nursing, University of Toronto, Canada
2Nurse Practitioner Consultant, Scarborough Ontario, Canada
Received: October 21, 2016 | Published: November 04, 2016
*Corresponding author: Melodie Cannon, Faculty of Nursing, University of Toronto, Canada, Tel: 416-284-8131, Email:
Citation: Cannon M, Tsang C (2016) The Applicability of a Cultural Community Assessment on Delivering Triple Aim Care in an Acute Care Hospital. Nurse Care Open Acces J 1(2): 00006. DOI: 10.15406/ncoaj.2016.01.00006


Realistic outcome measures for the Canadian Healthcare System are often debated. There is growing recognition of “Triple Aim”, a three-pronged approach to evaluate healthcare consisting of population health, value for money, and patient experience. These measures are often represented as a triangle, implying balance and trade-offs between them. However, as observed in the Central East Local Health Integrated Network (CELHIN), these measures can be positioned to reinforce each other in mutually beneficial ways when explored within the context of serving a multicultural population.

The Toronto/Scarborough area of the CELHIN was selected as a subject for exploration due to its unique demographics, where 58% are immigrants, and 20% of these are of Chinese-descent. A culturally-sensitive community assessment of Chinese seniors was conducted and applied to health care delivery. This article aims to explore the Chinese perspective on health beliefs and practices, common barriers to effective acute hospital care, and how practitioners can use this information to optimize outcomes and achieve the goals of “Triple Aim”.


Multiculturalism is a cornerstone of the Canadian identity. One in five people are immigrants [1]. In Toronto, those born outside of Canada represent 49% of the population and 48% speak a native language other than English or French [1]. Scarborough, a suburb of Toronto, is considered one of the most diverse areas with a significant concentration of Chinese and South Asians. Chinese seniors make up 2.6% of the total population, representing 19.5% of those aged 65 or older [2].

Cultural diversity can result in challenges for health care delivery. A Toronto study found that new immigrants under-utilize primary and preventative services. The key reasons were access barriers, language difficulties, and a lack of cultural sensitivity [3]. The impact on vulnerable, immigrant seniors is of particular concern if the result is the creation of a negatively reinforced cycle of health consequences, greater system costs, and poor patient satisfaction. Adopting a culturally sensitive lens can stem or reverse this effect by enhancing the care provider and client relationship, thereby addressing all three dimensions of “Triple Aim”

Community Assessment

Health care gaps in acculturation

In Toronto neighborhoods of ethnic clusters, residents are generally able to access many of their needs, including primary health care, in their native language, and with familiar social and cultural norms. However, in times of crisis, access to hospital services may be required. It is under such circumstances that ethnic seniors are most vulnerable. Language barriers may impede accurate history-taking, which in turn impacts the diagnosis, and treatment efficacy. Treatment compliance may also be influenced by cultural beliefs and traditions, which may exist beyond the care provider’s periphery and context. Adverse outcomes may be an unfortunate and unintended consequence.

Empowering an acute hospital to address this challenge requires a comprehensive approach. The first step is to conduct a discovery process to uncover challenges, assess opportunities, and derive fit-for-purpose strategies that meet the unique cultural needs of the community it serves. A CELHIN community hospital in Scarborough was selected as a subject for exploration and application with respect to how it cares for Chinese elders in an optimal, culturally sensitive manner.

Chinese elders beliefs and culture

To serve diverse populations, it is important that care practitioners are aware of their clients’ cultural backgrounds. The main ideology of Chinese culture is based on Confucianism, Buddhism, and Taoism. Confucianism teaches harmony, respect for parents and family loyalty. In order to achieve happiness and good health, elders must be respected. Buddhism teaches that enlightenment is obtained and good health achieved by helping others, being merciful and humble. Taoism believes in the virtues of a simple, honest life and maintaining harmony with nature [4].

 Given that the Chinese belief system advocates simplicity, harmony and order, avoidance of conflict is regarded as essential to inner peace and societal reputation. There is a strong sense of responsibility and obligation to family, and less focus on independence. There is a commonly held hierarchy of relationships in family and society, with the eldest male (husband or son) wielding decision authority on behalf of the family. Emotional restraint, self-control, politeness and deference to those in authoritative positions are foundational tenets of Chinese culture [5]. Protection of the young and elderly are important virtues as well, and withholding negative information from a senior patient may be regarded as kind and loving. Many Chinese believe in karma and that speaking of illness or death may cause it to occur [6]. These are all important considerations in delivering care to Chinese elders.

Health beliefs and practices

The Chinese perspective on health is focused on a balance between yin and yang forces, and Qi (vital energy) between body and environment [4]. The five elements of wood, fire, earth, metal and water must be kept in equilibrium [4]. These elements represent a cycle of nature that corresponds to bodily functions. Illness occurs when there is disorder of the natural process, potentially due to external forces such as weather conditions, emotional trauma, and/or contaminated food and water. As a result, imbalance occurs and illness is a physical symptom of disequilibrium.

Superstitious beliefs also play a role in Chinese culture. Many Chinese people believe in feng-shiu, a philosophy where a building’s position and furniture arrangement may influence a person’s fate. In addition, many Chinese believe in the concept of lucky and unlucky numbers. The number 8 is considered lucky as its pronunciation is phonetically similar to the Chinese word for prosperity. The number 6 suggests smoothness or continuity. However, the number 4 is considered unlucky as its pronunciation is similar to the Chinese word for death [7]. This has the potential to influence a patient’s reaction to an assigned area, room number, or hospital floor number, and may cause additional stress. There are commonly held rituals for life events such as weddings and death, and details down to the specific food dishes served have symbolic purpose for luck or fortune [7].

Prevention and treatment of illness may often include the use of traditional Chinese herbs, foods, massage therapy, acupuncture and folk healers. Healing practices are believed to boost the immune system, relieve inflammation and pain, and balance the mind and body [8]. The use of traditional Chinese herbal remedies is common and may be used in isolation or in combination with Western medicines. Reported [9] that approximately 65% of older Chinese immigrants reported the use of traditional therapies in addition to prescribed medications.

Acupuncture and massage are thought to stimulate the circulation of Qi and support illness resistance. Acupuncture is a common pain relief therapy. Traditional healers may use a method called qi gong to set broken or dislocated bones and joints, including neck and spinal cord injuries [8]. Coining, burning, and cupping are established methods of treating illness and the characteristic markings that result can be interpreted as signs of abuse if a health care provider is not familiar with this custom.

Older Chinese may also be unwilling to have blood drawn as it is believed that losing blood depletes the body’s strength and provides a route for the soul to leave the body. Qi, a circulating, nurturing force in the body is thought to be concentrated in the chest and mid-abdomen. Procedures that interfere with this life force may not be accepted for fear of causing harm or death [6].

A Chinese seniors’ agitation or refusal to participate in the treatment plan, may not be confusion or behavioral, but may be based on their cultural beliefs towards health care. In particular, elderly Chinese view the symptoms of dementia as part of the aging process. It is accepted that elderly will revert to a childlike state as they age, lacking self-control and discipline [4].

Barriers to effective hospital based care

When individuals strictly adhere to Chinese culture and beliefs regarding health care, there is a greater likelihood of incompatibility with a healthcare system operating under a Western medicine philosophy [10]. These beliefs may include a mistrust of Western medicine in that it conflicts with traditional Chinese concepts. The focus of Western medicine is perceived to focus on curing of disease, while Chinese medicine advocates for the restoration of harmony in body and spirit [4]. Further, Chinese seniors may be reluctant to seek health care outside of their community for fear of bringing shame, and additional burden to their family. Chinese traditionalists also believe that health is correlated to luck, karma or fate, and therefore illness is intertwined with divine punishment and potentially shame [10].

Chinese seniors often congregate in public spaces where Chinese is primarily spoken. Therefore, even those who have immigrated for many years may be unexposed to Western medicine until a crisis occurs. In such scenarios, arrival at an acute care facility may prove to be quite overwhelming. This culture shock may invoke fear and mistrust [11].

As Chinese beliefs include self-control, emotional restraint, and deference to persons of authority, some may view the care provider as an authority figure. Hence, senior clients may be reluctant to communicate and share needs for fear of distracting care providers unnecessarily [12]. Patients may harbor doubts about a treatment plan, never verbalize it and eventually choose not to follow through. This can be misinterpreted as noncompliance.

¬†Hospitals often have a culturally diverse staff of care providers but there is no guarantee that a match to the patient’s culture can be consistently coordinated. Although interpreter lines are available, there is often an associated cost and may not be an economical choice [13]. In addition, for patients who are physically or cognitively impaired, the use of interpreter lines will not overcome communication barriers.

In cases of language barriers, obtaining an accurate medical history may be time consuming, or even impossible, resulting in suboptimal treatment. The presence of family members, although reassuring for the patient, often does not facilitate care as language barriers may persist. Decreased visual and auditory acuity, which are common in many seniors, may further complicate matters for the non-English speaking Chinese senior [14]. Seniors may also be inaccurately labeled with dementia due to slowed responses or inappropriate answers. Impaired cognition can prevent the patient from reporting symptoms. This can impede making the diagnosis and providing adequate management. These issues are compounded by an inability to communicate in a language that is understood by the providers responsible for decision making. Unnecessary investigations may be undertaken as an attempt to make a diagnosis by exclusion, in order to offset the vague medical presentation.

Patients may have used traditional remedies/practices prior to presenting to the Emergency Department, and these practices, in particular the use of traditional Chinese herbs, can perpetuate an adverse event due to potential medication interactions. Self-medication is often the first response to illness and may occur in 70%-90% of cases [4]. Many patients are discharged, only to return again with new or worsening symptoms due to misunderstanding or communication challenges.

Strategies for improvement

The Patients First: Action Plan for Health Care 2015has outlined four key objectives: Access, Connect, Inform, and Protect. To achieve these key objectives, healthcare providers must first understand their patients. Currently, data categorizing patient ethnicity or language is not routinely collected or available. By adopting this change, hospital administrators can more effectively evaluate the interdependencies between cultural barriers, health outcomes, and system costs. A simple addition to request primary language would serve to remind practitioners of the need to consider patients’ culture and beliefs when providing care. It is not realistic to think that allowances and adjustments to care can be made for every culture and ethnicity. Identifying the top 3 or 5 cultures within a hospital’s area and proactively offering culturally sensitive education to staff would be a meaningful start. Hospital signage, patient information, and patient education brochures can also be translated into the appropriate languages. An easily accessed computer based overview of specific cultures health care and beliefs can be compiled and available to staff to facilitate communication and participation in care.

Based on a community assessment, language specific surveys can be developed and distributed to patients to evaluate new opportunities to provide culturally sensitive care. The answers may provide an insightful roadmap towards achieving the “Triple Aim”.

The use of interpreter lines should be encouraged despite the associated costs. Obtaining an accurate medical and medication history are critical to patient outcomes. Although computer based translation applications are available, providers must proceed with caution as accuracy may be unknown. When using a service to interpret signage, patient information and education, care must be taken to ensure the legitimacy and accuracy of the translation service. Experience has shown that even the slightest variation or error in translation, can entirely change the intent of the information being conveyed. A simple solution is to utilize the diversity of the health care team staff to report any additional languages they speak, and offer services as needed to clients who require translation.

Upon discharge, linking patients with culturally sensitive community support services is ideal. For example, in Toronto, CareFirst is a community resource that is dedicated to providing quality services to Chinese seniors. Determining similar resources for other ethnicities would be beneficial.

Community focus groups can be established to identify culturally specific issues for hospital-based care. Groups can be chaired by culturally matched staff to facilitate participation, credibility and support the commitment for change. The establishment of culturally specific volunteer services is another viable option. Strategies for improvement can only be of value if they are implemented and reviewed.

Realistically, change in process can be time consuming and frustrating. Long term strategies may be more attainable if short term strategies are accepted and implemented with minimal barriers. Choosing the most attainable short term goal as a starting point can form the foundation for future plans.

Implications for nursing

“Cultural Sensitive Care” practice guideline published by the College of Nurses of Ontario indicated the importance of cultural factor in nursing. To assess and respond appropriately to a client’s cultural expectation is the responsibility of a nurse. While it is impossible for any single nurse to learn all cultures, nurses can enrich their knowledge of the most prevalent cultures in their hospital community. The above study on Chinese seniors is an example that could be applied to other cultures. The study’s result and recommended improvement tactics could assist the front line nurses and management to develop effective programs to deliver culturally sensitive care that delivers on the promise of “Triple Aims”.


Chinese seniors account for a significant portion of hospital patients in Toronto’s east end. Their culture can directly influence patient perspective, receptiveness, and ability to access quality health care. This will significantly impact the success of the “Triple Aim” framework of population health, value for money, and patient experience. The potential for adverse outcomes, unnecessary investigations and culturally unacceptable practices can be mitigated by a more culturally sensitive treatment plan. This applies not only for Chinese seniors, but for other cultures and ethnicities as well.


  1. Statistics Canada (2011).
  2. Care first. No place like home. Advancing Integrated Care for All. 2012-2013 Annual Report.
  3. Access Alliance Multicultural Health and Community Services (2011) Toronto Public Health, The Globe City: Newcomer Health in Toronto.
  4. Lai DWL, Surood S (2009) Chinese health beliefs of older Chinese in Canada. Journal of Aging and Health 21(1): 38-62.
  5. Lin, Yii Nii (2002) The application of cognitive-behavioral therapy to counseling Chinese. American Journal of Psychotherapy. 56(1).
  6. Andrews JD (2005) Cultural, Ethnic, and Religious Reference Manual for Health Care Providers. 3rd Ed.  Winston-Salem, NC: JAMARDA Resources.
  7. Huang LS, Teng, CI (2009) The development of a Chinese superstitious belief scale. Psychological Reports 104(3): 807-819.
  8. Ma GX (1999) Between two worlds: The use of traditional and western health services by Chinese immigrants. Journal of Community Health 24(6): 421-437.
  9. Lai D, Chappell N (2006) Use of traditional Chinese medicine by older Chinese immigrants to Canada. Family Practice 24(1): 56-64.
  10. Lai DW, Chau SBY (2007) Predictors of health service barriers for older Chinese Immigrants in Canada. Health & Social Work 32(1): 57-65.
  11. Lai W, Tsang KT, Chappell N, Lai DCY, Chau SBY (2007) Relationships between culture and health status: A multi-site study of the older Chinese in Canada. Canadian Journal on Aging 26(3): 171-183.
  12. Ministry of Health & Long Term Care (2012) Ontario’s Action Plan for Health Care.
  13. Ministry of Health and Long-Term Care (2015) Patients First: Action Plan for the Health Care.
  14. Central East Local Health Integrated Health Network (2012) Community First: Integrated Health Service Plan 2013-2016.
© 2014-2018 MedCrave Group, All rights reserved. No part of this content may be reproduced or transmitted in any form or by any means as per the standard guidelines of fair use.
Creative Commons License Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at
Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version | Opera |Privacy Policy