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A snapshot of serving clients from diverse cultural backgrounds in a physical medicine setting

This is an excerpt from Recreational Therapy Assessment by Thomas Skalko & Jerome Singleton.

By Marc Zaremski

Case Study

A Snapshot of Serving Clients From Diverse Cultural Backgrounds in a Physical Medicine Setting

Written by Marc Zaremski, MS, CTRS: Clemson University

John is a 56-year-old male from Manila, Philippines. The primary language he speaks at home is Tagalog but he is also fluent in English. John moved from Manila to Florida when he was 13 years old with his parents. John has remained in Florida and he currently lives with his wife and youngest daughter. John's wife speaks Tagalog and some English and his daughter is bilingual. John was working on his roof when he experienced a dizzy spell and fell backward off of the ladder, approximately 15 feet, landing on his driveway. John did not lose consciousness and an ambulance was called immediately once he expressed to his wife that he could not move his legs. John sustained fractures in several thoracic vertebrae from T8 to T12. At the T10 level, he sustained a complete spinal cord injury, resulting in paralysis below the T10 level. The ambulance took him to the local trauma center, where he underwent several procedures to stabilize the spinal cord and relieve pressure at the injury site. After John was deemed medically stable, he was transferred to ABC Rehabilitation to receive inpatient rehabilitation approximately seven days postoperative.


At ABC Rehabilitation, John's therapy and medical teams consist of only English-speaking therapists who are all non-Hispanic Caucasian. The facility offers a translation service, when available, which is a live video feed of a translator that can assist during therapy sessions, doctor's visits, and any other time a patient might need information translated to or from a provider. John initially feels comfortable but some aspects of the hospital begin to conflict with his culture. The constant cold temperature throughout the hospital is concerning to him because he believes warmth promotes good health. John's more traditional relatives have expressed concern over food, the treatment plan, and the temperature of the facility as well. A member of John's family is a babaylan, which is a form of healer that uses prayers, herbs, and massage or tissue manipulation as a healing method. John asked his physician and physical therapist if this family member could perform their healing rituals on him. They deemed it unwise because the family member is not a medical professional and John has many precautions. John was disappointed but eventually convinced the medical team to allow this healer to work with him. They agreed, as long as John informed the babaylan of his medical precautions to avoid further injury. The healer is not fluent in English and John had difficulties translating some of the medical terminology. The therapy team used the translation service to confirm that the healer and John understand the restrictions of the treatment. John and the healer articulated that they understood the precautions and John was able to participate in this healing session. John enjoyed the healing session and it put his more traditional family members at ease.


Throughout John's stay he experienced some frustrations and setbacks. Some frustrations were because of how his life had changed due to his injury and some were because of language barriers and a lack of specific cultural knowledge from health care providers. With the flexibility and extra effort of his health care professional, John overcame some of these issues to progress into being independent in his wheelchair and was deemed eligible to return home safely.


It is unrealistic to expect every health care provider to be knowledgeable on the cultural traditions and preferences of every client or patient. But it is important to utilize available resources to gain some insight into what our patients and clients prefer and to find compromise between those beliefs and the best possible medical care.

Applying ICF and Purnell's Stages of Cultural Competence

Based on Purnell's (2012) cultural competence milestones, the level of cultural competence of the physicians and physical therapist does not appear to reach to the cultural sensitivity stage, as evidenced by careless rejections of the healing rituals. They might have noticed that John's background is Filipino; however, they were not aware of how important it was to John and his family members for John to receive healing rituals. In order for physicians and physical therapists to reach a higher stage of cultural competence, the ICF framework is helpful. Personal factors of ICF allow them to look at the person's worldview and value system, beyond race and ethnicity. By understanding the client's values, professionals are more likely to seek ways to achieve things that are important to the person.

Implications for Recreational Therapy Practice

Working with patients or clients from different cultural backgrounds can provide some difficulties for professionals. But many of these difficulties can be resolved or mitigated with extra effort and preparation. Taking the time to look at the resources of your facility and how to access them is a great starting point for establishing a protocol for future clients. If there is admission data or another professional at the facility that may have seen this client first, talking to them can be useful for knowing what resources you may need to acquire. For example, if a patient is admitted who only speaks Spanish, that fact should appear in admission data or a member of the treatment team may inform you prior to you seeing them. This will enable you to schedule that patient when a translator, translation device, or family member that can translate is available. Scheduling appropriately, however, is not a static solution, so a backup plan should be established in case those resources are unavailable. Online translators can be useful for getting some basic translations to assist in your sessions. When all resources are unavailable, a list of key translated words to assist in administering the intervention for that day or for their length of stay may be required. It is difficult to coordinate translation services throughout an entire length of a patient's stay, so having these backup words can be vital for continuing quality service delivery.


Information on those you serve is vital for providing quality care. But it is also important to remember that something you may have found to be true for one patient may not be true for another, even if they have similar backgrounds. The Internet can be useful for finding information on cultures and their traditions, but it is safer to not to make assumptions. The best source of information on your client's beliefs, traditions, and background is typically from the client or their close family members and friends.


Being an active listener allows you to hear concerns that your client may have. This opens up an opportunity for recreational therapists to mitigate those concerns that could be making the client feel uncomfortable. For example, at some facilities, the recreational therapist may have the opportunity to do cooking or kitchen interventions. On occasion, a patient will have religious or cultural dietary restrictions and the food service department may not be meeting these needs. Members of the recreation department should perform functional cooking tasks with patients that meet their religious or cultural needs. This can make the patient or client feel more comfortable during their stay and assist other medical providers in meeting their goals for the client or patient.

When working with patients or clients from diverse cultural backgrounds, the best strategy for working with them can be broken down into four parts:

  1. Take extra time to gather and access resources.
  2. Utilize all available data and information.
  3. Listen to the patient and their caregiver(s) and family members.
  4. Work to minimize any of the client's concerns.


To help yourself, it can be beneficial to write down or keep stock of the resources and strategies that were most effective for a given scenario. Using these strategies, a solid foundation can be made to assist recreational therapists in better serving populations from diverse cultural backgrounds.

Questions for Consideration

  1. What strategies did the treatment team use in order to understand John?
  2. Based on the descriptions of John, to what extent was John culturally assimilated?
  3. Viewing this case study through an intersectionality lens, what sociodemographic variables might be helpful to understand John?
  4. If you were a member of John's therapy team, what would you do to implement cultural safety?
  5. In what way can practitioners move up the stages of cultural competence? How are ICF's personal factors helpful in the process?