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Cultural Diversity Training: Ethnogeriatrics

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Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Purpose/Goals

      The purpose of this course is to help healthcare professionals understand the influence of culture on clients and to apply appropriate standards of care.

Objectives

Upon completion of this course the learner will be able to:

  1. discuss the stages of the Cultural Sensitivity Continuum,
  2. identify violations to patient’s federal and civil rights,
  3. develop cultural competence,
  4. discuss cultural disparity, and
  5. incorporate new skills for conducting cultural assessments,

Introduction

There are challenges not just for the entire healthcare delivery system due to the variety of cultural groups with different family structures and health beliefs. Over time, disparities in healthcare have developed.  Cultural disparities are racial or ethnic differences in the quality of healthcare. They are not due to access issues, clinical needs, patient preferences, or the appropriateness of intervention. Immigration patterns have changed, no longer isolating immigrants to certain geographic locations. This changes the service demographics of healthcare organizations. Cultural disparity in healthcare is a real concern and healthcare professionals need to respond.

An estimated three out of ten U.S. Residents have an origin other than white Anglos. About one million immigrants enter the United States annually, mostly of Latin American and Asian origin. 8  By 2006, the Hispanic population will outnumber the black population; and by 2030, one out of four residents will be either Hispanic or Asian. All nurses, regardless of ethic or cultural background, need to provide home care services according to laws, Federal regulation, and professional standards that address the need to provide better culturally diverse care. It begins with education, whether basic or advanced. This manuscript addresses cross-cultural education and is divided into three conceptual approaches:

  1. attitudes,
  2. knowledge, and
  3. skills.

As home care nurses, you have selected this practice environment and it is likely that your approach is holistic.  This choice of occupation does not ensure cultural competence. So, “welcome to my home” and let our ethnogeriatric journey begin…

Attitudes

Home care nurses are guests in patients’ homes and their attitude will impact communication and outcomes. Before one can be culturally competent, one has to possess cultural sensitivity.  The Administration on Aging developed an excellent resource and educational publication titled “Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and their Families”. 2 Provided in that guidebook is a “Cultural Sensitivity Continuum”; determine where you are on the following continuum by conducting a self-inventory/evaluation.  2

 The Cultural Sensitivity Continuum2

  1. Fear. Others are viewed with trepidation and contact is avoided.
  2. Denial. The existence of the other group is denied rather than viewed as part of the world in which you function and live as well.
  3. Superiority. The other group exists but is considered inferior.
  4. Minimization. The group is acknowledged, but the importance of cultural differences is minimized.
  5. Relativism. Differences are appreciated, noted and valued.
  6. Empathy. A more full understanding of how others perceive the world and how they are treated is achieved.
  7. Integration. Assessment of situations involving members of other cultures can be accomplished and appropriate actions undertaken.  

The staff’s attitude with patients is the culmination of many years of their life exposures and experiences.  The higher the score on the continuum, the better. 

Knowledge

Title VI of the Civil Rights Act was passed in 1964. It prohibits healthcare providers that receive federal dollars from the US Department of Health and Human Services, from conducting any of their programs, activities, and services in a manner that subjects any person or class of persons to discrimination on the grounds of race, color, or national origin. The term “Discrimination” should be replaced with the more proactive term “cultural disparity.”  This is not to say that discrimination is eradicated, but when it is viewed as a disparity, inappropriate behavior and blame can be removed. Knowledge then becomes the vehicle to improve healthcare for all recipients, regardless of ethnic or cultural background.    

The ANA‘s Position Statement on “Cultural Diversity in Nursing” can be found at web address: http://www.nursingworld.org/readroom/position/ethics/etcldv.htm. The following are definitions of culture and cultural competency as defined in the Core Curriculum in Ethnogeriatrics. 6

Culture

The way of life of a population, including shared knowledge, beliefs, values, attitudes, rules of behavior, language, skills, and world view among members of a given society. It shapes human behavior because it is the foundation of conscious and unconscious beliefs about "proper" ways to live. Cultures change constantly. Different members of a society internalize and express different parts of their culture. Subcultures can also reflect differences by geographic region or other subgroups within a larger society.

Cultural Competence in Geriatrics

Ability to give healthcare in ways that are acceptable and useful to elders because it is congruent with their cultural background and expectations. 6 At the provider level, it has been described as including the demonstrated integration of:

  1. awareness of one’s personal biases and their impact on professional behavior;
  2. knowledge of
    1. population-specific health-related cultural values, beliefs, and behaviors,
    2. disease incidence, prevalence or mortality rates,
    3. population-specific treatment outcomes; and
  3. skills in working with culturally diverse populations. 6

Aging and Health Statistics

According to the U.S. Census Bureau, the 2000 aging demographics of the U.S. are:

  • An estimated 84% of people age 65 or older are non-Hispanic white,
  • 8 percent are non-Hispanic black,
  • 2 percent are non-Hispanic Asian and Pacific Islander,
  • Less than 1 percent are non-Hispanic American Indian and Alaska Native.
  • Hispanic persons are estimated to make up 6 percent of the older population.

By 2050, the percentage of the older population that is non-Hispanic white is expected to decline from 84 percent to 64 percent. Hispanic persons are projected to account for 16 percent of the older population; 12 percent of the population is projected to be non-Hispanic black; and 7 percent of the population is projected to be non-Hispanic Asian and Pacific Islander. The Hispanic older population is projected to grow the fastest, from about 2 million in 2000 to over 13 million by 2050. 3

Aging and Morbidity

In 1997, the leading cause of death among persons age 65 or older was heart disease, followed by cancer, stroke, chronic obstructive pulmonary diseases, pneumonia and influenza, and diabetes. Among persons age 85 or older, heart disease was responsible for 40 percent of all deaths. The relative importance of certain causes of death varied according to sex and race. For example, in 1997, diabetes was the third leading cause of death among American Indian and Alaska Native men and women age 65 or older, the fourth leading cause of death among older Hispanic men and women, and ranked sixth among older white men and women and older Asian and Pacific Islander men.  Alzheimer’s disease was the sixth leading cause of death among white women age 85 or older; however, it was less common among black women in the same age group or men of either race. (Source: National Vital Statistics System.)

Aging and Vaccinations

Pneumonia and influenza are the fifth leading cause of death for individuals 65 years old or older. Healthy People 2000, a national initiative to improve health through establishing health objectives and measuring progress, set targets of 60% coverage for influenza and pneumococcal vaccinations among older Americans. 3 The following is the progress thus far for the years 1989 through 1995.

  • The percentage of non-Hispanic white persons who were vaccinated against influenza increased from 32 percent to 60 percent. 3
  • Influenza vaccination rates increased from 18 percent to 40 percent among older non-Hispanic black persons and from 24 percent to 50 percent among older Hispanic persons. 3
  • Vaccination rates also increased for pneumococcal disease, but none of the racial or ethnic groups have reached the 60 percent target.  3

From 1993 to 1995, the level of vaccination for both influenza and pneumococcal disease was similar among older women and men. Ages 75 to 84 had slightly higher levels of vaccination coverage than those between 65 to 74 years of age or individuals age 85 or older. The cost for these vaccinations are covered under Medicare Part B. 3

Cultural Assessments

It is important to remember that simply because a person is identified as a member of a particular ethnic group or religion does not necessarily mean that the person or the person's family has the set of beliefs that may be associated with that ethnicity or religion. Within ethnic groups are characteristics that define the use of language, the role of family, religion, spirituality, the definitions of illness, the use of healing practices in healthcare, and health-seeking behaviors. 6 For every case, an assessment must be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed.  An assessment requires both the knowledge and the skills of the clinician. 

Communication

Communication is probably the most important aspect of the assessment. Clinical information is dependent upon how willing patients are to relate information to the interviewer. When caring for the geriatric population, the nurses as well as the other team members are usually younger than the patient. Many of the learned communication skills apply to interactions with all older patients; however, social distance, racism, and unconscious fears of different ethnic groups can contribute to problems in the assessment of older patients. The nurse must establish a rapport with the patient first, and possibly the family prior to performing the assessment.  This is where attention to culture becomes important. If you try to “get to business” immediately with a patient of Mexican culture, they may find you cold and impersonal. In the Mexican culture, there is an expectation of casual conversation first. This is known as “personalismo”. 

Case Example:  You arrive at the home of your patient who is a male Hispanic who lives alone.  On the stove is a pot of homemade soup. Mr. M, rather enthusiastically, invites you to have a bowl. Your initial response will either facilitate open communication or close the door. There are several options available rather than flat out refusing such as explaining that you just ate but would love a small spoonful to taste or perhaps would love some to go for later. 

Besides cultural etiquette, there is the possibility that your patient has limited English proficiency (LEP) that creates a language barrier.  What will you do?  Wing-it, asks the patient’s daughter to interpret, or request a professional translator?  The Department of Health and Human Services Office for Civil Rights considers inadequate interpretation as a form of discrimination.  A common violation is the use of a patient’s child as a translator. 

Case Example:  You are caring for a Latino patient with LEP and asking her about her GYN check-up, being quite specific in asking for dates, about pap smears, and breast exams. Her son is translating for you. She is hesitant in responding. Is your patient forgetful? Probably not, it is common for older Latino women not to be comfortable in sharing this with young males, even when that person is her son.

The chart below presents an overview of English vs. non-English speaking residents of the United States.  This information is available for every state however a sample of the comparison data is presented. For additional information see http://www.census.gov/prod/cen2000/doc/sf3.pdf].

 

Total Population

18 years and over

Speak only English

Speak non-English  at home

% of pop.

Speak Spanish

Linguistically isolated

All speak
non-English language

US

209,279,149

172,107,320

37,171,829

17%

 

 

 

FL

12,347,806

9,511,352

2,836,454

23%

1,986,274

737,688

2,180,058

GA

6,020,679

5,417,941

602,738

10%

332,941

185,626

401,153

AL

3,324,488

3,193,164

131,324

4%

69,343

24,023

61,610

AK

1,993,342

1,896,493

96,849

4.9%

62,205

25,345

53,937

 

The U.S. Department of Health and Human Services’ (HHS) Office of Minority Health (OMH) developed recommendations for national standards for Culturally and Linguistically Appropriate Services (CLAS) for healthcare providers. The standards incorporate key laws, regulations, contracts, and standards currently in use by federal agencies, state agencies and other national organizations, and are an excellent resource tool. In addition, The Access Project and the National Health Law Program developed a Language Services Action Kit to ensure that people with limited English proficiency in their state get appropriate language assistance services in medical settings. The action kit includes materials that explain relevant federal policies, describe how states secure federal funds to help pay for language services in their Medicaid and SCHIP programs, provide information to demonstrate the need for language services, and offer resources and suggestions for undertaking advocacy efforts. For more information contact LEPactionkit@accessproject.org.

Patient Perception

Patient perception of their condition is sometime referred to as “acceptance”. Rather than asking the patient if they accept their diagnosis, a better format can be asking questions that elicit a cultural response. Patients may be taking herbal remedies, employing traditional healing methods or believe their illness is in direct response to past behaviors, a punishment of some sort. The following questions should be considered.

  • Do you think that there are ways to get better that your Physician may not be aware of?
  • What do you think is wrong or causing your health problem?  
  • Is there anyone else helping your get better? 

This approach is likely to provide a truer response to the patient’s acceptance of illness. The home care nurse must also take into consideration cultural beliefs on terminal diseases and death and dying practices.  There are also cultures that believe it is better to withhold terminal news.

Standardized Assessment Tools

Standardized assessments are the norm. Many of the assessment tools measure all of the body systems such as cognitive status, functional ability, depression, and nutritional status. However, any assessment tool it is subject to error. The assessment nurse must take into account the language barrier, the translated meanings, the patient’s literacy level, and any cultural nuances before marking the assessment. In addition, inconsistency in clinicians performing the assessments can elicit different responses. There are research studies that show patients from a cultural background other than white Anglo are falsely scored. These false scores can be partially attributed to literacy level, language barriers, and culturally non-specific assessment tools. In addition, time constraints on the nurse are a contributing factor.  

Case Example: Ms. R is a 72 year-old female who you are seeing for a functional decline and weight loss. She was born in Mexico and immigrated to the U.S. when she was 16 years of age. She speaks some English but prefers speaking in Spanish. Her 17 year-old granddaughter is present to translate. In gathering the history you find that over the past year she has been taking care of her 75 year-old husband who suffered a cerebrovascular accident that left him with right-sided paralysis. You try to obtain more information about her caregiving situation but her granddaughter reports that her grandmother says that this is just something she has to do and God will help her. Upon completing your assessment, you discuss the need for her to schedule the diagnostic and lab tests ordered by her physician and she conveys she will.  On your follow-up visit the granddaughter is present to translate, you are informed that Mrs. R completed her lab work but the x-rays were not done. Her granddaughter tells you that her grandmother has been busy caring for her grandfather.  What do you do? Reinforce the importance of the x-rays and tell her she needs to schedule them or do you pay more attention to the demands of her ill spouse? 

It is reported that the most common cultural misconception is an underestimation of the needs for formal support for ethnic elders based on the assumption that minorities "take care of their elder" within the family. 2 While there is supporting evidence, such as: unmarried older African Americans are twice as likely to live with family members as whites, Hispanic American and Asian American elders are three times as likely, and half of urban Native American elders live with family members. 2

Bear in mind that the responsibilities of minority families can make caregiving for ethnic elders overwhelming without any additional support. Studies have reported that Hispanic/Latino caregivers find themselves as the sole caregivers despite the “over-idealization” of family support. 6 Feelings reported by Mexican American caregivers included a sense of isolation and frustration. In another study Mexican American caregivers perceived their social support networks as smaller compared to the European American sample of caregivers. 6 To better assist patients who are also caregivers for spouses or children consider the following options.

  1. Organize a family meeting. This helps other members of the family unit to get a clear picture of the role that a primary caregiver has and elicit recommendations on how other family members can provide support or assistance.  6
  2. Assist the caregiver making referrals to resources that have the same bilingual/cultural staff. That may even include a HHA from your agency depending on the cultural similarities, or the services of your Agency’s Social Worker. 6
  3. Provide information about support groups in their preferred language. 6
  4. Provide caregivers with various types of patient education tools such as videos, patient -focused handouts related to his/her illness, and the vast amount of information available on the Internet.
  5. Contact your local Area Agency on Aging (AAA).  Some have developed successful bilingual and bicultural programs for elders residing in the county.

“Knowledge of community resources” is in the Scope of Home Health Nursing Practice.  

Pain

Besides the legality of civil rights, leaders within the healthcare systems address culture and language barriers via standards that many home care agencies function by. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Pharmaceutical Company produced two monographs on pain in the effort improve the quality of pain management.  Monograph One is Pain:  Current Understanding of Assessment, Management and Treatments and Monograph Two is Improving the Quality of Pain Management Through Measurement and Action.  These are available at no cost and can be accessed on the JCAHO website: http://www.jcaho.org/news+room/health+care+issues/pm+monographs.htm. Within the content of the monographs are the following suggestions.

  • For patients of different languages: Use words such as “pain,” “hurt,” and “ache” 10
  • For different behavioral responses to pain: Use assessment tools in appropriate language backgrounds 10
  • Different treatment preferences:  Provide patient education materials in native language, when possible. 10

End of Life Issues

Death currently has no cultural boundaries yet religion; faith and spirituality, have significant cultural and spiritual roles in end of life rituals as well as advanced directives.  If you are caring for a terminally ill patient and want to discuss the option of Hospice, his/her ethnic beliefs can greatly influence the conversation as well the decision.  For example, it is reported that   Hispanic/Latino elders do not make end-of-life decisions autonomously. 6There is a preference to make decisions as a family unit and with the advice of the patient’s physicians. In addition, the use of Hospice tends to be significantly lower for this population. 6 The concept of Hospice may even take on a meaning of giving up which might be in conflict with beliefs. Food/fruit baskets, not flowers, are sent to those who practice the faith of Judaism, where as in the Catholic religion, flowers are acceptable and commonly sent as a display of respect. Judaism does not promote organ donation or cremation, yet it is not uncommon to see the Urn of a loved one in your patient’s home.  6 

Skills

Nursing skills are demonstrative actions that describe common competencies for nurses. They are based on clinical nursing practice statements and authoritative regulating bodies within Healthcare. Whether it is pediatrics or ethnogeriatric nursing, specialized skills are added. The Scope and Standards of Home Health Nursing Practice provide authoritative nursing competency expectations. The standards have been adapted to assist you to be culturally competent. Consider the following questions.  For every negative answer, develop an improvement/action plan.

Standards of Care

·Standard I: Assessment

  • Did I collect health data during assessments based on a psychological/social/ biological/ cultural/ political/ spiritual model?
  • Standard II: Diagnosis
    • Did I analyze assessment data on minority patients with an understanding of cultural differences in pathology and morbidity?

·Standard III: Outcome Identification

  • Did I identify expected outcomes that where culturally appropriate?
  • Standard IV: Planning
    • Did I develop culturally sensitive treatment and care plans for the patient and family's concept of health and illness to attain expected outcomes? (Or did I use standard/canned care plans with no cultural modifications?) 

·Standard V: Implementation

  • Did I implement interventions, with an understanding of the cultural differences in accordance to the plan of care?
  • Did I communicate effectively with cross-cultural use of interpreters as much as I could have?
  • Standard VI: Evaluation
    • Did I evaluate the patient’s progress toward achieving goals?

Standards of Professional Performance

  • Standard I: Quality of Care
    • Did I systematically evaluate the quality and effectiveness of the nursing practice with respect to disparities?
  • Standard II: Performance Evaluation
    • Did I evaluate my nursing practice?
  • Standard III: Education
    • Did I acquire and maintain current knowledge and competency in ethnogeriatric practice?
    • Did I recognize a need for consultation?
  • Standard IV: Collegiality
    • Did I interact and contribute to development of peers and other clinicians?
  • Standard IV: Ethics
    • Did my decisions and actions demonstrate ethical behavior?
  • Standard VI: Collaboration
    • Did I collaborate with the patient, their families and other clinicians? 
    • Did I help patients to understand and maintain their own sociocultural identification?
  • Standard VII: Research
    • Did I use research findings?
  • Standard VIII: Resource Utilization
    • Did I assist the patient and his/her family to become knowledgeable consumers of health care?
    • Did I utilize community resources as much as I could have? 

Conclusion

Learning everything about a new culture and its sub groups can be a daunting assignment for clinicians. Learning about our healthcare system can be an overwhelming and complex challenge for individuals in need, particularly for those recipients that are not fluent in English.

As Clinicians move forward in understanding patients within their cultural, ethnic and spiritual framework quality of care improves.  Think twice before describing a patient or family member as “non-compliant”. Is “non-compliance” always a patient driven-outcome or can it be the outcome of culturally insensitive care? Ethnocentric clinicians and professionals do exist and so do healthcare disparities. 

References

  1. http://www.aoa.gov/minorityaccess/default.html. U.S. Department of Health and Human Services: Washington, DC.
  2. Administration on Aging, Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and their Families. January 2001. U.S. Department of Health and Human Services: Washington, D.C. http://www.aoa.dhhs.gov/minorityaccess/guidbook2001/default.htm#contents. Last accessed 6/6/03.
  3. Administration on Aging, “Facts and Figures:  Statistics on Minority Aging in the U.S,” http://www.aoa.dhhs.gov/minorityaccess/stats.html.  U.S. Department of Health and Human Services: Washington, D.C. Last Accessed 6/6/03.
  4. Ethnomed. http://ethnomed.org/.  Last accessed 6/1/03
  5. Compendium of Cultural Competence- Initiatives in Healthcare. The Henry J. Kaiser Family Foundation. January 2003.
  6. ETHNIC SPECIFIC MODULES, Supported by the Bureau of Health Professions Health Resources and Services Administration U.S. Department of Health and Human Services. October 1, 2001. Core Curriculum in Ethnogeriatrics.    Authors: members of the Collaborative of Ethnogeriatric Education in 1999 and 2000.
  7. Federal Interagency Forum on Aging-Related Statistics. "Older Americans 2000: Key Indicators of Well-Being," http://www.agingstats.gov. Centers for Disease Control, U.S. Department of Health and Human Services: Washington, DC.
  8. University of Washington. (2004). Health Links, Cultural Clues. Retrieved from http://depts.washington.edu/pfes/cultureclues.html.
  9. Institute of Medicine.  Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Authors: Board on Health Science Policy and Division of Health Sciences Policy.   The National Academies Health Press. 2002
  10. National Pharmaceutical Council, Inc. Pain: Current Understanding of Assessment, Management, and Treatments, 2001
  11. Office of Minority Health, “Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda”. ACTION: Final Federal Register: National Standards for Culturally and Linguistically Appropriate Services in Health Care December 22, 2000 (Volume 65, Number 247) [Page 80865-80879]
  12. Scope and Standards of Home Health Nursing PracticeAmerican Nurses Association. 1999.
  13. U.S. Census Bureau, Census 2000, http://www.census.gov/main/www/cen2000.html. Last accessed 05/17/03
  14. U.S. Census Bureau. January 2000. Population projections of the United States by age, sex, race, Hispanic origin, and nativity: 1999 to 2100. http://www.census.gov
  15. http://usinfo.state.gov/journals/itsv/0699/ijse/frey.htm