Cultural Diversity Training: Ethnogeriatrics

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].

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 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 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.  

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

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