A new world: handling diversity among staff and residents means going back to [everyone's] values. (Caregiving).

If you've been in the long term care industry for a while, you've probably seen the faces of your patients change in more ways than one. The percentage of foreign-born people in the United States is more than double that of 30 years ago.(1) Most immigrants then were of European origin; today many are from other areas as well. This cultural diversity is also reflected in the percentage of minorities in the population, which is predicted to grow to nearly 40 percent during the next two decades. And in the next decade, 30 percent of the population older than 65 will be from minority groups.(2)

This cultural overhaul is creating a major challenge for the long term care industry: providing culturally competent care to an increasingly diverse population. There are issues of verbal and nonverbal communications, such as not understanding each other's spoken languages or not knowing the meanings attached to body language. Perceptions of health and illness vary, as does what is considered appropriate treatment. Immigrants may mistrust health care providers or government agencies because of past experiences. And some may be from cultures where the concept of a long term care facility is not only non-existent but also clashes with that culture's values and beliefs.

Providing culturally competent care to a diverse population requires that a facility and its caregivers know something about the resident's beliefs and practices. Staff must demonstrate sensitivity, understanding and respect for the individuals and their culture while valuing the diversity. To do this effectively, caregivers must be aware of their own beliefs and how they may differ from those of the residents without being judgmental. (See "Requisites for Crossing Cultures," page 37.)

Culture clubs

Sue Ann Guildermann, director of Education and Staff Development at Richfield Health Center, a 126-bed facility in Richfield, Minn., focuses heavily on teaching cultural competence. More than 20 countries are represented among the facility's residents and staff.

In orientation sessions and follow-up in-services, Guildermann emphasizes the need for staff to understand and respect the differences in themselves and others. They also need to recognize that their own cultural upbringing and heritage sometimes "get in the way" when working with persons different from them. "Treat people as you want to be treated," she tells them, "and recognize your responsibility to create a comfortable environment for residents."

Galtier Health Center in St. Paul, Minn., has one entire unit dedicated to the care of Southeast Asians, many of whom have lived in the surrounding neighborhood. The unit has 38 residents, the majority of them Hmong, with the rest Laotian, Cambodian and Vietnamese.

Joan Jarombek, nurse manager of the unit, says she and her staff meet regularly with family and community members to assure they are providing the appropriate environment and honoring beliefs and practices. Staff education emphasizes acceptance of diversity in addition to learning the residents' ethnic customs.

The good word

Dr. Dula Pacquiao, professor and director of the Graduate Nursing Program, director of the Transcultural Nursing Institute at Kean University in Union, N.J., and president-elect of the Transcultural Nursing Society, studied Russian elders in seniors housing. Although many of them are highly educated, they have little to no grasp of the English language, she says. And the Russian Cyrillic alphabet makes it difficult to understand their handwriting.

Furthermore, because of a generally stoic personality, caregivers can't rely on nonverbal expressions until a good relationship and baseline impression has been established. This-and a tendency to be not as descriptive of complaints-means that caregivers need good language skills to communicate, she suggests.

To facilitate communication, Galtier Health Center employs a full-time Hmong interpreter who also speaks Laotian. Staff members have phone access to a 24-hour interpreter line. And the facility employs a number of Southeast Asian staff, according to Jarombek.

At Richfield Health Center, families are asked to help develop flashcard books to communicate about a dozen common phrases and commands. On one side of the card is the phrase in the resident's language; the other side is in English. Cards are fastened together with rings and stored at the bedside for easy use by the resident and staff. Each resident also has a 24-hour-a-day contact designated by the family for staff to access if communication problems arise.

"We don't necessarily assign a staff person to a resident because they speak the same language but we do use staff members as a resource when necessary, says Guildermann. She routinely polls new employees at orientation sessions to assess what languages they speak and is frequently surprised by multiple and unexpected language competencies. At one session, she discovered that a staff member of Turkish background had spent several years in Germany and spoke fluent German.

A daily dose of culture

Food and daily diets are a big part of the cultural diversity among residents. Although Richfield Health Center conducts a nutritional assessment immediately prior to admission, with regular follow-ups thereafter, meeting residents' nutritional needs in a culturally respectful way leads to special arrangements, according to Guildermann.

Some of the residents have cookers, rice steamers or woks in their rooms; in other cases families will occasionally bring in food packs that they or staff will prepare. "Some of our residents don't eat beef or want only vegetarian foods," Guildermann says. "We offer three meals a day with nourishments and snacks between meals, and we have lots of different beverages-teas, wines, juices, even after-dinner schnapps for those who want it-and fruits such as mango, papaya and coconut."

The story is a similar one at Galtier Health Center. "Many of our residents like rice for all meals, so we have a rice cooker on all day," says Jarombek. Because soup and noodles are so popular, they may be served twice a day, she says. Families also frequently bring meals in for the resident. "We find that the Hmong, especially, like their own food."

Going through customs

Religion is another multifaceted area, according to Guildermann Before admission, the social worker assesses religious practices and customs and then identifies what spiritual advisors or resources are needed, Guildermann says. Because of the wide diversity of residents, spiritual advisors from the community are frequently utilized. Religious holidays are identified and posted on calendars throughout the facility so residents and staff alike are aware of each other's celebrations.

Much effort is also put into helping residents observe their religious practices. Guildermann tells of one resident whose family wanted him to perform his Islamic prayers. Physical limitations prevented his kneeling, so a plan was devised to position him in his bed facing the appropriate direction during each prayer time.

Great care is also given toward honoring death matters, because in some cultural groups there are very specific practices to be followed during the dying process, says Jarombek. On the unit at Galtier Health Center, there may be many family members in attendance. "We ensure the resident is in a private room at this time to accommodate the large group. And because some require the burial clothing, usually an ethnic costume, to be worn during the dying process, we follow that practice if the family wishes," explains Jarombek. "It might be more difficult for staff to give care with the costume on the resident, but it is important to respect that custom." Other rituals, such as burning incense, may also be allowed.

Sometimes family members want to take the dying resident home to conduct a spiritual ritual, then return him or her to the nursing home. "Sometimes it's physically difficult for the resident," says Jarombek, "but we try to accommodate this whenever possible."

Physical properties

It is important to know what the residents believe to be appropriate medical care, says Jarombek. Various potential conflict areas abound, such as spiritual beliefs that prohibit amputation of limbs, artificial joints or caps on teeth, or the use of shamans or priests who practice magic.

Herbal medicines are a common form of treatment requested by residents. Jarombek says these are occasionally used at Galtier Health Center, but are given with physician guidance. Richfield Health Center's Guildermann says some of her residents use herbals and massage, and several staff members are qualified in rolfing, a type of touch therapy.

Pacquaio noted that many Russian elders used a combination of prescription medication and traditional folk medicines. But because of poor quality of care and lack of medications in Russia, they tended to be noncompliant until they developed a trust in the care provider, then frequently monitered dosages on their own. These elders, who showed a high incidence of coronary artery disease, hypertension, diabetes and cancer, believed in the heat and cold theory of health and illness.

References:

(1.) Henkel G. Staff serve as in-house multicultural resources for colleagues.

Caring for the Ages. 2001; 2(11):35.

(2.) http://waysandmeans.house.gov/socsec/106cong/2-10-00/02- l0burk.htm

RELATED ARTICLE: Requisites for crossing cultures

Culturally competent care depends on a facility's caregivers:

* valuing diversity

* having a capacity for cultural self-assessment

* being conscious of the dynamics of interacting cultures

* institutionalizing their cultural knowledge

* adapting to care delivery that reflects an understanding of cultural diversity

Source: Cross T. Bazron B, Dennis K, et al. Toward a Culturally Competent System of Care. Volume 1. Washington, D.C.: Georgetown University, 1989.

Woodbuyr, Minn.-based Jan Olsen, a member of CLTC's editorial advisory board and former director of nursing with the Amherst H. Wilder Foundation in St. Paul, Minn., is now a consultant, educator and writer in long term care. She may be reached at [e-mail]