Nursing Standard of Practice Protocol: Ethnogeriatrics and Cultural Competence for Nursing Practice

Melen McBride, PhD, RN

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Background

Demography of Minorities, age 65 and Older

• The increasing racial and ethnic diversity of people in the U.S. (Census 2000) and the compelling evidence of racial and ethnic health disparities (Smedley, Stith, & Nelson, 2002) are driving forces for incorporating an ethnogeriatric perspective into the practice of geriatric and gerontological nursing.
• Projected that by 2050, the older population will consist of 61% non-Hispanic white, 18% Hispanic, 12% black, 8% Asian, and 2.7 % all other races alone or combined.
• Older Hispanics anticipated to grow the fastest from 2 million in 2003 to 15 million and would be more than older blacks by 2028.
• Asian older persons are also projected to increase in size from 1 million in 2003 to 7 million in 2050.
• Diversity of older adults is already substantial in some states. For example, in California, 20% of older adults are older persons of color and it is expected to reach 41% by 2020. (State of California Census Data Center, 1990; California Department of Finance, 1988).

 

Diversity among Racial/Ethnic Minority Older persons

• The federally designated racial and ethnic groups are American Indian/Alaska Native, African American/Black, Asian American, Native Hawaiian/Pacific Islander, Hispanic/Latino American, and white/Caucasian American. The Hispanic/Latino term is considered an ethnic category while the others are racial categories (Office of Management and Budget, 2003).
• Vast differences or heterogeneity are found between and within these categories related to health beliefs and practices, access and utilization of health care, health risks, family dynamics and caregiving, decision making process and priorities, and responses to interventions and changes in health care policies (McBride & Lewis, 2004; McBride, Morioka-Douglas, & Yeo, 1996; McCabe & Cuellar, 1994; Richardson, 1996; Villa, Cuellar, & Yeo, 1993; Yeo, McCabe, Talamantes, Henderson, Scott, & Yee, 1996).
• The heterogeneity within each of the categories of ethnic/racial minority older persons such as sociodemographic characteristics, modes of social interaction and communication, health and healing belief systems, learning behaviors, and certain values and traditions contribute degrees of complexity to the delivery of culturally sensitive health care (Yeo, McCabe, Henderson, Talamantes, Scott, & Yee, 1996.
• While it is unrealistic to expect a health professional to be proficient in working with every category and subgroups of minority older persons, it is possible to develop levels of awareness, skills, and sensitivity that can be applied to interactions with ethnic minority older persons and their families.

 

Intra Group Differences among Racial Ethnic Minorities

 

Health Risks and Health Disparities

• Researchers have found non-white native born persons tend to live a much less healthy life compared to white natives (Rich & Ro, 2002).
• The cumulative effect of such lifestyle coupled with socio-economic and cultural factors suggest that ethnic minority groups have a greater chance of developing more complex health problems as they age (McBride & Lewis, 2004).
• Diseases of the heart and malignant neoplasms are the two leading causes of death for older people, including minority groups. However, certain causes of death vary for different older minority groups. For example, diabetes is the sixth leading cause of death for all groups; however, it is the fourth for black women and Hispanic men and women and fifth for black men (Federal Interagency Forum on Aging-Related Statistics, 2004).
• For more information on leading causes of death for older ethnic persons see 2002 "State of Aging" report of the Gerontological Society of America at http://www.geron.org.

 

Background Ethnogeriatrics 

In 2003, the Institute of Medicine provided compelling evidence on lower quality of health care received by racial and ethnic minorities compared to non-minorities including unequal care for minority older persons (Smedley, Stith, & Nelson, 2003). Access to culturally appropriate resources and programs on health promotion and management of acute and chronic health problems are critical elements to improve care. Efforts at eliminating health disparities must also focus on building patient-clinician trust relationships, understanding the cultural contexts of health behaviors, and sharpening one’s sensitivity to cultural nuances associated with decision making process and health care preferences (American Geriatrics Society, 2004; McBride & Lewis, 2004; McBride, Morioka-Douglas, Yeo, 1996; Moon, Lubben, & Villa, 1998).

 

Ethnogeriatrics and Older Personcare

• Ethnogeriatrics is a developing subspecialty in geriatrics with an emphasis on the intersect of knowledge from the fields of aging, health, and ethnicity (Yeo, 1991). See http://www.stanford.edu/group/ethnoger/index.html
• It is now generally accepted that cultural beliefs and practices influence an individual's health behavior including choices and use of health care services.
• Family support and their active participation are significant factors in eldercare that varies across cultures.
• For many ethnic older persons, the patient-clinician trust relationship is often influenced by cultural norms. Likewise, the clinical interaction is also impacted by the cultural background of health care providers (Takeshita & Ahmed, 2004).
• Over the past 15 years, an explosion of information on older minority health in professional literature and professional meetings has increased the availability of materials to further develop the field. Thus, the depth and reach of ethnogeriatrics will continue to evolve over time.

 

Key Concepts in Ethnogeriatrics

 

Explanations of Significant Concepts in Ethnogeriatrics
NOTE: The following explanations are composites of traditional definitions of the terms used in the social science literature; comments from the literature in ethnogerontology; and insights provided by the team of authors who are members of the Collaborative on Ethnogeriatric Education. Published sources used are referenced.

 

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 (Andrews & Boyle, 1995; Henderson, 1990: Klein, 1995).

 

Cultural Competence in Geriatrics: Ability to give health care in ways that are acceptable and useful to older persons because it is congruent with their cultural background and expectations. 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; and 3) population-specific treatment outcomes;
3. skills in working with culturally diverse populations.

At the institutional level, it can be viewed as those systems of care that acknowledge the importance of culture, assess cross-cultural relations, are alert to cultural differences and their repercussions and adapt services to meet cultural needs. Health care settings may be placed on a continuum of cultural competence that have been described as including stages of: monocultural, nondiscriminatory, and multicultural; or destructiveness, incapacity, blindness, competence, and proficiency (Cross, Bazron, Dennis, & Isaacs, 1989; Foster, Jackson, Cross, Jackson, & Hardiman, 1988; Green & Leigh, 1989; Lavizzo-Mourey & Mackenzie, 1997, Tirado, 1998; Tripp-Reimer, 1999).

 

Culture Bound: linking a perspective, belief, behavior, or practice to a culture.

 

Cultural Guide or Cultural Broker: Consultants (health care, social service, senior service provider or respected leader) from the target ethnic population who can provide insight and information on health beliefs, culturally appropriate methods of showing respect to older persons, and problem areas in health care interaction.

 

Emigration: movement of individuals or groups OUT of the country or region of their original residence to settle in another area.

 

Ethnic Group: originally defined by Gordon (1964) as a group of individuals with a shared sense of peoplehood based on race, religion, or national origin, it is now commonly used to refer to a group with a distinctive culture.

 

Ethnicity: the active expression of culture. An ethnic group is a large group in which members self-identify. They internalize and share a heritage of, and commitment to, unique social characteristics, cultural symbols, and behavior patterns that are not fully understood or shared by outsiders. (Barresi & Stull, 1993; Gelfand, 1993; Markides, Liang, & Jackson, 1990; Valle, 1998).

 

Ethnocentrism: belief or attitude that one's own cultural view is the only correct view.

 

Ethnogeriatrics: health care for older persons from diverse ethnic populations.

 

Ethnogerontology: the study of the causes, processes, and consequences of race, national origin, culture, minority group status, and ethnic group status on individual and population aging in the three broad areas of biological, psychological, and social aging (Jackson, 1985).

 

Immigration: movement of individuals or groups INTO a country or region to settle there.

 

Minority: subgroup within a population. In social science, it is used to identify a group that suffers subordination and discrimination within a society, usually because of their race, ethnicity or national origin. The term is used by the federal government to describe protected and/or disadvantaged ethnic or racial populations (Hooyman & Kiyak, 1999; Markides, 1993).

 

Race: socially constructed categories based on parentage and physical appearance. Although the term is now considered by many anthropologists to be obsolete because of difficulty classifying populations with widespread genetic diversity, it continues to be widely used. The term is used in official government documents, such as in the U.S. Census, in which individuals identify their own racial identity. It sometimes serves as a basis for discrimination and demarcation in conflicts over social resources (Fried & Mehrotra, 1998; U.S. Census, 1990).

 

Spirituality: can be defined as whomever or whatever provides someone a transcendent meaning in life. It may be expressed as a relationship with one's god(s) or the creator, but can also refer to values such as: nature, energy force, belief in the goodness of all, or belief in the importance of family and community. Among some populations, it includes organized religion. It may or may not include belief in, and communication with, forces in the form of spirits (Puchalski, undated).

 

Transcultural: a term used widely in nursing to apply to people of diverse cultures. Transcultural nursing is sometimes described as a body of humanistic and scientific knowledge with concomitant skills essential to help nurses care for people of diverse cultures (Leininger, 1997).

 

Assessment and Screening Tools

Assessment Preparatory Considerations
[These guidelines are general and may not apply to all cultural groups, individuals, and clinical situations. For additional information, please refer to the ethnic specific modules at http://www.stanford.edu/group/ethnoger].

Demonstrating respect (deference) to older patients in culturally appropriate ways helps to establish a trusting relationship. Many older adults from different ethnic backgrounds are more responsive to calmness and humility. Speed and self-assertion or directness can create barriers to the interaction. Specific strategies to foster the development of trust may include:

• Consult informed persons as to what is culturally appropriate.
• Generally, acknowledge and greet older persons first. Generally, use formal title such as "Mr." or "Mrs." to address the patient, at least initially. Find an appropriate time to ask the patient's how she/he prefers to be addressed by the provider.
• Consider use of informal conversation prior to formal assessment. It may not be respectful to ask business oriented questions without first acknowledging the patient in a more personal way.
  • For example, Mexican Americans may prefer to begin a conversation with questions such as "How is your family?" or "Did you have to travel long to come here?" before they wish to respond to more formal questions such as "What brings you here today?" or "How can I help you today?" When an older person inquires about you, be ready to share something personal about yourself.
• Despite the increasing pressure of limited time for patient care in clinical settings, an attitude of sincere concern usually helps to put the ethnic older person at ease.
• Avoiding the "invisible patient syndrome". Older patients need to be talked to and with, rather than talked about. Talking to someone else in the room as if the patient weren't there (or is incapable of understanding) demonstrates disrespect.
• Acknowledge the importance of ethnicity and ask for the patient's help as a cultural expert in understanding the current situation and incorporating salient cultural components in the plan of care.

 

Facilitating Communication Selecting Interpreters: Interpreters convert verbal language; translators work with written language. In health care settings, interpreters may be called medical interpreters.

• If you do not speak the same language as the patient or the patient has limited English proficiency (LEP), then trained interpreters should be used (Diaz-Duque, 1982).
• Use of family members, especially young children, as interpreters is strongly discouraged because of: possible lack of appropriate language skills in one or both languages; culturally based modesty barriers to discussion of sensitive topics, especially across genders and age hierarchy that lead to difficulty in discussing family problems (Jackson, 1998).
• Avoid using untrained interpreters.
• Providers can be advocates for effective on-site interpreter services and access to telephone based interpretation services. (Villarreal, Portillo & Kane, 1999).
• Always keep in mind that the interpreter is a member of the team to be treated with respect.
  • Develop a means to establish rapport.
  • Explain to the patient why an interpreter is needed. Some minority older persons with limited English language skills may feel insulted by the intervention or may assume that the provider perceives the patient as intellectually inadequate.

 

Maximizing Verbal and Non-verbal Communication
Pace of conversation: Some cultures are comfortable with long periods of silence, while others are fast paced and consider it appropriate to speak before the other person has finished talking.

 

Speak slowly: Questions should be adapted to the age and acculturation level of ethnic older persons. For example, avoid colloquial expressions or American slang when interviewing a new immigrant. Convey a message of caring when asking questions especially those that may be highly intrusive.

 

Physical distance: Provide patients with a choice about physical proximity by asking them to sit wherever they like.

• Individuals from some cultures (e.g., Northern European) tend to prefer to be about an arm's length away from another person while those from some other cultures tend to prefer closer proximity (e.g., some Hispanic/Latino cultures) or greater distance (e.g., some Asian cultures).

 

Eye contact: While European Americans typically encourage members to look people in the eye when speaking to them, some others may consider this disrespectful or impolite (e.g., some Asian and Native American groups). Some Muslim groups may consider eye contact inappropriate between men and women. Observe the patient when talking and listening to get clues regarding appropriate eye contact.

 

Emotional expressiveness: Some cultures value stoicism (e. g., British, Japanese), while others encourage open expressions of feelings, such as sorrow, pain, or joy. Older persons from some backgrounds may laugh or smile to mask other emotions (e.g. Japanese, Filipino, Thai).

 

Body movements: Body gestures can be easily misinterpreted based on what is considered culturally appropriate. Individuals from some cultures may consider some types of finger pointing or other typical American hand gestures or body postures disrespectful or obscene (e.g. Filipino, Chinese, Iranian), while others may consider vigorous hand shaking as a sign of aggression (e.g. some American Indian) or a gesture of good will (e.g. European). When in doubt, ask an interpreter or a cultural guide.

 

Touch: While physical touch is an important form of non-verbal communication, the etiquette of touch is highly variable across and within cultures. Gender and age differences between patient and provider may also determine the acceptability of giving comfort by touching the older person’s hand or arm. Practitioners should be thoroughly briefed about what kind of touch is appropriate for cultures with which they work. During the examination, ask for permission when specific body parts are about to be touched or palpated.

 

Modesty: Some ethnic groups believe that exposing one’s body or body parts to a stranger must be avoided. The belief may be associated with religiosity (e.g. some traditional Catholics) or a cultural norm (e.g., some Muslim groups). The clinician must observe the patient’s need for more clothing and covering when being examined.

To enhance the ability of agencies to effectively deliver linguistically appropriate and culturally competent health care to people with limited English proficiency, the Office of Minority Health developed recommended standards for culturally and linguistically appropriate standards for services (CLAS) (Yeo, 2004).

 

Ethnogeriatric Assessment
The information presented in this section is intended to augment the standard nursing assessment data (Mezey., Rauckhorst, & Stokes, 1993) collected to develop a care plan. The clinician can adapt specific areas of emphasis that are relevant to the ethnic older person’s health care needs within the geriatric continuum of care and to the specific clinical care setting.

 

Patient's Background and Contextual Information
Ethnicity: When the patient is asked to self-identify her/his ethnicity, the provider gains some insight into the individual’s self-concept and degree of ethnic affiliation. An older person may be classified by visual inspection as a black older person, however, the patient may self-identify as "Brazilian".

 

Level of Acculturation: The degree in which an ethnic older person has integrated the cultural beliefs, values, and practices of the mainstream society into her/his cultural beliefs and values. The blending of these cultural domains enables the patient to acquire a set of skills and level of comfort to carry on everyday living in mainstream society.

• Placing older patients on the continuum of acculturation can help providers avoid mistaken assumptions about expected differences or similarities from mainstream older persons.
• Informal indicators of acculturation that can be used quickly are:
  • Length of time older patients or their ancestor has been in the U.S.
  • Language used at home, fluency in spoken and written English

 

Religion and Spirituality: Information on affiliation with a specific religion, participation in church-based activities, use of pastoral services for spiritual and personal growth, and/or spiritual beliefs associated with non-deities may provide a pathway to understanding and appreciating the ethnic older persons' perspective about their health care needs.

 

Patterns of Decision-making (e.g., individual vs. inclusive of family members). A family genogram (Guerin and Pendergast, 1975; Blazer & Sigler, 1984) can be used to identify the hierarchy and number of decision makers specific to eldercare; their physical location, caregiving roles, and family relationships. Some cultures designate decision making to the first-born son (e.g. Chinese), and others may include non-biological members of the extended family (e.g., Hmong).

 

Preferred Interaction Patterns

• Language: Older persons from many different ethnic groups may speak English; however, their language proficiency is on a continuum from monolingual to high proficiency. The older person's preferred language for clinical interactions and literacy level are important cues. The cognitive process of translating English technical terms to the primary or preferred language during an interview takes time and emotional energy especially for recent immigrants or ethnic older persons who are linguistically isolated. Forms of communication may be direct/indirect, formal/informal, and other forms.

 

Preparatory Considerations, Facilitating Communication

Clinical Assessment Domains
Health and Social History

• Listen for words used to describe a symptom or an illness. Incorporate these words often into your interactions.
• Collect information about family and peer support that may help determine social isolation and/or risk for depression. Issues of elder abuse may emerge anywhere throughout the assessment, but particularly in the physical exam; evaluation of cognitive and affective status and functional status; family assessment. Consider possible abuse when there are physical signs (bruises, burns, etc.) and/or behavioral symptoms (e.g., depression) (Tatara, 1999). See Elder Mistreatment.

 

Physical Examination

• In many cultures cross gender physical exams are unacceptable. Ask for preference about the presence of other family members during the examination.
• Throughout the assessment, keep the older person informed of procedures and ask for permission to examine different areas of the body.
• When providing information during and after the exam, different cultures have varying preference for the amount and type of information to be communicated.
• Symptom recognition, meaning, and report is expressed differently by older persons of different cultures [e.g. "air heavy" or "air not right" may mean dyspnea for some Native American older persons (Kramer, 1996); "heavy heart" may indicate depression among Chinese.

 

Cognitive and Affective Status

• Dementia and depression are considered mental illness in some cultures and highly stigmatized. In others, dementia is seen as a normal part of aging and it is considered a minimal problem.
• Indigenous terms may be used to label a mental health problem such as "susto" (Hispanic), "bangungot" (Filipino). For ethnic labels of mental illness, review the list of DSM IV culture-bound terms in

Selected DSM IV Culture Bound Terms

 

Functional Status

• Activities of Daily Living and Instrumental Activities of Daily Questions can be translated, if needed, and administered orally or in writing if literacy and reading levels are adequate.
• Drawings, illustrations, and other culturally appropriate symbols may also be used.

 

Home and Family Assessment

• In some cultures, a trusted member of the ethnic community may be the preferred person to initiate an appointment for a home visit.
• Depending on the presenting health concern, the assessment may include issues related to safety and comfort, living arrangements, kinship patterns, and gender roles especially in intergenerational families, support from and expectations of household members, family composition and designated family spokes person(s) and/or decision maker(s), family connectedness, and economic stability and adequacy.

 

Stereotypes that ethnic families "take care of their own" can be very misleading since some older persons from ethnic backgrounds are not part of strong family networks and are vulnerable to loneliness and isolation. In many cultures, patient autonomy may not be an assumption as can be assumed in the U.S. ethical paradigm and the family is assumed the decision maker about health care. Culture influences whether the older person and family are more individualistic or collectivistic (allocentric).

 

Community and Neighborhood Assessment

• When appropriate, obtain information on the older person’s involvement in the community, relationships and support from neighbors, use of local services (e.g.. shops, transportation, educational and recreational services), alternative health practitioners, traditional healers and spiritual counselors, and proximity to formal services (e.g. social services, health clinics, pharmacy).
• Factors related to environmental safety (e.g., local topography, sidewalks, pavement, air and water quality, crime rate) and neighborhood emergency preparedness program (e.g. local alert and response system) are assessed relative to the older person’s functional capacity and literacy level.

 

Advance directives and End of Life Preferences

• Since talking about death is considered inappropriate in some cultures (e.g., Chinese, Navajo) the topic should be approached carefully and sensitively, and only in the context of an established trusting relationship. A possible introduction after several interactions might be - "In case something happens to you and you are not able to make decisions about your care, we will need to know your preferences."
• A direct approach about death may be too intrusive for some groups (e.g. Filipino). A minister/priest known to the older person may bring up the subject with - "When the time comes, what would you like your family and the health care providers do?"
• The family may be guided on how to bring up the subject. Other areas to explore include a) preferred site for end-of-life care (i.e., hospital or home), b) cultural practices associated with care of the body and mourning behaviors during and after death, and c) attitudes about organ donation and autopsy.
• There may be occasions when the family decides to transport the older person back to the country of origin either at the end-stage of life or for burial.

 

Screening Tools

Preventive Screenings Recommended for Older Persons
Translated Standardized Instruments
Lists translated standardized instruments to measure cognitive, emotional, and functional domains.

Guidelines for use of Standardized Assessment Instruments

• Cognitive Status
• Depression
• Functional Status
• Assess appropriateness of English version
• Educational Level

Results of the assessment may be influenced by variables other than culture, such as socio-economic/educational status. For example, False-negative on cognitive impairment was reported for the well educated subjects; false-positive on cognitive impairment was reported in less educated clients (Fillenbaum et al., 1998; Gurland et al., 1992; Mulgrew et al., 1999; Mungas et al., 1996).

Prevent errors due to inaccurate assessment data by getting information on

• Educational attainment of ethnic older persons.
• Hispanic Demographics
• Language fluency

Established population norm: Validated measures are usually available only for the largest of the specific language groups. With translated versions, it is important to use the adapted version for the intended subgroup of language category (e.g., Puerto Rican Spanish vs generic Spanish).

Appropriateness of format

Technical approach (interview, self report). Consider, for example, that some older persons or family members from Asian backgrounds may be more reluctant to express their feelings in interviews than self-report, and/or may tend more likely to respond in accordance to social desirability rather than their true feelings/attitudes in interviews compared to self-report format.

Response format such as true/false or yes/no may be acceptable to some groups while multiple choice or rating scales (e.g., Likert scale, semantic differential scale, or visual analogue scale) are acceptable to others.
Font size is particularly important when low vision is present such as diabetes retinopathy, macular degeneration, glaucoma, and cataract. Use font size 18 or higher for printed instruments.

Reading level [e. g. Smog index (McLaughlin, 1969)]: Literacy levels can be problematic since older persons in many ethnic communities had little access to formal education in English, or sometimes in their native language.

 

Nursing Care Strategies

The statement below provides a comprehensive framework for professional nurses in specialty areas at the direct care level who care for ethnically/racially diverse groups of older persons, their family members, and their communities.

"Culture filters how a message is heard and interpreted; conditions how a person responds to the message; plays a role in help-seeking and help-accepting communications; influences individual and group attitudes and actions; and influences future actions" (Valle, 1998; p. 33).
A selected number of culture-based issues are discussed in this section which can be adapted to generate nursing interventions for ethnic older persons. The above quote emphasizes the importance of heterogeneity between and within cultural groups and of cultural sensitivity in healthcare providers.

 

Health Promotion Strategies

Health screening and immunizations: Refer to section on Preventive Screening. High prevalence of conditions such as tuberculosis (e.g. American Indians and immigrants from Africa, Asia, and Latin America), hepatitis B (Korean American), and bone loss (Japanese American, African American, Puerto Rican, and Euro-American) should guide the clinician in recommending immunization and prophylaxis.

Health education and mental health counseling: A family focused approach for many ethnic groups would be more acceptable. Community education with pictures and videos are preferred over printed materials such as fotonovellas; "talking circles" have been a traditional mode of transmitting knowledge in American Indians communities; educational support groups are more acceptable when facilitated by a bilingual bicultural professional. Programs should be adapted to the health literacy level of the minority older person.

Nutrition and Exercise: Indigenous food (e.g., mango, papaya) and exercises (e.g., Tai Chi, yoga) may contribute to adherence. Ethnic food preferences and food used in rituals may be incorporated into special diets with appropriate nutritional guidance from the health professional and the traditional healer or health practitioner (e.g., Chinese medicine, Tibetan medicine). In some cultures, activities such as gardening, housekeeping are consider physical activity equivalent to exercise; participation in local health clubs may not be culturally acceptable or economically feasible.

Eliciting Explanatory Models The L.E.A.R.N. model* (Berlin and Fowkes, 1983) is a clinical tool with components that can be used at the assessment, and planning phase. The acronym stands for:

L listen with sympathy and understanding to patient and family's perspectives

E explain your perception of the problem

A acknowledge and discuss differences and similarities

R recommend an intervention

N negotiate an agreement

*Reprinted with permission from British Medical Journal.

Informed Consent

Enough time should be given to the patient and family to consider the information and to consult others as expected in some cultures. Consultations may occur at home, out-of-state, or in another country. Whether an interpreter is used, literacy level is a significant factor especially when medical terms can not be translated directly into the indigenous language. Below are examples of situations in patient/family–provider interactions that may lead to misunderstanding:

• Talking about possible negative outcomes of treatment in some cases is believed to "call forth" negative outcome.
• Explaining the possible negative outcome produces loss of hope.
• The family's belief that older persons should be protected from bad news.
• The family/patient replies "yes" to questions to show respect or avoid the impression of being less educated or having low intelligence.
• Culture-based family hierarchy in which a family member and not the patient is expected to be the decision maker.

To reduce confusion and misunderstanding, consider the use of cultural guides to ascertain if talking directly to the older person is acceptable; ask if the patient has a preferred spokesperson; ask if the older person wishes to consult or designate someone as decision maker; request the older person to use her/his own words and explain to the nurse what was understand about the procedure.

 

Advance Directives

When discussing the subject, there may be situations in patient/family–provider interactions that may lead to misunderstanding. For example:

It may be culturally unacceptable to talk about death or disability. Use of terms such as "cross over", "journey to the spirit land", "crossing the river", "meet one’s maker or ancestors", etc. may be preferred. However, some ethnic groups may be more open than others about discussing death and dying.

The knowledge and understanding of advance directives varies among ethnic groups and sub-groups. When a proxy decision maker is designated, the individual may be unknown to the older person’s family.

Distrust of providers as a result of historical trauma (i.e., oppression or persecution) or a belief that care of the older person maybe diminished after an advance directive is executed.

Cultural, social, economic, educational, and linguistic differences between provider and patient/family.

The patient/family may think that cultural rituals and traditions practiced at the time of death may not be honored.
Providers functioning within the biomedical model of autonomy in decision making may not recognize expectations in some cultures that someone (e.g. family member, son, or clan leader) would make health care decisions for the older person.

To reduce confusion and misunderstanding, the nurse could engage in self-assessment of her/his own values, attitude, and cultural beliefs about death; consult with a cultural guide for assistance to identify culturally appropriate approaches for the provider-patient interaction; and/or request the older person or the family to describe their customs, concerns, and beliefs about death, if appropriate. For a definition of "cultural guide" go to section "Key Concepts in Ethnogeriatrics".

 

Medication Management

There are culturally based attitudes that may influence an older person’s adherence to a medication regimen. It may be related to one or a combination of beliefs such as:

• The medication, i.e., prescription and over-the-counter (OTC) is too strong, resulting in taking less than the prescribed dose.
• Medications administered by injection is the only effective treatment, thus a competent provider would give a injection during each visit
• Acceptability of a type of medication may be influenced by cultural values. For example the side effect of impotence may threaten an ethnic older person’s sense of "machismo".

Attention is important not only to the beneficial (i.e., physiological) effects of medications but also the ethnic/racial differences in response (e.g., pharmacokinetics) to some medications, such as antihypertensives, anti-depressants, benzodiazapines, and neuroleptics (Lin, Poland, & Nakasaki,1993). Some culturally based herbal medications when used in combination with pharmaceuticals may alter the desired treatment outcome.

More and more, ethnic older persons are concerned about their ability to purchase medications despite the new prescription drug program (Medicare Part D).

In some ethnic groups it is common to "share" medications among family and friends. There are others who may have access to medication from other countries by purchasing directly from local pharmacies without prescription. Some new immigrants may travel with a supply of medications that may last for 6-12 months and continue to use them without medical supervision.

To encourage patient to inform the provider about medication use, older persons need to feel reassured that these medications or herbal products would not be taken away from them. When feasible, consider incorporating them into the current treatment and management plan.

To avoid or reduce misunderstanding and increase trust for providers, discuss patient's and provider's explanatory models for condition being treated (see above section on Eliciting Explanatory Models) and understand the cultural meaning of condition (e.g., is it hidden?, is there a word in the language for the condition?).

A list of selected DSM-IV-TR culture bound syndromes are examples of traditional terms by some in ethnic groups (Table 6, Appendix F)

When providing written information or instructions, consider the patient’s literacy level and appropriate reading level.
Writing the instructions in a prescription sheet, signed by the physician or primary care nurse is an important document to some older persons (e.g., Filipinos) and may improve adherence.

Use the prescription guideline "start low and go slow" keeping in mind the patient's individual characteristics; tracking carefully variations in medication response; and assessing different attitudes to taking the prescribed dosages.

 

Dementia and Family Caregiving

Dementia is a general term for progressive brain disorder that causes changes in cognitive functions (e.g. memory, judgment, language, planning) and gradually impairs the individuals social, functional and other abilities. See Dementia.

 

Cultural Differences in Family Participation

When working with culturally diverse older persons and family members the clinician may need to be aware of common cultural differences in the expected participation by family members in older persons' health care in these areas:

• Disclosure of terminal/ serious condition to family members but not to patient.
• Decision making by family member(s) instead of by patient
• Showing respect to older person through family caregiving rather than encouraging independence
• Spiritual/religious beliefs by family that the older person's life should be preserved by all means despite decreased quality; should allow time for a "miracle"; should allow God to control the time of death
• Importance of presence of large numbers of family members, which may interfere with medical or nursing care routines
• Cultural expectations of behavior (e.g., cross-gender touching)

To avoid or minimize intercultural conflict, the clinician can ask the older person or family to identify a family spokesperson and the preferred decision maker.

Remember to respect these choices and in emergencies, ask the family to designate a spokesperson for this period of time.

A situation may require the use of a cultural broker or cultural guide from the older person's ethnic or religious background. This resource person can help the clinician understand better the situation and offer culturally appropriate ways to work with the ethnic elder and the family. For a definition of "cultural broker or cultural guide" go to section "Key Concepts in Ethnogeriatrics".

Assist the team in working with the cultural components of the interactions by:

Alerting them to cultural communication patterns (e.g., meaning of eye contact/body language) and
Familiarizing the team with cultural explanatory models of older person's condition(s), if known to the nurse. The facilitative role of the professional nurse contributes to the collective cultural proficiency of the healthcare team.

 

Long-Term Care

Studies indicate that on average older persons from most ethnic minority populations use most formal health care services less than their white counterparts except emergency and acute care (Damron-Rodriguez, Wallace, & Kington, 1994).

Formal long-term care services have lower rates of utilization by older persons from most ethnic minority populations.

Family members may be preferred by the older person to provide home care based on cultural expectations. It is acceptable to compensate a family caregiver through formal service programs such as a local Homemaker or Home Health Aide Service of the Area Agency on Aging or the Visiting Nurse Services. However, these preferences can create extreme stress on family caregivers and their families, particularly in intergenerational households, even when the arrangement is a strong expression of cultural values to show respect, appreciation, and reciprocity (e.g., "pay back").

Day care, respite care, residential, and nursing home care can be culturally acceptable when the environment (i.e., physical, social, spiritual, etc) incorporates celebrations of cultural events and holidays, nutritious meals with ethnic food, and other activities that help to validate and affirm cultural identities.

Be mindful of the effect of certain cultural symbols that may be a source of comfort or discomfort (e.g., images, color, clothing, decor).

Understand and respect cultural taboos while avoiding cultural stereotyping or projecting a judgmental attitude.

The presence of a bilingual, bicultural health care provider would be an important asset to the program.

 

End-of-Life Care

There is increasing attention on end-of-life care in healthcare systems. The health professional must strive to have an understanding of the ethnic older person's perspective about life and death and incorporate them to the care plan. Conversely, the provider must be aware of her/his cultural values and views and respect the older person’s beliefs and preferences especially when they are culturally divergent.

Some cultures may confront directly end-of-life treatment issues; others may avoid these issues and allow the clinician to make decisions; and some may refuse an intensive approach while confronting death and dying issues (Adler, 2004).

A survey by the American Psychological Association (2000) showed a strong preference to use heroic methods for older persons to prolong life over the processes involved to hasten death.

In the Chinese tradition, it is disrespectful to openly discuss end-of-life preferences.

Advanced directives are not well understood and few have them. A common reason given is that the family knows what to do and that they can be trusted to make appropriate decisions (Hopp, 2000).

Because each culture has its nuances and traditions, the clinician must avoid making assumptions:
verify the meaning of cultural messages and behaviors

• approach a clinical encounter with an open mind;
• allow time for listening;
• consult culture guides enable participation of respected and trusted individuals in the older person’s network refer to appropriate institutional and community services; and
• use reasonable strategies applied in a respectful, gentle, and humane way

Some immigrant families may wish to take the older person back to the home country for burial or have family members travel to the US for the funeral services. It would be comforting to the grieving family to feel supported in this regard by healthcare providers.

 

Chronic Pain Management

Gender-based cultural norms may influence the ethnic older persons’ choice for pain intervention. The ability to withstand pain may be an aspect of "machismo" (e.g. Hispanic/Latino) or a survival skill (e.g., American Indian). In some cultures pain and suffering are intertwined with religiosity and the experience may be offered as a sacrifice to be a step closer to heaven (e.g. Catholics).

The assessment of the individual older person’s threshold for pain should include verbal and non-verbal information (e.g., facial expressions, emotional tone, and physical signs such as clammy skin, increase pulse rate, etc).
Some ethnic older persons may not ask the healthcare provider for pain relief but express the need to an intermediary (Kramer, 1996).

When appropriate, the primary care nurse can negotiate a culturally acceptable pain management plan that includes Western approaches and traditional methods (e.g., laying of hands, herbal products, prayer, exercise, etc.).
Surgery, Autopsy, and Organ Transplant Special concerns of different ethnic groups related to surgery, autopsy, and/or donating organs may include beliefs such as: sanctity/sacredness of the body; keep body whole to "cross over"; irreplaceable body fluids specific to blood loss (e.g., that blood is not replaced); or illegal harvesting of human organs. For a variety of cultural reasons, some ethnic older persons and their families may request to return body parts that are removed during surgery (Alvord, 1999). Cultural or religious ceremonies may be held to bury the body parts.

 

Coordinating HealthCare Team Interventions (Bio-Medical) and Traditional Therapies

Culturally competent healthcare delivery systems would include in its policies:

Programs that use healthcare providers who are valued by ethnic older persons and their family in the treatment team, including healers from non-biomedical traditions; and support the education of the healthcare team (biomedical) on cultural competency and ethnogeriatric care.

A system-wide effort to honor the older persons’ needs for healing practices or ceremonies that can be achieved by ensuring adequate space and time to conduct these activities in a meaningful and safe manner.
Administrative teams who consults with stakeholders in ethnic communities to build partnerships so that differences in goals between healthcare professionals and traditional ethnic providers are acknowledged, discussed, accepted, and respected.

Direct care providers who are guided by institutional policies that actively support treatment plans. A self-assessment tool on cultural awareness for healthcare providers and guidelines for clinicians are available in

 

• Self-Evaluation Questions on Cultural Awareness
• Guidelines for Clinicians to Provide Culturally Sensitive Care

 

Expected Outcomes

Patient

The patient will receive an appropriate ethnogeriatric assessment including ethnicity, acculturation level, religion and spirituality, decision making patterns, and preferred interaction patterns.

The patient will receive an ethnogeriatric health/social history, physical exam, cognitive and affective status, emotional status, functional status, home and family assessment, and advance directives; and problem specific data and intervention specific data.

The patient will have a highly personalized healthcare plan which incorporates cultural preferences, healing traditions, and/or ethnic specific approaches to implement the nursing care plan.

Professional

Increased awareness and understanding of the cultural contexts of the older person/family and of the provider will improve communication and interactions.

Increased competence and self-confidence in facilitating communication, by showing culturally accepted forms of respect, and building trust relationships with the ethnic older person, family, and healthcare team will improve the process of planning care and management of the treatment.

Increased clinical skills in planning culturally appropriate nursing interventions related to health promotion, medication and pain management, dementia care, long term care, and end-of-life care will help expand the clinician's resources.

Improved ability to articulate (in oral and written form) the effect of historical experiences, cultural preferences, and explanatory models will enrich the geriatric nursing assessment database for the patient and will contribute to the quality of care and quality of life for ethnic older persons.

Institution

The institution will increase its emphasis on culture-friendly institutional policies to deliver culturally congruent services to the community of ethnic older parsons and their families.

The institution will have more partnerships with ethnic community groups focusing on quality ethnogeriatric care and quality of life for ethnic older persons.

The institution will develop policies to support and reward direct care providers to develop treatment plans guided by ethnogeriatric concepts and principles.

 

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