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Caring about culture

October 1, 2007
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Acknowledging the ethnicity of residents can make a world of difference

For days after moving into Lancaster Health Group's Lake Shore facility in Chicago, a woman refused to allow herself to be bathed or to receive help changing her clothes. Eventually, the staff discovered that she was Muslim and had been mistakenly assigned a male certified nurse assistant (CNA), to whom she flatly refused to physically expose herself. If the facility hadn't had staff members who were of her culture and understood the problem, this situation could have turned very unpleasant, with the woman being labeled noncompliant. But because the facility did have such people on staff, the problem was easily resolved by providing the woman with a female CNA. Similar “culture clash” situations will likely become more common as our ethnic populations increase.

Increasing Ethnic Diversity

The percentage of people in nursing homes who are part of an ethnic minority—members of cultural groups that are not the dominant European-American culture—is growing, according to Lucinda Deason, PhD, an assistant professor at the University of Akron who studies cultural competence in nursing facilities and teaches workshops on the subject. She is also a fellow and research committee cochair for the university's Institute for Life-Span Development and Gerontology. “We're seeing a growth in ethnic minorities going into nursing homes,” says Deason, citing data provided by the National Center for Health Statistics. It's a trend that will likely continue. In fact, according to AARP, nearly 20% of people over the age of 50 belong to an ethnic minority.

“Given that fact, nursing homes need to consider the cultural backgrounds of their residents when thinking about the services they provide,” Deason says. Ways to address this issue include serving culturally appropriate foods, matching residents with staff members of their own culture, holding cultural competency workshops, providing an area for residents of the same culture to socialize, involving family members, and reaching out to ethnic communities and becoming a resource for them. Also, a facility can be creative in finding and retaining staff of the same cultures—providing or finding English as a second language (ESL) classes, recruiting from other countries, and providing help with citizenship exams.

Cultural Competence Improves Resident Care and Staff Satisfaction

Residents' personal care can benefit from matching them with CNAs who share an ethnic background, according to Deason's research. In its ethnic programs, Lancaster matches residents with staff by culture as much as possible, Cheryl Morris, vice-president of operations for Lancaster Health Group explains; but it can be difficult hiring certain positions for certain cultures. “Being a CNA is not something Indians have done a lot, although there are a lot of Indian nurses,” notes Singh. Morris adds, “However, we are fortunate enough to have at least one RN and one CNA represented for each culture.”

The benefits of matching residents by culture holds true for African-Americans and European-Americans as well, says Deason. For example, she's found that European-Americans who grew up during the Jim Crow era may have prejudices that make them uncomfortable receiving personal care from people of color. “Facilities need to look at ways to address [the situation] when a resident has a prejudice and try to match those residents with aides from their own ethnic background,” says Deason.

Prejudice can lead to difficult situations, including frustration for both the resident and the staff member, resident complaints, and even verbal and emotional abuse directed at the staff member. If a staff member comes to the director of nursing or administrator with reports of prejudice, the first thing to do is to let them talk, advises Deason. “The staff member will probably be upset, so listen to his or her issues and concerns, and then empathize and try to make him or her feel a little more at ease,” she says. Next, try “to explain to the staff person the context and environment that the resident grew up in, and say that, yes, it's not fair that the resident feels that way, but it's just the way the person was raised,” she adds.

Talk with the resident and “see if things can be worked out. If the problem can't be resolved, then for the peace of mind of the resident and staff person it would be better not to have the staff person work with that resident,” Deason notes.

Find a staff member to care for the resident who is from the same culture. “I don't think prejudice is okay,” Deason says, “but we have to be realistic.” Prejudice or cultural ignorance on the part of staff members can be combated directly through cultural competence workshops.

Holding Cultural Competence Workshops

Deason urges nursing facilities to conduct cultural competence workshops at least annually. Lancaster has diversity awareness workshops, and even dedicated one of their administrators' retreats to diversity awareness. In classes, staff members—especially direct care staff and others who interact with families—increase their awareness of differing cultural practices and worldviews, and are given skills in cross-cultural communication. More importantly, says Deason, they're taught how to break down their own stereotypes. “We all have them,” she notes. “We need to be aware of them and not let them become barriers to effective communication and service provision.”

For information about cultural competence consultants and diversity training materials, Deason recommends the National MultiCultural Institute ( Although Deason tailors her workshops to the specific facility's needs, they generally consist of four components: