We talk a lot about culture change, but what is it about the culture that needs to be changed, and which culture are we talking about? In all community care settings, there are actually a few cultures that come together and, sometimes, collide. We have examined culture before and used Edgar Schein's definition, which we have loosely summarized as “the way we do things around here.”
1 This definition applies to both the culture in the community where we are giving care and to the culture of the family from which this person has come, and sometimes these are the cultures that clash.
The culture of many healthcare environments, including residential care for elders, often follows traditionally hierarchic models in which the patient's schedule is determined by the schedules of the workday and shifts, task lists and power structure. In contrast to this, many families follow a more collaborative style of care, where family members consult with each other about how best to meet the needs of the elder. When the family member comes in and, because of a prior caregiving relationship or simply because they know and are concerned about the elder, assumes he or she is part of the care team in the community, we sometimes find ourselves with a problem. Perhaps we bristle at having a professional opinion questioned; perhaps we assume the family member is an adversary, taking time from our day with difficult questions or a different opinion of what a loved one may need.
In many cases, family members who want to be involved in informing care are viewed by the professional caregivers and managers as interlopers, or worse, nuisances. A conflict can naturally arise from this attitude because, of course, the family member simply sees involvement as a natural part of continuing to care for the elder. What ends up happening is a competition “over how care will be provided, with a corollary conflict over what actions, and by whom, constitute good care.”3 Those who have been hired to care for the elder often feel that their expertise has been called upon and they therefore constitute the de facto “solution team”-a term used to identify those who implicitly or explicitly have been assigned to solve the problem at hand.
These scenarios can often devolve into a conflict state with little productive value in terms of providing care. The clash between the cultures of the community and the family can result in a stalemate or escalating argument over care. But there is another way to look at this clash, and that is as an opportunity to expand the size, scope and membership in the solution team. “This alternate perspective sees conflict as a natural outgrowth of the diversity in knowledge, culture, technical expertise, values, and the specialized roles played by providers and patients/families.”3 This reframing takes the perspective that having more viewpoints will increase the number of ideas and options available for forming solutions to good care, and recognizes that the expertise of both family members and professionals will enrich the options.
The new perspective has five key principles:
Every stakeholder has expertise about something but not about everything.
Everyone in the institutional setting has a family (for better or worse).
Everyone needs to feel important, needed, useful and successful.
All people are at their best when they behave in accordance with their positive aspirations and views of themselves.
Everyone wants to be informed as completely as possible about the situation: ignorance breeds anxiety, fear and anger, which fuels the conflict cycle.3
Keep these principles in mind in order to involve all parties on the solution team. Those working on the professional side would do well to remember that when families push back it may be because they are viewing the same situation through the lens of their cultural values. The family might not feel that the providers are wrong or bad, but that they see the situation another way. By marginalizing the family's viewpoint, we create the anger that we then blame them for. They become, in our view, difficult to deal with and an impediment to good care for the elder. But because we have not been able to honor their viewpoint, we have left them out of the solution process, creating a difficult situation.
On the family side, it may be that they are discounting the expertise that professionals have been trained to, and are proud to, bring to the problem-solving phase of care. Family members being dismissive of professional opinions further widen the gap in cultures of care. The truth is that both perspectives are needed to present the fullest information about the person and the illness or challenge. The more data points brought for consideration to the solution team, the better. Each culture brings something valuable.