Caring about culture

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:

Awareness. In this segment, staff are taught about diversity in the United States and in their field. The point is to make them aware of how diverse their community is. “Diversity is defined broadly,” Deason says. “It includes ethnicity, age, disability, gender, sexual orientation, and any life-shaping factors.”

Knowledge. Deason explains what cultural competence is and why there's a need for training, supplying some statistics on discrimination and a discussion of stereotyping and biases.

Skills. This segment examines what skills the participants already have, and then teaches additional skills to help them interact and communicate more effectively across cultures and within cultures.

Action. In this component, Deason asks staff members to write what skills they would like to work on to improve their ability to interact and communicate, and to come up with a feasible 30-day plan to begin making changes. When working with managers, participants are asked to develop an organization action plan that involves exploring what they can do in terms of policies, procedures, and operations to improve their staff's ability to interact more effectively in a multicultural setting.

The workshops feature role-play scenarios, group exercises, and one-on-one interactions. Some of the exercises help participants learn to better understand the language or “jargon” of the residents in their care. “Language is important, even with African-Americans” as opposed to those who speak a language other than English, Deason says. “We all have jargon, and the elderly have a different type of jargon than the younger generation has. Even if we're all speaking English, the same term may mean something different to other individuals. Just take a little bit of time and get to know the resident and figure out what—when they talk to you—their words mean.” But when it comes to language barriers, recruiting staff who already speak the same language might be the most effective fix.

Recruiting Staff

One way Lake Shore acquires and retains staff that come from the same cultures as their residents is by identifying people who could use help in becoming trained a CNA. “I work with an organization that helps [Indian and Pakistani] women who are victims of domestic violence, and we help them to get CNA certification,” says Singh. Other efforts have included helping staff members become citizens. Lake Shore even recruits overseas to ensure that it has staff who match their residents culturally. Then they go the extra mile to ensure the new staff person transi-tions to living in a new country.

“When new nurses are recruited from out of the country, often we get them an apartment nearby, give them the household and kitchen supplies they need until they're on their feet,” says Singh. Making sure this staff also learn English is important. “We don't provide ESL classes directly, but we have contacts within the community,” he adds.

English as a Second Language

At La Posada at Park Centre, a continuing care retirement community in Green Valley, Arizona, residents—most of them former educators—have begun an award-winning program that offers tutoring in ESL and helps prepare staff members for citizenship exams, as well as offering scholarships for formal education, helping employees obtain general equivalency degrees, and providing student loan repayment for nurses. Some residents are certified to teach ESL to the facility's Hispanic employees.

La Posada is located 35 miles south of Tucson, which has a large Hispanic community, says Marketing Director Tim Carmichael. “As a result,” he says, “La Posada attracts employees from the surrounding area, but when we deal with the Hispanic market, that […] employee base often comes with limited ability to speak English.”

Although La Posada has independent living and assisted living apartments in addition to its memory care unit, its skilled nursing facility benefits the most from the program. “The nursing home itself is really reaping the rewards,” says Carmichael, “and it wasn't initially designed to do that. We're attracting employees now as a result of the program.”

If there isn't a resident or staff member certified to teach ESL, finding these classes in the community can take some legwork. According to Teachers of English to Speakers of Other Languages, (TESOL,, a professional organization for ESL teachers that also offers ESL credentialing, organizations that offer free or low-cost ESL classes differ from state to state, and from school district to school district. Classes may be offered by the local community college or may be part of the elementary school system. Church groups or other volunteer organizations, as well as immigration advocacy groups, may also offer classes. Start by calling the local department of education or public school system, TESOL recommends.

But all of these efforts won't quite reach the mark unless family members are involved, especially for residents of ethnic minorities whose families expect to be intimately involved in their loved one's care.

Involving Family Members

The family members of residents of ethnic minorities may be much more involved in their loved one's care than the typical Western son or daughter, which can increase tension between staff who aren't used to what might seem to be interference, and families whose culture is to keep the extended family closely together. “Typically, in a nursing facility or a hospital, Americans tend to visit and then leave their loved one there to heal, leave them in the hands of the medical staff,” says Singh. “But Latinos, Asians, South Asians, and Indians will stay with their family member morning to night, every day.”

This intense family involvement meant that Lake Shore had to approach family members as partners. “In a healthcare environment that typically doesn't have family members around all the time, we had to train both staff and family members to act as a team,” says Singh. “Instead of criticizing staff, we help the family to feel like part of a team by letting them do a lot of the little things for their loved one, such as getting a glass of water or massaging them.”

Reaching Out to the Community

Being truly culturally responsive requires a program coordinator who not only speaks the language and is of the same culture, but who networks within the ethnic community. “One of the reasons I was recruited to work here is because I have a huge number of contacts in the community,” says Singh. “And that's something that has to happen if you're running an ethnic program. You have to be known in the community, and ultimately it's a two-way street. We support organizations with donations, work with the Indo-American Center, and bring [Indian and Pakistani] seniors over here for religious holidays or other events. When you work in an ethnic community you have to be well known, have integrity, and be respected.”

Ultimately, honoring resident cultures can result in improved care and heightened quality of life for residents; enhanced satisfaction among staff, residents and, not insignificantly, their families and friends; and even improved census through community networking. Becoming culturally competent “helps put the family at ease,” says Deason. “Sometimes families are the biggest critics of nursing facilities,” she says, “but if they see the facility making an effort to meet the cultural needs of their loved ones, they'll understand on a deeper level that we truly see their loved one as an individual worthy of respect and good treatment.”

Kathleen Lourde is a freelance writer based in Oklahoma. Lucinda Deason,PhD, is an Assistant Professor at the University of Akron, Fellow, and Research Committee Cochair for the university's Institute for Life-Span Development and Gerontology. She can be reached at (440) 346-3602.

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The Comfort of Like Cultures

When the hospital told Ecidro Madrid that his mother, who had been ill, was too weak to live independently and needed to go to a nursing home, he looked first in Deming, New Mexico, where they both lived, but no nursing home beds were available. The closest available bed was 70 miles away at Casa de Oro in Las Cruces, New Mexico.

But what at first appeared to be a difficulty proved to be fortuitous for Madrid and his mother. A full 50% of Casa de Oro's residents and staff were Latino; the other 50% were European-American. That simple fact—that his mother's Latino culture was alive and well in her new home—made all the difference. In fact, it translated not only to heightened quality of life, but to improved quality of care, according to her son. Later, when a bed became available in Deming, Madrid, who was driving a 140-mile roundtrip every third day, and his mother agreed that she should stay where she was.

A number of the Casa de Oro staff are bilingual, and Madrid's mother could communicate with them, which was the main reason she wanted to stay. She didn't speak English well, and a sense of shame about that kept her from speaking up if she needed something, unless she could communicate in Spanish. “A lot of nursing homes don't have too many bilinguals,” says Madrid, “and that's what [some residents] need, either for Spanish, or now we're getting people from all parts of the world.” It's important to be able to communicate if you're in pain, he adds.

Speaking her language was important, but so was the way Madrid's mother was treated, like part of an extended Latino family. The bilingual staff “treated my mother like she was their own relative,” he says. “They would call her mother, or call her aunt, and she called some of them ‘my daughters,’ so she got real close to them.” She also liked that Latino meals were served alongside more mainstream American foods.

“I think it's important to honor residents' cultures,” says Les Szeide, Casa de Oro's administrator, “because it's a recognition of who they are and where they come from. I think it makes people feel more at home when their cultures and holidays are observed,” he adds.

Along with providing Latino meals celebrating Cinco de Mayo as well as the Fourth of July, Casa de Oro alternates between the cultures whenever there's a celebration of any kind. “We'll have salsa music or something similar alternating with more traditional Anglo entertainment,” says Szeide.

Such things not only ease the transition to institutional living for residents, but for family members as well. Madrid found it difficult to leave his mother in a nursing home because he was used to taking care of her. “Every day I would go to her house and buy things she needed from the store,” he says. “Not being able to take care of her was kind of hard at first. I was used to being able to do what she wanted, but at the nursing home they were taking my place.” These kinds of feelings could have caused him to become hypercritical of the facility's treatment of his mother. But when he saw how happy his mother was, he came to terms with it.

In a sense, he accepted the entire facility as his extended family. Even though his mother eventually passed away, Madrid and his wife, Carrie, still make that long trek to Casa de Oro to visit the other residents they all got to know so well during the five years his mother lived there.

In fact, he and his wife were so pleased with the care his mother received that he gave Casa de Oro a plaque “thanking them for the great job they did taking care of my mother.”


The Importance of Familiar Food

One way cultural competence can improve care, notes Deason, is by providing familiar ethnic foods, which can help combat weight loss. “Food is number one, in terms of resident comfort,” says Shiva Singh, community liaison for the Indian/Pakistani unit at Lake Shore, which has 30 Indian and Pakistani residents who enjoy not only food prepared by a Pakistani chef, but other culturally appropriate amenities such as Indian and Pakistani satellite TV programming and staff who speak many Indo-Pak dialects, including Hindi and Urdu. Two more of Lancaster Health Group's seven Illinois facilities feature ethnic minority units, including Polish, Korean, and Hispanic programs.

Above all, “food is the thing residents appreciate the most,” says Singh. But it's got to be the real thing. “You can't just say that when we have enough Indian residents we'll go to Costco and buy prepackaged Indian food,” warns Singh. “It has to be authentic.”

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