The influence of culture on aged care delivery

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The influence of culture on aged care delivery

• Professor Olga Kanitsaki AM
• Head
• Division of Nursing and Midwifery
• School of Health Sciences
• RMIT University

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Aims

• Identify what culture is and how it operates in
  public mainstream society
• Give an example of how culture care operates in
  ethno specific context
• Give an example of how the ruling normality
  speaks for, undermines or subjugates other
  cultures care practices in a multicultural
  society like ours
• Propose actions that can be taken to improve
  health services to ethnic aged in mainstream
  acute, community, residential and ethno specific
  care services

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Stats Aged 65 and over

• 2.4 Million aged 65 and over 12.5
• 784, 600 or 33 born overseas
• 479, 400 61 CALD/NESB or 19.9 of the total
  older population
• 305, 200 39 ESB
• By 2011 CALD 22.5 this is an increase of 66
  growth since 1996 compared to the same period of
  23 for the Australian born population
• Italy, Greece, Germany, Netherlands Poland
• ABS AIHW 2002 AIHW 2001

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Culture

• Human
• Construction

Shared
meaning, Symbols, Language
Individual collective experience, History
tradition
Living within interacting with environment in
time place
Core values, Beliefs, Expectations, Goals, Pattern
s of social behaviour interactions
Rules practices, Rewards, Punishments
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Cultural InterpretationsCommunicating Meaning

• Members of the same culture share sets of
  concepts, images, and ideas which enable them to
  think and feel about the world, to be able to
  interpret the world in roughly similar ways.
  (Giles Middleton 1999, P 59 ).
• It is not language alone that produces meaning,
  but also behaviours and practices.

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Culture is

• Internalised (embodied) by the individual
• Forgotten as embodied history (cf structure of
  grammar)
• Just as grammar (unconsciously) regulates our
  speech, so too culture regulates our action, i.e.
  through internalised individual dispositions.

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Australian Public Culture Institutional
Structure Base of Society
Margins of Society
Indigenous People
Ethnic
Ethnic
Scottish
of
English
Margins Society
Australian Dominant Public Culture
English
Irish
Margins of Society
Ethnic
Ethnic
Welsh
Margins of Society
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Transcultural Values and Moral Systems (Lay and
Professional)

• Values
• Individuality versus collectivity
• Privacy, confidentiality, truth telling
• Independence versus paternalism
• Dignity, privacy, quality of life etc..
• Family structure and relations
• Care practices
• Decision making processes
• Gender roles
• Consent and informed consent

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Mainstream/Dominant culture

• Well internalized and embodied by majority or
  mainstream of people
• Perceived as natural (like the laws of gravity)
  and hence objective, factual, true

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Mainstream/Dominant culture, Cont

• Anyone who fails to uphold the normal life way
  risks being labelled odd, different,
  inferior, other, difficult, not normal
  and even a threat to social cohesion

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Levels of culture
Global Human Cultures
Societal National Culture
Regional Community Culture
Group Family Culture
Individual Culture
LEININGER, M. 1995 P 23
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Greek Culture care

• Family structure, roles, values expectations
• Child centred
• Reflects ideal moral universe
• Gods family good father, mother, children
• Interdependent
• Family care trusted, strangers paid not trusted
• Care institutions not trusted, family would go
  with member. HCP surveillance by family

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Issues to be taken into account

• Generational differences in expectations
• Communication between generations
• Children working
• Elderly isolation
• Economic linguistic dependence
• Authority and respect for elderly may be
  diminished within family
• Difference between groups and individual aged
  people

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Case exemplars

• Case 1 Elderly Greek woman having a shower
• Case 2 Elderly Greek woman who experienced both
  mainstream and ethnospecific aged care

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Cultural relational spaces in the Home
Old Aged
Board CEO
Anglo Celtic Div 1 Managers
Aust Greek Born Div 1 Anglo Celtic
G C
G C
PC
PC
Greek Nursing Home Culture in Action
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Ethnospecific Home Benefits

• Greek residence, PCs, relatives Together share
  history, experience, language
• Able to have a two way verbal communication with
  carers, share jokes, reminisce, play games, have
  arguments etc
• Greek environment, space objects, artefacts,
  meaningful symbols
• Greek food

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Ethnospecific Home Benefits, Cont

• Greek activities and religious practices
• Greek entertainment, music, Greek TV, dancing,
  picnics and community visiting
• Name days
• National days

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Privileging Mainstream Normality (Culture)

• Official/formal language use English
• All official and government documents in English
• All meetings in English
• General Manager Director of Nursing Anglo-Saxon
  Celtic
• Formal Communication via the hierarchical system
• Governments Health Family Services Planning
• Approval Classification, Certification and
  Accreditation Funding Standards (management)
• When Anglo Saxon staff leave gifted flowers and
  appreciation/Greek staff got nothing

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• Concepts in the official documents too hard for
  PCs to understand, thus no use translating them
• PCs expected to learn English
• Pressure to learn English
• Classes compulsory, after hours without pay
• Anglo Saxon/Celtic not expected or requested to
  learn Greek

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Greek cultural capital devaluing

• Greek RNs Div. 1 employed as SENs PCs
• No systematic recruitment retention plans for
  Australian Greek or GA Born
• Reasons
• Funding Div 1 level 4 position required
• Inexperienced, young
• Greek women (ethnic, immigrants)
• Felt demeaned and insulted

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• Greek RNs Div. 1 employed as SENs PCs
• Because the other registered nurses and the
  other SENs knew I was registered as a Division
  1 nurse they would give me a little bit more to
  do. But their expectations of me were higher, and
  that was fine by me. I wanted to meet those
  expectations. So, yes, I think at that stage I
  didnt really know whether I was Arthur or Martha
  because I was an SEN (they were paying me as an
  SEN) and that was what my job description said I
  have to do. Yet there was that expectation from
  them that I would function as a Division 1 RN,
  and I also had that expectation of myself.

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• So here I was, experienced in terms of knowledge
  as a registered nurse, and I had the appreciation
  of the language and the culture, and so they
  expected me to establish a rapport with these
  residents and to do really well in my
  interpersonal relations in addition to my
  professional skills. I had them both, so the
  expectation was there. And from a gender
  perspective they saw me as a woman, a Greek
  woman, who should behave like a Greek woman.

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• The RNs saw me when I was on, Here's my little
  interpreter, and Here is my little second hand
  person. I didn't mind that. I loved the
  opportunity to be doing some other skills that
  reinforced what I was trained for.

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• Concepts in the official documents too hard for
  PCs to understand, thus no use translating them
• PCs expected to learn English
• Pressure to learn English
• Classes compulsory, after hours without pay

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• RNs PCs used as interpreters for Australian
  Management
• Messengers mediators to Greek staff and
  community
• Living in-between two ambivalent cultural worlds.
• Identity problems

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• Constructed as ethnic and inferior
• go and pick cherries or go and work down at
  Bosch a factory
• Other times she will speak to us like we are
  the last rubbish of the rubbish. It is not right
  to have us here at 7 in the evening and to have a
  meeting to last till 10 pm.
• Expected domestic staff who chipped or broke
  plates to pay for them.

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Other Issues

• Relatives
• Complaint about the variety of food
• Number of staff on night duty
• Harassment on food, and harassment on water.
• I was treated like I was a migrant. An
  illiterate migrant.

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• Anglo Saxon Celtic interpretation of dignity and
  privacy, for example, elderly was scared during
  the night and requested to put an intercom so
  that elderly can hear a voice. The manager
  dismissed the request and stated that this would
  violate the Residential Standards because of the
  noise and because of dignity and privacy. The
  relative stated that the elderly and those others
  sharing the room were concerned with safety not
  about dignity, noise or privacy.

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• MII She angrily instructed me to say to them,
  Take your sweets and go away from the nursing
  home. Then she went away. I thought if I send
  them away, it will be the wrong thing to do and
  we would not have accomplished anything.
• It is because they mistrust the nursing home
  because of the restrictions imposed upon them by
  the nursing management and because of the way
  they have imposed those restrictions.

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• All of the above mitigated against
  trans-formative cross-cultural practices
• Sustained mainstream culture superiority and
  domination and,
• Reinforces Greek cultural inferiority and
  subordination

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Transcultural Issues

• Patient family knowledge of health system
• Professional roles, rules and practices
• Cultural interpretations (whose prevail?)
• Communication and communication styles
• Ethnocentrism
• Stereotyping V Generalisations
• Transcultural ethical systems
• Consent and informed consent

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Transcultural care delivery at a professional
service level

• Culture care preservation/maintenance
• Culture care accommodation/negotiation
• Culture care repatterning/restructuring
• Results in culturally congruent nursing care that
  is healing and empowering
• Can be applied face to face delivery in acute,
  community and home care, administrative,
  managerial and institutional level.

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Transcultural care service delivery at
institutional level

• Policies and guidelines cross-cultural outcomes
  that can be measured
• Individual HCPs performance appraisals to take
  into account cross-cultural practices
• Policies and guidelines that explicitly require
  the inclusion of family/significant others in the
  medical, nursing and other care planing and
  delivery

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TN Care Continues

• Client/patient information sharing with
  family/significant others unless explicitly
  requested for information not to be given
• Systematic use of interpreters
• Establishing a multicultural work force,
  including transcultural nursing experts and
  staff. This should include increasing the number
  of bilingual and bicultural nurses, doctors and
  other health professional in aged care.
• Conscious effort should be made not to assimilate
  such professionals but to help them to work
  effectively in this country

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State National Levels

• Legal system to recognise relationships and
  interdependence beyond husband and wife and/or
  children to include those others that are
  significant to the aged
• Legal system to ensure that effective
  communication takes place and clients have
  relevant knowledge to participate in the
  decisions for their care and treatment

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• Additional funding to be geared for real ethnic
  aged needs in community, acute and residential
  care
• Specific funding to ethno specific homes to use
  for translation of government policies and
  documents
• Specific funding for teaching the relevant
  language to staff, English to the ethnic carers
  and the ethnic language to English speaking staff

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Ethno specific Services

• Accreditation standards to measure
• Consumer and staff communication and
  participation in decision making
• All government policies, guidelines translated to
  relevant language in the service
• All employees who work in the service to speak
  the relevant language(s)

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• Professionals to be educationally prepared to be
  able to transform government policies to serve
  the relevant ethnic group
• Health professional to be cross culturally
  educated to transform and manage care delivery
  within ethnic context (particularly DONs )
• Health professionals (RNs) in management to be
  representative of the ethnic group
• Provision of group health needs as defined by
  them

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• Level of appointment and quality of staff
• Staffing levels quality with relevant salary
• Continuous education Cross-cultural education
• Relevant community involvement and support

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