Cultural Competence and Chronic
Disease Management of Older Adults
Author: Elaine Gould, MSW
Principal, Aging Awareness Initiatives
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Learner Objectives
1. Be able to maximize patient trust and
communication effectiveness in the clinical
encounter for older adults with chronic
illness.
2. Understand and utilize specific techniques
that demonstrate cultural sensitivity in order
to provide effective person-centered care to
older adults with chronic illness.
3. Understand ways to influence an
organization’s ability to be culturally
competent.
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AACN Cultural Competence
Standards and Tool Kits
This module builds on the
assumption that students have
had an initial introduction to
cultural competence in their
BSN curriculum.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Culture - Definition
Culture:
A set of beliefs, attitudes, behaviors, and
policies to which people identify and adhere.
Is the sum total of ways of living including:
> Behavioral norms
> Language
> Communication style
> Patterns of thinking
> Beliefs and Values
(Center for Cultural Education, 2007)
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Many Determinants of “Culture”
Defined by:
1. Grouping / Setting
– ethnic, racial, religious,
corporate, professional,
age, socioeconomic
status, sexual orientation
2. Self-identification
3. Stereotyping by others
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“Active Culture”
 Even though we may share a
general culture with other
people, each of us has a special
set of experiences and
influences that makes us
unique.
 Active Culture is fluid – it
changes with time, experience,
and circumstances.
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Culture Creates Bias
 Personal view of provider
 Personal view of patient – older adult
 Family view
 Interdisciplinary team view
 Organizational setting perspective: acute,
primary, homecare, long-term care,
hospice
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Culture Influences
Components of Health Care
 Attitudes and behaviors
about health and illness
 Beliefs about causes of
disease
 Possible Treatments
 Expectations that older
adults have about care
provider
 Expectations that
providers have about
older adults and their
cultural identification
 Communication among all
participants
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Culture Influences Chronic Disease
Management of Older Adults
Western Medicine
management of older
adults with chronic
conditions.
Goal
Maximize
Function
Other cultures may not have this goal!
Culture influences:
 Older adult TRUST of health care provider and system
 COLLABORATIVE behavior of provider and older adult
 Readiness and ability of older adult to ADHERE to a care plan
 CARE PLAN that is both therapeutic and practical
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Cultural Competence
and Cultural Humility
Cultural Competence implies having the capacity to function
effectively as an individual and an organization within the
context of the cultural beliefs, behaviors, and needs
presented by consumers and their communities.
(Cross, 1989)
Cultural Humility – commitment to developing mutually
beneficial and non-paternalistic clinical relationships with
patients and communities.
(Turvalon, Murray-Garcia 1998)
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Benefits of Cultural Competence
 More accurate diagnosis
 More effective care plans
and patient adherence
 Earlier participation in
health care
 Enhanced communication
and satisfaction of
patients and providers
 Respond to health care
disparities
 Cost-saving - More
effective use of health
care services
 Decreased litigation
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Cultural Competence Standards
Federal
States
 Civil Rights Act ( Title VII 1964)
 Conditions of licensure
 Medicare Managed care
requirements
 Continuing education
requirements
 Medicaid requirements
 HHS – Office of Minority Health
- national CLAS (culturally and
linguistically appropriate
services) standards
Healthcare Industry SelfRegulation
 JCAHO – Joint Commission
 NCQA – National Committee
for Quality Assurance
 Accreditation council for
Graduate Medical Education
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Teaching About: Culture
 Have students identify
their own cultural
backgrounds and biases
about health care
 Have students interview
an older adult about that
person’s culture and
views on health care
 Have students look on the
Internet for Cultural
Competence Standards
(federal, state, healthcare
industry regulations)
 Students read and
comment on the following
books: Fadiman (1997),
Boyle (1995), and Baylor
and Chana (1990).
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Teaching about: Culture
Have students read the following suggested nursing texts:
 Ebersole (2008)
 Leinenger & McFarland (2002)
 Leinenger & McFarland (2006)
 Andrews & Boyle (2008)
 Purnell & Paulanka (2008)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Summary of Cultural Barriers that Affect
Communication with Older Adults
1. Beliefs
2. Expectations
3. Stereotyping
4. Language
5. Health Literacy
6. Genetic Trends
7. Professional Prisms
8. Mistrust
9. Provider Dominance
10. Geriatric Syndromes
11. Life Experiences
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Barrier 1: Beliefs – 5 Domains
 Respect
> Who gets respect - how old age is respected; influence of healers, religious leaders, medical
professionals - RNs MDs; appropriate or inappropriate behaviors to show respect– personal
space, body language, words.
 Nutrition/Medication
> Level of acceptance of Western medicine; cultural foods and medicines used, alternative
medicines.
 Pain
> How it is interpreted – a biological phenomenon or a punishment from God?
 Death
> Definition of death - when is a person dead; what happens when a person dies - where do they
go; what happens to those remaining; attitudes about interference in dying process -“assistance” toward death or “prolonging” life, advance directives; quality of life issues.
 Time
> Ability to “tell time” – Use of a clock and the concept of an hour, respect for time and what time
implies – adhering to regimens, being prompt or late.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Teaching about Cultural Barriers:
Belief Domains and their Impact
 Students self-identify own
cultural beliefs regarding 5
domains.
 Students interview an older
adult about his/her cultural
beliefs regarding 5 domains
and their chronic illnesses.
 Students examine how 5
belief domains influence the
4 components of chronic care
of older adults: trust,
collaboration, adherence, and
care plans.
 Students study one
culture or ethnic group
in-depth to understand
basic beliefs and
customs.
 Students find
publications about a
particular ethnic
group’s healthcare
beliefs and compare
those to interview.
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Cultural Barriers (cont.)
Barrier 2: Expectations of behavior based on beliefs
 Need to know each other’s beliefs so that we can have comparable
expectations about behavior.
Barrier 3: Stereotyping
 Misuses of individual characteristics and trends.
 “Exaggerated beliefs or fixed ideas about a person or group and
sustained by selective perception and forgetting.”
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Cultural Barriers (cont.)
Barrier 4: Language differences
Barrier 5: Low health literacy of older
adults and families
 Science literacy – understanding how
the body works; the concept of a
therapeutic dose; the difference between
viruses and bacteria.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Teaching about Cultural Barriers : Expectations,
Stereotypes, Language, Health Literacy
 Students identify own
expectations about older adults
participation in health care
 Students identify stereotypes of
older adults with chronic
diseases
 Students interview a provider
about descriptions of a specific
ethnic group and compare
against references about
specific cultures such as those
in Purnell and Paulanka (2008)
Transcultural Healthcare
 Students interview professional
interpreter and or investigate
regulations about language
services.
 Students interview older adults
with chronic diseases about
their health knowledge of the
disease
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Cultural Barriers (cont.)
Barrier 6: Older Adult and family Mistrust of health care
system
 Based on collection of poor health care experiences
 Lack of patient/provider cultural concordance
Barrier 7: Provider lack of understanding of genetic trends –
physiological and biological
 Diseases that are prevalent in certain races and ethnic groups
 Trends in responses to medications base on race or ethnic identity
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Cultural Barriers (cont.)
Barrier 8: Provider’s Professional Prism
 MD, RN, MSW, PharmD
 the culture of medicine
 Lack of understanding of non-Western medicines
Barrier 9: Provider Dominance instead of collaboration
 Use of provider-focused compliance approach (rather than
collaborative adherence)
 Conciliatory resistance – patient response to dominance
 Resistance seen as “bad” rather than as a source of additional
information
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Teaching about Cultural Barriers: Mistrust,
Genetic Trends, Provider Prisms, Provider Dominance
 Interview older adults of
different ethnicities to find
out about levels of
mistrust of the healthcare
system
 Study genetic trends of
differing ethnic groups
 Interview providers about
professional biases
 Interview providers about
their frustrations and
techniques to enhance
communication with older
adults with chronic
conditions
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Cultural Barriers (cont.)
Barrier 10: Cultural responses to Chronic/Geriatric
Syndromes
> sensory losses -- hearing, vision
> cognitive losses -- executive function, depression, dementia
> syndromes that affect activities of daily living
Barrier 11: Cultural Responses to Life Experiences of older
adults–
> historical events, levels of assimilation, socio-economic factors
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Teaching about Cultural Barriers:
Interplay of Cultural Response to Geriatric/
Chronic Syndromes and Life Experiences
 Interview older adults
about how their specific
culture views their chronic
conditions.
 Interview older adults
about how cultural and
historical experiences
affect how they approach
health care.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Solutions for Culturally Competent Care
to Older Adults with Chronic Illness
Create
Trust
Recognize barriers – cultural and geriatric
Ask about beliefs
Work within belief systems
Use professional interpreters
Verbal and Non-verbal communication skills
Transcultural Nursing ASSESSMENT
8 QUESTIONS for Patient’s Explanatory
Model of Illness
8. LEARN Model for communication in clinical
encounter
9. ETHNIC Framework for communication in
clinical encounter
10. Organizational level activities
1.
2.
3.
4.
5.
6.
7.
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Solutions to Create Cultural
Competence: Create Trust
Solution 1: Recognize the barriers that influence the clinical
encounter – cultural and geriatric
Solution 2: Ask about beliefs as relevant to goal of particular
encounter – respect, nutrition, pain, death, time
Solution 3: Work within the belief system when possible
Solution 4: Use language interpreters – professional
preferred over family
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Solution 5: Verbal and Non-verbal
Communication to Foster Respect
 Ask about older adult’s
cultural preferences
regarding:
 Eye contact
 Pace of conversation –
silences, interruptions
 Body movements
 Language literacy
 Physical distance
 Emotional expressiveness
 Touch
 Modesty
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Solution 6: Transcultural
Nursing Assessment
6 Areas of Human Diversity
Communication
ie language, intonation, silence
Space
body movement, positioning to others
Social Orientation
roles, respect, economic and educational status,
assimilation, spiritual, psychological orientation
Time
perceived, measured and valued differently
Environmental Control
how much control a person has over his
environment, cleanliness, personal history
Biological Variations
physiological and genetic trends
(Geiger and Davidhizar , 2008)
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Solution 7: 8 Questions to elicit
Patient’s Explanatory Model of Illness
1. What do you call the problem?
2. What do you think caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does?
5. How severe is the illness?
6. How has the sickness affected your life?
7. What kind of treatment do you think you should receive?
8. What do you fear most about the illness?
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Solution 8: LEARN Model
Guide in the Clinical Encounter
L
Listen with empathy and understanding to the patient’s
perception of the problem
E
Explain your perceptions of the problem
A
Acknowledge and discuss the differences and similarities
R
Recommend treatment / solution
N
Negotiate agreement
(Berlin and Fowkes)
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Solution 9: ETHNIC Framework
Guide in the Clinical Encounter
E
T
H
N
I
Explanation – older adult explains view of illness and causes
C
Collaboration – work with patient, family, and healers to
maximize adherence to agreed care plan. Readjust as needed.
Treatment – older adult explains utilization of personal
treatments
Healers – older adult explains alternative influences for advice
and medication outside of healthcare provider
Negotiate – negotiate health care plan based on beliefs and
readiness
Intervention – finalize an agreed upon plan of care for a
specific period of time
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Solutions 10: Organizational Level Activities
to Enhance Cultural Competence of Older Adults
with Chronic Disease
 Use of professional
interpreter services
 Use of community health
workers
 Recruitment and retention of
multicultural staff –
congruent with patients
 Culturally competent health
promotion patient education
materials
 Provider training on
culturally sensitive
communication
 Inclusion of family and/or
community members
 Coordination with traditional
healers
 Administrative and
organizational
accommodations –
scheduling, gender
preferences of providers
(Brach & Fraser, 2000)
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Solutions 10: Organizational Level Activities
to Enhance Cultural Competence of Older Adults
with Chronic Disease (cont.)
 Adopt all national and
professional guidelines
about cultural competence
 Conduct periodically cultural
competence proficiency
assessments of the
organization and individuals
 Prepare annual organizational
progress report based on
national cultural competency
standards
 Chart notation of patient
cultural self-identification and
primary language
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Teaching about:
Solutions for Cultural Competence
 Students role play verbal and
non-verbal communication skills
 Students use the Transcultural
Nursing Assessment on fellow
students or patients
 Leadership students conduct an
organizational level cultural
competence proficiency
assessment in a clinical setting
and report to leadership of that
organization
 Students take the Cultural
 Students role play using the 8
Competence Health Practitioner
Questions, LEARN and ETHNIC
Assessment (CCHPA) of The
models
National Center for Cultural
Competence
 Students use the 8 Questions,
LEARN and ETHNIC models in
a clinical encounter and analyze
difficulties and effectiveness
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Teaching about: Culture and Chronic
Diseases of Older Adults - Summary Project
Students choose a topic below and investigate about
how a particular culture specifically influences a
chronic disease, condition, or healthcare topic
important to care of older adults
•
•
•
•
•
•
•
Diabetes
Cancer
CHF
Arthritis
Incontinence
Depression
Dementia
•Advance Directives
•Palliative Care
•End-of-life care
•Loss of independence
•Pain management
•Medication management
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Cultural Competence Websites
 AACN Cultural Competency in Baccalaureate Nursing Education
 Tool Kit of Resources for Culturally Competent Education for Baccalaureate
Nurses. www.aacn.Nche.edu/Education/cultural.htm
 CLAS: A-Z: Practical Guide for Implementing the National Standards in
Culturally and Linguistically Appropriate Services (CLAS) in Health Care
www.minorityhealth.hhs.gov/assets/pdf/checked/CLAS_a2z.pdf
 Hartford Institute for Geriatric Nursing, NYU College of Nursing. Clinical
website: www.ConsultGeriRN.org topic: ethnogeriatrics
 Stanford University Curriculum for Ethnogeriatrics.
http://www.stanford.edu/group/ethnoger/index.html
 Cultural Competency Continuing Education Programs (CCCEP of the US
Center for Disease Control) and Culturally Competent Nursing Models – part
of the CLAS listing at www.thinkculturalhealth.org
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Cultural Competence Websites
(cont.)
 National Center for Cultural Competence. Georgetown University
www11.georgetown.edu/research/gucchd/nccc/ersity.
 National Center for Cultural Competence www.nccccurricula.info
 Transcultural Nursing
www.Culturediversity.org
 Transcultural Nursing Society www.tcns.org
 Leininger’s Discussion Board www.Madeleine-leininger.com/en/index.shtml
 Cultural Competence Self-Assessment Protocol for Health Care Organizations
and Systems ( no date) developed by Andrulis, Delbanco, Avakian and ShawTaylor Available at http://erc.msh.org/provider/andrulis.pdf
 Cross Cultural Health Care Program, Seattle Washington. www.xculture.org
 Resources for Cross Cultural Healthcare www.diversityRx.org
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References
References are found on this
slide’s Notes Page.
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