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Bridging the cultural gap between residents and staff
Bridging the Cultural Gap Between Residents and Staff After cross-cultural training, carers showed more understanding of ethnically different nursing home residents. JOANNA GOULD-STUART People working in nursing homes frequently must deal with residents who are culturally and racially different from themselves. Stereotypes held by carers about ethnically different residents can have a negative effect on the quality of care. It is important to create a milieu of increased respect and sensitivity through better communication between staff and residents(l). Most training programs convey to staff that nursing home residents have emotional and social as well as physical needs. Yet, few programs address the issues arising from cultural and racial differences between staff and residents. Anthropologists have an important contribution to make toward improving patient care in long-term care facilities by helping staff to focus on these issues. A cross-cultural approach to nursing practice has been gaining attenJoanna Gould-Stuart is a consultant and an-
thropologist who specializes in the cross-cultural issues related to aging. © 1986 Joanna Gould-Stuart
tion(2-4), and a cross-cultural perspective in nursing has indeed been shown to improve the quality of care(5). While the specialized anthropological field of cross-cultural studies in aging has been expanding--and nursing homes have sometimes been the focus of these investigations(6-7), anthropologists have not been directly involved in in-service education of nursing staff in long-term care. In fact, nursing staff in long-term carehave not been offered any systematic way of approaching the issues surrounding cultural and racial differences between themselves and the residents, with which they must deal every day. The "Anthropology of Aging" Pilot In-Service Seminar Nursing and anthropology are two fields that have only recently begun to join forces with respect to the care of the elderly. In The Jewish Home and Hospital for the Aged, a 514-bed long-term care facility in New York City, the nursing department launched a pilot in-service program for nursing staff, which focused on aging from a crosscultural perspective. The program was organized into three concurrent seminars that met for 90 minutes each week, for 10 consecutive weeks. Day nursing supervisors and nurses made up the first seminar group, day nursing assistants and orderlies the
second, and evening nursing assistants and orderlies the third. Each group had 14 or 15 volunteers. Nursing assistants and orderlies were American Blacks or Puerto Ricans or immigrants, while nursing supervisors and nurses were mostly U.S.-born and white. The racial and ethnic composition of the seminar groups was representative of the larger nursing staff. On the other hand, 85 percent of the residents were white and Jewish. The administration recognized that if residents' behavior and desires were judged negatively, from an ethnocentric standpoint, then trust would be thwarted and kindness diminished. Thus, a seminar dealing with cross-cultural issues was particularly relevant in this institutional setting. The seminar had two main goals: (1) to enable staff to gain awareness of cultural differences and similarities in behavior and values while appreciating individual variation, and (2) to enable staffto develop an open attitude and a "cultural relativist" perspective, whereby behavior and values of others could be better understood and respected. It was hoped that staff would learn to understand and accept the cultural basis of behavior patterns that they may have formerly perceived as unacceptable. Because the groups were small and the seminar lasted 10 weeks, participants and instructor were able to de-
velop mutual trust and thus could discuss sensitive issues that are rarely brought up in shorter in-service workshops. The instructor encouraged participants to talk about their own cultural backgrounds and how their behavior, beliefs, and values were different from or similar to those of the nursing home residents, This may have been the first time that some of these staff members analyzed the cultural background of the primarily Jewish nursing home residents within the same framework as their own cultures. In addition, participants studied ethnographic materials about various cultural groups, including the Bushmen, Eskimo, Kikuyu, Kaguru, Sherpa, East Indians, and Japanese.
Concept Development Using Ethnographic Materials The seminar used open discussions stimulated by ethnographic materials. Specific discussion topics included: universals in aging, the concept of culture, the status and roles of old people (male and female) and intergenerational relationships in different cultures, the concepts of dependence and reciprocity, economic and demographic processes influencing intergenerational relationships, non-kin-based patterns of providing care to elders, and the increasing need for extra-familial supports for old people in non-Western as well as Western cultures. Discussions of other cultural patterns increased participants' understanding of their own behavior and attitudes. For example, the group discussed a cultural pattern which ensures that the most vulnerable members of society get food: Among the Sirion6 in Bolivia, agouti meat may be eaten only by children and old people. A Haitian participant familiar with the animal described it in detail and compared Haitian eating practices with those of the Sirion6. Thus this participant bridged the gap between his own culture and that of the Sirion6. The discussion of eating practices led staff to recount the food preferences of nursing home residents and triggered complaints about the "Jewish" food they were offered in the
staff cafeteria, since the institution was a "Jewish place." In the ensuing discussion, staff realized that there was nothing "Jewish" about the cafeteria food. Staff meals were prepared separately from those of residents and included many international dishes, such as arroz con polio (chicken with rice), empanadas (fried dumplings stuffed with beef), and fried chicken. The food was not kosher, nor was it cooked kosher-style. Furthermore, the chef was not Jewish.
Staff members had to admit that arroz con polio and empanadas were not Jewish food.
Although there was nothing objectively "Jewish" about the food, staff had come to associate institutional food--about which they had many complaintsmwith Jewish culture and people. The group realized that their real quarrel was with institutional meal preparation. An orderly in the group who had previously worked in the dietary department explained how difficult it was to please everyone. In the end they all realized that the quality of the cafeteria's food was in no way based on Jewish cultural patterns. In another session, a discussion of reciprocity dealt with tipping behavior of residents and administrative policies and staff reactions toward tipping. The complexities of the exchange relationship between residents and staff were explored. This discussion was particularly relevant since, during the course of the seminar, some of the stresses that emerge at the holiday season were beginning to be felt, and it was especially during the holiday season that residents offered to tip the staff. Ethnographic descriptions of nursing homes in other parts of the world, such as Kenya and Samoa, surprised many seminar group members, who had maintained that only certain kinds of people "put their old folks
away." When economic and demographic changes were given as an explanation of the increasing need for non-kin-based assistance to old people around the world, participants had to reexamine the view that only "uncaring relatives abandoned their kin in the Home." The notion that relatives were "dumping" old people in nursing homes was seen to be a value judgment, usually based on insufficient information and stereotyping. In four of the ten sessions, participants divided into small groups of three or four to work on a case study exercise about an old person or several old people in another culture. After reading a few paragraphs about these characters, their life circumstances, and their options and dilemmas, each group answered several questions and presented their responses to the larger group when it reconvened. One case study described Doric, an old Sherpa man who lived in a village high in the mountains of northeastern Nepal.* Although he was in excellent physical condition, Dorje was lonely and disappointed because his youngest son, whom he had expected would live with him in his old age, had migrated to India for work. Dorje had other children in the village but refused their invitations to live with them, since by accepting he would lose control over his fields and his authority within the household. Seminar participants were asked to compare Dorje's view of dependence and independence with their own, to explore the cultural basis of his viewpoint and their own, and to discuss how dependence may have different meanings for the elderly in other cultures with which they were familiar, as well as for the nursing home residents. "The case study exercise on the Sherpa was developed from the following sources: "Work, Agingand Dependency in a Sherpa Population in Nepal," by C. M. Beall and M. C. Goldstein, Soc.ScL andMed. 16(2), 141-147, 1982;"Modernization and Aging in the Third and Fourth World: Views. from the Rural Hinterland in Nepal," by C. M. Beall and M. C. Goldstein, Hum.Org. 40:48-55, Spring 1981; and The Ti-
betan Symbolic World, Psychoanal3"ticExplorations, by R. A. Paul, Chicago, University of Chicago Press, 1982.
Structured Improvisations In three separate sessions, actortrainers from P.A.C.T. (Performing Arts for Crisis Training), led structured improvisations. The actors played the parts of nursing home residents and their family members, and seminar participants volunteered to join in the "scene" by acting in their normal professional capacity in response to the problems presented by the actor-trainers. The characters exhibited problems arising from cross-cultural misunderstanding, stereotyping, and value judgments. They mirrored as closely as possible characteristics of real residents and their family members. Staff participants were invited to respond to the anger and fears of the resident, the offer of a tip, or the emotional state of the resident's daughter visiting from out-of-town. Following each scene, everyone was free to react to what had taken place during the improvisation.
Participants' Response to Seminar During the last session, participants evaluated the seminar. Responses were overwhelmingly positive. The most favored seminar topic was "the status and roles of old people in different societies," followed by"intergenerational relationships in different societies," "life in nursing homes outside the United States," and "worldwide demographic changes." The most revealing responses were answers to three open-ended questions. The first asked participants to cite three ideas or concepts they had learned. Here is a sample of responses: I learned a lot of things that will help me in the future, like how to accept a person as he i s . . . a n d not to joke about anyone's behavior that I don't understand (day nurs-
ing assistant). The elderly population the world over is increasing, and changes are necessary for society to adapt to this reality and to include the elder in the mainstream of society (ev-
ening nursing assistant). Residents
in
nursing
homes
should be allowed to carry on their own traditions as much as possible (Nurse). The second question asked what they found (or may find) useful in doing their jobs. I have gotten a lot out of this class. There is a feeling that is hard to explain. It seems as ifI understand the residents much more; I am more compassionate (day nursing
assistant). I have learned to cope with old people in a more peaceful manner and to understand more about their behavior (evening nursing
assistant). I have a better understanding of the differences that exist among old people; they are indeed a product of their culture and tend to see things in a unique way. With understanding comes greater tolerance and acceptance (nurse super-
visor). Finally, participants were asked to offer additional comments or suggestions. One nurse suggested that continuing cross-cultural education be offered to staff. She said a yearly review of the anthropology seminar would be very helpful for those working in a multi-ethnic institution.
Conclusions Over a lO-week period, the participants in a seminar on cross-cultural perspectives in aging began to question some of their assumptions about "good" and "bad" behavior, as well as reflect on their own belief systems. They learned to look at the nursing home residents as products of their cultural, historical, and generational backgrounds and gained more appreciation of them as people. Discussions of case studies in both large and small groups fostered objective thinking and exposed participants to new, sometimes startling ideas. Discussions ofcultural and racial conflicts were possible, especially in the second half of the seminar, because earlier sessions had created a framework for them and because group members had grown to feel supportive of one another and did
not feel threatened by the instructor. The tone of the entire seminar was informal and personal. The instructor worked to create an atmosphere in which participants took into account one another's life history, family, cultural background, and professional skills and goals. In this informal setting, learning could take place not only on an intellectual level, but also through participants' expressing emotional reactions to highly charged subjects--such as food, filial responsibilities, and rituals--and relating these reactions to those of the old people in their care. Nursing staffshowed a high degree of commitment, motivation, and interest throughout. They exhibited this with their virtually perfect attendance. Even more impressive was the attendance at each week's session of two or three nursing assistants and orderlies who had come in for the seminar on their day off. This seminar, which used an anthropological approach, demonstrafed that staff can be taught to broaden their perspectives in order to deal more effectively with the issues and problems they face. The humanitarian values, cultural relativism, and open-mindedness inherent in this approach may well be prerequisites for ensuring the development of a caring attitude of staff toward the elderly in long-term care facilities.
References I. Stanley, K. R. Staffdevelopment and training. IN Management of Personnel in Long Term Care, ed. by M. O. Hogstel. Bowie, MD, Brady Communications Co., 1982, pp. 124-144. 2. Osborne, O. Anthropology and nursing: some common traditions and interests. IN Tra~cultural Nursing:A Book ofReadings, ed. by P. J. Brink. Eoglewood Cliffs, NJ, Prentice-Hall, 1976, pp. 6-15. 3. Lcininger, M. Nursing and Anthropology: Two Worlds to Blend. New York, John Wiley & Sons, 1983. (2nd ed.) 4. . . Trar~cultural Nursing Concepts: Theories and Practices. New York, John Wiley & Sons, 1986. (2nd ed.) 5. Sophier, Raphella. Gaining awareness ofcultural difference: a case example. IN Transcultural Nursing Concepts: Theories and Practices, ed. by M. Leininger. New York, John Wiley & Sons, 1983, pp. 6-18. (2nd edition) 6. Kayser-Jones, J. S. Old, Alone and Neglected: Care of the Aged in Scotland and the United States. BerKeley, University of California Press, 1981. 7. Vespcri, M. The reluctant consumer, nursing home residents in the post-Bergman era. IN Growing Oldin Different Societies: Cross CulturaI Perspectives, ed. by J. Sokolofsky. Belmont, CA, Wadsworth Publishing Co., 1983, pp. 225-237.
thropologist who specializes in the cross-cultural issues related to aging. © 1986 Joanna Gould-Stuart
tion(2-4), and a cross-cultural perspective in nursing has indeed been shown to improve the quality of care(5). While the specialized anthropological field of cross-cultural studies in aging has been expanding--and nursing homes have sometimes been the focus of these investigations(6-7), anthropologists have not been directly involved in in-service education of nursing staff in long-term care. In fact, nursing staff in long-term carehave not been offered any systematic way of approaching the issues surrounding cultural and racial differences between themselves and the residents, with which they must deal every day. The "Anthropology of Aging" Pilot In-Service Seminar Nursing and anthropology are two fields that have only recently begun to join forces with respect to the care of the elderly. In The Jewish Home and Hospital for the Aged, a 514-bed long-term care facility in New York City, the nursing department launched a pilot in-service program for nursing staff, which focused on aging from a crosscultural perspective. The program was organized into three concurrent seminars that met for 90 minutes each week, for 10 consecutive weeks. Day nursing supervisors and nurses made up the first seminar group, day nursing assistants and orderlies the
second, and evening nursing assistants and orderlies the third. Each group had 14 or 15 volunteers. Nursing assistants and orderlies were American Blacks or Puerto Ricans or immigrants, while nursing supervisors and nurses were mostly U.S.-born and white. The racial and ethnic composition of the seminar groups was representative of the larger nursing staff. On the other hand, 85 percent of the residents were white and Jewish. The administration recognized that if residents' behavior and desires were judged negatively, from an ethnocentric standpoint, then trust would be thwarted and kindness diminished. Thus, a seminar dealing with cross-cultural issues was particularly relevant in this institutional setting. The seminar had two main goals: (1) to enable staff to gain awareness of cultural differences and similarities in behavior and values while appreciating individual variation, and (2) to enable staffto develop an open attitude and a "cultural relativist" perspective, whereby behavior and values of others could be better understood and respected. It was hoped that staff would learn to understand and accept the cultural basis of behavior patterns that they may have formerly perceived as unacceptable. Because the groups were small and the seminar lasted 10 weeks, participants and instructor were able to de-
velop mutual trust and thus could discuss sensitive issues that are rarely brought up in shorter in-service workshops. The instructor encouraged participants to talk about their own cultural backgrounds and how their behavior, beliefs, and values were different from or similar to those of the nursing home residents, This may have been the first time that some of these staff members analyzed the cultural background of the primarily Jewish nursing home residents within the same framework as their own cultures. In addition, participants studied ethnographic materials about various cultural groups, including the Bushmen, Eskimo, Kikuyu, Kaguru, Sherpa, East Indians, and Japanese.
Concept Development Using Ethnographic Materials The seminar used open discussions stimulated by ethnographic materials. Specific discussion topics included: universals in aging, the concept of culture, the status and roles of old people (male and female) and intergenerational relationships in different cultures, the concepts of dependence and reciprocity, economic and demographic processes influencing intergenerational relationships, non-kin-based patterns of providing care to elders, and the increasing need for extra-familial supports for old people in non-Western as well as Western cultures. Discussions of other cultural patterns increased participants' understanding of their own behavior and attitudes. For example, the group discussed a cultural pattern which ensures that the most vulnerable members of society get food: Among the Sirion6 in Bolivia, agouti meat may be eaten only by children and old people. A Haitian participant familiar with the animal described it in detail and compared Haitian eating practices with those of the Sirion6. Thus this participant bridged the gap between his own culture and that of the Sirion6. The discussion of eating practices led staff to recount the food preferences of nursing home residents and triggered complaints about the "Jewish" food they were offered in the
staff cafeteria, since the institution was a "Jewish place." In the ensuing discussion, staff realized that there was nothing "Jewish" about the cafeteria food. Staff meals were prepared separately from those of residents and included many international dishes, such as arroz con polio (chicken with rice), empanadas (fried dumplings stuffed with beef), and fried chicken. The food was not kosher, nor was it cooked kosher-style. Furthermore, the chef was not Jewish.
Staff members had to admit that arroz con polio and empanadas were not Jewish food.
Although there was nothing objectively "Jewish" about the food, staff had come to associate institutional food--about which they had many complaintsmwith Jewish culture and people. The group realized that their real quarrel was with institutional meal preparation. An orderly in the group who had previously worked in the dietary department explained how difficult it was to please everyone. In the end they all realized that the quality of the cafeteria's food was in no way based on Jewish cultural patterns. In another session, a discussion of reciprocity dealt with tipping behavior of residents and administrative policies and staff reactions toward tipping. The complexities of the exchange relationship between residents and staff were explored. This discussion was particularly relevant since, during the course of the seminar, some of the stresses that emerge at the holiday season were beginning to be felt, and it was especially during the holiday season that residents offered to tip the staff. Ethnographic descriptions of nursing homes in other parts of the world, such as Kenya and Samoa, surprised many seminar group members, who had maintained that only certain kinds of people "put their old folks
away." When economic and demographic changes were given as an explanation of the increasing need for non-kin-based assistance to old people around the world, participants had to reexamine the view that only "uncaring relatives abandoned their kin in the Home." The notion that relatives were "dumping" old people in nursing homes was seen to be a value judgment, usually based on insufficient information and stereotyping. In four of the ten sessions, participants divided into small groups of three or four to work on a case study exercise about an old person or several old people in another culture. After reading a few paragraphs about these characters, their life circumstances, and their options and dilemmas, each group answered several questions and presented their responses to the larger group when it reconvened. One case study described Doric, an old Sherpa man who lived in a village high in the mountains of northeastern Nepal.* Although he was in excellent physical condition, Dorje was lonely and disappointed because his youngest son, whom he had expected would live with him in his old age, had migrated to India for work. Dorje had other children in the village but refused their invitations to live with them, since by accepting he would lose control over his fields and his authority within the household. Seminar participants were asked to compare Dorje's view of dependence and independence with their own, to explore the cultural basis of his viewpoint and their own, and to discuss how dependence may have different meanings for the elderly in other cultures with which they were familiar, as well as for the nursing home residents. "The case study exercise on the Sherpa was developed from the following sources: "Work, Agingand Dependency in a Sherpa Population in Nepal," by C. M. Beall and M. C. Goldstein, Soc.ScL andMed. 16(2), 141-147, 1982;"Modernization and Aging in the Third and Fourth World: Views. from the Rural Hinterland in Nepal," by C. M. Beall and M. C. Goldstein, Hum.Org. 40:48-55, Spring 1981; and The Ti-
betan Symbolic World, Psychoanal3"ticExplorations, by R. A. Paul, Chicago, University of Chicago Press, 1982.
Structured Improvisations In three separate sessions, actortrainers from P.A.C.T. (Performing Arts for Crisis Training), led structured improvisations. The actors played the parts of nursing home residents and their family members, and seminar participants volunteered to join in the "scene" by acting in their normal professional capacity in response to the problems presented by the actor-trainers. The characters exhibited problems arising from cross-cultural misunderstanding, stereotyping, and value judgments. They mirrored as closely as possible characteristics of real residents and their family members. Staff participants were invited to respond to the anger and fears of the resident, the offer of a tip, or the emotional state of the resident's daughter visiting from out-of-town. Following each scene, everyone was free to react to what had taken place during the improvisation.
Participants' Response to Seminar During the last session, participants evaluated the seminar. Responses were overwhelmingly positive. The most favored seminar topic was "the status and roles of old people in different societies," followed by"intergenerational relationships in different societies," "life in nursing homes outside the United States," and "worldwide demographic changes." The most revealing responses were answers to three open-ended questions. The first asked participants to cite three ideas or concepts they had learned. Here is a sample of responses: I learned a lot of things that will help me in the future, like how to accept a person as he i s . . . a n d not to joke about anyone's behavior that I don't understand (day nurs-
ing assistant). The elderly population the world over is increasing, and changes are necessary for society to adapt to this reality and to include the elder in the mainstream of society (ev-
ening nursing assistant). Residents
in
nursing
homes
should be allowed to carry on their own traditions as much as possible (Nurse). The second question asked what they found (or may find) useful in doing their jobs. I have gotten a lot out of this class. There is a feeling that is hard to explain. It seems as ifI understand the residents much more; I am more compassionate (day nursing
assistant). I have learned to cope with old people in a more peaceful manner and to understand more about their behavior (evening nursing
assistant). I have a better understanding of the differences that exist among old people; they are indeed a product of their culture and tend to see things in a unique way. With understanding comes greater tolerance and acceptance (nurse super-
visor). Finally, participants were asked to offer additional comments or suggestions. One nurse suggested that continuing cross-cultural education be offered to staff. She said a yearly review of the anthropology seminar would be very helpful for those working in a multi-ethnic institution.
Conclusions Over a lO-week period, the participants in a seminar on cross-cultural perspectives in aging began to question some of their assumptions about "good" and "bad" behavior, as well as reflect on their own belief systems. They learned to look at the nursing home residents as products of their cultural, historical, and generational backgrounds and gained more appreciation of them as people. Discussions of case studies in both large and small groups fostered objective thinking and exposed participants to new, sometimes startling ideas. Discussions ofcultural and racial conflicts were possible, especially in the second half of the seminar, because earlier sessions had created a framework for them and because group members had grown to feel supportive of one another and did
not feel threatened by the instructor. The tone of the entire seminar was informal and personal. The instructor worked to create an atmosphere in which participants took into account one another's life history, family, cultural background, and professional skills and goals. In this informal setting, learning could take place not only on an intellectual level, but also through participants' expressing emotional reactions to highly charged subjects--such as food, filial responsibilities, and rituals--and relating these reactions to those of the old people in their care. Nursing staffshowed a high degree of commitment, motivation, and interest throughout. They exhibited this with their virtually perfect attendance. Even more impressive was the attendance at each week's session of two or three nursing assistants and orderlies who had come in for the seminar on their day off. This seminar, which used an anthropological approach, demonstrafed that staff can be taught to broaden their perspectives in order to deal more effectively with the issues and problems they face. The humanitarian values, cultural relativism, and open-mindedness inherent in this approach may well be prerequisites for ensuring the development of a caring attitude of staff toward the elderly in long-term care facilities.
References I. Stanley, K. R. Staffdevelopment and training. IN Management of Personnel in Long Term Care, ed. by M. O. Hogstel. Bowie, MD, Brady Communications Co., 1982, pp. 124-144. 2. Osborne, O. Anthropology and nursing: some common traditions and interests. IN Tra~cultural Nursing:A Book ofReadings, ed. by P. J. Brink. Eoglewood Cliffs, NJ, Prentice-Hall, 1976, pp. 6-15. 3. Lcininger, M. Nursing and Anthropology: Two Worlds to Blend. New York, John Wiley & Sons, 1983. (2nd ed.) 4. . . Trar~cultural Nursing Concepts: Theories and Practices. New York, John Wiley & Sons, 1986. (2nd ed.) 5. Sophier, Raphella. Gaining awareness ofcultural difference: a case example. IN Transcultural Nursing Concepts: Theories and Practices, ed. by M. Leininger. New York, John Wiley & Sons, 1983, pp. 6-18. (2nd edition) 6. Kayser-Jones, J. S. Old, Alone and Neglected: Care of the Aged in Scotland and the United States. BerKeley, University of California Press, 1981. 7. Vespcri, M. The reluctant consumer, nursing home residents in the post-Bergman era. IN Growing Oldin Different Societies: Cross CulturaI Perspectives, ed. by J. Sokolofsky. Belmont, CA, Wadsworth Publishing Co., 1983, pp. 225-237.