- Email: [email protected]
Culturally competent care for Latino elders in long-term care settings
GN Management
Culturally Competent Care for Latino Elders in Long-Term Care Settings Bernie Gorek, RNC, GNP, MA, Jan Martin, RN, PhD, GNP, Nancy White, RN, PhD, Diane Peters, RN, PhD, CTN, and Faye Hummel, RN, PhD, CTN
The decision to place a family member in a long-term care (LTC) facility results in a variety of experiences for families. The experience of Latino families can be particularly problematic for the different relatives involved in the process. Placing a loved one in an LTC facility goes against cultural norms for Hispanic families that can lead to problems for both the family and the facility staff. Information about the cultural norms that are violated along with ways that the care providers and administrative staff can make adjustments in the environment to assist these residents will improve outcomes and meet the needs of diverse health care consumers. (Geriatr Nurs 2002;23:272-75)
F
amily obligations to care for aging parents are more prevalent among Latino and Asian cultures compared with the dominant culture, and respect for the elderly is the basis of intergenerational care.1,2 However, a new survey by AARP compared the stresses experienced by the sandwich generation across racial and ethnic groups.3 Results indicate that 34% of Latinos provide care for their aging parents, in-laws, or other relatives, yet 65% thought they were not doing enough. Several trends are likely to have a profound effect on cultural norms and elder Latino caregiving in the home. First, the percentage of Latinos in the United States has reached 12% (equal to African Americans), and Hispanic elders represent 5.1% of the entire Latino population. Second, the number of Latino elders is expected to increase 400% during the next decade as much of the current population enters the elderly ranks.4,5 Third, economic demands have resulted in the loss of the traditional female/daughter caregiver to the paid workforce. Finally, enculturation into the dominant culture, lifestyle changes, and geographic dispersion of immediate and extended family members may influence the preferred living arrangements for elder Latinos. As a result, the number of Latino elders admitted to long-term care (LTC) facilities will be significant. As one of the most prevalent minority groups in the United States, Mexican Americans have been the focus of 272
several research studies.6-9 Leininger10 summarized cultural values and norms (Table 1) on the basis of her own work and that of other transcultural nurse studies in the United States. Prominent among these norms are the importance of the extended family and respect for the elderly. In addition, Leininger’s work has identified direct family teaching, aid, and filial love as ways in which family members demonstrate care and respect for one another. We conducted a qualitative study to explore the process that led to the LTC placement of Latino elders by their families and their expectations regarding care in the facility. The research is briefly summarized here to establish the basis for recommendations for providing culturally congruent care in LTC facilities. We propose the development and implementation of a cultural liaison within the facility to accomplish cultural congruence.
METHODS The setting for the study was an LTC facility in an agricultural/ranching community of 80,000 people with a 27% Latino population. The facility’s administrative staff wished to better understand the disproportionately high number of complaints by family members of Latino residents regarding the care of their elders. The nature of the complaints centered on hygiene, hair care, and personal appearance. A cultural care committee was developed and included these subcommittees: communication/language, education, community involvement, and preadmission expectations. The overall purpose was to improve the quality of care and services provided to Latino residents and their families. Each subcommittee developed goals and objectives with time frames for meeting them. We were members of the preadmission expectations subcommittee, which included Latino members of the community, Latino and nonLatino staff members, and nursing faculty interested in cultural care. The goal was to better understand how Latinos prefer to care for aging parents or spouses and under what circumstances the family feels the need to place the elder in an LTC facility. Geriatric Nursing 2002 • Volume 23 • Number 5
To understand this culture better, we interviewed 24 informants. The interviews followed a semistructured interview guide. Six informants had family members who were facility residents; the remainder consisted of health care workers/LTC staff, facility administration, and older Latino members of the community. The interviews with family members were conducted in English or Spanish as they chose. Interviews were conducted in a place where the informants were most comfortable—their homes or mutually agreed places. Interviews were tape-recorded, transcribed, and examined as they were completed.
➤ Importance of the extended family ➤ Interdependence with kin and social activities ➤ Patriarchal importance ➤ Exact time less valued ➤ High respect for authority and the elderly ➤ Importance of religion ➤ Native foods as a means to well-being
RESULTS Committee members reviewed the transcribed information to determine if any answers appeared similar in nature. Through this analysis, three major themes were identified: • Family aid and love are very important in the Latino culture. • Cultural norms and values were violated with the difficult decision for LTC placement. • Despite such placement, families attempted to maintain cultural norms and routines for their parents. Examining the behaviors of Latino family members in light of these themes makes it easier for nonLatino nurses to understand some of the potential problems that may follow LTC placement. The results reflect the participants for this study. Although these findings may not necessarily be unique to the Latino culture, we found these themes to be consistent with the cultural norms of Mexican Americans and of particular importance for the Latino families in this facility.
Family Aid and Love Because of the importance of family aid and love, children of Latino elders feel honor-bound to continue care as long as possible, even after relinquishing that care to the LTC facility. Gloria expressed this by saying, “Because in our blood, Hispanics, we don’t put families in nursing homes; we take care of them to the very last day. That’s the way I saw it; they took care of us when we were little, and I figured we had to pay them in return.” The granddaughter of another resident said, “I was told that they were going to put her in a nursing home, and when I heard about it, I was very angry because she was there to help everybody, and now that she needed help, why put her away?” Additionally, the importance of direct family aid and love was demonstrated by the use of extended family and professional care resources to support the caregiver and extend the elder’s time at home. Mary said, “My sister and her boyfriend, they would go there and they would help shave him, change him sometimes, cut his hair.”
Violation of Cultural Norms The decision to place a family member in an LTC facility is always difficult. For people from the Latino culture,
September
Mexican-American Cultural Norms and Values
• October 2002
➤ Traditional folk-care healers for folk illnesses ➤ Belief in hot/cold therapies for health care Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League of Nursing Press; 1991. p. 179-201, 356.
it also violates cultural norms and values. The decision for LTC placement among participants in this study was reached only when adequate caregiving no longer could be provided and both family members and medical staff determined there was no other choice. Mary spoke of her father’s deteriorating Alzheimer disease and her mother’s inability to continue to care for him because of her own poor health. Another family member viewed LTC placement as perhaps the only means to keep her mother alive. “About every 2 or 3 weeks, she’d end up in the hospital again, and she’d throw up and she was losing so much weight. She was nothing but skin and bones. I was afraid that maybe I wasn’t doing, you know, taking care of her the right way.” Most informants described the elders’ physician as being very supportive of decisions for LTC placement. The role of the physician in suggesting or confirming the need for LTC placement seemed to relieve some of the adult children’s feelings that they were letting their parents down. Sometimes the elders themselves provided input into LTC placement. Unfortunately, as often happens when cultural norms are violated, the decision to place the elder in a facility sometimes produced significant conflict among family members. Several informants talked about the anger they felt toward other family members for the admission. Some of these conflicts subsided over time and family unity was restored, but frequently resentment about the LTC admission did not go away.
Maintenance of Norms and Routines The final theme is perhaps more unique for the Latino culture. Despite LTC placement, families attempted to maintain cultural norms and routines for their
273
parents. Family members expressed this through their visiting patterns and the need to monitor the care given by staff. Additionally, the family had a strong need to have the LTC staff show respect to their elders and not have their Latino (Mexican) heritage and routines ignored. More specifically, even though the elders were living away from family, many family members made extraordinary attempts to maintain normalcy, such as wanting to take the elder home for weekends and special occasions. When they were unable to bring their parents home, families made frequent visits to the LTC facility to visit them. In the group interviews with elder Latinos, one woman said she had her children drive her 40 minutes one way each day so she could visit her husband in the nursing home. With regard to respect, families spoke at great length about the difficulties that resulted from staff being unable to talk to the residents in Spanish. Enrique explained that his father could understand some English but could speak only Spanish. When his father was experiencing pain in his side, he was unable to make the staff understand what was wrong with him. Enrique went on to explain, “The only problem I see there is that the communication isn’t there for people that speak Spanish. There’s going to be more Spanish-speaking people in there—and if they don’t do something with that, they are going to have a lot of problems, not only with the residents, but with the families that have residents there.” Finally, several informants perceived a lack of regard for Latino heritage by mentioning that their elders did not like the facility’s food and would have preferred Mexican dishes. The LTC facility acknowledged that, even when they did try to accommodate food preferences on some occasions, they were unable to prepare “authentic” Mexican food and had problems with nonLatino residents complaining about the food tasting too spicy. The study revealed many issues that could lead to conflict between the Latino family members and the LTC staff. Using this information can help staff understand Latino family behavior and make adjustments to care when possible.
DISCUSSION AND RECOMMENDATIONS Although some of these findings may not be unique to Latino families, the purpose of this study was to gain a depth of understanding in the Latino family response to LTC placement. The discussion and recommendations are applicable to the Latino group and might be helpful for people of other cultural groups. We believe that, if these findings are not unique to Latinos, further study might reveal that the needs of nonLatinos are being overlooked, as well.
Preserving Cultural Norms and Values This research demonstrated strong familial and intergenerational bonds for Latino families that need to be supported once an individual is admitted to an LTC facility.
274
Supporting the continued interconnectedness of the family is essential. Professionals working in this setting need knowledge and understanding of Latino cultural values, beliefs, and practices relative to making decisions about LTC placement. Modifications in the ways care is provided can be made by individual staff members and by administrative changes in facility philosophy and policy. One nursing action would be to support the strong respect that Latino family members demonstrate toward their elders. The frequency with which residents were taken home on weekends and for special family events showed the importance of family bonds. These activities are important and should be encouraged. Facilities should find ways to promote family gatherings and celebrations on the premises. This compromise might be accomplished through different cultural days versus just meeting a specific family need; for example, each first Tuesday could be a Latino celebration day for families and friends of all residents. Similar days could be established for other cultural groups. Family participation in care and their involvement in decision-making should be encouraged. Efforts to include the family should be part of the admission process and should continue throughout the elders’ stay. Finally, family care rituals need to be explored and maintained to the extent possible in the LTC environment. Family involvement in care can increase residents’ quality of life and the family members’ level of comfort and trust. Family members involved in care feel more connected and valued by being able to express their involvement in resident care needs. A thorough social history is essential to help determine family care rituals. If staff understand that family caregiving is a cultural norm for the Latino family, they can provide opportunities that will benefit residents, families, and staff.
Caregiver Interventions to Support Cultural Norms and Values LTC facilities can improve the quality of life for Latino residents and increase the comfort of their families by making modifications that support cultural norms while maintaining quality care standards. Examples of cultural adaptations that could be made include serving ethnic foods and playing ethnic music. Providing special religious services and bicultural staff for care delivery in Spanish will add to the comfort and quality of life of Latino elders. Many truly traditional Latino meals are not spicy and can be served to a variety of residents. (Traditional food in Mexico is much less spicy than Mexican food served in the United States.) Providing competent interpreters during the admission process, for care conferences, and for problem resolution increases resident and family comfort, fosters trust, and helps families feel respected. Although not mentioned in this study, a facility might want to provide ethnic artwork and color schemes throughout the facility. Signage in Spanish will help prospective residents and family mem-
Geriatric Nursing 2002 • Volume 23 • Number 5
bers feel welcomed and respected. Having important documents (admission paperwork, consents for treatment, etc.) translated into the resident’s language also increase comfort and trust. Many families described intrafamilial conflicts associated with LTC placement. Social workers within the facility and care planning conferences can help resolve or work with the family to come to terms with these issues. In keeping with the importance of religion, it may be more appropriate at times to use spiritual leaders when helping families deal with conflict. Residents’ physicians also can be excellent resources for families, given the importance a doctor has in the decision to place a person in the LTC facility. It is important to have a place for families to gather and hold celebrations, especially when the elders are unable to be taken home. Family potlucks and special music should be encouraged. Helping Latino residents and families celebrate special events and holidays related to their culture can increase quality of life. Using care plans to identify events that are important to residents can help facilitate the celebration of special days, recognizing that these may be different than the special days celebrated by the majority culture (eg, first communion, summer/winter solstice). Frequently, staff lack the ability to demonstrate respect in the same fashion the family desires. One example given in the study had to do with how a resident’s hair was styled. Although she was clean, her hair was very untidy, which was disturbing to her family. Additionally, staff members may not know about important care rituals that families use to show respect. Addressing these rituals during the care planning process is necessary so they can be incorporated into the resident’s daily care. Family members who wish should be allowed to assist whenever possible.
Administrative Support for Change Institutional change requires that cultural values and sensitivity be a part of the institution’s mission and philosophy. For facilities with residents from multiple cultures, policies and procedures need to represent each different culture. Community resources can be used to help develop policies and procedures that reflect these cultural values. When Latino residents live in a facility, it is important to teach Latino culture care values to all LTC staff during the initial orientation and periodically throughout the year. Representatives from the Latino community can be invited into the facility to help provide staff education. A cultural care committee can be formed to identify areas of need and develop a process to increase the quality of care for people of diverse cultures. This committee should be an integral part of the continuous quality improvement process. To assist the committee and administration, information from expert sources should be sought to help develop a plan for change.11 Additionally, to show broader concern and respect for the Latino community, LTC facilities must participate in organizations and activities within the community to create a
September
• October 2002
positive presence. Given that many Latinos are not familiar with LTC, the industry overall can be more proactive in providing information and knowledge to potential consumers. This rapport can be accomplished by encouraging Latino groups to use the facility for meetings and programs. Latino groups can be invited to provide educational programs and entertainment for residents and staff. The facility can invite members of the Latino community to serve on advisory and quality improvement committees. Conversely, facility staff can be encouraged to provide educational programs for Latino groups. There are also opportunities to do volunteer work within the Latino community. A cultural care liaison should be designated to coordinate these activities. The person must be knowledgeable and able to communicate effectively with facility staff and external/community resources to identify needs, initiate change, and ensure follow through.
CONCLUSION Knowledge of cultural values, beliefs, and practices of Latino family members faced with the decision to place elders in an LTC facility is important in providing culturally competent care. It is the responsibility of the health care industry to ensure this knowledge imparts a positive change in health care. Nurses in LTC management positions can take a leadership role in shaping a health care system that will meet the needs of diverse health care consumers. REFERENCES 1. Cox C, Monk A. Hispanic culture and family care of Alzheimer’s patients. Health Social Work 1993;18:92-100. 2. Kao H, Stuifbergen AK. Family experiences related to the decision to institutionalize an elderly member in Taiwan: an exploratory study. Social Sci Med 1999;49:1115-23. 3. Cuthbert A. The Boomer Sandwich. Modern Maturity 2001 Oct:94. 4. Pausada L. Hispanic-American elders: implications for health care providers. Clin Geriatr Med 1995;11:39-52. 5. Frey W. Elderly demographic profiles of U.S. states: impacts of new births, migration, and immigration. Gerontologist 1995;35;761-70. 6. McFarland M. Cultural care of Anglo- and African-American elderly residents within the environmental context of a long-term care institution [dissertation]. Detroit: Wayne State University; 1995. 7. McFarland M. Use of culture care theory with Anglo- and AfricanAmerican elders in a long-term care setting. Nurs Sci Q 1997;10:186-92. 8. Berry A. Culture care expression, meanings, and experiences of pregnant Mexican-American women within Leininger’s culture care theory [dissertation]. Detroit: Wayne State University; 1996. 9. Berry A. Mexican-American women’s expressions of the meaning of culturally congruent prenatal care. J Transcultural Nurs 1999;10:203-12. 10. Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League of Nursing Press; 1991. p. 179-201, 356. 11. Bonder B, Martin L, Miracle A. Culture in clinical care. Thorofare (NJ): Slack, Inc.; 2002.
BERNIE GOREK, RNC, GNP, MA, is the RehabCare program director at the United Medical Center in Cheyenne, Wy. JAN MARTIN, RN, PhD, GNP, NANCY WHITE, RN, PhD, and DIANE PETERS, RN, PhD, CTN, are professors in the School of Nursing at the University of Northern Colorado in Greeley. FAYE HUMMEL, RN, PhD, CTN, is an associate professor. Copyright 2002 by Mosby, Inc. 0197-4572/2002/$35.00 + 0 34/1/128792 doi:10.1067/mgn.2002.128792
275
Culturally Competent Care for Latino Elders in Long-Term Care Settings Bernie Gorek, RNC, GNP, MA, Jan Martin, RN, PhD, GNP, Nancy White, RN, PhD, Diane Peters, RN, PhD, CTN, and Faye Hummel, RN, PhD, CTN
The decision to place a family member in a long-term care (LTC) facility results in a variety of experiences for families. The experience of Latino families can be particularly problematic for the different relatives involved in the process. Placing a loved one in an LTC facility goes against cultural norms for Hispanic families that can lead to problems for both the family and the facility staff. Information about the cultural norms that are violated along with ways that the care providers and administrative staff can make adjustments in the environment to assist these residents will improve outcomes and meet the needs of diverse health care consumers. (Geriatr Nurs 2002;23:272-75)
F
amily obligations to care for aging parents are more prevalent among Latino and Asian cultures compared with the dominant culture, and respect for the elderly is the basis of intergenerational care.1,2 However, a new survey by AARP compared the stresses experienced by the sandwich generation across racial and ethnic groups.3 Results indicate that 34% of Latinos provide care for their aging parents, in-laws, or other relatives, yet 65% thought they were not doing enough. Several trends are likely to have a profound effect on cultural norms and elder Latino caregiving in the home. First, the percentage of Latinos in the United States has reached 12% (equal to African Americans), and Hispanic elders represent 5.1% of the entire Latino population. Second, the number of Latino elders is expected to increase 400% during the next decade as much of the current population enters the elderly ranks.4,5 Third, economic demands have resulted in the loss of the traditional female/daughter caregiver to the paid workforce. Finally, enculturation into the dominant culture, lifestyle changes, and geographic dispersion of immediate and extended family members may influence the preferred living arrangements for elder Latinos. As a result, the number of Latino elders admitted to long-term care (LTC) facilities will be significant. As one of the most prevalent minority groups in the United States, Mexican Americans have been the focus of 272
several research studies.6-9 Leininger10 summarized cultural values and norms (Table 1) on the basis of her own work and that of other transcultural nurse studies in the United States. Prominent among these norms are the importance of the extended family and respect for the elderly. In addition, Leininger’s work has identified direct family teaching, aid, and filial love as ways in which family members demonstrate care and respect for one another. We conducted a qualitative study to explore the process that led to the LTC placement of Latino elders by their families and their expectations regarding care in the facility. The research is briefly summarized here to establish the basis for recommendations for providing culturally congruent care in LTC facilities. We propose the development and implementation of a cultural liaison within the facility to accomplish cultural congruence.
METHODS The setting for the study was an LTC facility in an agricultural/ranching community of 80,000 people with a 27% Latino population. The facility’s administrative staff wished to better understand the disproportionately high number of complaints by family members of Latino residents regarding the care of their elders. The nature of the complaints centered on hygiene, hair care, and personal appearance. A cultural care committee was developed and included these subcommittees: communication/language, education, community involvement, and preadmission expectations. The overall purpose was to improve the quality of care and services provided to Latino residents and their families. Each subcommittee developed goals and objectives with time frames for meeting them. We were members of the preadmission expectations subcommittee, which included Latino members of the community, Latino and nonLatino staff members, and nursing faculty interested in cultural care. The goal was to better understand how Latinos prefer to care for aging parents or spouses and under what circumstances the family feels the need to place the elder in an LTC facility. Geriatric Nursing 2002 • Volume 23 • Number 5
To understand this culture better, we interviewed 24 informants. The interviews followed a semistructured interview guide. Six informants had family members who were facility residents; the remainder consisted of health care workers/LTC staff, facility administration, and older Latino members of the community. The interviews with family members were conducted in English or Spanish as they chose. Interviews were conducted in a place where the informants were most comfortable—their homes or mutually agreed places. Interviews were tape-recorded, transcribed, and examined as they were completed.
➤ Importance of the extended family ➤ Interdependence with kin and social activities ➤ Patriarchal importance ➤ Exact time less valued ➤ High respect for authority and the elderly ➤ Importance of religion ➤ Native foods as a means to well-being
RESULTS Committee members reviewed the transcribed information to determine if any answers appeared similar in nature. Through this analysis, three major themes were identified: • Family aid and love are very important in the Latino culture. • Cultural norms and values were violated with the difficult decision for LTC placement. • Despite such placement, families attempted to maintain cultural norms and routines for their parents. Examining the behaviors of Latino family members in light of these themes makes it easier for nonLatino nurses to understand some of the potential problems that may follow LTC placement. The results reflect the participants for this study. Although these findings may not necessarily be unique to the Latino culture, we found these themes to be consistent with the cultural norms of Mexican Americans and of particular importance for the Latino families in this facility.
Family Aid and Love Because of the importance of family aid and love, children of Latino elders feel honor-bound to continue care as long as possible, even after relinquishing that care to the LTC facility. Gloria expressed this by saying, “Because in our blood, Hispanics, we don’t put families in nursing homes; we take care of them to the very last day. That’s the way I saw it; they took care of us when we were little, and I figured we had to pay them in return.” The granddaughter of another resident said, “I was told that they were going to put her in a nursing home, and when I heard about it, I was very angry because she was there to help everybody, and now that she needed help, why put her away?” Additionally, the importance of direct family aid and love was demonstrated by the use of extended family and professional care resources to support the caregiver and extend the elder’s time at home. Mary said, “My sister and her boyfriend, they would go there and they would help shave him, change him sometimes, cut his hair.”
Violation of Cultural Norms The decision to place a family member in an LTC facility is always difficult. For people from the Latino culture,
September
Mexican-American Cultural Norms and Values
• October 2002
➤ Traditional folk-care healers for folk illnesses ➤ Belief in hot/cold therapies for health care Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League of Nursing Press; 1991. p. 179-201, 356.
it also violates cultural norms and values. The decision for LTC placement among participants in this study was reached only when adequate caregiving no longer could be provided and both family members and medical staff determined there was no other choice. Mary spoke of her father’s deteriorating Alzheimer disease and her mother’s inability to continue to care for him because of her own poor health. Another family member viewed LTC placement as perhaps the only means to keep her mother alive. “About every 2 or 3 weeks, she’d end up in the hospital again, and she’d throw up and she was losing so much weight. She was nothing but skin and bones. I was afraid that maybe I wasn’t doing, you know, taking care of her the right way.” Most informants described the elders’ physician as being very supportive of decisions for LTC placement. The role of the physician in suggesting or confirming the need for LTC placement seemed to relieve some of the adult children’s feelings that they were letting their parents down. Sometimes the elders themselves provided input into LTC placement. Unfortunately, as often happens when cultural norms are violated, the decision to place the elder in a facility sometimes produced significant conflict among family members. Several informants talked about the anger they felt toward other family members for the admission. Some of these conflicts subsided over time and family unity was restored, but frequently resentment about the LTC admission did not go away.
Maintenance of Norms and Routines The final theme is perhaps more unique for the Latino culture. Despite LTC placement, families attempted to maintain cultural norms and routines for their
273
parents. Family members expressed this through their visiting patterns and the need to monitor the care given by staff. Additionally, the family had a strong need to have the LTC staff show respect to their elders and not have their Latino (Mexican) heritage and routines ignored. More specifically, even though the elders were living away from family, many family members made extraordinary attempts to maintain normalcy, such as wanting to take the elder home for weekends and special occasions. When they were unable to bring their parents home, families made frequent visits to the LTC facility to visit them. In the group interviews with elder Latinos, one woman said she had her children drive her 40 minutes one way each day so she could visit her husband in the nursing home. With regard to respect, families spoke at great length about the difficulties that resulted from staff being unable to talk to the residents in Spanish. Enrique explained that his father could understand some English but could speak only Spanish. When his father was experiencing pain in his side, he was unable to make the staff understand what was wrong with him. Enrique went on to explain, “The only problem I see there is that the communication isn’t there for people that speak Spanish. There’s going to be more Spanish-speaking people in there—and if they don’t do something with that, they are going to have a lot of problems, not only with the residents, but with the families that have residents there.” Finally, several informants perceived a lack of regard for Latino heritage by mentioning that their elders did not like the facility’s food and would have preferred Mexican dishes. The LTC facility acknowledged that, even when they did try to accommodate food preferences on some occasions, they were unable to prepare “authentic” Mexican food and had problems with nonLatino residents complaining about the food tasting too spicy. The study revealed many issues that could lead to conflict between the Latino family members and the LTC staff. Using this information can help staff understand Latino family behavior and make adjustments to care when possible.
DISCUSSION AND RECOMMENDATIONS Although some of these findings may not be unique to Latino families, the purpose of this study was to gain a depth of understanding in the Latino family response to LTC placement. The discussion and recommendations are applicable to the Latino group and might be helpful for people of other cultural groups. We believe that, if these findings are not unique to Latinos, further study might reveal that the needs of nonLatinos are being overlooked, as well.
Preserving Cultural Norms and Values This research demonstrated strong familial and intergenerational bonds for Latino families that need to be supported once an individual is admitted to an LTC facility.
274
Supporting the continued interconnectedness of the family is essential. Professionals working in this setting need knowledge and understanding of Latino cultural values, beliefs, and practices relative to making decisions about LTC placement. Modifications in the ways care is provided can be made by individual staff members and by administrative changes in facility philosophy and policy. One nursing action would be to support the strong respect that Latino family members demonstrate toward their elders. The frequency with which residents were taken home on weekends and for special family events showed the importance of family bonds. These activities are important and should be encouraged. Facilities should find ways to promote family gatherings and celebrations on the premises. This compromise might be accomplished through different cultural days versus just meeting a specific family need; for example, each first Tuesday could be a Latino celebration day for families and friends of all residents. Similar days could be established for other cultural groups. Family participation in care and their involvement in decision-making should be encouraged. Efforts to include the family should be part of the admission process and should continue throughout the elders’ stay. Finally, family care rituals need to be explored and maintained to the extent possible in the LTC environment. Family involvement in care can increase residents’ quality of life and the family members’ level of comfort and trust. Family members involved in care feel more connected and valued by being able to express their involvement in resident care needs. A thorough social history is essential to help determine family care rituals. If staff understand that family caregiving is a cultural norm for the Latino family, they can provide opportunities that will benefit residents, families, and staff.
Caregiver Interventions to Support Cultural Norms and Values LTC facilities can improve the quality of life for Latino residents and increase the comfort of their families by making modifications that support cultural norms while maintaining quality care standards. Examples of cultural adaptations that could be made include serving ethnic foods and playing ethnic music. Providing special religious services and bicultural staff for care delivery in Spanish will add to the comfort and quality of life of Latino elders. Many truly traditional Latino meals are not spicy and can be served to a variety of residents. (Traditional food in Mexico is much less spicy than Mexican food served in the United States.) Providing competent interpreters during the admission process, for care conferences, and for problem resolution increases resident and family comfort, fosters trust, and helps families feel respected. Although not mentioned in this study, a facility might want to provide ethnic artwork and color schemes throughout the facility. Signage in Spanish will help prospective residents and family mem-
Geriatric Nursing 2002 • Volume 23 • Number 5
bers feel welcomed and respected. Having important documents (admission paperwork, consents for treatment, etc.) translated into the resident’s language also increase comfort and trust. Many families described intrafamilial conflicts associated with LTC placement. Social workers within the facility and care planning conferences can help resolve or work with the family to come to terms with these issues. In keeping with the importance of religion, it may be more appropriate at times to use spiritual leaders when helping families deal with conflict. Residents’ physicians also can be excellent resources for families, given the importance a doctor has in the decision to place a person in the LTC facility. It is important to have a place for families to gather and hold celebrations, especially when the elders are unable to be taken home. Family potlucks and special music should be encouraged. Helping Latino residents and families celebrate special events and holidays related to their culture can increase quality of life. Using care plans to identify events that are important to residents can help facilitate the celebration of special days, recognizing that these may be different than the special days celebrated by the majority culture (eg, first communion, summer/winter solstice). Frequently, staff lack the ability to demonstrate respect in the same fashion the family desires. One example given in the study had to do with how a resident’s hair was styled. Although she was clean, her hair was very untidy, which was disturbing to her family. Additionally, staff members may not know about important care rituals that families use to show respect. Addressing these rituals during the care planning process is necessary so they can be incorporated into the resident’s daily care. Family members who wish should be allowed to assist whenever possible.
Administrative Support for Change Institutional change requires that cultural values and sensitivity be a part of the institution’s mission and philosophy. For facilities with residents from multiple cultures, policies and procedures need to represent each different culture. Community resources can be used to help develop policies and procedures that reflect these cultural values. When Latino residents live in a facility, it is important to teach Latino culture care values to all LTC staff during the initial orientation and periodically throughout the year. Representatives from the Latino community can be invited into the facility to help provide staff education. A cultural care committee can be formed to identify areas of need and develop a process to increase the quality of care for people of diverse cultures. This committee should be an integral part of the continuous quality improvement process. To assist the committee and administration, information from expert sources should be sought to help develop a plan for change.11 Additionally, to show broader concern and respect for the Latino community, LTC facilities must participate in organizations and activities within the community to create a
September
• October 2002
positive presence. Given that many Latinos are not familiar with LTC, the industry overall can be more proactive in providing information and knowledge to potential consumers. This rapport can be accomplished by encouraging Latino groups to use the facility for meetings and programs. Latino groups can be invited to provide educational programs and entertainment for residents and staff. The facility can invite members of the Latino community to serve on advisory and quality improvement committees. Conversely, facility staff can be encouraged to provide educational programs for Latino groups. There are also opportunities to do volunteer work within the Latino community. A cultural care liaison should be designated to coordinate these activities. The person must be knowledgeable and able to communicate effectively with facility staff and external/community resources to identify needs, initiate change, and ensure follow through.
CONCLUSION Knowledge of cultural values, beliefs, and practices of Latino family members faced with the decision to place elders in an LTC facility is important in providing culturally competent care. It is the responsibility of the health care industry to ensure this knowledge imparts a positive change in health care. Nurses in LTC management positions can take a leadership role in shaping a health care system that will meet the needs of diverse health care consumers. REFERENCES 1. Cox C, Monk A. Hispanic culture and family care of Alzheimer’s patients. Health Social Work 1993;18:92-100. 2. Kao H, Stuifbergen AK. Family experiences related to the decision to institutionalize an elderly member in Taiwan: an exploratory study. Social Sci Med 1999;49:1115-23. 3. Cuthbert A. The Boomer Sandwich. Modern Maturity 2001 Oct:94. 4. Pausada L. Hispanic-American elders: implications for health care providers. Clin Geriatr Med 1995;11:39-52. 5. Frey W. Elderly demographic profiles of U.S. states: impacts of new births, migration, and immigration. Gerontologist 1995;35;761-70. 6. McFarland M. Cultural care of Anglo- and African-American elderly residents within the environmental context of a long-term care institution [dissertation]. Detroit: Wayne State University; 1995. 7. McFarland M. Use of culture care theory with Anglo- and AfricanAmerican elders in a long-term care setting. Nurs Sci Q 1997;10:186-92. 8. Berry A. Culture care expression, meanings, and experiences of pregnant Mexican-American women within Leininger’s culture care theory [dissertation]. Detroit: Wayne State University; 1996. 9. Berry A. Mexican-American women’s expressions of the meaning of culturally congruent prenatal care. J Transcultural Nurs 1999;10:203-12. 10. Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League of Nursing Press; 1991. p. 179-201, 356. 11. Bonder B, Martin L, Miracle A. Culture in clinical care. Thorofare (NJ): Slack, Inc.; 2002.
BERNIE GOREK, RNC, GNP, MA, is the RehabCare program director at the United Medical Center in Cheyenne, Wy. JAN MARTIN, RN, PhD, GNP, NANCY WHITE, RN, PhD, and DIANE PETERS, RN, PhD, CTN, are professors in the School of Nursing at the University of Northern Colorado in Greeley. FAYE HUMMEL, RN, PhD, CTN, is an associate professor. Copyright 2002 by Mosby, Inc. 0197-4572/2002/$35.00 + 0 34/1/128792 doi:10.1067/mgn.2002.128792
275