Course:SOWK551/2021/Cross Cultural Communication with Seniors
Literature review on strategies in cross-cultural communications with seniors in hospitals and healthcare settings.
As of 1st July 2021, adults older than 65 years old are estimated to comprise 18.5 % of the total population in Canada and it is expected that Seniors will outnumber children for the first time in Canada’s history and, by 2056, a third of the population will be 65 or older (Canadian Medical Association, 2022; Statistics Canada, 2021). In addition to an increasing number and proportion of older adults in Canada, there is a significant shift in the racial and ethnic composition as the Canadian policies welcome migrants moving in as well as considering its historical background over time. First generation immigrants, which refers to the people born outside Canada accounted for 22.0% of the total population in 2011 and senior immigrants represented 31% of the total senior population over the age of 65 in 2016 meaning a culturally diverse older adults population in Canada (Statistics Canada, 2011; Statistics Canada, 2016). Both the demographic shift and cultural diversity can create many challenges in the provision of healthcare services (State of Victoria, 2016). Acknowledging there is a great need in examining the cultural impact on senior care in Canada, this paper aims to provide a literature review on exploring strategies in cross-cultural communications with seniors in hospitals and its relevance to social work practice.
Recognizing the impact of culture and race in gerontology, the term ethnogeriatrics was established in 1987 (Aggarwal, 2010). It refers to “the influence of culture, race, and ethnicity on health care for older persons from diverse ethnoracial populations'' (p.3, Cummings-Vaughn & Cruz-Oliver, 2016). It is found that health disparities exist in different ethnic groups, for instance, racial−ethnic minorities experience shorter life expectancies, and higher rates of morbidity and disability than non-Hispanic Whites generally in America (Cummings-Vaughn & Cruz-Oliver, 2016). Asian elders are found to have the longest life expectancy among all other ethnics groups (Cummings-Vaughn & Cruz-Oliver, 2016).
Studies indicate that, in cases of diverse culture, there are linguistic and communication barriers that lead to deficient communication for both clients and medical workers (Even-Zohar et al., 2021). Research proved that communication difficulties may exist between patients of ethnic minority clients and health care professionals because of differences in languages spoken, culture, beliefs about end-of-life care and communication styles, which may manifest as cultural insensitivity and lead to a lack of trust (Yarnell et al., 2020).
Social workers in the health care settings are often responsible for facilitating communication between multidisciplinary workers, which might include conveying messages from physicians and facilitating discussion on interventions among workers. Given the prevalence of ethnic diversity in older adults, they encounter clients with different ethnic backgrounds every day.
Culturally sensitive communication and culturally competent practice
Culturally sensitive communication and culturally competent practice are the key terms often mentioned in health care settings. Culturally sensitive communication demonstrates understanding and respect for individuals and promotes patient and family satisfaction (Brooks et al., 2019). It also requires the workers to critically reflect on their own values, beliefs, preferences and culture, as well as understandings of traditions, perspectives and practices of culturally diverse individuals, families and communities (Brooks et al., 2019).
Culturally competent practice, on the other hand, is defined as the ability to understand, appreciate and interact with people from cultures or belief systems different from one's own (DeAngelis, 2015). It involves careful coordination of individual behaviour, organizational policy, and system design to facilitate mutually respectful and effective cross-cultural interactions so it is considered as an approach in combining the understanding of attitudes, knowledge base, acquired skills and behaviour (American Geriatrics Society, 2004).
Researchers found that the self-awareness in workers embedded in culturally sensitive communication is the first step leading to culturally competent practice, then followed by cultural sensitivity, knowledge and implementation (Agness-Whittaker & Macedo, 2016; Even-Zohar et al., 2021). It is hoped that by improving cultural competence among health care providers, it may also be a critical step toward addressing health disparities (Cummings-Vaughn & Cruz-Oliver, 2016).
Cultural competency models in psychiatry
Researcher Aggarwal (2010) reviewed the cultural competency models in psychiatry which could also be relevant to social work practice, and researchers found that there are four domains in clinical cultural formulation. They focus on examining clients’ relationships with cultural identity, illness, social networks, and the medical system (Aggarwal, 2010). The cultural formulation has been however underutilized due to the time consuming exploration and the critics that it separates the cultural components from clinical assessments (Aggarwal, 2010). These four domains provide insights in raising health care professionals’ cultural sensitivity and knowledge, and in turn provide preliminary guidelines to cultural implementation in cultural competent practice that serves as a tool to understanding clients.
Clients’ perception on cultural identity
Similar to the recommendation suggested by American Geriatrics Society (2004), they indicated that cultural identity as one important domain in culturally sensitive care. How the clients identified themselves may be different from what the workers assumed. As culture is dynamic and can be individually determined, and some people reported experiencing a cultural generation gap, studies suggested workers ask clients about their cultural identity (Aggarwal, 2010; American Geriatrics Society, 2004). The degree of formality differs between cultural groups and some suggestions include asking clients about their preference on their title in addressing them and even how they prefer to address the workers (Aggarwal, 2010; American Geriatrics Society, 2004).
Cultural explanation on clients’ illness
The second domain in cultural formulation in regards to how the clients perceive the illness aimed to explore their understanding of their illness in their cultural context (Aggarwal, 2010). Some other research shared similar notions that there are cultural beliefs that shape clients’ worldview on illness and death which in turns impact on their end of life health care decision making (Kwak & Haley, 2005; Chan et al., 2019). For example, some may say that illness and early death are caused by past wrongdoings in the traditional Chinese beliefs, and death is a taboo to avoid discussion (Kwak & Haley, 2005; Chan et al., 2019). They believed that the more they talk about it, the more likely it will occur so sometimes they preferred not to be told about the diagnosis (Kwak & Haley, 2005). Apart from understanding client’s perception on the illness, a study found that clients’ perception on the intervention is also crucial in treatment (Dutta et al., 2020). They found that ethnic-minority families may perceive advance directives to be an intrusive legal mechanism of the mainstream culture which interferes with their responsibility to care for their loved ones (Dutta et al., 2020). Therefore, it is essential for health care professionals to ask about their perceptions without making assumptions directly.
The cultural formulation also identifies the social network within the clients’ cultural context (Aggarwal, 2010). In some cultures, collectivism informs clients’ decisions made by family instead of individuals which may contradict with the western culture that health care decisions are individually determined (Dutta et al., 2020). The ethnographic literature also addressed the complexities involved in elder care, such as joint family systems, familial expectations based on generations rather than individuals solely (Aggarwal, 2010).
Cultural elements on client-work relationships
Similar to acknowledging the preference and cultural identity of clients, clinical cultural formulation also suggested acknowledging the client-worker relationships in clients’ perspectives (Aggarwal, 2010). In some cultures, physicians and health care professionals are considered authority figures (Dutta et al., 2020). Literature identified that these perceptions influenced the decision making process of clients (Dutta et al., 2020). Some ethnic minorities expressed distrust towards the medical system due to their personal experience of poor access to medical care and the awareness of abuse and in turn are less likely to implement advance directives (Kwak & Haley, 2005). Other researchers recognized the importance of trusting relationships between clients and workers in facilitating effective communication (Brooks et al., 2019). Therefore, they put forward the suggestions of using open and non-threatening body language to demonstrate the willingness to help (Brooks et al., 2019). Other than body language, active listening and using clients’ language such as their phrases could also help build rapport and trusting relationships with clients (Brooks et al., 2019).
Language barrier in cross-cultural communication
Studies in both Israel and Ontario found that language being one dominant barrier in cross cultural communication among older adults in different ethnicities (Even-Zohar et al., 2021; Yarnell et al., 2020). Some clients expressed feeling distant from medical staff due to language and communication barriers as they could not understand physicians’ explanation on the illness as well as the instructions of care (Even-Zohar et al., 2021). It could lead to poor health outcomes, increased prevalence of adverse events, and repeated admissions to hospitals (Brooks et al., 2019). Social workers are sometimes seen as the bridges between clients and medical workers, and when they do not speak clients’ language, it is almost impossible for effective communication to take place. Brooks and other researchers (2019) identified that appropriate use of professional interpreters as the best practice when the clients’ first language differs from the workers. American Geriatrics Society (2004) also proposed that even clients who speak fluent English might feel more comfortable having to discuss their illness and diagnosis in their mother tongue. Workers could best use professional interpreters when it happens especially when it comes to medical terminology. Even if social workers can speak the same language, it is best for them to use professional interpreters in conveying accurate messages to clients.
American publishing in promoting understanding cross-cultures in older adults
In light of promoting the understanding of cross-cultural communication among older adults and health care professionals, Ethnogeriatrics Committee of the American Geriatrics Society published a series of books called “Doorway thoughts: Cross-cultural health care for older adults” in 2004-2008. They acknowledge the importance of the role of ethnicity and religion in health decision-making in America so they introduced some concepts of nonverbal communication, acculturation, health beliefs in different ethnicity so clinicians can develop an understanding of how to care for older adults in a culturally competent way (American Geriatrics Society, 2004; American Geriatrics Society, 2006; American Geriatrics Society,2008). They emphasized that the key concepts discussed are “doorway thoughts” that workers can reflect on before they step into the doorway as culture and beliefs vary from one individual to another even in the same ethnic group.
Recommendation from literature review
The studies shed light on how cross cultural communication can be better facilitated by health care professionals. The four stages of culturally competent practice mentioned by Brooks and other researchers which are the cultural awareness, sensitivity, knowledge and implementation could serve as guidelines in facilitating and enhancing culturally competent work in hospitals. In the first stage of cultivating awareness, sensitivity and knowledge of workers, Agness-Whittaker & Macedo (2016) suggested that cultural competency training is essential and effective. It can equip both workers and students, and future workers-to-be to acquire knowledge, skills, and attitudes to care for and communicate well with a culturally diverse older adults population. It can raise their awareness of their personal bias and to reflect on the culturally based health beliefs (Agness-Whittaker & Macedo, 2016).
Apart from that, Brooks and researchers (2019) recommended open communication among workers and clients to a degree where they feel comfortable. As mentioned, there are some taboos in certain cultural beliefs so workers might have to be sensitive in using appropriate language in disclosing information and discussing sensitive topics. At the same time, clients are encouraged to give their personal views for effective communications (Brooks et al., 2019). Researchers also mentioned the importance of using professional interpreters in removing the language barriers (Brooks et al., 2019).
In the American context, the cultural competency formulation in psychiatry can be used to implement cultural competency practice by psychiatrists whereas Tool for Assessing Cultural Competency Training is used in medical schools as trainings (Aggarwal, 2010; Agness-Whittaker & Macedo, 2016; Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services). However, it needs further exploration on whether these tools are applicable to Canadian context and social work practice.
Limited research has been done on the Canadian context with limited studies on exploring clients’ perspectives and experience in hospitals. Most research has been done on health care professionals and students in the healthcare courses so the perspectives from clients are lacking. There is indeed some research focusing on more specific topics such as cultural impact on health care decision making in older adults but limited within the Canadian context. Although there is limited study on the role of social workers in this topic, it is assumed that the communication strategies recommended by researchers would still be transferable and applicable to various disciplines including social workers as the awareness and the attitudes are forefront concepts in implementing culturally competent practice.
Future research can be done on exploring the cultural impacts on health care for older adults in Canada given its prevalence of ethnic diversity. It could be possible to adopt the idea of publishing the “doorway thoughts” just like American Geriatrics Society did to provide some fundamental concepts workers can reflect on, raising their self-cultural awareness.
As mentioned by some studies, workers and researchers have to be mindful that cultures vary according to each individuals’ personal experience and it may only serve as one factor that shapes their worldview. It is believed that within the concept of self-awareness, social workers need to carefully put aside all the assumptions before truly understanding the clients’ perspectives and views so that clients’ wishes and voices can be respectfully heard and addressed.
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