Eileen R. Chichin, Ph.D., R.N.
Co-Director of the Kathy and Alan C. Greenburg Center on Ethics in Geriatrics and Health Care
Simply walking through any nursing home in the city of New York, one is struck by the cultural diversity of those who live and work here. How members of these disparate cultures co-exist within the facility impacts upon many aspects of nursing home care and, depending upon one's respective role in the facility (staff, residents, or family member), clearly affects how people feel about the care they receive and the work they do.
Traditionally, long-term care facilities were home to a primarily white resident population. Today this is changing and we are seeing members of various other cultures residing side by side. Of not are the many members of cultures who historically care for their dependent family members at home and who are now seeking entrance into a nursing home. Evidence of this phenomenon (as well as descriptions of the experience of some of the individuals involved) can be found in the ongoing work of Patricia Kolb, Ph.D., from the Columbia School of Social Work. Dr. Kolb's fascinating study of the impact of nursing home admission on Hispanics, and more recently, her work with Afro-Americans, has implications for both nursing home residents and staff members. These cultural groups, rarely seen in nursing home beds in the past, are entering nursing homes in increasing numbers. Similarly, we are seeing more Asians in our long-term care facilities, as is documented by the work of Zheng-Bo Huang, MD, a geriatric fellow at the Mount Sinai Medical Center and The Jewish Home and Hospital.
Despite the growing diversity of nursing home residents, the fact remains that their primary caregivers, certified nursing assistants (CNAs), are also drawn from various cultural and ethnic backgrounds that more often than not differ from those of the residents for whom they care. This clearly has implications for resident care at the very end of life when it is obvious that death is imminent, since every culture has its own particular beliefs and practices about death and dying. However, cultural issues probably have an equal if not more pronounced impact on everyday issues in long-term care settings than they do on actual end-of-life care. Particularly prominent are issues associated with food, language, and religious practices. Imagine an 80 year old woman born and raised in the Dominican Republic, who enters a nursing home near her New York City apartment. Chances are the food in the nursing home is markedly different from what she was accustomed to eating. Could this possibly be the cause of her loss of appetite?
Another concern is language, when individuals who are unfamiliar with English enter a nursing home and few, beside their family members, may be able to communicate with them. Entering a long-term care facility is a traumatic experience; imagine how this is magnified when the new resident does not speak English. Additionally, resident care may be compromised if care givers do not have the time or the inclination to learn at least a few words of a foreign-language speaking resident.
Yet another "everyday" as well as "end-of-life" issue centers on an individual's religious beliefs and practices, as well as the extent to which the religious beliefs and practices of others are tolerated and respected. Does this resident believe in an afterlife? Does this resident believe there is meaning in suffering? Does this resident or staff member have religious beliefs that preclude the withholding or withdrawing of life-sustaining treatment? Is this CNA fearful of caring for the dying, and is he/she able to care for a resident who is close to death? If nursing homes are to care for the "whole" person, we need to be sensitive to residents' religious and spiritual needs, as well as beliefs of its staff members.
Challenges associated with cultural diversity in nursing homes became evident while conducting a study of the knowledge and attitudes of CNAs about the ethical issues and end-of-life treatment decision-making in nursing homes in New York and New Jersey which was funded by The Greenwall Foundation. During a discussion with CNAs in a large Jewish facility in New York City, one nursing assistant made the following statement to us: "Nothing against you people, but I'm from Trinidad, and in our country, we don't put people in nursing homes." Another nursing assistant then raised her hand and said, "Well, I'm from Ethiopia, and in my country, we don't put people in nursing homes either. But I live here now, and I have a husband and two children in college. If I did not work, and I had to stay home and care for our parents, we would not be able to keep our children in college."
With respect to the use of life-sustaining treatment, in our conversations with care- givers--both professional and paraprofessional--in nursing homes, we have found that staff members are often conflicted about the use of medical technologies used to prolong the lives (and often the dying) of frail elderly residents. Particularly noteworthy are feelings about the use of artificial nutrition. When staff from other cultures are asked what would be done in their countries, they usually respond that they do not use feeding tubes in their countries and that they would simply keep the person at home and care for them there. But, they add, they work in a nursing home here now, and this is what is done here, and this is their job.
Other anecdotes seem to indicate that certain issues transcend culture. Specifically, when a nursing home resident is very close to death, anyone, regardless of culture or religious background, can provide solace and support. A nursing assistant in a small Catholic facility in New Jersey told a story of caring for a Catholic resident whom she had known for a long time. "I knew she was dying, " the nursing assistant said. "I'm from a different religion--I'm Hindu, and she was Catholic. But I just took her hand, and sat with her, and I said, 'I know you are very tired now. It's okay for you to go. I will stay and hold your hand.' And then she died."
Clearly, we need to increase our sensitivity to cultural issues in nursing homes, and encourage and support endeavors such as the program conducted at the Hebrew Home for the Aged in Riverdale a few years ago to enhance cultural awareness. But what else should we consider? Perhaps most significant to individualized, compassionate resident care is the need to learn and respect each resident's unique belief system and values. Heightened awareness of our own beliefs, as well as those of our colleagues, is also important. We also need to be careful not to assume that culture explains all the views and beliefs of others. It is difficult to tease out how much of one's belief system is a function of culture, or religion, or personal experience. With respect to nursing home staff members, and particularly where treatment issues are concerned, to what degree does the philosophy of a particular discipline influence how one feels? To what degree does the overall "institutional culture" of each long-term care facility influence how its staff members think, feel, and behave?
Cultural issues are now and will remain a significant part of nursing home life, both enriching it and presenting it with challenges. The degree to which we will meet these challenges has profound implications for both quality of care where resident and families are concerned and job satisfaction for nursing home staff.
Source:Chichin, E. R. (1997). The role of culture in the nursing home: An everyday issue, an end-of-life issue. Ethics Network News, 4(3), 4-5.
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