The influence of culture on aged care

delivery

Professor Olga Kanitsaki AM

Head
Division of Nursing and Midwifery
School of Health Sciences

RMIT University
 Aims
 Identify what culture is and how it operates in
public mainstream society
 Give an example of how culture care operates in
ethno specific context
 Give an example of how the “ruling normality”
speaks for, undermines or subjugates other cultures
care practices in a multicultural society like ours
 Propose actions that can be taken to improve health
services to ethnic aged in mainstream acute,
community, residential and ethno specific care
services
 Stats Aged 65 and over

 2.4 Million aged 65 and over 12.5%

 784, 600 or 33% born overseas
 479, 400 61% CALD/NESB or 19.9% of the total older
population
 305, 200 39% ESB
 By 2011 CALD 22.5% this is an increase of 66% growth
since 1996 compared to the same period of 23% for the
Australian born population
 Italy, Greece, Germany, Netherlands & Poland

– ABS & AIHW 2002 &AIHW 2001

 Culture

Shared Human
meaning, Construction
Symbols, Individual &
Language collective
Living within & experience,
Core values,
interacting History &
Beliefs, with environment tradition
Expectations, in time & place
Goals,
Patterns of Rules &
social behaviour practices,
& interactions
Rewards,
Punishments
 Cultural Interpretations
Communicating Meaning
 Members of the same culture share sets of
concepts, images, and ideas which enable them to
think and feel about the world, to be able to
interpret the world in roughly similar ways. (Giles
& Middleton 1999, P 59 ).
 It is not language alone that produces meaning,
but also behaviours and practices.
 Culture is:

 Internalised (embodied) by the individual

 Forgotten as ‘embodied history’ (cf
structure of grammar)
 Just as grammar (unconsciously) regulates
our speech, so too culture regulates our
action, i.e. through internalised individual
dispositions.
 Australian Public Culture & Institutional Structure:
Base of Society
Margins of Society

Indigenous People
Ethnic

Scottish
Margins of
Society

Margins of Society
English
English Ethnic
Irish

Ethnic Welsh Ethnic

Margins of Society
Transcultural Values and Moral Systems
(Lay and Professional)
 Values
– Individuality versus collectivity
– Privacy, confidentiality, truth telling
– Independence versus paternalism
– Dignity, privacy, quality of life etc..
 Family structure and relations
– Care practices
– Decision making processes
– Gender roles
 Consent and informed consent
Mainstream/Dominant culture
 Well internalized and embodied by majority
or ‘mainstream’ of people
 Perceived as ‘natural’ (like the laws of
gravity) and hence objective, factual, true
Mainstream/Dominant culture,
Cont…
 Anyone who fails to uphold the ‘normal’
life way risks being labelled ‘odd’,
‘different’, ‘inferior’, ‘other’, ‘difficult’,
‘not normal’ and even a threat to social
cohesion
 Levels of culture

LEININGER, M. 1995 P 23
 Greek Culture care
 Family structure, roles, values expectations
 Child centred
 Reflects ideal moral universe
 God’s family: good father, mother, children
 Interdependent
 Family care trusted, strangers & paid not trusted
 Care institutions not trusted, family would go with
member. HCP surveillance by family
 Issues to be taken into
account
• Generational differences in expectations
• Communication between generations
• Children working
• Elderly isolation
• Economic & linguistic dependence
• Authority and respect for elderly may be
diminished within family
• Difference between groups and individual aged
people
 Case exemplars

 Case
#1: Elderly Greek woman having a
shower

 Case#2: Elderly Greek woman who

experienced both mainstream and ethnospecific
aged care
 Board
Cultural relational spaces in
CEO
the Home
Anglo Celtic Div 1 Managers

Aust Greek Born Div 1&

Anglo Celtic

G G
C C
Old Aged
PC
PC

Greek Nursing Home Culture in Action

 Ethnospecific Home Benefits
 Greek residence, PC’s, relatives: Together share history,
experience, language
 Able to have a two way verbal communication with
carers, share jokes, reminisce, play games, have
arguments etc
 Greek environment, space objects, artefacts, meaningful
symbols
 Greek food
 Ethnospecific Home Benefits, Cont…

 Greek activities and religious practices

 Greek entertainment, music, Greek TV,
dancing, picnics and community visiting
 Name days
 National days
 Privileging Mainstream Normality
(Culture)
• Official/formal language use: English
• All official and government documents in English
• All meetings in English
• General Manager & Director of Nursing Anglo-
Saxon Celtic
• Formal Communication via the hierarchical system
• Government’s Health & Family Services Planning
• Approval Classification, Certification and
Accreditation Funding Standards (management)
• When Anglo Saxon staff leave gifted flowers and
appreciation/Greek staff got nothing
 Concepts in the official documents too hard for PC’s to
understand, thus no use translating them
 PCs expected to learn English
 Pressure to learn English
 Classes compulsory, after hours & without pay
 Anglo Saxon/Celtic not expected or requested to learn
Greek
 Greek cultural capital devaluing

 Greek RN’s Div. 1 employed as SEN’s PC’s

 No systematic recruitment & retention plans for
Australian Greek or GA Born
Reasons
 Funding & Div 1 level 4 position required
 Inexperienced, young
 Greek women (ethnic, immigrants)
 Felt demeaned and insulted
 Greek RN’s Div. 1 employed as SEN’s PC’s
 “Because the other registered nurses and  the other  SEN’s 
knew  I  was  registered  as  a  [Division  1]  nurse  they  would 
give me a little bit more to do. But their expectations of me 
were  higher,  and  that  was  fine  by  me.  I  wanted  to  meet 
those  expectations.  So,  yes,  I  think  at  that    stage  I  didn’t 
really know whether I was Arthur or Martha because I was 
an  SEN  (they  were  paying  me  as  an  SEN)  and  that  was 
what  my  job  description  said  I  have  to  do.    Yet  there  was 
that  expectation  from  them  [that  I  would  function  as  a 
Division 1 RN], and I also had that expectation of  myself”.
 “So  here  I  was,  experienced  in  terms  of 
knowledge  as  a  registered  nurse,  and  I  had 
the  appreciation  of  the  language  and  the 
culture, and so they expected me to establish 
a  rapport  with  these  residents  and  to  do 
really  well  in  my  interpersonal  [relations]  in 
addition  to  my  [professional]  skills.  I  had 
them both, so the expectation was there. And 
from a gender perspective [they saw me] as a 
woman, a Greek woman, who should [behave 
like a Greek woman]”. 
 “The RN’s saw me when I was on, ‘Here's my 
little interpreter’, and ‘Here is my little second 
hand  person’.    I  didn't  mind  that. I loved the 
opportunity to be doing some other skills that 
reinforced what I was trained for.”
 Concepts in the official documents too hard for
PC’s to understand, thus no use translating them
 PCs expected to learn English
 Pressure to learn English
 Classes compulsory, after hours & without pay
 RN’s & PC’s used as interpreters for Australian
Management
 Messengers & mediators to Greek staff and
community
 Living in-between two ambivalent cultural worlds.
 Identity problems
 Constructed as ethnic and inferior
“go and pick cherries or go and work down at 
Bosch [a factory]”
“Other times she will speak to us like we are the 
last rubbish of the rubbish. It is not right to have 
us  here  at  7  in  the  evening  and  to  have  a 
meeting to last till 10 pm.”
 Expected domestic staff who chipped or broke 
plates to pay for them. 
 Other Issues

Relatives 
 Complaint about the variety of food
 Number of staff on night duty
 “Harassment on food, and harassment on 
water”. 
 “I was treated like I was a migrant. An 
illiterate migrant”.
 Anglo Saxon Celtic interpretation of dignity 
and privacy, for example, elderly was scared 
during  the night and requested to put an 
intercom so that elderly can hear a voice. The 
manager dismissed the request and stated that 
this would violate the Residential Standards 
because of the noise and because of dignity 
and privacy. The relative stated that the elderly 
and those others sharing the room were 
concerned with safety not about dignity, noise 
or privacy.
 [MII] She angrily instructed me to say to them, ‘Take your 
sweets and go away from the nursing home’. Then she went 
away. I thought if I send them away, it will be the wrong thing 
to do and we would not have accomplished anything. 
 It  is  because  they  mistrust  the  nursing  home  because  of  the 
restrictions imposed  upon them by the nursing  management 
and because of the way they have imposed those restrictions.
 All
of the above mitigated against trans-
formative cross-cultural practices

 Sustained
mainstream culture superiority and
domination and,

 ReinforcesGreek cultural inferiority and

subordination
 Transcultural Issues

 Patient& family knowledge of health system

 Professional roles, rules and practices
 Cultural interpretations (whose prevail?)
 Communication and communication styles
 Ethnocentrism
 Stereotyping V Generalisations
 Transcultural ethical systems
 Consent and informed consent
 Transcultural care delivery at a
professional service level
 Culture care preservation/maintenance
 Culture care accommodation/negotiation
 Culture care repatterning/restructuring

 Results in culturally congruent nursing care that is

healing and empowering
 Can be applied face to face delivery in acute,
community and home care, administrative, managerial
and institutional level.
 Transcultural care service delivery at
institutional level
 Policies and guidelines: cross-cultural outcomes
that can be measured
 Individual HCP’s performance appraisals to take
into account cross-cultural practices
 Policies and guidelines that explicitly require the
inclusion of family/significant others in the
medical, nursing and other care planing and
delivery
 TN Care Continues
 Client/patient information sharing with
family/significant others unless explicitly requested
for information not to be given
 Systematic use of interpreters
 Establishing a multicultural work force, including 
transcultural nursing experts and staff. This 
should include increasing the number of 
bilingual and bicultural nurses, doctors and other 
health professional in aged care.
 Conscious effort should be made not to 
assimilate such professionals but to help them to 
work effectively in this country
 State & National Levels
 Legal system to recognise relationships and
interdependence beyond husband and wife and/or
children to include those others that are significant
to the aged
 Legal system to ensure that effective
communication takes place and clients have
relevant knowledge to participate in the decisions
for their care and treatment
 Additional funding to be geared for real
ethnic aged needs in community, acute and
residential care
 Specific funding to ethno specific homes to
use for translation of government policies
and documents
 Specific funding for teaching the relevant
language to staff, English to the ethnic
carers and the ethnic language to English
speaking staff
 Ethno specific Services

Accreditation standards to measure:

 Consumer and staff communication and
participation in decision making
 All government policies, guidelines translated to
relevant language in the service
 All employees who work in the service to speak
the relevant language(s)
 Professionals to be educationally prepared to be
able to transform government policies to serve
the relevant ethnic group
 Health professional to be cross culturally
educated to transform and manage care delivery
within ethnic context (particularly DON’s )
 Health professionals (RN’s) in management to be
representative of the ethnic group
 Provision of group health needs as defined by
them
 Level of appointment and quality of staff
 Staffing levels & quality with relevant salary
 Continuous education & Cross-cultural education
 Relevant community involvement and support