Editor's Note: The cover story in the September/October issue of ADVANCE highlighted the major findings of AAHSA's Better Jobs Better Care program. This article will cover many of the program's findings on cultural competence.

The staff at Broomall Presbyterian Village, a skilled nursing facility in Broomall, Pa., could be a study in cultural diversity. Team members hail from locations across the globe, including Africa, Jamaica, Trinidad & Tobago, Guyana, Haiti, India, Puerto Rico, China, Vietnam, Cambodia and the Philippines.

 The direct care staff members at Aberjona Nursing Center, a long-term care and rehab facility in Winchester, Mass., represent 19 different countries from Uganda to Haiti. The staff at Cedar Sinai, a continuum of care campus in Portland, Ore., includes immigrants from 27 different ethnic cultures, ranging from Hispanic to Eastern European.

While these three facilities are located in different regions of the United States, they are shining examples of the global workforce diversity that is mirrored in long-term care facilities across the country.

With such varying languages, accents, customs, interests and attitudes, it's no wonder that cultural competence becomes a challenge. In fact, this area needs attention now as long-term care communities face the constant struggle of finding and keeping good direct care workers, reports Ingrid McDonald in the Better Jobs Better Care issue brief, Respectful Relationships: The Heart of Better Jobs Better Care.¹

To create an environment of respect in the workplace, long-term care management should focus on acknowledging, addressing and celebrating the diversity of the workforce, which, in turn, will help with resident care, retention and the bottom line.

A DIVERSE WORKFORCE

David Fuks, MSW, who is chief executive officer of Cedar Sinai Park, says that having 240 employees from 27 different ethnic groups is a constant challenge, but also a learning opportunity. "There are two ways to respond to this diversity. We can ignore it, or we can treat it as an asset, an opportunity for people to learn and grow," he says in the BJBC issue brief.¹

Marcia Walsh, RN, BSN, SDC, sees it the same way at Aberjona Nursing Center. As staff development coordinator, she's continually coming up with ways to satisfy the needs of employees from 19 different cultures. But, first, she says, it's important to understand the cultural differences among your employees.

CULTURAL DIFFERENCES

Diversity of such magnitude creates a host of cultural differences that range from basic communication to non-verbal communication and various attitudes and customs.

Boston University's Victoria Parker, DBA, who completed a field study of nursing home workers in 10 facilities across the eastern Massachusetts area, found that basic conversations can be the starting point for misunderstandings.

In some facilities, immigrant workers who'd learned English in other countries spoke English quite well, but with different accents and usages. After things like slang and idioms caused communication gaffes, workers were often told to speak English. "To them, this didn't make any sense and was hurtful because they had grown up speaking English, but a different kind of English," says Parker, who is assistant professor at the Boston University School of Public Health.

Parker found this problem went far beyond dialect. "We found that the issue of spoken language is the tip of the iceberg and that a lot of the difficulties in communication and misunderstandings also had to do with non-verbal communication and different cultural norms.things like eye contact and tone of voice and how to ask for clarification if someone is confused," Parker says.

For example, Parker found that eye contact is not the hallmark of non-verbal communication everywhere that it is in the United States. In fact, immigrant workers from Africa and other regions consider it rude. In the BJBC issue brief, she quotes a manager who saw this issue in her facility: "In our culture, when you don't look at us, that is disrespectful. We expect you to look at us when we're speaking to you. Otherwise, we feel that you aren't looking or aren't interested or are blowing us off or whatever. But now, we've heard . that [in your culture people] don't do that."¹

Other differences in cultural attitudes can hamper even the best communication intentions, says Robyn Stone, DrPH, executive director of the Institute for the Future of Aging Services, the applied research arm of AAHSA. For example, in the Philippines, the culture is to defer to people who've been in the job longer. So, it may be very difficult for a charge nurse to supervise front line CNAs who've been at their jobs more than 20 years, she says.

RACISM AND DISCRIMINATION

With cultural differences getting in the way of effective communication among your employees, things can quickly turn ugly-and not just among the staff. The dual-headed beast of racism and discrimination can become a problem between residents and staff.

"Long-term care may be one of the few work settings in the United States where staff still encounter blatant racism," Gretchen Henkel writes in a 2004 article in Caring for the Ages.¹ She attributes this to the sharp contrast between the racial demographics of long-term care staff and the clients they serve and, in many cases, their supervisors. Another contributing factor is that many elderly people grew up in environments where racist attitudes were acceptable. Racist attitudes also may emerge from elderly people who suffer from dementia and have little control over what they say.¹

The evidence on racism isn't just anecdotal. Celia Berdes of the Buehler Center on Aging, McGaw Medical Center of Northwestern University, and John Eckert of the Statewide Independent Living Council of Illinois examined the effects of racial differences between nursing home residents and nurse's aides. They found that one-third of residents exhibited race-related attitudes and three-quarters of the aides had experienced racism on the job.²

In addition, two BJBC research projects found that 70 percent of direct care workers interviewed in Ohio had heard residents or clients make racial or ethnic remarks.¹

Parker's research discovered similar occurrences. "The number-one issue that has become clear in our research is how pervasive these experiences are for direct care workers. Over and over, they report that they are targets of racial or culturally motivated abuse and derogatory comments-from the residents and their family members, their supervisors and in some cases, their co-workers," she says in the BJBC issue brief.¹

Racism, left unchecked, quickly gives birth to discrimination. In fact, Berdes and Eckert also found foreign-born aides were more likely to experience discrimination on the job than African Americans. Immigrant workers experienced prejudice from residents, family members and fellow staff members, including U.S.-born co-workers of the same race.²