CULTURALLY COMPETENT CARE FOR CHILDREN AND OLDER ADULTS

The modern family is diverse, and culturally competent care for children involves an awareness of elements of culturally competent care for patients and caregivers of all races, ethnicities, religions, and sexual orientations. Similarly, patients of advanced age may face health disparities related to ageism, which is prejudice based solely on a person’s age.

Best Practices for Culturally Competent Care of Children

Culturally competent care of children requires an awareness of cultural differences that may have an impact on growth/development as well as other healthcare-related concerns. For instance:

Common diets and feeding practices differ among groups and may contribute to nutritional or weight status in children.
Parenting styles and health promotion behaviors can vary significantly, such as encouraging or discouraging independence in infants and toddlers.
Practices such as infants and small children sharing a bed with parents may be of significance for the comfort of pediatric inpatients.
Emotional development, such as acceptance around crying, can be affected by cultural views.
For adolescents, cultural values and attitudes toward sexuality vary.

Clinicians must consider these and other cultural habits, beliefs, language, and ethnicity in order to provide appropriate care for all children and families (Ricci et al., 2021).

In order to improve health equity, culturally competent care should be provided in primary care, particularly during well-child visits. Results from recent research indicated that care provided in pediatric primary care offices that is rated by caregivers as culturally sensitive is correlated with higher-quality well-child care (Okoniewski et al., 2022).

Examples of interventions that support culturally competent care include:

Offering the use of language supports, such as professional medical interpreters or healthcare workers qualified to translate, to all patients
Explaining health issues based on social or cultural values
Providing evidence of a health issue’s influence on a cultural group
(Okoniewski et al., 2022)

CASE

Mali is a nurse who works at a pediatrician’s office. She is providing an initial assessment for an infant named Hana Li, whose mother has brought her in for her one-month well-child visit. Mali asks the infant’s mother to remove the diaper so they can take an accurate weight. Mali notices a blue mark on the infant’s left buttock that she thinks may be a bruise. She assesses the area and notes that it is not swollen or tender. Mali points the mark out to the patient’s mother, who tells Mali that the infant was born with it.

Mali completes her assessment and lets the mother know that the doctor will be in shortly. Before the pediatrician goes in to see the infant, Mali lets her know of the mark that she saw on the infant and expresses concern that it may be a bruise. The pediatrician looks in the chart to verify that the infant was born with the mark. She shows Mali the previous charting about the mark and explains that some infants, mostly commonly Asian and Native American, are born with a blue-colored skin lesion sometimes referred to as a Mongolian spot. She states that the mark usually dissipates as the child gets older and that it can often be mistaken for a bruise. Mali understands that the lesion does not indicate child abuse but is a congenital birthmark that is more common in Asian infants such as Hana (Galanti, 2019).

Best Practices for Culturally Competent Care of Older Adults

Older adults are generally considered to be those ages 65 years and older. In the United States, the population of older adults is expected to double to 83.7 million individuals by 2050 (IHI, 2023). Health disparities become magnified in the older adult population, and issues around race, ethnicity, sex, gender identification, sexual orientation, and disability continue to impact these patients’ access to healthcare and outcomes (Taylor et al., 2019).

Older adults have different healthcare needs due to normal physiologic changes of aging, the increasing prevalence of age-related disease, and other psychosocial factors. Despite these differences, culturally competent care for older patients requires nurses to avoid bias and discrimination based on age (referred to as ageism).

Stereotypes about aging, particularly in North America, are primarily negative—a time of ill health, loneliness, dependency, and poor physical and mental functioning (Donizzetti, 2019). Such negative attitudes toward and discriminatory treatment of older adults are present throughout the healthcare community and affect the quantity and quality of care provided to older patients, putting them at increased risk for undertreatment or overtreatment. For example, if a nurse has the belief that older adults are less healthy, less alert, and more dependent, then their initial assessment of the patient will reflect this belief (Swan & Evans, 2024).

A few common myths and realities about older adults include:

Myth: Old age means mental deterioration. In reality, neither intelligence nor personality normally decrease because of aging.
Myth: Older adults are not sexually active. In reality, although less frequent, sexual activity lasts well into their 90s in healthy older adults.
Myth: Bladder problems are a problem of aging. In reality, incontinence is not a part of aging; it generally has a root cause and requires medical attention.
(Taylor et al., 2019)

AGEISM AND HEALTHCARE

Ageism arises when age is used to categorize and divide people in ways that lead to harm, disadvantage, and injustice. It can take many forms, including prejudicial attitudes, discriminatory acts, and institutional policies and practices that perpetuate stereotypical beliefs.

Ageism is ingrained in our culture. It remains socially acceptable and is a stubborn prejudice. Ageism messages indicate that being old is something to avoid, and people of all ages show bias against older adults.

In medical settings, stereotypes associated with aging may influence treatment decisions. In the mental health field in particular, age bias and stereotypes can influence attitudes and practices. Many in the mental health field, for example, exhibit a preference against working with older patients, assuming less favorable outcomes for older patients and believing that depression is a natural consequence of older adults (Weir, 2023; WHO, 2021).

“Dwelling on negative aspects of aging can have a measurable negative impact on physical health and the ability to respond to stress.” Negative self-perceptions of aging are associated with a higher prevalence for chronic health conditions, including hypertension, heart disease, lung disease, diabetes, musculoskeletal disorders and injuries, and loss of cognitive function (Rosbach, 2022).

Despite the growing need for more providers with geriatrics expertise, many medical and nursing students come to view the care of older adults as frustrating, uninteresting, and less rewarding overall. Attitudes are further shaped by the persistent misconceptions that older patients are demented, frail, and somehow beyond saving.

Other factors that increase the risk for under- and overtreatment include the decline in the number of providers with advanced geriatrics training. Secondly, more practitioners are opting out of participation in the Medicare system. Thirdly, older adults are frequently excluded from clinical trials of medications that are meant to help them, resulting in data that are problematic when caring for those with multiple chronic illnesses (Gutterman, 2023).

AGE-FRIENDLY HEALTH SYSTEMS

The Age-Friendly Health Systems initiative recognizes that older adults in the United States deserve safe, effective, and patient-centered care that aims to follow an essential set of evidence-based practices, cause no harm, and align with what matters to the older adult and their family caregivers. Age-Friendly Health Systems include a framework referred to as 4 Ms:

What Matters: Know what matters to the older adult concerning specific outcome goals and care preferences, and align care with them across settings of care, including end-of-life issues.
Medications: If medications are necessary, prescribe age-friendly ones that do not interfere with what matters to the older adult, their mentation, or their mobility across settings of care.
Mentation: Prevent, identify, treat, and manage delirium across settings of care.
Mobility: Ensure that each older adult moves safely and on a daily basis to maintain function.

(IHI, 2023)

BEST PRACTICES FOR COMMUNICATING EFFECTIVELY WITH THE OLDER ADULT

For the older adult, the ability to communicate effectively is central to self-esteem, identity, and quality of life. For the healthcare provider, effective communication is essential for understanding and assessing older adults and promoting their health.

Therapeutic communication is a person-centered interaction that involves using eye contact, open body language, and active listening. There are three separate subcategories to communication:

Seeing the individual
Being respectful
Showing empathy and compassion

Older adults often report being treated with lack of respect and negative attitudes and receiving insufficient information. It is important to remember that older people are not a homogeneous group but have a wide range of life experiences that influence their perception of illness and their ability to communicate with healthcare professionals. Ineffective communication can cause older people to feel inadequate, disempowered, and helpless. It is important for providers to treat older people as individuals and to monitor and adapt communication accordingly.

It is helpful for healthcare providers to recognize whether they are communicating by talking with the older adult or talking to them. Older people need and are entitled to be recognized when matters involve them. Even if a person has dementia or memory loss, attention and comments should be directed to the patient.

Following are examples of practices to enhance communication with the older patient:

Addressing the patient face-to-face and by their last name, using the title the patient prefers (e.g., Mr., Ms., Mrs.) until told otherwise
Avoiding familiar terms such as Dear and Hon/Honey
Introducing oneself and showing an interest in wanting to hear the person’s concerns
Providing professional translation services and written material in different languages when needed
Assessing and matching the person’s communication style by listening to the volume, pace, pitch, and tonality (expressive or reserved) of their speech
Being alert to and compensating for deficits in hearing or vision
Not rushing and speaking more slowly so that the person will have time to process what is being asked for or said, since feeling rushed often leads to people believing they are not being heard or understood
Avoiding interrupting, since once interrupted, an older adult is less likely to reveal all of their concerns
Using active listening skills by facing the patient, maintaining appropriate eye contact, and using brief responses to indicate one has been listening
Demonstrating empathy by watching for opportunities to respond to the person’s emotions
Avoiding medical jargon and using simple, common language
Introducing information by first asking patients what they already know about their condition
Asking if clarification is needed, such as having something written down
Asking patients to state what they understand about their presenting problem and what they think needs to be done
Using family history to gain insight into an older patient’s social situation as well as risk of disease
Asking about living arrangements, transportation, and lifestyle to help determine appropriate interventions
Considering cultural differences and avoiding healthcare provider bias
Giving clear and specific written notes or printed handouts about their medical conditions
(Jack et al., 2019; NIA, 2023)

CASE

Sophia is a home health nurse who has just arrived at the home of a new patient. The patient is a 78-year-old man named Bruce Blankenship who is recovering from a hip replacement. Mr. Blankenship experienced a fall while in the hospital after surgery; he was discharged from the hospital the day before. He lives with his 76-year-old wife.

Sophia rings the door bell, and the wife answers. “Oh, I’m so glad you’re here!” she tells Sophia.

“Thank you, Mrs. Blankenship. It’s nice to meet you. How can I help?” Sophia replies.

“Well, I’ve been having such a hard time getting Bruce to wait for me to help him get up! He’s such a stubborn man, and he insists he doesn’t need my help going to the restroom,” Mrs. Blankenship says.

Sophia follows Mrs. Blankenship to where her husband is sitting in the living room. She sees that the walker is on the other side of the room.

“Hello, Mr. Blankenship,” Sophia says, and introduces herself. “I’m here to check on how you’re doing.”

“Huh?!” Mr. Blankenship replies. “I’m hard of hearing! You need to speak up!”

“Of course,” Sophia says, raising her voice and slowly repeating her greeting. She proceeds to ask him about how he is feeling and whether he has been using his walker to get up the way the physical therapist instructed him.

“I don’t need that dumb walker!” Mr. Blankenship replies. He starts talking about himself and his past career as a mechanical engineer. He expresses his frustration about having to use the walker and needing to rely on his wife to use the restroom. Sophia listens without interrupting and maintains appropriate eye contact. After a few minutes, Mr. Blankenship is done speaking.

“That sounds very frustrating,” Sophia says in a clear, raised voice. “Would you like to tell me more about it while I change your surgical dressing?” By the end of the visit, Sophia has listened to Mr. Blankenship’s concerns and patiently gone over the care plan in simple terms. She discusses the role of physical therapy to improve his mobility and the importance of using the walker every time he is up and moving around. Sophia places the walker next to his armchair after he agrees to use it and to ask for his wife’s help.

As she is getting ready to leave, Mr. Blankenship says, “Thanks for listening to me, kid. I feel like nobody likes to listen to us old people anymore.”

“It’s my pleasure, Mr. Blankenship.” Sophia replies. “I’ll see you in a few days at our next visit.”