The Importance of Cultural Safety in Aged Care

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Published: 21 July 2022

To read about cultural safety in home care settings, see: The Importance of Cultural Safety in Home Care.

The Royal Commission into Aged Care (2021) found that Australian aged care services are not appropriately meeting the needs of culturally and linguistically diverse residents, stating that the existing system cannot adequately provide care that is ‘non-discriminatory and appropriate for people’s identity and experience’.

Furthermore, the Royal Commission identified a systemic lack of appropriate staff training in culturally safe practice, reporting that staff have little knowledge about the additional needs of people from diverse backgrounds (RCACQS 2021).

In Australian aged care facilities, residents will have come from vastly different backgrounds and have varied life experiences. Having knowledge of and respecting an individual’s cultural background is crucial to being able to provide person-centred care.

The necessity of cultural awareness in aged care is reinforced by The National Aged Care Quality Alliance’s definition of quality care:

- ‘Services that are consumer-driven, have a wellness and reablement approach, are affordable, sustainably provided, and are inclusive of the diversity of older people according to their needs.’

(RCACQS 2019)

Elderly woman rubbing her neck | Image
Having knowledge of and respecting an individual’s cultural background is crucial to being able to provide person-centred care.

What is Culturally Safe Care?

The term culture refers to values, customs, languages, social structures, beliefs, patterns of human activity, and experiences shared with others - the symbolic structures that provide meaning and significance to human behaviour (Engebretson 2016; Rawson 2019).

Culture is fundamental to how we live our lives and informs the way in which we interact with the world (Rawson 2019).

Cultural safety involves being mindful of the similarities and differences between cultures, and using this knowledge to inform your communication with members of different cultural groups (HETI 2018).

In healthcare, this means you must act in a way that recognises, respects and nurtures your resident’s identity while ensuring you meet their needs, expectations and rights. Instead of working from your own perspective, it’s important to consider the cultural perspective of the person you are caring for (HETI 2018).

As a health professional, you can make a difference in the lives of your residents by doing your own research (see SBS's Cultural Atlas) and by incorporating cultural awareness into your care.

In the Broome hearing of the Royal Commission interim report - in which culturally safe care to Aboriginal and Torres Strait Islander peoples was a primary focus - Graham Aitken, a Yankunytjatjara descendant and the Chief Executive Officer of Aboriginal Community Services, explained what culturally safe care should look like:

- ‘The judge of what is culturally-safe is up to the individual. We will speak to the Elder about what they need for us to be culturally safe or appropriate. It’s a respect that we treat everyone as an individual and with dignity and to us that’s what cultural safety is about.’

(Transcript, Graham Aiken 2019)

Diversity in Australia

Statistics from the most recent national Census in 2021 reveal how culturally diverse Australia is, with just over one quarter (27.6%) of Australians being born overseas (ABS 2022).

In fact, over half (51.5%) of Australians were either born overseas themselves (first generation Australian) or had one or both parents born overseas (second generation Australian) (Khorana 2022).

As of 2016, there were over 300 separately identified languages spoken in Australia More than one-fifth (21%) of Australians spoke a language other than English at home (ABS 2017).

As a health professional, you should be able to appropriately and sensitively care for residents of all backgrounds, including:

  • People from culturally and linguistically diverse (CALD) backgrounds
  • Aboriginal and Torres Strait Islander peoples
  • Members of the LGBTQI community
  • People living in rural or remote areas
  • People living with mental illness
  • People living with cognitive impairment (e.g. dementia)
  • People living with disability
  • People who have been separated by their parents by forced adoption or removal
  • Care leavers
  • People who are homeless or at risk of becoming homeless
  • Veterans
  • People living in socio or economic disadvantage.

(DoH 2017)

Unfortunately, the perception of Australia’s healthcare system among people of culturally and linguistically diverse (CALD) backgrounds is far from positive.

People from diverse cultural backgrounds (including Aboriginal and Torres Strait Islander Peoples) are also known to have difficulty accessing and using healthcare services in Australia, leading to poorer health outcomes (Khatri & Assefa 2022; White et al. 2019; AIHW 2022).

Reports from the Federation of Ethnic Communities’ Councils of Australia found that many people from CALD backgrounds did not wish to enter residential aged care at all (Rawson 2019).

The potential for error in the absence of culturally-aware healthcare is vast. Misunderstandings, miscommunication and culturally-unsafe care by healthcare professionals are often reported (Johnstone and Kanitisaki 2006). People of a non-Anglo-Saxon background have cited feelings of powerlessness, vulnerability, loneliness and fear (Garrett et al. 2008).

Failure to address cultural diversity can lead to a variety of adverse outcomes such as medication errors and interactions, misdiagnosis, inappropriate treatment and poor patient adherence to treatments (Brach et al. 2019).

Despite this, the government has signalled its commitment to helping people from CALD backgrounds access care that meets their needs through the Aged Care Diversity Framework.

The Framework is a set of principles that intends to ensure an accessible aged care system in which everyone, regardless of their social, cultural, linguistic, religious, spiritual, psychological, medical and care needs, can access respectful and inclusive aged care services (DoH 2017).

Elderly male looking at photos | Image
In 2021, just over one quarter of Australians were born outside of Australia.

Languages Barriers in Aged Care

Language barriers have been found to have significant adverse effects on care, including:

  • Increased difficulty accessing healthcare
  • Poorer health outcomes
  • Reduced satisfaction for both the client and staff
  • Decreased quality of care
  • Increased costs and time required for services due to the need for interpreters.

(Shamsi et al. 2020)

It is the responsibility of aged care facilities to do what they can to support people from culturally diverse backgrounds. Government funding is available to support facilities to care for people of specific cultures. These services reflect post-war migration and are offered to Greek, Italian, Dutch, Jewish and Chinese older adults (Rawson 2019).

Language barriers can significantly reduce the experience of care in aged care facilities. Older people with English as their second language report losing their ability to communicate in English as they age and experience cognitive decline, and so will often revert to their first language (Rawson 2019).

Providing Culturally Safe Care

Culturally safe and sensitive practice is defined by the Medical Board of Australia (2020) as:

  • Understanding how your own culture, values, attitudes, assumptions and beliefs influence your practice
  • Acknowledging the social, economic, cultural, historic and behavioural factors influencing the health of different communities
  • Respecting diverse cultures, beliefs, gender identities, sexualities and experiences
  • Genuinely making an effort to adapt your practice, when required, in order to provide culturally safe care
  • Challenging assumptions based on gender, disability, race, ethnicity, religion, sexuality, age and political beliefs.

The following are some practical tips for providing culturally safe care in aged care:

  • Consult with residents and their families/carers about aspects of their cultural traditions or religion that are important to them
  • Access resources that can help you gain insight into different languages, ethnicities or religious traditions and migration/refugee experiences of older migrants in Australia
  • Use culture-specific information as a guide to facilitate questions - as not all people from the same cultural or religious background identify in the same way
  • Always avoid stereotyping and making assumptions about someone else’s culture, heritage, language or needs
  • Be aware of judging other people's behaviour and beliefs according to your own life experiences
  • When required, involve an interpreter in the resident’s care. If this isn’t possible, work with their family to create a list of important words or phrases for staff. They may include: ‘Are you comfortable?’ Or ‘Are you in pain?’
  • Ensure the resident is not isolated in their care. Ways to prevent this may include engaging with their cultural community or asking volunteers to visit the older resident.

(Centre for Cultural Diversity in Ageing n.d.; Rawson 2019)

Culture-specific information allows us insight into the lives of people who share ethnicity, language, religion or other characteristics that individuals identify with, or groups that they belong to (Centre for Cultural Diversity in Ageing n.d.).

While culture-specific information will inform your work with individual residents, keep in mind that within any cultural group, peoples' values, behaviour and beliefs can vary greatly (Centre for Cultural Diversity in Ageing n.d.).

Acronyms to Remember

ABCD for Cultural Assessment

Learn and remember the ABCD Cultural Assessment Model developed by Kagawa-Singer & Backhall (2001). Make it part of your routine to take time to discuss the following with the residents in your care, as well as their families:

A - Attitudes
  • Traditional healing practices as well as Western healthcare
  • What illness and care mean to them and their family
  • How they prefer to communicate about death and dying, and diagnosis and prognosis
B - Beliefs
  • The resident and their family’s religious and spiritual beliefs - particularly in relation to death, dying, the afterlife, and healing
  • How they and their family cope with suffering
  • How you can accommodate their spiritual and religious needs
C - Context
  • Determine the historical and political context of the resident and their family’s lives. This may include:
    • Place of birth
    • Refugee or immigrant status
    • Poverty
    • Experience with discrimination
    • Health disparities
    • Language spoken
    • Degree of integration within their ethnic community and the degree of assimilation into Western culture.


Also identify community resources that may be of assistance to healthcare professionals, residents and family members, such as translators, healthcare workers, community groups, religious leaders, and traditional healers.
D - Decision-making style Identify the general decision-making style of the cultural group, and specifically, the resident and their family. Explore whether individual or family decision-making processes are used. Ask questions such as:

  • How are decisions about healthcare made in your family?
  • Who is the head of the family?
  • Is there anyone else I should talk to in your family about your condition?
E - Environment Determine whether there are community resources available to the resident and their family.

(Kagawa-Singer & Backhall 2001)

Mugs that say 'hello' in multiple languages | Image
Older adults with English as their second language report losing their ability to communicate in English as they age and experience cognitive decline.

The ACCESS Model for Transcultural Care

A - Assessment Emphasis on the cultural aspects of a resident’s lifestyle, health beliefs and health practices.
C - Communication Awareness in variations between verbal and non-verbal responses.
C - Cultural negotiation and compromise Awareness of aspects of other people’s culture as well as understanding the resident’s views and how they articulate their problems.
E - Establishing respect and rapport Forster a therapeutic relationship that portrays genuine respect for the resident’s cultural beliefs and values.
S - Sensitivity Provide culturally-sensitive care to a culturally diverse group.
S - Safety Create a space for residents to derive a sense of cultural safety, placing emphasis on the cultural aspects of a resident’s lifestyle, health beliefs and health practices.

(Narayanasamy 2002)

A Case Study From the Royal Commission into Aged Care

In the Royal Commission's interim report, the importance of connection and communication was reinforced by witness George Akl, who recounted his late father’s experience of residential aged care while also living with Lewy body dementia.

Mr Akl’s father was born in Egypt, his first language was Arabic and he also spoke English fluently. However, following his diagnosis of dementia, his ability to speak English decreased. As this occurred, Mr Akl became the intermediary between his father and the facility’s staff (RCACQS 2019).

Mr Akl explained that when speaking Arabic, his father was significantly happier, prouder and more alive. As his father’s disease progressed, he became more attached to his culture, particularly through language, food and sounds. Studies into dementia show that sounds, food and culture enliven the minds of those living with dementia (RCACQS 2019).

As his son put it, Mr Akl "had the ability to communicate, there just wasn’t space for him to communicate properly: (Transcript, George Akl 2019).

Conclusion

Although we, as healthcare professionals, constantly strive to provide sensitive, compassionate care, there is no doubt we may find ourselves in situations that challenge us. Although we don’t need to have a comprehensive understanding of every cultural and ethnic norm of all those who live in our society, we do need to make an effort to communicate with our residents and understand their needs in order to provide culturally safe care.

Remember respecting the dignity and human rights of each resident is fundamental to providing quality care.

References


Test Your Knowledge

Question 1 of 3

Which of the following is NOT part of the ABCD Model of Cultural Assessment?

Authors

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Ausmed View profile
Ausmed’s editorial team is committed to providing high-quality, well-researched and reputable education to our users, free of any commercial bias or conflict of interest. All education produced by Ausmed is developed in consultation with healthcare professionals and undergoes a rigorous review process to ensure the relevancy of all healthcare information and updates to changes in practice. If you have identified an issue with the education offered by Ausmed or wish to submit feedback to Ausmed's editorial team, please email ausmed@ausmed.com.au with your concerns.
Sarah Vogel View profile
Sarah Vogel specialises in producing well researched articles in the field of health and medicine. She has a BHlthSci (MRT), having studied and worked as a Radiation Therapist, as well as being trained as a telephone counsellor. She has written for a variety of online websites and blogs, but particularly enjoys focusing on health education and psychosocial issues.
Tracy Levett-Jones View profile
Professor Tracy Levett-Jones is the Director of the Research Centre for Health Professional Education at the University of Newcastle. Her research interests include: belongingness, clinical reasoning, empathy, interprofessional education, cultural competence, simulation and patient safety. Tracy has authored ten books, the most recent being 'Clinical Reasoning: Learning to think like a nurse' and Critical Conversations for Patient Safety'; as well as over 200 book chapters, reports and peer reviewed journal articles. Tracy has been the recipient of multiple teaching and learning awards and has been awarded over two million dollars in grant funding.