Challenges Faced By Nurses While Working With Linguistically And Culturally Diverse Geriatric Patients

The healthcare sector in Australia and patients belonging to linguistically and culturally diverse backgrounds

Question:

What are the acute challenges faced by the nurses in working with people over sixty-five years from linguistically and culturally diverse backgrounds?
 

The Society of Australia is pluralistic with various traditions and values. Thus, the healthcare sector has classified the patients from the non-English backgrounds as the patients belonging from the linguistically and culturally diverse backgrounds and specifically includes the migrant and indigenous backgrounds. The healthcare sector of Australia can be strongly identified as Anglo-centric and the Anglo-Australian background dominates the practice of nursing (Johnstone et al. 2016). Therefore, there exist the chances of dual ethnocentrism between the patients and the nurses that make the care provision for the patient-nurse encounters difficult. It is quite frustrating and challenging for the experiences of the nurses and it is quite difficult for the nurses to deal with the culturally and linguistically diverse aged patients (Eliopoulos 2013). The specific and acute challenges experienced by the nurses are language barriers, quality care delivery, bureaucratic system of healthcare, client-nurse relationships, dealing with the patient family and personal stress. Acquiring the cultural knowledge is regarded as intrinsic for caring for the patients who are culturally diverse (Adebayo, Durey & Slackâ€ÂSmith 2016). This can be done by identification of the sources of cultural knowledge in the workplace and includes the sources like bilingual colleagues and health workers, the patients and their families with the support persons, who can significantly help in acquiring the bilingual knowledge (Deegan and Simkin 2010). The present review protocol deals with the acute challenges faced by the nurses in working with the people aged over 65 years from linguistically and culturally diverse background and will include a systematic review of relevant literature.

‘What are the acute challenges faced by the nurses in working with people over sixty-five years from linguistically and culturally diverse backgrounds?’

A research question typically helps to center and guide a research program. Therefore, it has to be focused and clear and should include the synthesizing of the various resources for presentation of the argument. Formulation of a research question should include the conduction of preliminary research for obtaining an overview of the topic, based on the peer-reviewed journals and periodicals. For the formulation of the question, PICO framework has been used in this review protocol. The PICO framework is implemented in the evidence-based practice for framing questions that are related to healthcare (Fruijtier et al. 2014). It is also utilized for developing the strategies of the literature search. The acronym of PICO has been summarized below.

P – Population or patient

I – Intervention

C – Comparison

O – Outcomes

Well-focused questions are essential for searching the relevant evidence and identification of the appropriate resources. Therefore, PICO framework helps to identify the main elements related to the question and makes the question statement relevant (Hruby et al. 2016). In the present review protocol, the comparison part is ignored due to the lack of its scope. Thus, the framework used in this protocol is PIO framework, considering only the patient/ population, intervention and outcome.

Acute challenges faced by nurses in providing care to geriatric patients

The PIO acronyms used for this protocol have been summarized below.

P – Patients over 65 years of age / Communication challenges of nurses

I – Cultural competencies

O – Effective patient care

Developing the research question had the primary concept of development of a research hypothesis. Predictions were made regarding examination of the research phenomenon that forms the foundation of the research. Hypothesis helps to make specific predictions about the direction and nature of the relationship that exists between two different variables. For drafting the research question in the present protocol, insight was given to the research hypothesis that stated the acute challenges that the nurses face on a daily basis while working with the geriatric patients. The measurable and testable parameters of the proposed parameters were analyzed that included the patients with culturally and linguistically diverse backgrounds. Finally, the staff experience was taken into consideration that drafted the final question, conjugating the other two hypotheses and resulted in the research question stating ‘What are the acute challenges faced by the nurses in working with people over sixty-five years from linguistically and culturally diverse backgrounds?’. 

Interest in a particular topic initiates the process of research. However, the subject familiarity defines the appropriate research question. The deficit of the perceived knowledge raises the question within the field of study and the investigational research defines the importance of the research question. It is important to know the boundary between the ignorance and the perceived knowledge that helps to determine the clinical uncertainties rationalizing the importance of the research question. In the present research protocol, the importance of the research question lies in the fact that it helps to determine the acute challenges faced by the nurses while caring for the geriatric patients with diverse backgrounds.

According to the health service framework for the older people in Australia, it has been found that one out of five of the geriatric population in Australia have been born overseas, primarily in the countries with non-English speaking culture. This statistics is expected to grow further in the future and present challenges for the healthcare service providers in terms of bilingual support requirements and devices that are culturally safe (Johnstone et al. 2016). Due to the greater diversity in the aged population dwelling in Australia, various challenges emerge for the nurses that are influenced by the individual health goals and appropriate responses. The specific challenging factors include the spiritual, environmental, cultural, social, emotional and economic that interweaves across the different health profiles in various ways for influencing the behavior of the patients, including their families and determines the role of the nurses in providing care and support treatment. The societal wellbeing of the Aboriginals and the Torres Strait Islanders have to be taken into consideration as well for ensuring culturally safe and respectful care to the aged patients of this population (SA Health, 2016).

The challenges that the nurses face for caring for the geriatric patients of diverse backgrounds involve the patients along with their families. The primary challenges include assessment, communication, working limitations with the interpreters and holistic care provision. Education and confidentiality are the issues that were related to the patients. Visiting and aggression were the issues with the families. Types of health workers who are bilingual, commitment of the health officials and organizational flexibility are the issues with the healthcare system (Deegan and Simkin 2010). The commitment willingness and the provision of culturally congruent care are the keys to the care of the culturally diverse patients. Nurses possess a stereotypical view of the cultural group of the patient and consider that a culturally diverse patient is just like any other patient (Johnstone et al. 2016). On the other side, some perceive them as separate individuals and not as the members of culturally diverse societies with certain beliefs, lifestyles and values.

Cultural knowledge acquisition for providing care

Trans-cultural nursing aids to improve the cultural competence of the nurses for the care of the patients with diverse backgrounds. Experience can help the nurses in this aspect by building knowledge within the care episodes by facing variable challenges (Bourgeault et al. 2010). Education has to be adequate with proper training towards the development of understanding and knowledge for caring the culturally diverse patients. 

The strategy of search initiates with the searching of a database where data is collected in an organized pattern. The available data is organized reality aspects of a model supporting the processes that require information gathering. In the present protocol, data was collected from the database of PubMed, which is a free search engine and access the MEDLINE database of abstracts and references. The United States National Library of Medicine maintains the database in association with the National Institutes of Health for retrieval of information.

Identification of the keywords is the next step of search strategy and it is used for searching the keywords. The present protocol utilized PIO strategy for the database search string and its implementation. Suitable keywords were used in various combinations as per the framework to search the database and extract the research articles required for answering the research articles. Relevant keywords were identified using the PIO framework and it helped extensively for combining the relevant search terms of the research articles.

Boolean operators are the connecting words that are placed in between the terms of search to expand or narrow the search. The Boolean operators used for the search are OR, NOT and AND. OR helps to find the citations that contain either of the keywords that are specific. AND helps to find the citations that contain all of the keywords that are specific. NOT helps to find the citations that contain the keywords that are specific. Search string is a stepwise guide to using the Boolean operators and keywords for searching the selected database. Search strings like * and ? have been used on a trial and error basis for searching the relevant articles.

Truncation was used for broadening the search process as it identifies the word variations. The symbols used for search were *, ? and $ as nurs* for retrieving nurse and nurses. Abbreviations used in the search process was CLD for culturally and linguistically diverse. Wildcards were used for trying different spellings for a word like patient skin colour and color were searched with the ? symbol. These were all implemented on a trial and error basis but could not retrieve relevant search results.

Table 1: Searched Keywords

P Population  / Problem	I Intervention	O Outcome
Geriatric patients Linguistically diverse Culturally diverse Acute challenges Communication challenges	Cultural competency Linguistic competency Professional ethics Nursing knowledge Moral values	Patient care Effective care Patient compliance Patient satisfaction Respect and dignity

A detailed account of the search strategy and the results has been provided in the appendix.

The relevant research articles retrieved using the search keywords have been provided below.

1. Duffy, S., Jackson, F., Schim, S., Ronis, D. & Fowler, K. 2006, “Cultural concepts at the end of life”, Nursing older people, vol. 18, no. 8, pp. 10.
2. Dobbs, D., Baker, T., Carrion, I.V., Vongxaiburana, E. & Hyer, K. 2014, “Certified nursing assistants’ perspectives of nursing home residents’ pain experience: communication patterns, cultural context, and the role of empathy”,Pain management nursing : official journal of the American Society of Pain Management Nurses,vol. 15, no. 1, pp. 87.
3. Mager, D.R. & Grossman, S., 2013. Promoting Nursing Students’ Understanding and Reflection on Cultural Awareness with Older Adults in Home Care.Home Healthcare Now, 31(10), pp.582-588.
4. Thyli, B., Athlin, E. & Hedelin, B. 2007, “Challenges in community health nursing of old migrant patients in Norway – an exploratory study”, International journal of older people nursing, vol. 2, no. 1, pp. 45-51.
5. Yeo, T.P., Phillips, J., Delengowski, A., Griffiths, M. & Purnell, L. 2011, “Oncology Nursing: Educating Advanced Practice Nurses to Provide Culturally Competent Care”, Journal of Professional Nursing, vol. 27, no. 4, pp. 245-254. 

Article No.	Reference	Study Design	Population P	Intervention I	Outcomes O	Tutor Comment
1.	Duffy et al. (2006)	The study design constitutes of Survey questionnaire that was structured with open ended questions.	Survey conducting nurses with five ethnic groups of patients (Arab Christians, Arab Muslims, Hispanics, White and Black ) in the US in 10 focus groups of geriatric patients	Examination of the ethnic and racial preferences among the older patients and the influence of the nursing intervention.	Nurses face acute challenges and dilemma while caring for the geriatric patients from various backgrounds as they had problem in understanding the preferences of patients regarding end life situation. Arabs had problem using the word “death and cancer”. Women believed that cultural differences were related to the end of life care. Hispanic women were against “pulling of plug” and preferred extensive medical intervention. However, Hispanic and Arab men preferred assisted dying.  Women among Arab Christians were against nursing homes and men were mostly into spiritual life. Black women did not support assisted suicide but black men did. White men wanted antibiotics, feeding tubes, CPR, dialysis but were against life support system.
2.	Dobbs et al. (2014)	In this study the research design used was Qualitative study. Group session was conducted. Approach used was “content analysis” where data was analyzed by the use of “use of Atlas.ti version 6.2.”	Respondents constitute of 28 nurses in 4 focus groups with 6 – 8 participants in each group. Inclusion criteria were English speaking and employed for greater than 3 months.	Communication patterns between the nurses and the older residents of varied ethnicity and race with the personal experience of the nurses. How does race and ethnicity impact pain experience of NH residents was investigated. Other things were if residents can accurately report their pain experience.	Cultural and linguistic factors directly affect the beliefs of the nurses for pain treatment for the older residents. Cultural influence was observed both in staff and nurse. Patient centered approach is appropriate if it is culturally competent. The continuum of diversity awareness is cultural competence. The Spiritual and religious belief effect the preference of pain management. Emotional, sensory, and cognitive impairment, lack of standardized assessment tools, side effects of drugs, and lack of knowledge about pain and ways to reduce it are indicators for which NH residents are at greater risk of unmanaged pain. Cognitive and emotional empathy help in pain management. CNAs have perception that the residents highly rely on pain medication due to lack of knowledge of treatment methods or plans and medication options. Close relation with the resident was the only effective way to recognize and  assess  residents pain.
3.	Mager & Grossman (2013)	The research designed used Qualitative analysis. In this study focused case studies, self-reflective writing activities simulations, were included. Cases and simulations were designed in a way that depicts patients living at home with a variety of demographic characteristics, such as health history, age, family involvement, religion, dietary preferences, culture, marital status, and socioeconomic status.	Respondents constitute of 114 nursing students with 59 junior and 55 senior nursing students.	Question-based research was carried out to collect the experience of the nursing students regarding cultural competence. In this study, the strategies that encourage reflection capacity of the students on cultural awareness were examined.	Summing up the student experiences for the challenges of cultural competency and improving their knowledge for their future profession. In both the groups of students who participated in this study the Levels of reflective writing improved using the “N. Hatton and D. Smith’s (1995) framework”.
4.	Thyli, Athlin & Hedelin (2007)	The research design used in this study was Exploratory study. Survey questionnaire. The questions were based on experiences related to nursing older people as well as on the literature review based on trans-cultural nursing From the questionnaire Data were collected. Questions were structured containing open-ended questions.18 nurse managers were involved to answer. The data analysis was descriptive.	Respondents constitutes of 22 nurse managers involved in nursing practice. Only 18 nurses responded the questionnaire. All were females trained in Norway. Study was conducted in medium-sized Norwegian community.	Intervention includes Exploration of the perception of the nursing managers involved in the care of culturally diverse geriatric patients in northern western countries. Identify the challenges faced by these nurses while caring for this group of patients.	Overall findings say that community care for non western migrant patients were deficient. According to the findings, leadership and organizational issues were factors affecting the multicultural care. Older   migrants lacked a knowledge of health care  Additionally, nurses has withdrawn attitude towards older patients showing a lack of responsibility in their care. The major issue identified in this study is less awareness and knowledge related to cultural issues. Nurses lacked cultural care assessments. Language barriers have been identified as the most important and difficult problem in the patient – nurse relationship. It greatly affected the communication and nursing assessment. Other problems include lack of family involvement in care which greatly impacts the recovery process. There is a need for development due to lack of cultural competencies. Challenges can be managed with increased responsibility, action and competencies. Nurses require attending trans-cultural courses.
5.	Yeo et al. (2011)	Systematic literature review	The population in this study includes Advanced practice nurses providing cancer care to the geriatric patients of diverse cultural and linguistic background.	Decision making for cancer care is influenced by the cultural belief systems	Requirement of nursing education program for addressing the needs of the geriatric cancer patients from diverse ethnicity. Significant disparities related to cancer were observed in diverse population. The reasons were from inadequate funding, less knowledge of disease symptoms among patients due to poor educational attainment. Nurses from different backgrounds (racial, cultural and ethnic) should be employed to provide care for cancer patients, due to rapidly changing U.S. population demographics. Nurses prepared in oncology educational programs are needed to address the requirements of critical patients of care.  The outcome is the need of promoting and sustaining advanced practice nurses.

The present research protocol has broadened my understanding of evidenced based practice for nursing. Writing a research question and identification of the related articles has helped me immensely in understanding of the challenges of the nursing profession. This protocol has helped me to learn the ways to deal with the challenges faced by the nurses in acute care and long-term settings for the care of the culturally diverse geriatric patients. In addition to this, I have learned the procedures of database search using the key features of truncation, abbreviation, wildcard and Boolean. I developed a clear knowledge of the inclusion and exclusion process of the key search words and determining the relevancy of the searched literature. My understanding has deepened and my skills have enhanced regarding the search string for the literature that describes the nursing care profile for the transcultural patients and their families.

Formulation of a research question using PICO framework

Experiences of the nurses with the culturally and linguistically diverse patients sought for the knowledge required to provide care oriented around an individual and stereotypical perspective. The nurses faced a number of challenges and dilemma with patients as well as their families while working with these patients (Warburton, Bartlett & Rao 2009). For accommodating the patients who are culturally diverse, it was considered that sufficient knowledge and training is required regarding the culture and belief of the patients. To prepare the future nursing professionals to face this challenges effectively, they should be exposed to the present situation and train them to make them capable enough to face these acute challenges (Bourgeault et al. 2010). In addition to these, the healthcare system should increase its flexibility, the number of bilingual health workers must be increased and interpreters should be easily accessible. Cultural and linguistic issues come up as barriers to treatment and care of the geriatric patients and therefore, patient – nurse relationship is never built up. Due to the lack of proper communication, there exists a gap in treatment that becomes critical if the geriatric patient is suffering from a long-term disease like cancer (Kalengayi et al. 2012).

Nurses possess empathy for the culturally diverse geriatric patients and have a positive attitude towards facing the acute challenges related to patient care. In order to increase the cultural congruence of the patients, the nurses exhibit the willingness to increase their knowledge for learning the cultural diversity (Xiao et al. 2013). They strive continuously to achieve the ability to work within the cultural context of the patient. They work on the efforts to become more culturally knowledgeable and aware that facilitates the interaction with the patient population along with their families. Since this experimental learning took place in various workplaces, there were potentials of spreading of the inaccurate cultural information (Kalengayi et al. 2012). This raised the fact that there is a requirement of staff improvement programs that provided opportunities to the nurses and the nursing managers to discuss the patient care concerns that are culturally diverse.

As the global mobility of the patient population increases in the facilities of acute care in Australia, the population has become more ethnically diverse than ever. Nursing staff is required to work with the patients belonging from the diverse cultural and lingual backgrounds, with respect to their own (Komaric, Bedford and van Driel 2012). Therefore, it is becoming increasingly challenging to the nurses to provide acute care to the people who are aged over 65 years and are from linguistically and culturally diverse backgrounds. The identification of the experiences of the nurses for the caring of the aged patients who are culturally diverse in the acute care settings has a significant contribution towards the trans-cultural knowledge of nursing (Hines 2012). The challenges faced by the nurses can be described by the experiences they had while caring for the culturally diverse patients. The experience can be gained by providing care that is oriented around an individual or stereotypical perspective (Small et al. 2015). The challenges faced in this situation are multiple and includes the professional and personal issues with the patients, visitors, families and colleagues.  

References

Adebayo, B., Durey, A. & Slackâ€ÂSmith, L.M., 2016. Culturally and linguistically diverse (CALD) carers’ perceptions of oral care in residential aged care settings in Perth, Western Australia. Gerodontology.

Bourgeault, I.L., Atanackovic, J., Rashid, A. and Parpia, R., 2010. Relations between immigrant care workers and older persons in home and long-term care. Canadian Journal on Aging/La revue canadienne du vieillissement,29(01), pp.109-118.

Deegan, J. and Simkin, K., 2010. Expert to novice: experiences of professional adaptation reported by non-English speaking nurses in Australia. Australian Journal of Advanced Nursing, The, 27(3), p.31.

Eliopoulos, C., 2013. Gerontological nursing. Lippincott Williams & Wilkins.

Fruijtier, S., van Asselen, S., Hettinga, S. & Krieckaert, M., 2014. PICO: a framework for sustainable energy design. In Geodesign by Integrating Design and Geospatial Sciences (pp. 55-70). Springer International Publishing.

Hines, D., 2012. Cultural competence: assessment and education resources for home care and hospice clinicians. Home Healthcare Now, 30(1), pp.38-45.

Hruby, G.W., Hoxha, J., Ravichandran, P.C., Mendonça, E.A., Hanauer, D.A. and Weng, C., 2016. A data-driven concept schema for defining clinical research data needs. International journal of medical informatics, 91, pp.1-9.

Johnstone, M.J., Hutchinson, A.M., Rawson, H. % Redley, B., 2016. Assuaging death anxiety in older overseas-born Australians of culturally and linguistically diverse backgrounds hospitalised for end-of-life care.Contemporary nurse, (just-accepted), pp.1-32.

Kalengayi, F.K.N., Hurtig, A.K., Ahlm, C. and Ahlberg, B.M., 2012. “It is a challenge to do it the right way”: an interpretive description of caregivers’ experiences in caring for migrant patients in Northern Sweden. BMC health services research, 12(1), p.433.

Komaric, N., Bedford, S. & van Driel, M.L., 2012. Two sides of the coin: patient and provider perceptions of health care delivery to patients from culturally and linguistically diverse backgrounds. BMC health services research, 12(1), p.1.