clinical focus
Does it work the other way around? Do doctors and nurses
from other cultures have different ideas of pain and pain
management?
KT: Yes and no. It can depend on how culturally competent
the health professional is, but medicine traditionally is very
Westernised, in terms of the scientific beliefs and value systems.
If the doctors or nurses are not particularly mindful of their
own cultural health beliefs, or values and practices, they can
take much more of an ethnocentric perspective. Then they can
unwittingly impose their own beliefs and their own practices,
thinking they’re doing the right thing without giving credence
to, or accommodating, views that may not align with their own
medicalised views.
I saw you both speak recently at a dementia conference and
you told a story about Francesca. Could you tell us about
that?
Yes. Francesca was a name I made up. She’s a lady I was involved
with in my role as a residential support program clinician. She
was a 76-year-old Italian resident who had not been in residential
aged care long, and was referred to us to help manage some of
her behavioural and psychological symptoms of dementia. The
behaviour took the form of loud and disruptive calling-out during
the day and the night.
This lady had quite advanced dementia and multiple
medical problems, including type 2 diabetes, heart disease,
hyperthyroidism, osteoporosis, depression and anxiety. So quite
a complex medical history. Her English language proficiency was
low. She did speak a few words of English but she was actually the
only Italian speaker in the residential aged care facility.
She was being looked after by staff from different cultural
backgrounds, predominantly Greek, Indian and Asian, with
some Australian-born senior staff as well. There were different
interpretations about what was causing the behaviour, and there
were differing professional views about whether or not pain was
an issue for her or whether it was already adequately treated.
Some of my assessments involved documenting the behaviour,
when it occurred, and having staff score a pain assessment tool.
Then we looked for any correlation between the two. I was certain
that some of the contributing factors were her anxiety, depression
and sense of isolation.
I wondered if cultural factors were in play here as well. I did
a bit of homework and looked up a culture app that gives you
an insight into cultural backgrounds, and I looked at the Italian
cultural background. It started off saying there are regional
differences in the expression of pain. I’d just found out that
Francesca was Sicilian, and then it described Sicilians as the most
forthcoming and generally very expressive. They expected to
have company when they were in pain, and an expectation of
attention seems to give them some pain relief. Family support
was very important. They do place a lot of trust in doctors and
specialists. It did warn me about stereotyping and the importance
of person-centred care.
We set about putting some things in place to see whether it
would help alleviate some of her concerns and meet the needs
of those cultural expectations. If they were applicable to her, we
would know by getting some response, because sadly she wasn’t
able to communicate with us.
We scheduled reassurance visits. We made sure the door to her
room was left open so she could see people walking around and
not feel so isolated. We provided some cue cards; we used the Talk
to Me app to try to communicate some instructions to her, but
also for her to hear her own language. Then with these tools, staff
started to use a few Italian words. It really helped with her sense of
connection with staff.
Her family started visiting on a rotating basis, so there was
someone coming every day. I referred her to the Co.As.It
community visitors – the Italian support service in Melbourne.
Then we tried some Italian music, talking books and
reminiscence books. We tried to make her environment a little bit
more familiar to her, so we made sure she could see pictures of
her family, and that she had her religious items beside her: rosary
beads, pictures of Our Lady and so on. The staff would put SBS on
television for her to watch the Italian mass each Sunday.
Eventually there were improvements in the frequency and
volume of the calling-out. Because of the dementia, you can’t
change the behaviour, but you can modify it. Eventually she
started to feel more at home, more cared for, and the volume of
the calling-out really reduced. With the implementation of some
pain relief, her condition settled and the calling-out behaviour was
improved.
Monita, if you were going to give your top tips for aged
care providers and workers to be culturally and language
sensitive, what would you say?
MM: To start off with, from a language perspective, there are some
interventions that are quite easy to put in place. It’s very hard of
course to provide an interpreter, but the development of personal
cue cards, not general cue cards, for residents can be helpful.
We have found, for instance, with one resident, where with
the help of an interpreter, a family member and the resident, a
personal selection of cue cards was developed. That was quite
helpful during their stay to communicate with staff.
Culture influences the way we perceive
and have empathy for others [as well as]
pain tolerance, pain threshold, anxiety, pain
severity, and the emotive expression of pain.
Also, having language and ethnic concordant care. So, making
sure there is some link between the cultural background of
staff does help as well. It doesn’t have to be the same cultural
background; sometimes there are overlapping cultural values that
are helpful.
There are practical items like the Talk to Me app or the call assist.
And what Karen was talking about: radio and television programs,
from a language perspective.
From a cultural perspective, training is vital. At St Vincent’s
we provide a comprehensive training program to our staff, and
certainly in residential facilities they have access to it.
I think we go across about three or four times a year at the
very least in our residential facilities, and we’re always available
for that conversation. That’s more to go through specific cultural
backgrounds staff might not be familiar with, and allowing for that
conversation to unpack in a safe workshop environment is helpful.
There are also the simple, practical things that Karen was talking
about in her case study: making sure there are reminiscence items
around for the residents, and making sure the place feels culturally
safe and welcome. ■
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