The communication of safety in linguistic and cultural diversity: A study of residential care

Jonathan CrichtonFiona O’Neill

Background• A rapidly ageing population, and a growing need for people to care for the elderly in residential settings in Australia (Fine &Mitchell 2007, Hugo 2007, 2009)

• ‘the ageing of the aged’ (Hugo 2007, p170): Aged care residents presenting with more complex health profiles including dementia (communication issues, aggression)

• Increasing cultural and linguistic diversity amongst aged care residents (Jeffries 2006, Orb 2002) and more recently the workers employed to care for them, but often these two groups are not from the same linguistic and cultural backgrounds (Pearson et al. 2007, King et al. 2012, Fine & Mitchell 2007, Hugo 2009)

Background research

• Decreased reporting of injuries by culturally and linguistically diverse (CALD) workers

(WorkSafe SA 2008, WorkCover NSW 2002)• Higher injury rates /psychological risk due to language/communication issues?

(Johnstone & Kanitsaki 2007, King et al. 2012)

Question

How do CALD workers disseminate, interpret, and understand OHSW information and carry out OHSW instructions in the aged care industry?

Design

• 2 locations – A and B residential aged care facilities• Participants – Residents, Managers, non culturally & linguistically diverse nurses and carers and culturally & linguistically diverse nurses and carers

• Process – interviews with participants from each group, observations of the various sites of communication, documents associated with these sites

• Thematic analysis• Interventions

Sites of communication

• Induction training, WHS training days, Intranet, memos and noticeboards

• Meetings – Health and Safety committee, clinical nurse/manager meetings, carer meetings

• Handovers between shifts and between levels of staff – changes in residents’ conditions

• Documentation – resident care plans and clinical records• Documentation and reporting – hazards, near misses and

incidents, auditing• Informal communication between staff – “backstage”

conversations, notes in the nurses’ station• Interaction between staff and residents

Languages other than English spoken by staff

• Cantonese, Mandarin, Malay, Sinhalese, Korean, Tagalog, Vietnamese, Japanese, Samoan, Farsi, Hindi, Punjabi, Gujarati, Yoruba (West Africa), Dutch, Italian, German, French, Bosnian, Serbian, Croatian…

Languages other than English spoken by residents

• Hindi (x1), Cantonese (x1), French, German, Croation, Italian, Greek…

Diversity

Interview data

• 20 culturally & linguistically diverse carers and nurses

• 9 managers (non culturally & linguistically diverse)• 24 non culturally & linguistically diverse carers and

nurses• 22 Residents

Culturally & linguistically diverse nurse

…you know she told me “You smell like curry”, I told her “You smell like sandwich a rotten one” and I told her “A rotten one … you should be better”, it helped me, it ruined my day I can still remember it after 5 years but that’s how it is, there can be difficult things.

Q. What sort of strategies have you done to adapt to that or to deal with that?

A. Nothing you can’t do anything about it, it’s this way I will explain, there is a highway, everyone else is going over the speed of 100k per hour and you’re just trying to enter this highway and your speed is probably 45 what do you do you can’t take your car there and let them smash into you so what do you do? You just drive carefully around the corner and try to get to the speed 100k and then when you have 100k you manipulate yourself you can’t fight with everyone can you?

(p58, lines 174-181)

Culturally & linguistically diverse nurseWell we have a little difficulty in terms of clients, we get clients from different cultural backgrounds and they don’t have a charting of expectations, as a nurse I can work within the legislations within my work ethics, within the policies and procedures of the place but client does not understand that, his or her expectations is something else because that’s how he or she has seen it happening in their own culture, now this is confronting for us and the families are also there, their understanding is also the same and when you try to explain it at that point in time they listen but it comes round and round again the same.

(p60, lines 280-287)

Culturally & linguistically diverse nurseThere is a perception that nurses are busy, I’m very busy here, I’m not that busy in hospital but there is a code there is a client code which is defined there and there is good to be in hospital if you are good … if you are rough if you swear to me I’m not coming to you “I’m sorry you calm down then I’ll talk to you” … as a nurse I don’t take any shit there … in hospital it’s written if you behave properly you’re being treated if you don’t “I’m sorry I can’t do it somebody else” … I’ll say “Look he called me a black Indian go away I’m not going there” and nobody will question me why you are not going there that’s it alright “Look after yourself mate somebody else will go there” but in aged care it doesn’t happen, it really doesn’t happen, oh they can call you anything and we to do counseling with them but they keep on doing those things.

(p61, lines 320-329)

Culturally & linguistically diverse carer

…you see there is this problem here in Australia because in my country if you are like a year older than me, I have to respect you, I don’t have the right to look you straight in your eyes while I’m talking to you, yeah so when I came to Australia it was very difficult like in Australia here if you’re talking to someone and you don’t maintain the eye contact they look at you like you’re lying to them but in my country it is quite different, when you’re talking to like I’m talking to you now I don’t have the right to look at you straight in the eyes, its disrespectful.

(p98, lines 105-111)

Culturally & linguistically diverse carer

Q. You’re not shy but people interpret you as shy?

A. Yeah just because of my culture, but now I’ve been trying to get along with a lot of things so and I’m sure I’ll be alright.

The only thing I could add is a lot of people still need to like listen closely to you before they answer quickly, like if they, it’s not like a racist or something, some people they see that you’re black, they’ve already made up their mind that they won’t understand whatever I’ve got to say so you know people need to listen first before they judge.

Q. So for you, you feel sometimes that people are judging?

A. Sometimes before I speak they are like “What are you saying?”, I say “Why don’t you just listen first so then we understand what I was about to say”, so you have to listen before you understand yeah there is no way you understand something if you don’t listen.

(p100, lines 185-200)

Culturally & linguistically diverse carerQ. So if you see someone doing the wrong thing or if you’re worried about someone getting hurt what can you do?A. That’s the very very good question because its happening here now but because this is confidential I don’t like to tell you because so many people they don’t like to be told and I went downstairs and I told them and they called me bitchy bossy because I’ve been here more experienced and when I see new staff they come as soon as they know what to do and they make so many things wrong and when you go to tell them, like for example I’ve seen staff they’re giving wash to resident and putting the dirty flannel back like not rinsing or wet flannel on the towel and I said excuse me that’s wrong that’s a cross infection and they gave me horrible looking you know you think I’m bossy but no, if I go to RN that person goes back to behind me and said she’s bossy but I’m not bossy I’m saying for residents safety and I’ve seen wrong things doing with the lifter we had a argument they don’t want to do it you know its so many things we haven’t got that power to you know no one listening just not enough people to understand us and I just shut my mouth and I said well what way they want to do it do it, I give up.(p101, lines 41-54)

Culturally & linguistically diverse carerYeah yeah. Look I’m from different background, but the first thing when I come to the ward and I said ok told myself I have to prepare myself to be mix with these people and respect for their culture what they want you know I’m not a religious person at all, I’m from a Muslim country but I’m not religious at all but I’ll always respect for people they are religious very totally, I never ever, if I find they are religious I just do the way they want, … I follow them but I found some people they just attack to other people I think and they can’t get in you know, most the African they can you know its just always a problem and they take advantage of it, as soon as things goes a little bit wrong for them they say “You are racist” but I don’t believe that it’s that way and very very smart way they’re doing it and no one will understand.

(p102, lines 89-100)

Non culturally & linguistically diverse manager

They (staff) always just come up and say “Look I’ve been working with so and so and I’ve asked them to do a couple of things and they’ve actually gone and done this and I’m wondering if they understand what I’m saying” … so, with the safety and wellness aspect of things we’re very quick to pick up if we think someone’s got an English barrier

(p18, lines 208-212)

Non culturally & linguistically diverse nurse

So I find that some of them will nod their head as if they are listening and understand but sometimes they don’t really understand what you’re actually trying to get across to them … I also find that some cultures will not speak up they will just like stand back and just watch, but you don’t really understand whether or not you don’t really know if they’re actually understanding what’s happening, or if that’s just their way of being polite

(p35, lines 355-363)

Non culturally & linguistically diverse nurse

I think there’s lots of things that come into play and this is just my personal view, I think a lot of it is cultural, I think you know and I don’t really know that people who come here don’t always understand that you know we have rules and regulations for a reason and I don’t think they understand. I think also it can be quite difficult with male care workers who are from and particularly patriarchal cultures, find it very difficult to take instruction from a female and they tend to want to do things on their own, you know, and take risks unnecessarily, because sometimes I find it is difficult for them to come and ask a woman for help. Even though we’re not a patriarchal society here in Australia they come from you know what their culturally used to, so….

(p63, lines 61-69)

Non culturally & linguistically diverse carer

The facility is culturally diverse, especially over the last 2 years there are more languages and cultures here. It’s really good because I learn more about others and their languages and cultures but sometimes it is difficult to understand accents. There is one of the residents, the wanderer down in the locked dementia wing who is Scottish and her accent is really hard to understand. There was also a RN who was Scottish and her accent was really hard to understand, so it can be a bit confusing.

(p68, lines 95-100)

Non culturally & linguistically diverse carer• I think sometimes, where we have different languages and cultures

coming in, it helps for us to know a bit about those languages and cultures. We have a gentleman here at the moment, an Indian man, and he is of Sikh religion, now I don’t know anything about that. In his culture, the elderly stay at home and the family looks after them. I know there is a lot of resentment there, towards his daughter, who can’t look after him at home. He has to be in here. But in his mind, because he is of that age and background, he believes she should be looking after him and she is not. So that then causes problems for us because he does not want to be here, so he won’t always communicate as effectively as he can. He can but he just doesn’t want to because he doesn’t want to be here. It’s things like palliative care. They have rituals and we don’t know what those rituals are and the last thing you want to do is to offend anyone at that time but it’s very hard it you don’t know what those rituals are and you can’t find out what those rituals are.

• (p91, lines 230-242)

Non culturally & linguistically diverse carer

• Some of the African workers have come from refugee camps and are used to death, if I can say that, but it is very different here to what it would be like there. Even the processes that we use, you know, when they are on palliative care, it’s a different type of caring to what we would do every day, you know. And it’s trying to explain to them those processes, like the processes the body is going through as it is dying and shutting down, you know. If they already have a limited English base, then that can be very hard to explain to them. This is what we need to do, this is why they are this color, this is why they are doing that.

• (p91, lines 249-257)

Non culturally & linguistically diverse carer

That’s when I would seek help from my EN or RN. And just raise the question of whether they are listening or not … Raising the question of whether they are actually understanding first because if they are not understanding, then it appears that they are not listening

(p96, lines 196-199)

Non culturally & linguistically diverse resident

… they’re (CALD workers) very good at explaining if you can’t quite understand and you give them a bit of help. “Do you mean this or do you mean that?” Oh no they will tell you straight away and there’s no difficulty there. I can’t think of any trap I fell into by misinterpreting any question I can’t think of any

(p173, lines 29-33)

Non culturally & linguistically diverse resident

Oh well very good and I’ll tell you something off the record but I have people from Liberia, Ivory Coast, Ethiopia, Nepal, India and Australia oh and Chinese and so some of the carers don’t get on with each other and I said ‘well, I have to accept you all coming in to help me so’.

(p144, lines 11-14)

Non culturally & linguistically diverse resident

Oh its mostly the ones that are on of a night they have trouble where you ask them to put their clothes because they seem to have a different language, would it be for your clothes, and some of them are alright but some of them I don’t know whether it’s a bit lax or whether they don’t understand or what it is but on the whole I suppose you would say they were alright it’s just that, I get a bit sometimes a bit, as if I could scream.

(p148, lines 22-26)

Non culturally & linguistically diverse resident

It’s a bit shattering at first especially when you get to the stage where you’ve got to be showered by other people, especially if a great big 6 foot 10 Nigerian comes in to shower you and you’ve never met him before, I make him laugh and I say to him look just pretend you’re washing a car scrub my back I said you’re doing the body work on the car now your arms and legs they’re the four wheels so give them all a good scrub, now I said just give me the sponge I’ll be doing my face while you clean the windscreens, well they finish up laughing and enjoying themselves instead of they being embarrassed as I was you see.

(p166, lines 114-121)

Non culturally & linguistically diverse resident

I think the carers are well named, they are carers, I am glad they’re not called helpers or something like that because they really do care for us, they really do and I think it’s a very apt name for people who care for us and nurses may nurse us or not, shall I say, they may not have me as a patient or a resident but the carers I think they’re wonderful in what they do.

(p163, lines 97-101)

Preliminary thoughts• The importance of communication to safety• The reliance on a transmission model of

communicating information about safety• The complexity of communication within and

between groups e.g. assuming, second and third guessing of intentions, competence and meaning among people of different

• languages and cultures • organisational roles

• How people are making sense of/what people are doing to manage this complexity

References

• Fine, M. D., & Mitchell, A. (2007). Immigration and the aged care workforce in Australia: Meeting the deficit. Australasian Journal in Ageing, 26(4), 157-161.

• Hugo, G. (2007). Contextualising the ‘crisis in aged care’: A demographic perspective, Australian Journal of Social Issues Australian Journal of Social Issues, 42(2), 169-182.

• Hugo, G. (2009). Care worker migration, Australia and development. Population, Space and Place, 15, 189-203. doi: 101 1002/psp

• Jeffries, A. (2006). Language diversity and older Australians: Issues, special needs and the recognition of language/cultural rights in aged care services. Paper presented at the Australian Association of Gerontology, Sydney.

• Johnstone, M.-j., & Kanitsaki, O. (2007). An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context. Journal of Transcultural Nursing, 18(3), 247-256.

• King, D., Mavromaras, K., Wei, Z., He, B., Healy, J., Macaitis, K., . . . Smith, L. (2012). The Aged Care Workforce Final Report 2012: Flinders University.

• Martin, B., & King, D. (2008). Who cares for older Australians? (F. University, Trans.): National Institute for Labour Studies.

• Orb, A. (2002). Health care needs of elderly migrants from culturally and linguistically diverse (CALD) backgrounds: A review of the literature. Perth: Curtin University of Technology.

• Pearson, A., Srivastava, R., Craig, D., Tucker, D., Grinspun, D., Bajnok, I., . . . Gi, A. A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare, 5, 54-91. doi: 10.1111/j.1479-6988.2007.00058.x

• WorkCover NSW (2002) Improving health and safety information to immigrant workers in NSW, NSW Government: 1-188.

• WorkSafe Victoria (2008) Communicating occupational health and safety across languages, Victorian WorkCover Authority: 1-28.