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Communicating with older ethnic minority patients Likupe G (2014) Communicating with older ethnic minority patients. Nursing Standard. 28, 40, 37-43. Date of submission: July 31 2013; date of acceptance: December 9 2013.
Abstract In a time of increasing cultural diversity, it is essential that healthcare professionals respond by providing culturally competent care. Healthcare professionals must recognise the diverse needs of people from ethnic minority communities to ensure that they receive equal standards of care. This is particularly pertinent when providing care for older ethnic minority patients who may not be fluent in English. This article focuses on the need to communicate effectively with this group of patients to meet their health and social care needs, with the ultimate aim of improving patient outcomes.
Author Gloria Likupe Lecturer, University of Hull, Hull. Correspondence to: [email protected]
Keywords Communication skills, cultural competence, cultural diversity, ethnic minorities, holistic care, older people, patient-centred care
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
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A RISE IN INTERNATIONAL migration, with increasingly older ethnic minority populations living in the UK, means healthcare professionals need to keep a close eye on how they meet the needs of these individuals. In particular, healthcare research is focused on communication problems between older ethnic minority patients and those who provide care for them. The minority ethnic population in England and Wales has increased from 8% in 2001 to 16.5% in 2011 (Office for National Statistics 2011), and is likely to continue to rise. This means health services are faced with an increasingly culturally diverse population. Communication with people from different ethnic groups can be challenging for healthcare professionals (Likupe 2011), who need to be sensitive to cultural diversity, stereotyping and prejudice. It is essential that professionals can demonstrate good communication skills to meet the needs of people from ethnic minority communities (Kai 2005). The Nursing and Midwifery Council (NMC) (2010) Standards for Pre-Registration Nursing Education stipulate that nursing students should seek support from nurse lecturers in universities and mentors in practice to develop self-awareness, challenge their prejudices and foster relationships that enable them to provide care without compromise, in other words care that is individualised and not influenced by prejudice. A supportive environment and culture could be achieved by considering diversity issues in care-giving relationships. However, this requires adequate training and financial resources, which may be a limiting factor for a health service that is already under significant financial burden. Most literature on communication with older ethnic minority patients is concerned with translation of either the spoken or written word june 4 :: vol 28 no 40 :: 2014 37
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Art & science cultural issues (Yehieli et al 2004). Age UK, previously Age Concern, for example, promotes the practice of producing translated materials from English to other languages for older people who may not be fluent in English and for whom English may not be their first language (Age Concern England 2006). However, it is also important to recognise that some of these individuals may not be literate in their own language. In addition, the Policy Research Institute on Ageing and Ethnicity Research Briefing (2004) reported that care for people from ethnic minority communities is compromised by limited communication between healthcare professionals and ethnic minorities, and a lack of involvement of these patients in their care. All patients, including those from ethnic minority communities, wish to be treated with respect by healthcare professionals and want their dignity to be maintained. However, respect may mean different things to people from different cultures, and it is these cultural differences that need to be taken into account when providing care. For example, in most African cultures, older people prefer not to be addressed by their first names and may like to be referred to as uncle, aunt or mama, depending on the relationship and difference in age between those they are communicating with (Likupe 2011). In Asian cultures, older people may prefer to be addressed by their titles, such as doctor, Mr or Mrs (Pecchioni et al 2008). This article explores communication between healthcare professionals and older ethnic minority patients, considering common issues and potential solutions. Several themes on communication with older people in general and older ethnic minorities in particular have been identified, including young people’s perception of older people, barriers to communication and ways to overcome such barriers.
Young people’s perception of older people Studies on ageing and communication have reported both actual and perceived examples of declining ability of people to communicate as they age (Ryan et al 2004), and little contact between people of different generations (Harwood 2007). Communication between people of different generations was found to be unsatisfactory, basic and lacking any depth, and ageism was frequently encountered, with older people being portrayed as nagging and long-winded, and exhibiting various forms of physical decline (McCann and Giles 2002, McCann et al 2004). In some cases, older people were stereotyped as being slow thinking, incoherent, inarticulate and demanding, and frequently complaining (Harwood 2007). 38 june 4 :: vol 28 no 40 :: 2014
Younger people tend to make generalisations about older people without considering their individual capacity and capabilities (Giles and Dorjee 2004). Younger people tend to depersonalise older people in a process known as ‘over-accommodation’, involving being overly polite and warm, with a slowed speaking rate, increased volume of speech and use of exaggerated intonation and simple language (Giles and Dorjee 2004). Many older people attribute this behaviour to a lack of respect and ignorance of their needs on the part of younger people (Giles and Dorjee 2004). Although these findings are not specific to older ethnic minority patients, this behaviour may be exaggerated in the presence of cultural and language differences. Over-accommodation can lead to negative outcomes for the older person, including loss of personal control, low self-esteem and reduced social interaction (Ryan et al 1995). Similarly, ‘elderspeak’ – infantilising communication – is also recognised as a patronising form of communication that unwittingly reinforces dependency and engenders isolation and depression in older adults. Elderspeak includes using inappropriate terms of endearment (Williams et al 2003), speaking slowly, altering intonation and using simplified syntax. This type of communication may be viewed as condescending by the older person who, in some cases, may end up conforming to the way he or she is seen or perceived by healthcare professionals or carers. In addition, elderspeak has been shown to increase aggressive behaviour and decrease receptiveness to care interventions (Williams et al 2009). In a study of young adults from three Western countries (Canada, United States (US) and New Zealand) and three East Asian nations (the Philippines, South Korea and Japan) and their perceptions of interactions with older people in general, older family members and same-age peers, Giles et al (2003) found that intergenerational communication with non-family older people was perceived less positively than interactions with older family members and same-age peers. Intergenerational communication was reported to be more problematic than intragenerational communication, which potentially exacerbates the problems faced by ethnic minorities in Western countries, where interaction and care provision is often between young people and non-family older people. The findings of this study demonstrate the need to ensure that all those who provide care for older people from ethnic minority communities have access to education and training on meeting the needs of this patient group and how to overcome communication barriers. It might be necessary to ensure that translation services are available
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and can be easily accessed, and that healthcare professionals are given information about different ethnic minority communities and some of the main cultural differences. Education could include information about how different cultures view older adults. For example, how in some communities, old age is associated with wisdom, and often used to indicate status and power, and younger people are expected to respect older people (Harwood 2007). Mold et al (2005) identified the need to explore how healthcare services can best acknowledge the needs of older ethnic minorities. They emphasise that the views of older people regarding the care they receive can only be known ‘if researchers are willing and able to involve residents and workers in the research process and choose methodologies that can adequately explore their views, for example, interviewing and observation’. If the views of older people from ethnic minority communities are sought in this way and taken into consideration when planning and delivering care, these individuals are more likely to feel respected and empowered, and may also be more receptive to care interventions.
Barriers to communication In a study of people from ethnic minority groups aged 65 or older in Finland, Eriksson-Backa (2008) found that barriers to communication originated with both seekers and providers of information. There were barriers to obtaining the desired information, including feelings of inferiority, lack of time or information, and confusion caused by contradictory information. Respondents reported not receiving answers to their questions about examinations and treatment. Older people did not ask for clarification of information received because they feared being labelled confused and demented. Barriers to communication can lead to misunderstandings and the misinterpretation of information, thereby compromising patient safety. Poor communication between patients and healthcare professionals may also have implications for informed consent. For example, some patients may consent to treatment without fully understanding what is involved, or may choose not to undergo a particular procedure for the same reason (Department of Health 2009). It is, therefore, important that healthcare professionals recognise the importance of communicating effectively with older ethnic minority patients. This may include ensuring that translation services are available and avoiding the use of medical jargon. Murphy and Clark (1993) interviewed nurses caring for patients from ethnic minority
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communities. The nurses reported that they felt unable to provide holistic care and develop therapeutic relationships because of difficulties in communication and lack of knowledge about cultural differences. This caused significant frustration and stress for staff. The study emphasised the importance of incorporating and developing cultural knowledge in nurse education, and providing support, such as access to foreign language courses and translation services, for healthcare professionals who deal with communication difficulties in practice. Johnson et al (2004) reported that physicians in the US were more verbally dominant and engaged in less patient-centred communication with African-American patients compared with white patients. As a result, African-American patients demonstrated reduced adherence to treatment regimens and less satisfaction with care compared with white patients in the study. The authors concluded that lack of patient engagement and participation in care, rather than the overall time spent with the physician, may contribute to health disparities, for example, care may be prescribed for ethnic minority patients without their involvement. Johnson et al (2004) explained that communication skills programmes that focus on patient-centred care and developing rapport with patients may help to reduce racial and ethnic disparities in health care. Patient-centred care includes getting to know the person as an individual, and involving him or her in decision making and care planning. Factors such as racism, poverty and the desire for cultural maintenance may also be difficult for older people to communicate to healthcare professionals, and this may lead to stress and anxiety for older ethnic minority patients (Yehieli et al 2004). Yehieli et al (2004) identified that different cultures might have differing concepts of health, differing ways of communicating and differing perceptions about the role of healthcare professionals. To prevent culture from acting as a barrier to communication, particularly with older people from ethnic minority communities, it may help if these patients receive care from someone who is familiar with their cultural background. This view is also supported by Sims (2010), who reported that African-American women received different treatment from white women and that stereotyping influenced this treatment. These women were often stereotyped as being aggressive and this affected their interactions with healthcare professionals. Sometimes they felt that their conversations were being misinterpreted. One woman in the study described how a doctor was scared of her because she used her hands often when june 4 :: vol 28 no 40 :: 2014 39
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Art & science cultural issues speaking and the doctor thought she was going to hit him. The study concluded that unfamiliarity with cultural practices and behaviours could lead to misinterpretation and misunderstanding, with patients not receiving the desired care, thereby affecting patient safety and outcomes. Mold et al (2005) reported a paucity of literature concerned with older ethnic minorities in care homes. However, findings identified racial disparities in relation to accessing care homes, care satisfaction and decision making. The study highlighted the need to offer a range of services that meet this patient group’s cultural and religious needs and effective communication to ensure the provision of high quality care.
Overcoming communication barriers Good communication is essential to ensure optimum health care for people from different cultural backgrounds. With this in mind, Ryan et al (1995) developed the Communication Enhancement Model which promotes health in old age through recognition of individualised cues, modification of communication to meet the needs of the person and the particular situation, appropriate assessment of the health and/or social problem and empowerment of older patients and healthcare staff. The model is especially beneficial to older individuals from ethnic minority communities and those with dementia. After using the model and following education on culture and communication, healthcare professionals’ perception of older people changed, with staff demonstrating an understanding of the ageing process and acting as advocates for older people. The model can also be used to guide the development and evaluation of any educational intervention designed to improve the care of older people. Edwards and Chapman (2004) developed the Health Promoting Communication Model, which expanded Ryan et al’s (1995) Communication Enhancement Model and included the role expectations of care givers and care receivers. It was recognised that dysfunctional patterns of communication develop not only in response to stereotypical expectations of older people, but also as a result of stereotypical expectations of both the care giver and the receiver of care concerning their role in the care-giving relationship. The Health Promoting Communication Model suggests that effective communication and productive caregiving relationships can be promoted through modification of role expectations and behaviour (Edwards and Chapman 2004). The model 40 june 4 :: vol 28 no 40 :: 2014
focuses on the individual rather than stereotypical expectations about the older person’s competence or ability. In a study of healthcare professionals working in the United Arab Emirates, a linguistically and culturally diverse society, El-Amouri and O’Neill (2011) identified the need for translation of material and for people to be orientated to different cultures. Nurses suggested that to improve culturally competent care – care that recognises and respects the cultural needs of individuals – the following were required: Skills to assess and understand different cultures. Staff professional development programmes. Improved interpreter or translator support. More multimedia resources and visual aids to support communication. Greater empowerment of staff in decision making. Additional help and support for low socioeconomic and elementary educated patients. These suggestions require additional resources from service providers and an ongoing commitment from healthcare staff. The study also identified the need for team building activities to improve communication (El-Amouri and O’Neill 2011) . Gerrish (2001) conducted an ethnographic study in one English community NHS trust serving an ethnically diverse population. Over half of South Asian patients had little or no understanding of English, with women and older people least likely to speak the language. Ethnic minority patients and carers who were not fluent in English were disadvantaged in that they could not understand and follow treatment instructions that might ultimately affect treatment adherence, successful patient outcomes and patient safety. Furthermore, Gerrish (2001) found that psychological support for these patients was limited and that identification of patients’ needs was questionable, in that care provided might be based on the norms of the white population. However, it is the responsibility of all healthcare professionals to provide equitable care for patients irrespective of their cultural background or communication abilities. Including older ethnic minorities in research that aims to identify their needs can provide valuable information that can be used to improve practice. However, there is a lack of research about how older people from different ethnic backgrounds wish and expect to be cared for. Heikkilä and Ekman (2003) conducted a qualitative study involving older Finnish immigrants in Sweden to establish their expectations of care. Findings revealed that older people from Finland wanted
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to feel settled, irrespective of where their care was provided. They also wanted continuity in their daily lives. Nursing homes were viewed negatively because they were associated with increasing older peoples’ dependency. All but one nursing home in Sweden provided care for Finnish immigrants. Finnish older people reported that companionship and security were priorities for them. Culturally appropriate care was thought to provide the means for communication and companionship between staff and fellow residents. Research, such as this, on the needs of older ethnic minority patients will provide valuable information that can be used to enhance practice. Johnson (1996) reported on 200 studies in health and health services delivery relating to communication issues between practitioners and people from ethnic minority communities. Findings revealed that effective communication can be achieved by focusing on the strengths of different cultures and examining the role of social structures. Johnson (1996) emphasised that communication is a two-way process between the health service provider and patient and that this process includes ‘all forms of information transmission, and attempts by patients and potential users to access health services’. Johnson (1996) made several recommendations designed to improve communication between ethnic minorities and healthcare professionals, including the need for more research into training on communication styles and cultural sensitivity, communication and use of translators, and communication with minority groups involving more personal, individual intervention rather than reliance on booklets and leaflets. It was recommended that staff should not rely on stereotypical notions of culture or language ability when communicating with ethnic minorities. Johnson (1996) also recommended that healthcare professionals should identify their communication needs, and receive training on multicultural working. Johnson (1996) stated that telephone and postal surveys are associated with a poor response rate when researching communication issues in minority groups in the UK. The author recommended personal visits, if necessary to the home, and using wherever possible ‘matched’ interviewers – matched by gender, and preferably by origin as well as language competence. Moreover, Johnson (1996) suggested that studies should focus on issues relating to race, ethnicity and language in addition to culture. Research of this nature could provide valuable information to inform practice about the communication needs of older ethnic minority patients. Gunaratnam (2008) reported that caregivers felt that it would be helpful to have some knowledge
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of the patient’s culture to enable them to provide holistic care. However, it has also been suggested that it is important to recognise the patient’s wishes, rather than categorising him or her into a particular culture. Gunaratnam (2008) argued that although cultural knowledge may sometimes facilitate culturally responsive care, it can take priority over individualised care and this may not be desirable. The author recognised that most of the time, older people from ethnic minority communities are expected to be custodians of their culture and to tell professionals what is expected. When this information is not forthcoming, healthcare workers may become angry that the cultural information is not provided, and this may obstruct the provision of effective and holistic care. Suggestions for improving communication between ethnic minority older patients and carers include recruitment of nurses from different ethnic groups, development of translation services and leisure clubs offering culture-specific activities such as traditional dress and dance celebrations, as well as investment in education and training for carers (Mold et al 2005). A study by Kluge et al (2007) demonstrated improved confidence and communication among nursing students following training with a simulated computer programme. Students were recorded communicating with a virtual older person on video and then allowed to watch the video and assess their own communication skills. Students noted several occasions when their communication skills could have been improved, for example listening more closely and using proper forms of address when speaking to the older person. The authors emphasised the need for healthcare professionals to develop communication skills through peer assessment and training packages such as the one used in the study. Kai (2005) described how communication can sometimes be challenging when interacting with those perceived as different from the majority population. To communicate successfully, healthcare professionals need to accept the discomfort of unfamiliarity and uncertainty, and address their prejudices by familiarising themselves with different cultures. Kai (2005) also emphasised the importance of understanding the role of culture in communication and how factors such as gender, age, education, socioeconomic background, language, family, religion, sexual orientation, disability and previous experiences, as well as the healthcare professionals’ own culture, may affect communication. Poor communication, stereotyping, lack of understanding, and derogatory attitudes are often june 4 :: vol 28 no 40 :: 2014 41
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Art & science cultural issues cited by ethnic minority patients as the main issues in poor care. Gerrish (1997) acknowledged that although human caring is perceived as a universal phenomenon, patterns and expression of caring vary among cultures and within cultures. Therefore, nurses need to develop an understanding of different cultures to provide individualised patientcentred care. However, Stokes (1991) argued that a transcultural approach to care ignores issues of gender, class, race, religion, politics and employment. Giuntoli and Cattan (2012) reported similarities between older migrants and older British nationals in their expectations of care and support from care services. These expectations included respect for dignity, high professional standards and communication. Older migrants described the need for ongoing dialogue within and between services, between services and patients and between the care giver and the person receiving care, regarding individual entitlements and preferences. Cultural and spiritual backgrounds were also identified as important in determining specific issues that older migrants considered important in the communication process. Another expectation was the older person’s need for time to process information. Carers suggested that older people should be given more time to process information and should share the information with their next of kin if possible and appropriate (Giuntoli and Cattan
2012). This is particularly important for older people from ethnic minority communities because there may be language problems and cultural issues. It is essential that patients understand the information being communicated to them in order to be able to participate in their care and decision making, and to consent to treatment.
Implications for practice The literature has shown that in general, young adults perceive older people to have reduced capacity and capability, which can lead to unsatisfactory communication such as overaccommodation and elderspeak (Williams et al 2003, Giles and Dorjee 2004). As a result, many older people feel unrespected, and may exhibit low self-esteem and reduced social interaction. Older ethnic minority patients may be disadvantaged by lack of involvement in their care if they experience racism and poor care as a result of barriers to communication. These barriers include language, culture and the negative attitudes of healthcare professionals. Research has found that racism, poverty and cultural differences may make it difficult for older ethnic minority patients to communicate their needs to authority figures such as doctors and nurses (Johnson et al 2004, Giuntoli and
References Age Concern England (2006) Communicating with Diverse Audiences: A Practical Guide to Producing Translated Materials in Appropriate Languages and Formats for People from Minority Ethnic Communities. www.rightsnet. org.uk/pdfs/ACE_Comm_Div_Auds. pdf (Last accessed: May 8 2014.) Department of Health (2009) Reference Guide to Consent for Examination or Treatment. tinyurl. com/kkhm4c3 (Last accessed: May 12 2014.) Edwards H, Chapman H (2004) Caregiver-carereceiver communication part 2: overcoming the influence of stereotypical role expectations. Quality in Ageing. 5, 3, 3-10. El-Amouri S, O’Neill S (2011) Supporting cross-cultural communication and culturally competent care in the linguistically and culturally diverse hospital settings of UAE. Contemporary Nurse. 39, 2, 240-255.
Eriksson-Backa K (2008) Access to Health Information: Perceptions of Barriers Among Elderly in a Language Minority. www. informationr.net/ir/13-4/paper368. html (Last accessed: May 8 2014.) Gerrish K (1997) Preparation of nurses to meet the needs of an ethnically diverse society: educational implications. Nurse Education Today. 17, 5, 359-365.
young people’s perceptions of conversations with family elders, non-family elders and same-age peers. Journal of Cross-Cultural Gerontology. 18, 1, 1-32. Giuntoli G, Cattan M (2012) The experiences and expectations of care and support among older migrants in the UK. European Journal of Social Work. 15, 1, 131-147.
Executive and West Midlands Regional Health Authority. Research Paper in Ethnic Relations No. 24. http://web.warwick.ac.uk/fac/ soc/CRER_RC/publications/pdfs/ Research%20Papers%20in%20 Ethnic%20Relations/RP%20No.24. pdf (Last accessed: May 8 2014.)
Gunaratnam Y (2008) From competence to vulnerability: care, ethics, and elders from racialized minorities. Mortality. 13, 1, 24-41.
Johnson RL, Roter D, Rowe NR, Cooper LA (2004) Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health. 94, 12, 2084-2090.
Harwood J (2007) Understanding Communication and Aging. Sage Publications, London.
Kai J (2005) Cross-cultural communication. Medicine. 33, 2, 31-34.
Giles H, Dorjee T (2004) Communicative climates and prospects in cross-cultural gerontology. Journal of Cross-Cultural Gerontology. 19, 4, 261-274.
Heikkilä K, Ekman SL (2003) Elderly care for ethnic minorities: wishes and expectations among elderly Finns in Sweden. Ethnicity & Health. 8, 2, 135-146.
Kluge MA, Glick LK, Engleman LL, Hooper JS (2007) Teaching nursing and allied health care students how to ‘communicate care’ to older adults. Educational Gerontology. 33, 3, 187-207.
Giles H, Noels KA, Williams A et al (2003) Intergenerational communication across cultures:
Johnson MRD (1996) Ethnic Minorities, Health & Communication: A Research Review for the NHS
Gerrish K (2001) The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers. Journal of Advanced Nursing. 33, 5, 566-574.
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Likupe G (2011) Motivations, Migration and Experiences of
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Cattan 2012). This could result in poor treatment and care. Communication models, such as the Communication Enhancement Model (Ryan et al 1995) and the Health Promoting Communication Model (Edwards and Chapman 2004), have been devised to overcome communication barriers between healthcare professionals and older people. However, it is important that models such as these consider patients’ views to ensure that their needs are recognised and met. Johnson (1996) recommended that personal visits and matched interviews should be used in research with older people from ethnic minority communities to seek their views and expectations of care. This is vital if culturally sensitive care is to be delivered. Cultural sensitivity includes being aware of one’s own values and beliefs and recognising how these influence attitudes and behaviours of older ethnic minority patients. Healthcare professionals need to be aware of the style of communication used in a particular culture and of the respect afforded to older people in various cultures. In particular, care providers must be aware that the use of stereotypes is demeaning and should be avoided. All healthcare professionals should participate in cultural training and education that emphasises the importance of: Being sensitive to one’s own values and beliefs. Being aware of different cultures and values.
Black African Nurses in the United Kingdom. www.rcn.org.uk/__data/ assets/pdf_file/0004/458977/ gloria_likupe_thesis_2011.pdf (Last accessed: May 8 2014.) McCann RM, Giles H (2002) Ageism in the workplace: a communication perspective. In Nelson TD (Ed) Ageism: Stereotyping and Prejudice Against Older Persons. MIT Press, Cambridge MA, 163-199. McCann RM, Cargile AC, Giles H, Bui CT (2004) Communication ambivalence toward elders: data from North Vietnam, South Vietnam, and the USA. Journal of Cross-Cultural Gerontology. 19, 4, 275-297. Mold F, Fitzpatrick JM, Roberts JD (2005) Minority ethnic elders in care homes: a review of the literature. Age and Ageing. 34, 2, 107-113. Murphy K, Clark JM (1993) Nurses’ experiences of caring
Understanding communication styles and values within different cultures. Respecting individuality, while recognising diversity within cultures. Adopting a holistic approach when caring for older people. Involving older people in their care and decision making. Developing effective communication skills requires training and financial provision for such training. These challenges could be addressed partly by including cultural training in pre-registration nurse education, learning beyond registration modules, and training sessions for nurses and support staff in care homes.
Conclusion With an increasing older population and a rise in the number of immigrants in the UK, nurses will be involved in providing care for patients from different cultural backgrounds and with varied and often complex needs. Effective communication is integral to good quality and compassionate care, and it is essential that all staff working in the health services have an understanding of how to communicate with people from diverse cultures. Education and training are required urgently to promote culturally competent care for these patients NS
for ethnic-minority clients. Journal of Advanced Nursing. 18, 3, 442-450. Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. http://standards. nmc-uk.org/PublishedDocuments/ Standards%20for%20preregistration%20nursing%20 education%2016082010.pdf (Last accessed: May 8 2014.) Office for National Statistics (2011) Census 2011. Who we are. How we live. What we do. www.ons.gov.uk/ ons/guide-method/census/2011/ index.html (Last accessed: May 12 2014.) Pecchioni LL, Ota H, Sparks L (2008) Cultural issues in communication and aging. In Nussbaum JF, Coupland J (Eds) Handbook of Communication and Aging Research. Lawrence Erlbaum Associates, London, 167-207. Policy Research Institute on
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Ageing and Ethnicity Research Briefing (2004) Minority Elderly Health & Social Care in Europe. www.priae.org/assets/PRIAE_ publications/1_PRIAE_MEC_ European_Research_Summary_ Results_Launched_Brussels_ European_Parliament_dec_2004. pdf (Last accessed: May 8 2014.) Ryan EB, Meredith SD, MacLean MJ, Orange JB (1995) Changing the way we talk with elders: promoting health using the communication enhancement model. International Journal of Ageing and Human Development. 41, 2, 69-107.
encounters among older Black women. Ethnicity & Health. 15, 5, 495-514. Stokes G (1991) A transcultural nurse is about. Senior Nurse. 11, 1, 40-42. Williams K, Kemper S, Hummert ML (2003) Improving nursing home communication: an intervention to reduce elderspeak. Gerontologist. 43, 2, 242-247. Williams KN, Herman R, Gajewski B, Wilson K (2009) Elderspeak communication: impact on dementia care. American Journal of Alzheimer’s Disease and Other Dementias. 24, 1, 11-20.
Ryan EB, Jin YS, Anas AP, Luh J (2004) Communication beliefs about youth and old age in Asia and Canada. Journal of CrossCultural Gerontology. 19, 4, 343-360. Sims CM (2010) Ethnic notions and healthy paranoias: understanding the context of experience and interpretations of healthcare
Yehieli M, Grey MA, Vander Werff A (2004) Caring for Diverse Seniors: A Health Provider’s Pocket Guide to Working with Elderly Minority, Immigrant, and Refugee Patients. www. culturalconnections.org/docs/ caring_for_seniors_booklet.pdf (Last accessed: May 8 2014.)
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Communicating with older ethnic minority patients Likupe G (2014) Communicating with older ethnic minority patients. Nursing Standard. 28, 40, 37-43. Date of submission: July 31 2013; date of acceptance: December 9 2013.
Abstract In a time of increasing cultural diversity, it is essential that healthcare professionals respond by providing culturally competent care. Healthcare professionals must recognise the diverse needs of people from ethnic minority communities to ensure that they receive equal standards of care. This is particularly pertinent when providing care for older ethnic minority patients who may not be fluent in English. This article focuses on the need to communicate effectively with this group of patients to meet their health and social care needs, with the ultimate aim of improving patient outcomes.
Author Gloria Likupe Lecturer, University of Hull, Hull. Correspondence to: [email protected]
Keywords Communication skills, cultural competence, cultural diversity, ethnic minorities, holistic care, older people, patient-centred care
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
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A RISE IN INTERNATIONAL migration, with increasingly older ethnic minority populations living in the UK, means healthcare professionals need to keep a close eye on how they meet the needs of these individuals. In particular, healthcare research is focused on communication problems between older ethnic minority patients and those who provide care for them. The minority ethnic population in England and Wales has increased from 8% in 2001 to 16.5% in 2011 (Office for National Statistics 2011), and is likely to continue to rise. This means health services are faced with an increasingly culturally diverse population. Communication with people from different ethnic groups can be challenging for healthcare professionals (Likupe 2011), who need to be sensitive to cultural diversity, stereotyping and prejudice. It is essential that professionals can demonstrate good communication skills to meet the needs of people from ethnic minority communities (Kai 2005). The Nursing and Midwifery Council (NMC) (2010) Standards for Pre-Registration Nursing Education stipulate that nursing students should seek support from nurse lecturers in universities and mentors in practice to develop self-awareness, challenge their prejudices and foster relationships that enable them to provide care without compromise, in other words care that is individualised and not influenced by prejudice. A supportive environment and culture could be achieved by considering diversity issues in care-giving relationships. However, this requires adequate training and financial resources, which may be a limiting factor for a health service that is already under significant financial burden. Most literature on communication with older ethnic minority patients is concerned with translation of either the spoken or written word june 4 :: vol 28 no 40 :: 2014 37
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Art & science cultural issues (Yehieli et al 2004). Age UK, previously Age Concern, for example, promotes the practice of producing translated materials from English to other languages for older people who may not be fluent in English and for whom English may not be their first language (Age Concern England 2006). However, it is also important to recognise that some of these individuals may not be literate in their own language. In addition, the Policy Research Institute on Ageing and Ethnicity Research Briefing (2004) reported that care for people from ethnic minority communities is compromised by limited communication between healthcare professionals and ethnic minorities, and a lack of involvement of these patients in their care. All patients, including those from ethnic minority communities, wish to be treated with respect by healthcare professionals and want their dignity to be maintained. However, respect may mean different things to people from different cultures, and it is these cultural differences that need to be taken into account when providing care. For example, in most African cultures, older people prefer not to be addressed by their first names and may like to be referred to as uncle, aunt or mama, depending on the relationship and difference in age between those they are communicating with (Likupe 2011). In Asian cultures, older people may prefer to be addressed by their titles, such as doctor, Mr or Mrs (Pecchioni et al 2008). This article explores communication between healthcare professionals and older ethnic minority patients, considering common issues and potential solutions. Several themes on communication with older people in general and older ethnic minorities in particular have been identified, including young people’s perception of older people, barriers to communication and ways to overcome such barriers.
Young people’s perception of older people Studies on ageing and communication have reported both actual and perceived examples of declining ability of people to communicate as they age (Ryan et al 2004), and little contact between people of different generations (Harwood 2007). Communication between people of different generations was found to be unsatisfactory, basic and lacking any depth, and ageism was frequently encountered, with older people being portrayed as nagging and long-winded, and exhibiting various forms of physical decline (McCann and Giles 2002, McCann et al 2004). In some cases, older people were stereotyped as being slow thinking, incoherent, inarticulate and demanding, and frequently complaining (Harwood 2007). 38 june 4 :: vol 28 no 40 :: 2014
Younger people tend to make generalisations about older people without considering their individual capacity and capabilities (Giles and Dorjee 2004). Younger people tend to depersonalise older people in a process known as ‘over-accommodation’, involving being overly polite and warm, with a slowed speaking rate, increased volume of speech and use of exaggerated intonation and simple language (Giles and Dorjee 2004). Many older people attribute this behaviour to a lack of respect and ignorance of their needs on the part of younger people (Giles and Dorjee 2004). Although these findings are not specific to older ethnic minority patients, this behaviour may be exaggerated in the presence of cultural and language differences. Over-accommodation can lead to negative outcomes for the older person, including loss of personal control, low self-esteem and reduced social interaction (Ryan et al 1995). Similarly, ‘elderspeak’ – infantilising communication – is also recognised as a patronising form of communication that unwittingly reinforces dependency and engenders isolation and depression in older adults. Elderspeak includes using inappropriate terms of endearment (Williams et al 2003), speaking slowly, altering intonation and using simplified syntax. This type of communication may be viewed as condescending by the older person who, in some cases, may end up conforming to the way he or she is seen or perceived by healthcare professionals or carers. In addition, elderspeak has been shown to increase aggressive behaviour and decrease receptiveness to care interventions (Williams et al 2009). In a study of young adults from three Western countries (Canada, United States (US) and New Zealand) and three East Asian nations (the Philippines, South Korea and Japan) and their perceptions of interactions with older people in general, older family members and same-age peers, Giles et al (2003) found that intergenerational communication with non-family older people was perceived less positively than interactions with older family members and same-age peers. Intergenerational communication was reported to be more problematic than intragenerational communication, which potentially exacerbates the problems faced by ethnic minorities in Western countries, where interaction and care provision is often between young people and non-family older people. The findings of this study demonstrate the need to ensure that all those who provide care for older people from ethnic minority communities have access to education and training on meeting the needs of this patient group and how to overcome communication barriers. It might be necessary to ensure that translation services are available
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and can be easily accessed, and that healthcare professionals are given information about different ethnic minority communities and some of the main cultural differences. Education could include information about how different cultures view older adults. For example, how in some communities, old age is associated with wisdom, and often used to indicate status and power, and younger people are expected to respect older people (Harwood 2007). Mold et al (2005) identified the need to explore how healthcare services can best acknowledge the needs of older ethnic minorities. They emphasise that the views of older people regarding the care they receive can only be known ‘if researchers are willing and able to involve residents and workers in the research process and choose methodologies that can adequately explore their views, for example, interviewing and observation’. If the views of older people from ethnic minority communities are sought in this way and taken into consideration when planning and delivering care, these individuals are more likely to feel respected and empowered, and may also be more receptive to care interventions.
Barriers to communication In a study of people from ethnic minority groups aged 65 or older in Finland, Eriksson-Backa (2008) found that barriers to communication originated with both seekers and providers of information. There were barriers to obtaining the desired information, including feelings of inferiority, lack of time or information, and confusion caused by contradictory information. Respondents reported not receiving answers to their questions about examinations and treatment. Older people did not ask for clarification of information received because they feared being labelled confused and demented. Barriers to communication can lead to misunderstandings and the misinterpretation of information, thereby compromising patient safety. Poor communication between patients and healthcare professionals may also have implications for informed consent. For example, some patients may consent to treatment without fully understanding what is involved, or may choose not to undergo a particular procedure for the same reason (Department of Health 2009). It is, therefore, important that healthcare professionals recognise the importance of communicating effectively with older ethnic minority patients. This may include ensuring that translation services are available and avoiding the use of medical jargon. Murphy and Clark (1993) interviewed nurses caring for patients from ethnic minority
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communities. The nurses reported that they felt unable to provide holistic care and develop therapeutic relationships because of difficulties in communication and lack of knowledge about cultural differences. This caused significant frustration and stress for staff. The study emphasised the importance of incorporating and developing cultural knowledge in nurse education, and providing support, such as access to foreign language courses and translation services, for healthcare professionals who deal with communication difficulties in practice. Johnson et al (2004) reported that physicians in the US were more verbally dominant and engaged in less patient-centred communication with African-American patients compared with white patients. As a result, African-American patients demonstrated reduced adherence to treatment regimens and less satisfaction with care compared with white patients in the study. The authors concluded that lack of patient engagement and participation in care, rather than the overall time spent with the physician, may contribute to health disparities, for example, care may be prescribed for ethnic minority patients without their involvement. Johnson et al (2004) explained that communication skills programmes that focus on patient-centred care and developing rapport with patients may help to reduce racial and ethnic disparities in health care. Patient-centred care includes getting to know the person as an individual, and involving him or her in decision making and care planning. Factors such as racism, poverty and the desire for cultural maintenance may also be difficult for older people to communicate to healthcare professionals, and this may lead to stress and anxiety for older ethnic minority patients (Yehieli et al 2004). Yehieli et al (2004) identified that different cultures might have differing concepts of health, differing ways of communicating and differing perceptions about the role of healthcare professionals. To prevent culture from acting as a barrier to communication, particularly with older people from ethnic minority communities, it may help if these patients receive care from someone who is familiar with their cultural background. This view is also supported by Sims (2010), who reported that African-American women received different treatment from white women and that stereotyping influenced this treatment. These women were often stereotyped as being aggressive and this affected their interactions with healthcare professionals. Sometimes they felt that their conversations were being misinterpreted. One woman in the study described how a doctor was scared of her because she used her hands often when june 4 :: vol 28 no 40 :: 2014 39
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Art & science cultural issues speaking and the doctor thought she was going to hit him. The study concluded that unfamiliarity with cultural practices and behaviours could lead to misinterpretation and misunderstanding, with patients not receiving the desired care, thereby affecting patient safety and outcomes. Mold et al (2005) reported a paucity of literature concerned with older ethnic minorities in care homes. However, findings identified racial disparities in relation to accessing care homes, care satisfaction and decision making. The study highlighted the need to offer a range of services that meet this patient group’s cultural and religious needs and effective communication to ensure the provision of high quality care.
Overcoming communication barriers Good communication is essential to ensure optimum health care for people from different cultural backgrounds. With this in mind, Ryan et al (1995) developed the Communication Enhancement Model which promotes health in old age through recognition of individualised cues, modification of communication to meet the needs of the person and the particular situation, appropriate assessment of the health and/or social problem and empowerment of older patients and healthcare staff. The model is especially beneficial to older individuals from ethnic minority communities and those with dementia. After using the model and following education on culture and communication, healthcare professionals’ perception of older people changed, with staff demonstrating an understanding of the ageing process and acting as advocates for older people. The model can also be used to guide the development and evaluation of any educational intervention designed to improve the care of older people. Edwards and Chapman (2004) developed the Health Promoting Communication Model, which expanded Ryan et al’s (1995) Communication Enhancement Model and included the role expectations of care givers and care receivers. It was recognised that dysfunctional patterns of communication develop not only in response to stereotypical expectations of older people, but also as a result of stereotypical expectations of both the care giver and the receiver of care concerning their role in the care-giving relationship. The Health Promoting Communication Model suggests that effective communication and productive caregiving relationships can be promoted through modification of role expectations and behaviour (Edwards and Chapman 2004). The model 40 june 4 :: vol 28 no 40 :: 2014
focuses on the individual rather than stereotypical expectations about the older person’s competence or ability. In a study of healthcare professionals working in the United Arab Emirates, a linguistically and culturally diverse society, El-Amouri and O’Neill (2011) identified the need for translation of material and for people to be orientated to different cultures. Nurses suggested that to improve culturally competent care – care that recognises and respects the cultural needs of individuals – the following were required: Skills to assess and understand different cultures. Staff professional development programmes. Improved interpreter or translator support. More multimedia resources and visual aids to support communication. Greater empowerment of staff in decision making. Additional help and support for low socioeconomic and elementary educated patients. These suggestions require additional resources from service providers and an ongoing commitment from healthcare staff. The study also identified the need for team building activities to improve communication (El-Amouri and O’Neill 2011) . Gerrish (2001) conducted an ethnographic study in one English community NHS trust serving an ethnically diverse population. Over half of South Asian patients had little or no understanding of English, with women and older people least likely to speak the language. Ethnic minority patients and carers who were not fluent in English were disadvantaged in that they could not understand and follow treatment instructions that might ultimately affect treatment adherence, successful patient outcomes and patient safety. Furthermore, Gerrish (2001) found that psychological support for these patients was limited and that identification of patients’ needs was questionable, in that care provided might be based on the norms of the white population. However, it is the responsibility of all healthcare professionals to provide equitable care for patients irrespective of their cultural background or communication abilities. Including older ethnic minorities in research that aims to identify their needs can provide valuable information that can be used to improve practice. However, there is a lack of research about how older people from different ethnic backgrounds wish and expect to be cared for. Heikkilä and Ekman (2003) conducted a qualitative study involving older Finnish immigrants in Sweden to establish their expectations of care. Findings revealed that older people from Finland wanted
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to feel settled, irrespective of where their care was provided. They also wanted continuity in their daily lives. Nursing homes were viewed negatively because they were associated with increasing older peoples’ dependency. All but one nursing home in Sweden provided care for Finnish immigrants. Finnish older people reported that companionship and security were priorities for them. Culturally appropriate care was thought to provide the means for communication and companionship between staff and fellow residents. Research, such as this, on the needs of older ethnic minority patients will provide valuable information that can be used to enhance practice. Johnson (1996) reported on 200 studies in health and health services delivery relating to communication issues between practitioners and people from ethnic minority communities. Findings revealed that effective communication can be achieved by focusing on the strengths of different cultures and examining the role of social structures. Johnson (1996) emphasised that communication is a two-way process between the health service provider and patient and that this process includes ‘all forms of information transmission, and attempts by patients and potential users to access health services’. Johnson (1996) made several recommendations designed to improve communication between ethnic minorities and healthcare professionals, including the need for more research into training on communication styles and cultural sensitivity, communication and use of translators, and communication with minority groups involving more personal, individual intervention rather than reliance on booklets and leaflets. It was recommended that staff should not rely on stereotypical notions of culture or language ability when communicating with ethnic minorities. Johnson (1996) also recommended that healthcare professionals should identify their communication needs, and receive training on multicultural working. Johnson (1996) stated that telephone and postal surveys are associated with a poor response rate when researching communication issues in minority groups in the UK. The author recommended personal visits, if necessary to the home, and using wherever possible ‘matched’ interviewers – matched by gender, and preferably by origin as well as language competence. Moreover, Johnson (1996) suggested that studies should focus on issues relating to race, ethnicity and language in addition to culture. Research of this nature could provide valuable information to inform practice about the communication needs of older ethnic minority patients. Gunaratnam (2008) reported that caregivers felt that it would be helpful to have some knowledge
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of the patient’s culture to enable them to provide holistic care. However, it has also been suggested that it is important to recognise the patient’s wishes, rather than categorising him or her into a particular culture. Gunaratnam (2008) argued that although cultural knowledge may sometimes facilitate culturally responsive care, it can take priority over individualised care and this may not be desirable. The author recognised that most of the time, older people from ethnic minority communities are expected to be custodians of their culture and to tell professionals what is expected. When this information is not forthcoming, healthcare workers may become angry that the cultural information is not provided, and this may obstruct the provision of effective and holistic care. Suggestions for improving communication between ethnic minority older patients and carers include recruitment of nurses from different ethnic groups, development of translation services and leisure clubs offering culture-specific activities such as traditional dress and dance celebrations, as well as investment in education and training for carers (Mold et al 2005). A study by Kluge et al (2007) demonstrated improved confidence and communication among nursing students following training with a simulated computer programme. Students were recorded communicating with a virtual older person on video and then allowed to watch the video and assess their own communication skills. Students noted several occasions when their communication skills could have been improved, for example listening more closely and using proper forms of address when speaking to the older person. The authors emphasised the need for healthcare professionals to develop communication skills through peer assessment and training packages such as the one used in the study. Kai (2005) described how communication can sometimes be challenging when interacting with those perceived as different from the majority population. To communicate successfully, healthcare professionals need to accept the discomfort of unfamiliarity and uncertainty, and address their prejudices by familiarising themselves with different cultures. Kai (2005) also emphasised the importance of understanding the role of culture in communication and how factors such as gender, age, education, socioeconomic background, language, family, religion, sexual orientation, disability and previous experiences, as well as the healthcare professionals’ own culture, may affect communication. Poor communication, stereotyping, lack of understanding, and derogatory attitudes are often june 4 :: vol 28 no 40 :: 2014 41
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Art & science cultural issues cited by ethnic minority patients as the main issues in poor care. Gerrish (1997) acknowledged that although human caring is perceived as a universal phenomenon, patterns and expression of caring vary among cultures and within cultures. Therefore, nurses need to develop an understanding of different cultures to provide individualised patientcentred care. However, Stokes (1991) argued that a transcultural approach to care ignores issues of gender, class, race, religion, politics and employment. Giuntoli and Cattan (2012) reported similarities between older migrants and older British nationals in their expectations of care and support from care services. These expectations included respect for dignity, high professional standards and communication. Older migrants described the need for ongoing dialogue within and between services, between services and patients and between the care giver and the person receiving care, regarding individual entitlements and preferences. Cultural and spiritual backgrounds were also identified as important in determining specific issues that older migrants considered important in the communication process. Another expectation was the older person’s need for time to process information. Carers suggested that older people should be given more time to process information and should share the information with their next of kin if possible and appropriate (Giuntoli and Cattan
2012). This is particularly important for older people from ethnic minority communities because there may be language problems and cultural issues. It is essential that patients understand the information being communicated to them in order to be able to participate in their care and decision making, and to consent to treatment.
Implications for practice The literature has shown that in general, young adults perceive older people to have reduced capacity and capability, which can lead to unsatisfactory communication such as overaccommodation and elderspeak (Williams et al 2003, Giles and Dorjee 2004). As a result, many older people feel unrespected, and may exhibit low self-esteem and reduced social interaction. Older ethnic minority patients may be disadvantaged by lack of involvement in their care if they experience racism and poor care as a result of barriers to communication. These barriers include language, culture and the negative attitudes of healthcare professionals. Research has found that racism, poverty and cultural differences may make it difficult for older ethnic minority patients to communicate their needs to authority figures such as doctors and nurses (Johnson et al 2004, Giuntoli and
References Age Concern England (2006) Communicating with Diverse Audiences: A Practical Guide to Producing Translated Materials in Appropriate Languages and Formats for People from Minority Ethnic Communities. www.rightsnet. org.uk/pdfs/ACE_Comm_Div_Auds. pdf (Last accessed: May 8 2014.) Department of Health (2009) Reference Guide to Consent for Examination or Treatment. tinyurl. com/kkhm4c3 (Last accessed: May 12 2014.) Edwards H, Chapman H (2004) Caregiver-carereceiver communication part 2: overcoming the influence of stereotypical role expectations. Quality in Ageing. 5, 3, 3-10. El-Amouri S, O’Neill S (2011) Supporting cross-cultural communication and culturally competent care in the linguistically and culturally diverse hospital settings of UAE. Contemporary Nurse. 39, 2, 240-255.
Eriksson-Backa K (2008) Access to Health Information: Perceptions of Barriers Among Elderly in a Language Minority. www. informationr.net/ir/13-4/paper368. html (Last accessed: May 8 2014.) Gerrish K (1997) Preparation of nurses to meet the needs of an ethnically diverse society: educational implications. Nurse Education Today. 17, 5, 359-365.
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Executive and West Midlands Regional Health Authority. Research Paper in Ethnic Relations No. 24. http://web.warwick.ac.uk/fac/ soc/CRER_RC/publications/pdfs/ Research%20Papers%20in%20 Ethnic%20Relations/RP%20No.24. pdf (Last accessed: May 8 2014.)
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Likupe G (2011) Motivations, Migration and Experiences of
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Cattan 2012). This could result in poor treatment and care. Communication models, such as the Communication Enhancement Model (Ryan et al 1995) and the Health Promoting Communication Model (Edwards and Chapman 2004), have been devised to overcome communication barriers between healthcare professionals and older people. However, it is important that models such as these consider patients’ views to ensure that their needs are recognised and met. Johnson (1996) recommended that personal visits and matched interviews should be used in research with older people from ethnic minority communities to seek their views and expectations of care. This is vital if culturally sensitive care is to be delivered. Cultural sensitivity includes being aware of one’s own values and beliefs and recognising how these influence attitudes and behaviours of older ethnic minority patients. Healthcare professionals need to be aware of the style of communication used in a particular culture and of the respect afforded to older people in various cultures. In particular, care providers must be aware that the use of stereotypes is demeaning and should be avoided. All healthcare professionals should participate in cultural training and education that emphasises the importance of: Being sensitive to one’s own values and beliefs. Being aware of different cultures and values.
Black African Nurses in the United Kingdom. www.rcn.org.uk/__data/ assets/pdf_file/0004/458977/ gloria_likupe_thesis_2011.pdf (Last accessed: May 8 2014.) McCann RM, Giles H (2002) Ageism in the workplace: a communication perspective. In Nelson TD (Ed) Ageism: Stereotyping and Prejudice Against Older Persons. MIT Press, Cambridge MA, 163-199. McCann RM, Cargile AC, Giles H, Bui CT (2004) Communication ambivalence toward elders: data from North Vietnam, South Vietnam, and the USA. Journal of Cross-Cultural Gerontology. 19, 4, 275-297. Mold F, Fitzpatrick JM, Roberts JD (2005) Minority ethnic elders in care homes: a review of the literature. Age and Ageing. 34, 2, 107-113. Murphy K, Clark JM (1993) Nurses’ experiences of caring
Understanding communication styles and values within different cultures. Respecting individuality, while recognising diversity within cultures. Adopting a holistic approach when caring for older people. Involving older people in their care and decision making. Developing effective communication skills requires training and financial provision for such training. These challenges could be addressed partly by including cultural training in pre-registration nurse education, learning beyond registration modules, and training sessions for nurses and support staff in care homes.
Conclusion With an increasing older population and a rise in the number of immigrants in the UK, nurses will be involved in providing care for patients from different cultural backgrounds and with varied and often complex needs. Effective communication is integral to good quality and compassionate care, and it is essential that all staff working in the health services have an understanding of how to communicate with people from diverse cultures. Education and training are required urgently to promote culturally competent care for these patients NS
for ethnic-minority clients. Journal of Advanced Nursing. 18, 3, 442-450. Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. http://standards. nmc-uk.org/PublishedDocuments/ Standards%20for%20preregistration%20nursing%20 education%2016082010.pdf (Last accessed: May 8 2014.) Office for National Statistics (2011) Census 2011. Who we are. How we live. What we do. www.ons.gov.uk/ ons/guide-method/census/2011/ index.html (Last accessed: May 12 2014.) Pecchioni LL, Ota H, Sparks L (2008) Cultural issues in communication and aging. In Nussbaum JF, Coupland J (Eds) Handbook of Communication and Aging Research. Lawrence Erlbaum Associates, London, 167-207. Policy Research Institute on
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Ageing and Ethnicity Research Briefing (2004) Minority Elderly Health & Social Care in Europe. www.priae.org/assets/PRIAE_ publications/1_PRIAE_MEC_ European_Research_Summary_ Results_Launched_Brussels_ European_Parliament_dec_2004. pdf (Last accessed: May 8 2014.) Ryan EB, Meredith SD, MacLean MJ, Orange JB (1995) Changing the way we talk with elders: promoting health using the communication enhancement model. International Journal of Ageing and Human Development. 41, 2, 69-107.
encounters among older Black women. Ethnicity & Health. 15, 5, 495-514. Stokes G (1991) A transcultural nurse is about. Senior Nurse. 11, 1, 40-42. Williams K, Kemper S, Hummert ML (2003) Improving nursing home communication: an intervention to reduce elderspeak. Gerontologist. 43, 2, 242-247. Williams KN, Herman R, Gajewski B, Wilson K (2009) Elderspeak communication: impact on dementia care. American Journal of Alzheimer’s Disease and Other Dementias. 24, 1, 11-20.
Ryan EB, Jin YS, Anas AP, Luh J (2004) Communication beliefs about youth and old age in Asia and Canada. Journal of CrossCultural Gerontology. 19, 4, 343-360. Sims CM (2010) Ethnic notions and healthy paranoias: understanding the context of experience and interpretations of healthcare
Yehieli M, Grey MA, Vander Werff A (2004) Caring for Diverse Seniors: A Health Provider’s Pocket Guide to Working with Elderly Minority, Immigrant, and Refugee Patients. www. culturalconnections.org/docs/ caring_for_seniors_booklet.pdf (Last accessed: May 8 2014.)
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