Racism and LTC

Dr. Eleanor Barbera
Dr. Eleanor Barbera

A friend of mine called me this week, upset about the racial tension making headlines in the news. We discussed what we could do as individuals to improve the situation.

“I called a friend of mine of a different race,” she said. “I told him we need to stay in touch right now, even if we're busy.”

“My column this week is about the issue,” I responded. We talked about how differences are bridged in a healthcare environment.

In long-term care, we provide services to, and work with, individuals from backgrounds different than our own. Residents share rooms and break bread with types of people they may never have encountered more than superficially in their previous 80 years of life. Barriers recede when we come to know each other as people, yet it's not always a smooth road.

Studies of racism in LTC

I've observed firsthand various culturally charged interactions — both positive and negative — and I wondered what types of racial challenges are common in long-term care.

I turned to the research to see what's been studied formally and found that racism is observed in the following ways:

•  Residents refusing care based on the racial or ethnic group of the caregiver, as noted in the New England Journal of Medicine article, “Dealing with Racist Patients.”

•  Unpleasant work environments due to hearing racial remarks by family members or other workers, in “Racism Reported by Direct Care Workers in Long-Term Care Settings.”

•  Nursing homes in areas with high poverty being more likely to close: “Why Medicaid's Racism Drove Historically-Black Nursing Home Bankrupt.”

•  The changing demographics of nursing homes due to people from minority groups having increased entrance to that level of care, but reduced access to privately paid home and community-based care such as assisted living: MedicareAdvocacy.org, “The Changing Demographics of Nursing Home Care: Greater Minority Access…Good News, Bad News.”

Increasing inclusion

While some of these problems are beyond the scope of any one LTC organization, there are ways in which the first two points can be addressed within our communities:

•  Highlight policies regarding tolerance to new staff members, residents and families so that they're aware of their rights and the procedures for handling policy violations.

•  Use onboarding, in-service training and ongoing supervision to help staff members increase their level of comfort in working with residents of different backgrounds. For example, new staff in a kosher facility would be taught how to maintain this practice; treatment teams could have a mini-lessons about new residents' unfamiliar origins, beliefs or lifestyles.

•  Find ethical ways to handle residents' refusal of treatment from workers based on race or ethnic background. In “Dealing with Racist Patients,” the authors note that there's a balance between respecting the right of a competent patient to refuse care and the right of a worker to have a workplace free of discrimination. The article suggests that, “The patient's medical condition and the clinical setting should drive decision making” and offers guidance that can be applied to LTC settings.

•  Increase the ease of communication with people who speak different languages by including on your website the various languages spoken at the facility and distributing a frequently updated list of potential staff translators or using a telephone-based translation service. (I love this resource!).

•  Emphasize cultural inclusivity by asking residents about their countries or cultures as part of activities or have them suggest activities that are important to them. Use activities to address world problems, such as when a nursing home with many Haitian residents and workers raised money for Haiti after the earthquake.

•  Encourage staff members to check with coworkers to avoid potential cultural misunderstandings. For example, one day I was helping a hoarding resident clear out some belongings and she told me that it was OK to throw away a stale slice of bread only after I'd run some water over it. “That's the way we do it in Guyana,” she assured me. Skeptical, I complied and then went to the nursing station to ask the Guyanese nurse about the watered bread tradition. “Is that a thing?” I asked. “Yes,” the nurse replied, much to my surprise.

•  Allow residents to be experts on their own cultures. Another time I was providing psychotherapy to a Bangladeshi resident whose illness gave him an unusual appearance and garbled his speech. This, in combination with his tendency to wear mixed stripes and plaids, made him seem, and be treated, as far more impaired than he actually was. While he (and his aide and his family) disregarded my suggestion to wear clothing that didn't clash, he took delight in discussing our cultural differences. Several weeks after I gave up trying to intervene in his attire, I saw a South Asian-looking man in my neighborhood wearing mixed plaids and stripes. Horrified, I asked my patient, “Was I being culturally insensitive? Are mixed plaids and stripes a thing in Bangladesh?” No, he told me, and we both shared a hearty laugh that further cemented our therapeutic relationship.

Our multidisciplinary, multicultural teams can be a source of misunderstanding and conflict but with proper guidance and support, they can also be a source of strength.

I'll end with the rest of my conversation with my friend:

“I read about how a large group of people gathered to meditate on peace and they found that it actually resulted in less crime in the area during the meditation period,” my friend in Louisiana (who is white) was saying.

“Oh my gosh, a black woman just walked by with a t-shirt that reads, ‘Just so you know, no one cares,'” she interjected, referring to a shirt expressing no hope. “Hold on, I'm going to yell at her.”

A moment later, I heard my friend hollering, “Just so you know, I care! I really, really care!”

According to my friend, the lady smiled.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the 2014 American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.

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