By the year 2060, America’s population will look different than it does today. It will be older, and more racially and ethnically diverse, according to the U.S. Census Office. All in all, the non-white population – now 37 percent of the U.S. population – will become 57 percent of the population in 2060.

As Home Care Aides (HCAs) work with an increasing number of diverse Consumer identities, such as race, religion, class, ethnicity, sexual orientation, disability and gender identity, it is important for HCAs to develop skills to better work with Consumers of all backgrounds.

Whenever you care for Consumers, it is important to learn about their preferences and needs. For example, grooming is important – smelling nice, looking good – but there can be differences based upon various individual, cultural, or other factors.

For example, in some cultures, modesty is important – so how do you bathe a Consumer without offending them? What if the Consumer has a different skin or hair type than you have – how will you learn to care for the Consumer? What if the Consumer uses a grooming tool that you’ve never encountered before?

Ninfa Quiroz is the director of the community relations department at Sea Mar Community Health Centers, a Seattle-based organization serving Latino health, housing, and human services needs.

“We are going to be facing such a huge need, and more cross-cultural training is imperative,” Quiroz says.

The Beauty of Difference: Cultural Competency

What is “cultural competency?” It is a deep respect for cultural differences, and the many ways of viewing the world, says Mikaela Louie, the program manager of cultural competency training at The Cross Cultural Health Care Program (CCHCP). CCHCP is a Seattle nonprofit with 22 years of experience in the field of culturally and linguistically appropriate health services.

No one person can act as an expert on cultural groups or beliefs, she points out.

“Every human individual is a cultural being and has their own personal culture, which influences the way we communicate, how we access care, and how we interact with healthcare systems,” Louie says.

It can be normal – even human – to jump to conclusions, particularly when we’re short on time and in high demand. “We make shortcuts and unconscious bias can easily seep in,” Louie says. “As humans and cultural beings, we all have biases – understanding that is the freedom of cultural competency. Biases and assumptions are not inherently good or bad, in fact we can have both positive and negative ones.”

“You want to do some self examination,” Louie says. “Figuring out what are my biases, what assumptions do I make, personally and professionally?” These may come from upbringing, training, or professional belief systems. “It’s a lifelong process, not a one-hour training, or one article you read,” she says, but a long-term process of how one thinks, behaves, and communicates.

A Consumer may differ from day to day, depending upon the conditions. “People’s realities change,” she says. “A big piece of our work is to help caregivers try to understand the other things happening in the Consumers’ lives that are affecting their behavior.” For example, chronic illness, family matters, and personal factors can influence needs and behavior.

To learn more about your Consumer, ask open-ended questions, Louie suggests. For example, asking, “Do you want your hair up?” leads to one of two answers: Yes or No. An open-ended question would be, “How would you like your hair done today?” or “How will you do your hair today?”

Ask your consumer open-ended questions about how they would like to be dressed and/or groomed.

“By asking those questions, you’ll hear what the client desires,” Louie says, and decrease the chances of making an assumption.

Even something that many people take for granted – gender identity – can’t be assumed. After comfort and trust has been established, you may find that a Consumer prefers a different pronoun for themselves, or wishes to dress or groom in a way different than their assigned sex (male or female).

“Familiarity leads to comfort which leads to trust, and that’s really the critical piece here,” Louie says. Consumers want an HCA they trust and feel comfortable with, as it leads to easier and more effective communications.

Communication as the Key

So much of that trust and interaction between diverse HCAs and Consumers depends upon communication.

Bria Chakofsky-Lewy, a supervisor with Community House Calls/Interpreter Services at Harborview Medical Center, suggests requesting an assignment with a Consumer who speaks the same language from your agency, if possible. Keep in mind that the dialect and word choices may differ.

If a medical interpreter is assigned at times, don’t rely on the interpreters to explain cultural or personal nuances. “The medical interpreter should only serve as a direct messenger,” Louie says. If an interpreter is present, speak directly to your Consumer. Even if you don’t share a language, Quiroz says it’s important to use the “universal language” of human facial expression, body language, gesture, and sounds.

Regardless of the ability to speak the Consumer’s language, “Individuals know whether we’re rejecting or embracing them,” she says.

The Latino community is very diverse in education, culture, income, etiquette and dialect, Quiroz says, and learning Spanish can be a useful skill if working with someone from the Latino community. Otherwise, sign language, gesture – and even pictures on a cell phone – can help increase communication.

“We want to train workers on that perspective, but it is also important to learn a greeting or basic language expressions, and even paying attention to how we walk into a client’s home,” Quiroz says. For example, some Consumers don’t want HCAs to wear street-shoes into the home – instead, they prefer taking off shoes or wearing indoor shoes or slippers.

“We should never be afraid to ask when we are uncertain, or do not understand,” Quiroz says. “Say, ‘I’m sorry, can you show me what you mean?’ It may require a longer sentence,” but it’s worth the effort, particularly if it means the comfort, health, and well-being of a Consumer.

Quiroz shares the story of a Spanish-speaking older adult Consumer assigned to an English-only nursing home. She pointed toward the bathroom, as she needed to use the toilet. However, the staff member misinterpreted her gesture, and instead placed her on a seat near the bathroom. Tears silently rolled down the woman’s face; she was heartbroken and frustrated that such a basic human need was misunderstood.

Cultural Quandaries

What can go wrong when biases and miscommunication combine, and lead to misunderstandings? Plenty. For example, in cultures from Russia to China, a traditional healing technique called “cupping” or “coining” can cause the skin to look bruised. In the past, some healthcare workers have mistaken the bruises for child or elder abuse. However, it is very important to verify without judging, Louie says.

“Approach with humility and a desire to learn more, particularly if you don’t share a similar cultural background,” Louie says. “You can’t assume anything about an individual until you ask,” Chakofsky-Lewy says.

A man chews on a miswak toothbrush. Photo via Flickr by Carsten ten Brink

However, if you know you are working in a Somali home, you could learn a few basics about Somali culture, customs, and etiquette. For example, some Somali immigrants use a toothbrush – called a miswak, commonly bought in Somali grocery stores. The brush may be different than the one many North Americans are familiar with, and different than any shown in HCA training.

Some Muslim individuals undertake specific requirements for cleaning the body in preparation for praying, she notes. “If you’re taking care of someone who is going to do those prayers, it’s good to know,” Chakofsky-Lewy says, including which body parts the Consumer might want to wash alone or with help.

“If I’m working in a community where there have been an influx of Consumers from a particular place and I’m not from that place, I might go to my agency and request an in-service on customs of this community and surrounding practices,” Chakofsky-Lewy says.

In Latino culture, it’s considered polite to be generous with food and many Consumers may consider their HCAs to be guests, Quiroz says. Consumers may keep offering food to an HCA – even if it means that they eat less. Learning polite ways to decline is important – “Oh, I’m so sorry, I just ate, but you are so kind and nice to offer, and it smells good.” You are establishing a professional boundary, without hurting the feelings of the Consumers.

People have differences in concepts of care, health, and disease, Louie notes. “There’s so much room, and it’s a beautiful thing to learn and understand that the client may have a different world view.” By doing so, we uncover our unconscious bias and beliefs, and by learning more about Consumers, we may learn more about ourselves, “unweaving and unraveling your own beliefs,” she says.