LeadingAge Magazine · July/August 2016 • Volume 06 • Number 04

Cultural Competence for a Diverse Future

July 13, 2016 | by Linda Barbarotta

Aging-services providers will need to know how to welcome multicultural staff and care for multicultural clients.

In June, LeadingAge Washington presented an award to The Hearthstone in Seattle for the positive changes they have made through cultural diversity commitment and inclusion with residents, staff and future leaders. It was no small feat for a life plan community with staff representing 27 different countries and islands.

“What makes our community unique is that our celebration of cultures is intentional and is integrated into operational and programmatic areas,” says Communications Director Kellie Moeller.

“One lesson we absorb from such diverse staff is how different cultures treat their elders. Many come from countries that traditionally honor and respect seniors more than our own culture here in the U.S. We have much to learn from others in caring for older adults,” says Moeller.

The Hearthstone celebrates staff through the popular monthly event, Culture Day. Employees take turns presenting their countries of origin to residents and other staff, often wearing traditional dress, sharing their experiences and serving traditional foods with the help of the dining services staff.

The employees feel honored to share about their country. They often tell moving personal stories, including the challenges they overcame to immigrate to the U.S. Many are still connected to their country and families who live there, often supporting them financially.

“The residents love it,” says Moeller. “About 50 to 75 residents attend every month. Residents learn more about the staff who provide their care and where they came from.”

In additional to monthly Culture Days, each department honors many cultures during the holidays, inviting staff to share their food and holiday traditions with residents. Plans are underway to set up ESL (English as a second language) classes for interested staff to be taught by an experienced resident.

HR Coordinator Mulu Habtyimer from Ethiopia attests to the welcome and respect she receives from The Hearthstone’s community. “It’s almost like coming home, where your family awaits you. Respect for all cultures is one of The Hearthstone’s most prized values. I see it on a day-to-day basis in the interaction between staff and residents.”

Significant staff retention/longevity on all levels is one indicator that the employees feel welcomed and appreciated. According to John Paulson, chief human resource officer, overall staff turnover is very low, even for certified nursing assistants, whose turnover rate last year was 4%. The Hearthstone also values its employees through competitive salaries and a 403(b) retirement fund.

“We have a fabulous, rich diverse staff. It’s wonderful to celebrate and work in a place that’s as joyful as this. It’s a real gift,” says Paulson.


The U.S. Census Bureau projects the U.S. will become a majority-minority population around 2044—when no one group will have majority. The percentage of non-white adults over 65, which was 21% in 2012, will rise to 42% in 2050. Direct care and home care workers are already a diverse group; 48% are white, non-Hispanic, 31% are African American, and 15% are Hispanic/Latino and 7% are of other racial/ethical backgrounds, according to PHI (the Paraprofessional Healthcare Institute).

Robyn Stone, executive director of the LeadingAge Center for Applied Research, believes that while melding cultures can be hard work, it is important to creating a healthy workplace and achieving better quality of care and quality of life for elders.

“When you have diverse workers caring for a growing population of diverse consumers and their families, culture competence needs to be a 360° model in aging services,” explains Stone. “Training for workers, their colleagues, those who run the organizations and the individuals receiving care and their families is essential. We need deliberate efforts to create an organizational culture that respects, appreciates and celebrates diversity, rather than viewing it as a problem or a challenge.”

Cultural competence is even more important in aging services than in hospitals. “In our sector, residents are often there much longer, sometimes years and, more importantly, many are receiving care in their home—whether in a residential setting or their own homes or apartments. The ongoing relationship between staff and residents/clients is a critical component of successful service delivery,” says Stone.


LeadingAge Thrive provides resources to help members better serve seniors and their communities. The 7 major topic areas in Thrive include questions designed to stimulate discussion among your leadership team and board of directors. Thrive also includes resources such as white papers, articles, tools, presentations and business intelligence.

 

Under the “Workforce and Leadership Development” section of Thrive, see the resources connected to these questions:

  • Do we have a comprehensive orientation program for new employees across all staff levels and settings?
  • Do we provide ongoing state-of-the-art training for administrators, midlevel managers, clinical staff and frontline providers across all departments and settings?
  • Do we have specific plans to strengthen our workforce by putting into practice competencies and competency-based training? If so, do you build these competencies into your performance evaluations?
  • Do we provide mentoring and peer support initiatives to enhance frontline supervisors’ and workers’ self-image and encourage them to grow in their job?
  • Do we have a comprehensive cultural competence strategy to support healthy staff-to-staff and staff-to-resident/client relationships and quality service delivery?
  • Do we have in place a comprehensive employee orientation program?
  • Do we provide clinical placements and internship opportunities for those who are or may be interested in pursuing a career in aging services?
  • Do we conduct performance evaluations to provide employee feedback and improve performance?

Thrive is a LeadingAge member benefit, and access is limited to members. Use the MyLeadingAge login page to log in or create an account.

Visit the Thrive main page.

A research study conducted in 2010-11 by the Mather LifeWays Institute on Aging found most aging services providers and their employees lacked the training to care for multicultural clients.

Administrators, directors of nursing, nurse educators and nurses from 240 aging-services communities reported only 22% of their workforce had received training in culturally competent care and only 24% were able to demonstrate and apply this knowledge. Nearly half rated the cultural competence of their workforce as poor or very poor.

Study report author Linda Hollinger-Smith, former vice president of the Institute, found follow-up focus groups wanted skill building not just between staff and residents but among and between staff and staff teams. “How staff members treat each other can affect the quality of care they deliver as well as their job satisfaction and retention, says Hollinger-Smith, now with the Champlain College of Nursing.


Researcher Victoria Parker from Boston University has concluded that the prevalent concept of cultural competence is too narrow, in her 2010 article on cultural competence in aging services. Some organizations just look at language barriers or focus specifically on teaching providers and managers about the beliefs, experiences and values of specific cultural groups. According to Parker, “not only has this training been found to be largely ineffective but it can also lead to stereotyping and oversimplification of cultural differences. This emphasis on racial or ethnic differences, does not take into account the diversity within cultures or the invisible diversities of lesbian, gay, bisexual and transgender (LGBT) community.”

Parker advises that relationship-based models and a focus on effective communication skills need to replace models that focus on short, encounter-based interactions, e.g., such as “How do I discuss managing diabetes with older Latino residents?”

“Communication across cultural differences, whether between provider and consumer, between providers or between manager and provider, becomes part of a larger need for enhanced self-awareness, reflection and communication skills.”

This broader view reflects the emerging concept of cultural humility. Initially developed for physician training, cultural humility looks at the assumptions and beliefs of the provider as well as the care recipient.


Cultural competence is not just about race and ethnic differences. LGBT older adults have often faced discrimination and misunderstanding when receiving care.

Fortunately, SAGE, the country's largest and oldest LGBT organization, offers providers training, technical assistance and educational resources (some in Spanish) through the National Resource Center on LGBT Aging. Created in 2010, the Center’ goal is to improve the quality of services and supports LGBT older adults receive.

Last year, Tim Johnston, SAGE assistant director of social enterprise and training, and his team created SAGECare, a nationally credentialed training program on LGBT aging for aging services providers. Providers chose between 4 credential levels, ranging from bronze to platinum, that depend on the training length (1 hour for most staff, 4 hours for senior leadership) and the number of employees trained. Each credentialed provider receives the SAGECare logo to post in a public area and use on communications, advertising and websites. SAGECare staff work individually with clients to determine the training fee.

“We created the SAGECare credential to give providers a strong visible sign to LGBT clients that they are welcome and require annual training because we want to build on-going relationships with the organizations that work with us,” says Johnston.

With 40 SAGECare-certified trainers, the training is consistent throughout the country and more trainers will be added this year.

Johnston shared a story of the power of symbols in this work. A recently trained senior center staff in Brooklyn, NY, placed a small rainbow sticker on her bulletin board as a “welcome sign” to LGBT clients. A few months later, she began meeting with an agitated client to investigate his concerns. One day, she saw the client notice the rainbow. His whole demeanor and attitude changed and from that point on, they worked together to resolve the issues.

SAGECare has also taught a wide range of senior care staff, including those in home care and residential settings, to be more aware of the subtleties of LGBT relationships. If a client refers to his or her “roommate,” staff can gently probe the bond by asking if the client would like the roommate to be present during care planning. This ensures that a very important person to the client will not be excluded.

Seventy-six providers have received the SAGECare credential so far. Large providers include the Alzheimer’s Association, the Lutheran Care Network, the New Jewish Home (formerly Jewish Home Lifecare) and River Spring Health (including the Hebrew Home at Riverdale) and the Visiting Nurse Service of New York (VNSNY) Hospice and Palliative Care Center.

“Our goals are to reach more providers and achieve financial sustainability so that our training work can continue regardless of grants or foundational support,” says Johnston.

Aging services providers will need to become culturally competent to continue their mission of delivering quality care through a valued workforce—a challenge, but as Stone envisions it, one that will enhance us all. “I see an equally strong potential to enrich our care settings by inviting people from different cultures to work and live together while appreciating the gifts that all bring.”

Sodexo, which works with aging-services providers around the world, approaches cultural competence with its “five pillars” approach. LeadingAge interviewed David Boyd Williams, director of global diversity for Sodexo, by email for insights on the company’s approach.


LeadingAge: In your own workforce, how do you define success in reaching your diversity goals? Is your program evaluated by the quality of your process or by the outcomes (i.e., numbers of employees broken down by group)?

David Boyd Williams: We always keep in mind that the programs, processes, and policies we set in place are in alignment with our overarching strategy around the development of our people. Our 5 global dimensions of diversity (gender, cultures and origins, generations, people with disabilities, sexual orientation and gender identity) are broadly named across our global strategy. Within each region and country where we operate (we operate in 80 countries) we take a nuanced approach in alignment with the local and national legal environment. In some instances, we have programs and policies in place that supersede the national legal requirements. In the United States, we define diversity in the broadest sense according to our commitment to EEO/AA. We utilize a combination of global and regional metrics to measure the progress and success of our diversity and inclusion (D&I) programming. These include increases in workforce representation, improvements in employee engagement by demographic group, metrics on internal advancement rates, impact of our D&I work on Sodexo’s brand, our ability to partner with clients in supporting their own D&I journey, and other measures that enable us to track and report on the impact and effectiveness of our work.

In terms of “quality of process or by the outcomes,” I would say both are true. These 2 are not mutually exclusive. In fact, it is the quality of the rigorous processes we engage which allows for outcomes which, year after year, build on the business case for diversity and inclusion at Sodexo. We constantly evaluate the processes by which outcomes are achieved. As an example, throughout the course of the past 10 years, our mentoring program, “IMPACT,” has adjusted to business needs and responded to the needs of the ever-changing markets in which we operate. In the United States specifically, we have developed and routinely reevaluate an annual diversity scorecard which entails a sophisticated process for measuring the performance of business lines as well as individual executives, leaders and managers against targeted criteria linked to our North American D&I strategy. Now, to be fair, if we are not achieving desired outcomes through certain programs, we then will step back to the quality of the process and evaluate whether or not a different approach is needed. Our global marketplace is ever-changing, and the means by which we evaluate success in D&I must stay in sync with those changes.


LeadingAge: What sort of metrics do you use to measure your own workforce in this area?

David Boyd Williams: Sodexo has a diversity scorecard which runs in close alignment with our fiscal year. In particular we are careful to evaluate processes that lead to meaningful outcomes with regard to the recruitment, advancement and retention of women and minorities. These measurements are based on both internal and external availability.

We also track metrics every 2 years with our Global Employee Engagement Survey, which is administered by Aon Hewitt. Diversity and inclusion is consistently cited as a top driver of employee satisfaction in our employee engagement surveys.


LeadingAge: Diversity and inclusion can be considered as ends in themselves, but how do you believe they impact the quality of your services and the success of your clients?

David Boyd Williams: Diversity and inclusion is positioned strategically at the core of our organizational identity. Our values of Service Spirit, Team Spirit and Spirit of Progress are reflected in the diversity of services we provide our clients. At the end of the day, we aim to improve the quality of life for our clients and their residents from a variety of diverse backgrounds. Whether through the recognition of cultural or religious meal requirements, helping managers know how to create an inclusive and comforting environment for LGBT residents, inviting our employees to share their own cultural festivals and activities with residents, or providing diversity and inclusion strategic planning sessions with leadership at our client sites, we are committed to walking together with our clients to explore the endless possibilities we have in common as we look to improve the quality of life for residents.