LeadingAge Magazine · May/June 2012 • Volume 02 • Number 03

Cultural Competence in the Workplace: Challenges and Solutions

May 15, 2012 | by Jane Sherwin

Here’s why education, respect and open communication are the keys to serving and employing a diverse mix of people.

TELACU Residential Management in Los Angeles, CA, with 2,600 residents in more than 2,300 units, has a lot of property to maintain, and residents with a wide variety of ethnic backgrounds. But diversity means more than just ethnic differences, and Jasmine Borrego, president of the residences group, tells a story about training maintenance workers sent to fix a faucet in a unit occupied by HIV-positive residents.

“They were wearing protective gear, just to go in and fix a sink,” says Borrego. “Now, it’s true that if they were cleaning up blood stains they would need to protect themselves. But we worked to help them see that in this case they needn’t assume that this unit was any more risky than any other.

“We constantly train our staff to be very sensitive,” Borrego adds. “There are two fair housing sessions a year for our managers, run by a law firm specializing in housing law and a consulting firm with a similar expertise. We also provide staff training four times a year. This is led by our supervisors, and they spend a whole day on policy, procedures, fair housing regulations, and what can lead to a discriminatory lawsuit. For example, so many of our residents are limited English speakers, so staff must make sure they have translators available—this is a HUD requirement, and they mustn’t worry about cost.”

Human relationships being at the heart of residential services, it’s not surprising that cultural differences can play a big part in quality of services. Managers and consultants alike report a growing commitment to understanding and supporting diversity, especially among staff, as they go about their work of caring for senior and disabled clients.

One significant reason for attending to the stresses, and values, of a diverse staff, is to reduce, or hold down, the high turnover that tends to characterize the senior care industry. Five years ago, turnover rates among “frontline” workers in nursing homes averaged 70%; rates in home care were 40% to 60%.

High turnover, in any field, can reflect problems with the quality of human resource management. At the same time, with the increasing age of the baby-boomer population, and a shrinking younger population, immigration is increasingly essential to staffing for the care of seniors. With employees from cultures all over the world, diversity is becoming a central characteristic.

Victoria Parker, an associate professor in health policy management at Boston University, has researched the place of respect in building employee satisfaction and performance. Why respect, rather than education about different cultures?

“Education is too often focused on knowledge, rather than shifts in attitude and behavior,” says Parker. “Respect puts the focus on those other pieces: even if you don’t know a lot about someone else’s culture, when you approach working together with a respectful attitude, this goes farther than knowledge.

“Also, knowledge can give the false sense that you understand something about someone else’s experience. It’s hard to separate facts and stereotypes. These can completely wash over individual differences that exist within groups and sub-groups. For example, in some parts of the country Asian Americans are a big part of the long-term care work force. It’s too easy to group all of them together. The fact is that each group, Vietnamese, Cambodians, and Chinese American, have their significant cultural differences, and education can conceal these.”

Parker’s research findings include the discovery that how managers and co-workers respond to a difficult incident is more important than whether the incident actually occurs. Consider a manager who simply says, “That’s your job; it doesn’t matter what they say to you” when an aide reports painful racist words from a resident. The positive alternative is for the manager to say, “I’m sorry you had to hear that,” or for a coworker to offer to take over, or share, the difficult resident’s care for a while.

“There is a lot of denial that these things get said,” says Parker. “We advise training staff to acknowledge and provide tools for working with incidents like these, instead of pretending they don’t happen. We encourage managers to make it clear they want to hear about these incidents. And training should start during orientation.”

Parker describes one organization that designated a regular meeting time as a place for strategizing when staff encountered particular difficulty with a resident’s attitude. This same senior residence also spends a week each year celebrating cultural differences with staff, with themes such as food and music. After a few years they progressed to talking about other topics such as traditions and beliefs around death. They found that staff members from different parts of world, with low-status jobs, became experts, in the eyes of residents as well as staff.


1. Remember that diversity doesn’t just mean ethnic differences. Education, expertise, and even kinds of illness represent differences that can make a difference in employee and resident experience.

2. Education about ethnic diversity can be useful, but the capacity to respect each employee, their strengths, and their needs is equally, if not more, important.

3. Acknowledgment and support for situations where difficult residents use derogatory language is as important as efforts to prevent such behavior.

4. Support for professional advancement of employees, a form of respect in itself, also helps to build a diverse staff and may reduce turnover.

5. Diversity is not going away! The growing senior population, and the smaller, younger workforce, means that immigration is essential to staffing residential and home care.

Cedar Sinai Park, in Portland, OR, founded 91 years ago, serves 600 residents on and off-campus, with a staff of 250. About 50 percent of clients are Jewish.

“Our philosophy is derived from our faith,” says David Fuks, chief executive officer. “We remember that we were strangers once, in a strange land, and we seek to be good to the stranger in return. Some of our residents are Holocaust survivors, or refugees from the Soviet Union, and we help our staff understand and be sensitive to their outlook.”

At the same time, Cedar Sinai puts considerable work into supporting staff, who come from a wide variety of ethnic backgrounds.

“We probably employ as many Muslims as Jews,” said Fuks. “Our nursing home receptionist is Muslim and wears a head scarf, and we serve one meal a day which is both kosher and halal [suitable for Muslim dietary requirements].”

Fuks said that the most important thing Cedar Sinai is doing for its staff is to provide scholarships and tuition reimbursement.

“We have 20 staff at a time pursuing degrees in higher education. Our policy is to pay for any class relevant to the staffer’s career goals—as long as these pertain to their work with us. And we prepay because that may be the only way they can afford the tuition. The result is that we can promote staff within the organization. At this point our business office has Anglo, Filipino, and Vietnamese workers. We have an African accountant.” Staff are able to move up, and to move around, on a career lattice that gives them considerable choice.

MariaElena Del Valle is an organizational change consultant with PHI National, a firm focused on strengthening working experience in home and residential care. One of her current clients is Independence Care Systems in New York, which recently decided to extend its services to include seniors as well as the disabled.

“As ICS grows,” said Del Valle, “so does the diversity of its population. There are Russians, Chinese, and Koreans, and the staff needs to be culturally competent, so the organization will seek to use existing staff personal networks to reach out to new employees that understand the language and the culture.”

Del Valle is a strong advocate of inviting sustained dialogue among staff.

“We need to explore together what’s happening, to ask, ‘What am I doing to create a respectful environment, and what do people need from leadership?” The clients I have seen, in the past 25 years, are beginning to understand the need for a culture of responsibility and dialogue, and the importance of being able to respond to any situation with curiosity. It’s a beautiful thing, curiosity, it stops you and you just look, you gain emotional control in the middle of differences.”

No one is yet talking about the end of difficulties with diversity and cultural competence. Cedar Sinai’s Fuks said that, while their goal is a grade of A, they “are only at B.” Their turnover rate of 17 percent, compared to much higher averages elsewhere in the field, does suggest that they are taking the right steps.

“Workforce diversity needs to be made a priority,” says Del Valle. “We have to acknowledge that the world has changed. In any given organization there’s a high probability that 15 to 20 different languages are being spoken. Some days I think we’ve fallen back to square one, but other days I do feel that we are beginning to understand the situation. Diversity involves a personal journey: How are you holding yourself accountable?”