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EmailCulturally Sensitive Care for Elderly Holocaust Survivors
Lesley Carstairs
Toronto
As a practicing transcultural nurse working with elderly Holocaust survivors and their caregivers, it is essential that I be attuned to their unique cultural values, beliefs, and lifeways and that I proceed to implement meaningful care practices that correspond to their way of life and specific care needs. “Personal accounts by survivors of the Holocaust are powerful. They connect us, person to person, with an era in history that is difficult, yet necessary, to comprehend” (Florida Center for Instructional Technology, 2001, p. 1). This paper will explore how Leininger's Theory and Sunrise Model can help me to provide care that meets Miss S. diverse needs. The knowledge I acquire from this paper will allow me to provide culturally sensitive care that addresses the unique needs of aging Holocaust survivors and their families.
Over the past five decades, the healthcare environment has grown increasingly more diverse shifting from a common ethnic origin to one that includes a multitude of ethnic and racial groups. As a result, “clients from a variety of racial and ethnic backgrounds [are now seeking] medical interventions and treatments [from health care professionals]” (Tate, 2003, p. 213). Leininger (1997) recognized this dynamic transformation and believed that it “created a critical need for nurses to become more knowledgeable and culturally aware to care for and work with people of other cultures” (Tate, 2003, p. 213). From this she began the development of the first ever transcultural theory of nursing, the Culture Care Theory. Leininger (1978) asserts “transcultural nursing involves understanding and helping cultural groups with their nursing and health care needs, values, beliefs, and practices” (Binder, 1995, p. 17). Transcultural nursing is a practice which compares cultural care values, beliefs, and practices of individuals or groups to raise understanding and to provide culture-specific nursing care practices that promote health and well-being of diverse individuals in meaningful ways. She deems culture as a “pervasive and continuous force that influences and shapes the lives of human beings in significant ways and acts as a guide for decisions and actions taken in health and in illness” (McGee, 2001, p. 1) . Nurses must recognize and respect their own cultural values and beliefs as well as those of others. Leininger's Culture Care Theory emphasizes how “human beings of any culture in the world have a right to have their cultural care values known, respected, and appropriately used in nursing and other health care services” (Eliason, 1993, p. 171). Leininger (1995) defines culturally congruent care as the utilization of “sensitive, creative, and meaningful care practices to fit with the general values, beliefs, and lifeways of clients for beneficial and satisfying health care, or to help them with difficult life situations, disabilities, or death” (Leininger, & McFarland, 2002, p. 12). Furthermore, she asserts that respect of clients can be achieved when culturally congruent care becomes an integral part of a nurse's thinking and decisions for individual and family care practices. “Providing culturally competent, safe, and congruent care to people of diverse or similar cultures is the central and dominant goal of transcultural nursing and should be with all health care providers worldwide” (Leininger et al., 2002, p. 12).
Leininger (1996) bases her theory on a holistic approach, which is illustrated in her Sunrise Model, a method for assessing patients in a comprehensive and culturally sensitive manner. The Sunrise Model “helps nurses initiate patient-nurse dialogue, ask pertinent questions, and suggest nursing modes that will facilitate culturally congruent care” (Steefel, 2004, p. 2). Her model outlines the client's 'world view' as the “way individuals or groups look at the universe to form values related to their lives and the world around them” (Cortis, 2004, p. 33), and the client's social structure is also an important factor to be considered. These views can be explored through the seven dimensions presented in the Sunrise Model, all of which influence or have the potential to influence the individuals care and well-being. Once information is obtained for each of these dimensions, health care professionals are able to achieve a better level of understanding, leading to a holistic approach to care that encompasses the mind, body, and spirit. “With the Sunrise Model, a truly holistic and comprehensive picture can be discovered to reflect the totality of knowing individuals in their lifeworld or culture” (Leininger et al., 2002, p. 80).
For the purpose of this paper, I will focus on the environmental context, language, and ethnohistory dimension as well as the kinship and social factor dimension of elderly Holocaust survivors. Ethnohistory is an important aspect of social structure in this model. “The long cultural history of the Jewish people with their migrations into different places in the world for freedom, to practice their religion, and to preserve their family lifeways needs to be understood to facilitate culturally congruent care” (Leininger et al., 2002, p. 465).
Kinship is also included as an important social structure dimension is the Sunrise Model. “The family is the core of the Jewish lifeways buttressed by religious beliefs and cultural values. For example, one is expected to honour one's father and mother and to care for one another in the family” (Leininger et al., 2002, p. 29). This is congruent with what I observed during my experience with an elderly Holocaust survivor. I was reminded how sacred family is in the Jewish culture. Additionally I observed how this survivor's family provided her with comfort and affection. Furthermore, I observed families spending countless hours at the bedside of their loved ones, attending to their needs. It was apparent that family is especially important to Holocaust survivors who experience anxieties about being abandoned. My client expressed closeness with her family and displayed great pride in her family's achievements. I believe it is important for a nurse to be able to articulate who their client is, where they have come from, what their early life experiences have been and how they have shaped them into the person they are today.
As a culturally congruent nurse, I must assess the family's needs and strive to ensure their needs are met. “Nurses need to understand the family's role as advocates for a member who is a survivor” (David, & Pelly , 2003, p.139). It is important that health care professionals remain sensitive to consequences that challenge aging Holocaust survivors as well as their families. In order to provide culturally congruent care I must honour the role family plays in the pursuit to improve the health and well-being of elderly Holocaust survivors. Leininger's Culture Care Theory concurs with the importance of exploring kinship and states that one of the principles of kinship is to “seek a holistic view of the client's world within his/her environmental context” (Sochan, personal communication, February 26, 2004 ). After determining the role of the family and how it influences health and well-being of clients, I can adapt caring practices that respect the families' roles and their responsibilities to their family members. “The primary role of the nurse is to support the person, family, or group with their physical, psychosocial, behavioural, and personal care needs. The nurse often is the coordinator of care and should also be a strong advocate for the individuals and his/her family” (David et al., 2003, p. 136).
My client belongs to an ethnohistory group and has endured a traumatic event that greatly changed her life. Awareness of the ethnohistory of clients is something Leininger feels is imperative for nurses to know, respect, and understand and it is displayed in her Sunrise Model. By showing interest and a willingness to listen, I was able to establish a trusting relationship with my client. “Doctors and other health care professionals should let Holocaust survivors know that they are interested in hearing their experiences if they wish to talk about them” (David et al., 2003, p. 120). This provided her with an environment where she felt secure and she was able to share some of her background and life experiences. Once she trusted me, I was able to learn the tremendous impact the holocaust had in her life and how she suffers from post-traumatic stress and flashbacks frequently. “When speaking to Holocaust patients about their experiences, it is important to let them take the lead” (David et al., 2003, p. 120). Furthermore, with this new knowledge I am able to prevent triggering her painful flashbacks of the horror of the Holocaust. I also understood why she was reluctant to talk with nurses and visitors. “Specific circumstances have the potential to trigger painful memories for Survivors of the Holocaust…Staff and family members should consider the individualized needs of the person they are caring for as well as using personalized common sense, encouragement and caring” (David et al., 2003, p. 51).
A thorough understanding of the ethnohistory of Holocaust survivors will allow clients care to be “individualized because nursing staff will have the background to appreciate the diversity and unique needs of their clients…With good support and training nursing staff will feel more confident in assessing Survivors' needs and developing strategies to meet these needs” (David et al., 2003, p. 120). Additionally, nursing staff will feel “more fulfilled by providing optimum care to Survivors [and their families] who lives remind us all of man's capacity for evil” (David et al., 2003, p. 120). Without this understanding, it would have been easy to regard this client as unfriendly and uncooperative with her care. For many Holocaust survivors basic trust has been destroyed and many are suspicious and cynical. This results in reluctance to seek help from health care professionals. Without achieving a thorough understanding of my client's ethnohistory, I would not have been able to provide care in a meaningful way. “Health care professionals must develop the skills, knowledge, and patience to explore and validate what the patient says and does” (Health Resources and Services Administration, 2003, p. 1). Leininger (1996) recognizes the occurrence of deeming clients with diverse cultural backgrounds as non-compliant by stating, “the consequence of stereotyping is inadequate or negligent client care. A client of a different culture may be labelled as ‘uncooperative, non-compliant or resistive to a health care regimen', when in reality, the care may be incongruent with the client's cultural beliefs and values” (Grant, & Letzring, 2003, p. 6) . Furthermore, Leininger asserts how this occurrence can be counteracted when her concepts of transcultural nursing are applied. “When transcultural nursing knowledge is applied to a situation and cultural-specific interventions are implemented, the client's compliance to the medical regimen improves, health status improves, and use of health care services is initiated more frequently” (Grant et al., 2003, p. 6)
By listening carefully to the client's experiences, I did not make assumptions and was able to make what I hope was an unbiased, informed assessment of her unique cultural needs. Being aware of biases helped me understand and respect the cultural differences individuals possess and how they may not be the same as mine but they are worthy of my attention. Leininger (1993) asserts the importance of nurses' self-examination. “Nurses need to critically and continually examine their own beliefs…Only by knowing one's own cultural beliefs well can one be ready to learn about another culture” (Eliason, 1993, p. 171). According to Leininger (1996) “nurses must be able to recognize, respect, and intervene in a manner that is congruent with the values of the client while recognizing their own cultural values and beliefs” (Berrios, 2003, p. 112). By allowing the elderly Holocaust survivor to express her feelings, I was able to provide her with support. The sensitive and knowledgeable transcultural nurse must be “aware of the importance of letting Jewish clients openly talk and express feelings and listen to their concerns…If some Jewish clients are shunned or avoided, they may feel discriminated against” (Leininger et al., 2002, p. 471).
By recognizing my client's need and willingness to talk, I looked beyond her physical problems to care for her mind and soul, not just her technical diagnosis. Leininger suggests that information obtained from the dimensions of her Sunrise Model led the nurse in providing holistic care, which results in a better understanding of people. Leininger's objective of transcultural nursing is for nurses to “greatly expand their thinking as they realize different cultural factors influence illness, wellness, and ways patients maintain their wellness or become ill” ( Mahon, 1997, p. 220). In order for this to be accomplished Leininger feels nurses must take a holistic approach to her transcultural nursing care practices, one that encapsulates the mind, body, and spirit of individuals as a whole. “ Nursing is a holistic science, and because culture is holistic and comprehensive, the nurse discovers important emic (local) views, as well as etic (outsider's) views to develop nursing care practices” (Mahon, 1997, p. 1). The Theory of Culture Care asserts how all individuals are affected by the cultural experiences and how culture becomes a part of everything individuals do in life. The concept of past impacts on present. “As they age and are confronted with new losses-declining personal health and ability to function, plus the natural death of friends and family –Survivors are easily reminded of their earlier tragedies” (David et al., 2003, p.103).
Cultural practices “are learned, shared between members of the group, and passed down from generation to generation to strongly influence health and illness states” ( Berrios, 2003, p. 112) . According to Leininger (1994), “ culture is largely the blueprint for predicting human motivation, action patterns, and consequently nursing interventions” ( McGee, 2001, p. 105). Although it is important for me as a nurse to consider my client's culture and how it influences their health, I feel it is important to not automatically assume that the behaviours of Holocaust survivors are directly a result of their past life experiences. “Holocaust survivors may be particularly vulnerable to experience that are often part of the aging process, such as loss, separation, illness or institutionalization” (David et al., 2003, p. 50). As a nurse working with elderly Holocaust survivors I feel it is imperative to not let other symptoms of aging such as dementia and Alzheimer's disease hide by masking them with the label of post-traumatic stress which is predominate in this culture. I feel nurses should attempt to eliminate physical and mental causation factors associated with normal aging before considering that their symptoms are solely caused by post-traumatic stress. “As the population ages and traumatic events continue to affect lives, caregiver knowledge of traumatic events and an understanding of what those events signify to an individual” will ensure they get the respect and dignity they require (Rosenfield, 2001, p. 8).
As a practising nurse, I will continue to explore the diversity of caring and how it can be carried out effectively for people of different cultural values, beliefs, and patterns. The Holocaust will never be over for my clients. As a nurse, I must be aware of the sorrow and anxieties of my patients. Building a therapeutic relationship with my clients is a priority, however in order to do this, I must understand the clients' experiences. A s a nurse, I must be sensitive and knowledgeable about care situations that may trigger traumatic memories for the aged survivor. “ Cultural competency is a journey. It is a process that requires constant learning and an acceptance of difference” (French, 2003, p. 252) .
“Together with patients, their families and other health care professionals, a nurse can expand the profession's capacity to provide care that is meaningful, supportive and respectful to the hospitalized elderly survivors and her or his family” (Bernick, Grinberg, Holynaty, & Rodgers, 2001, p. 29). “ The road to culturally competence can be a challenge for many healthcare providers, but the rewards are great. The rewards are an enhanced ability to ‘know our patients' and provide the highest quality healthcare” (French, 2003, p. 252) .
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Appendix A
Case Study: A Holocaust Survivor's Struggle
Miss. S. is an eighty-five year old survivor of Auschwitz concentration camp where she witnessed the deaths of her husband, two sons, and three daughters. She immigrated to Canada from Russia as an adult, alone, frightened and the only survivor in her family. She endured many obstacles starting her life over again with no financial backing and no family support. Miss. S. has frightening memories of her wartime incarceration intruding on her daily life, in the form of flashbacks and anxiety.
To this day, she vividly recalls the horrors of the Holocaust and the loss of her friends and family. Despite these flashbacks and her loneliness, Miss. S. built a new life, remarried, and had a second family. Her husband has died, and her children are living with their own families, so Miss. S. lives alone. She has visited the Baycrest clinic weekly for the past year.
As a student nurse at Baycrest, I saw Miss S. on a regular basis. Often I received a hello and then she would keep to herself for the rest of visit, walking with her head down, avoiding contact with others and appearing frightened and fearful when her name was called. After a few weeks, Miss. S. began to trust me, talking and sharing news. One afternoon the Baycrest clinic was running late, so I went over to talk with Miss. S. I asked her how she was and she asked me how I was. It was clear to me that a therapeutic relationship has been formed and she wished to share more. I did not want to push her but being a student, I was eager to learn the effects of Holocaust on its survivors. I asked her questions about her past and cultural heritage. She willingly began sharing information and began talking about her traumatic experiences during the Holocaust. Additionally she told me she suffered post-traumatic stress and she was well aware how it affected her life. She continued, sharing how blessed she feels to have a family that loves her dearly. She talked about how close to her heart her family is and their many academic achievements and how well they take care of her. The pride she felt for her family was very evident.