Transcultural Perspectives in the Nursing Care of Older Adults

This chapter is organized in three sections that follow an ecological model, which
recognizes that an older adult is a participant in an encompassing societal context, a
local community setting, and also interacts in an interpersonal setting that includes
family roles. Each of these areas influences the older adult’s help-seeking behavior:
 The encompassing social and economic factors affect the affordability and
accessibility of health care options for acute, chronic, and long-term care.
 The older adult’s cultural values, practices, patterns of caregiving, as well as
available community resources (informal and formal sources of help) will
influence when and where older clients interact in the biomedical health care
system or other systems.
 The older adult is also influenced by his or her nuclear and extended family
evident in diverse lifestyles and patterns of health-promoting or risk-taking
behavior, coping behavior to manage acute and chronic conditions, and
decision making about care and services. Chronic conditions may include
diabetes, hypertension, arthritis, and other illnesses that require medication,
diet modification, or symptom monitoring.

Theories of Aging
● There are several theories of aging that have been very popular over the
years and continue to be relevant in explaining how older adults are viewed
in society.
● Disengagement theory focuses on explaining that older adults whose status is
linked to employment perceive less self-worth in retirement when relieved of their
roles and responsibilities.
 Activity theory describes that older adults may substitute recreational and
meaningful opportunities to take the place of previous occupations and
careers. Active older adults are recognized for contributing as family caregivers
and as volunteers for social service organizations among other productive
activities.
 Continuity theory focuses on supporting adults to remain engaged by
adapting patterns of behavior from their younger adulthood to keep them
involved into older adulthood.
 Erickson’s developmental theory advances that older adults may struggle
with the tension between maintaining the integrity of their experience while
facing the reality of declining physical and mental functions. In late older
adulthood, individuals may despair with the perception that life is too short and
with old age comes less authority and power (Erickson & Erickson, 1997), but
they may also find joy in being a keeper of meaning and holding enduring
relationships (Agronin, 2014). Cohen (2011) has described that older adults
may “sum-up” their lives, which includes a search for larger meaning in life,
before having an “encore” phase of reflecting, reaffirming, and celebrating the
major themes of their lives.
The Older Adult in the Community: Cultural Influences
In community settings, we observe differences in how culturally and ethnically diverse
older adults’ life experiences will shape their health behavior and illness behavior.
Older adults may carry out positive health behavior, such as not smoking, eating
healthy foods, or maintaining regular exercise. Older adults could have walked daily
when living in their home countries and eaten diets high in vegetables. When they
are relocated into an urban setting, they may no longer feel safe to walk in unfamiliar
areas and they may alter their diets to include available prepared and packaged
foods.
Among refugees from different regions, including Eritrea and Ethiopia in East Africa, as
well as immigrants from Eastern bloc nations, many have lived through civil wars,
ethnic tensions, and political revolution, and they feel depleted in trying to cope with
more changes in their lives after leaving their homelands. As aging adult immigrants,
they may experience adjustment problems that warrant care in the health and
mental health care system, but at the same time, they may distrust the system or
have very limited experience in seeking biomedical health care. Nurses who are
providing care to clients whose background differs from their own need to be
sensitive to assessing the client’s culture. Individuals who have immigrated from the
same country or region will differ in their needs and in the ways that their cultural
background influences their health- and illness-related actions. These differences
are based on a number of factors:
1. Regional or religious identity Situation in their homeland that may have prompted
them to emigrate
2. Length of time they have spent in the country where they resettled or immigrated
including degree of acculturation
3. Proximity to immediate family or extended family members
4. Network of friends and social support from their homeland
5. Link with ethnic, social, and health-related institutions

Understanding Culture Change

 Some older adults have relocated to different regions of the country or have
made a significant transition in their late adult years to be close to younger
family members or for other reasons. Older clients may have the common
experience of relocating or migrating, but they may vary in adjusting to new
settings and to a new social environment (Keith,2014).
 Cultural change can contribute negatively to mental health, and this
psychological stress is more intense for older refugees. For example, among
some Central American immigrants living in a metropolitan area in the United
States, their perceived stress was correlated with their psychological health.

Caregiving of Older Adults

 Older family members are part of the informal social support in their families,
so they may be the caregivers for grandchildren or younger family members
and they may receive assistance and support from other family members
(see Figure 8-3) (Khan, 2014).
  If the older adult becomes ill, then families may have to adapt to find an
alternate caregiver. Older adults in their family social support networks may
also be in need of assistance and nurturing. Consider the preferences of the
older person and his or her family members, as well as the capacities of the
older adult for selfcare and the willingness and capabilities of the families to
offer support and assistance with care.
 The type and duration of support that can be provided by family members
must be considered in relation to sources of formal support from home health
workers, hospice care, and visiting nurses and therapists that could be used
to sustain the family care.

Dimensions of Social Support

Social support has been delineated in three ways: affective support, or expressions of
respect, and love; affirmational support, or having endorsement for one’s behavior and
perceptions; and tangible support, or receiving some kind of aid or physical assistance,
such as accompanying a person to an appointment. Many older adults are deprived of
the informal social supports due to losses:
 Separation from immediate family members because of geographic mobility
 Age-related segregation caused by increased nuclear creased nuclear families in
neighborhoods
 Loss of spouse or partner because of death or illness
 Loss of leisure pursuits or entertainment due to illness, loss of income, or declining
physical abilities

It is especially important for many older adults to have social, emotional, and physical
sources of support to assist them to remain as independent as possible. We know that
social support may mitigate the negative effects of social stress, but the exact
mechanisms are unclear. We do understand variations in these patterns of support,
which helps to prepare nurses who work in acute, extended-care, or community
settings. Some minority older adult clients may have more connections to kin in their
support networks, but they may also be more vulnerable to conflicts in tight-knit
networks; this is less common for older adults who have multiplex networks of family,
friends, neighbors, and coworkers (Lincoln, 2014).

Variations Among Members of Cultural Groups

● The large older Hispanic population includes very diverse individuals who not
only represent different countries, traditions, and acculturation status but who
also have many variations in their patterns of social support from friends and
family.
● While there are intragroup and intergroup differences, some patterns have
been observed in studies of Hispanic elders. Older Cuban Americans are more
likely than Mexican Americans and older Puerto Ricans to get together often
with friends. Older Mexican Americans are more likely than either Cuban
Americans or Puerto Ricans to attend church and to have daily contact with
their children (Friedemann, Buckwalter, Newman, & Mauro, 2013).
 ● There are also significant variations in groups of older Asian Americans and
Pacific Islanders. Older Korean Americans may have immigrated with their
highly educated adult children, but a higher proportion of the older clients wish
to live independently from the adult children. The Korean American elderly
may socialize with their peers through Korean churches but some are more
likely to be lonely and isolated than Chinese, Japanese, and Filipino elderly
(Park, Roh, & Yeo, 2011).
● The nurse may look for ways to support an older adult immigrant in making ties
to his or her home country to enhance self-esteem and feelings of belonging.
Nurses may ask if an older adult can talk to a group of children at an ethnic
community center, such as the Ukrainian Community Center, El Centro de la
Raza, or the Polish Association.
● The older adult can also tell the history of his or her immigration to adolescents
who may be tracing their cultural heritage for an oral history project. Senior
adults may also be connected to school-age children by walking them to and
from school or tutoring them through an after-school project. Nurses who are
working with ethnic elderly clients may want to look for resources in the local
community to do outreach to these community members and to involve them in
their care.

The Older Adult: Caring for Individual Clients

● At an individual level, older adults continue to meet developmental tasks similar
to the way young adults and middle-aged adults also fulfill developmental tasks.
The developmental tasks that older adults achieve include the satisfaction of
basic needs, such as safety, security, and dignity, and the fulfillment of integrity
and
self-actualization.
● For the majority of older adults, meeting these needs is intertwined with the
lifestyle and the residence of the older adult. The older adult also usually
prefers to maintain self-esteem through exercising self-determination in
planning where he or she will live. Older adults may confer with their family
members in discussing what housing option provides a safe environment where
risks for injury or falls are reduced and social and health supports are available
for the older adult.

Faith and Spirituality

● Many older adults experience an increase in religion or spirituality, which is
evident in showing increased humanistic concern for future generations,
changing relationships with others, and spending time coming to terms with
one’s mortality.
● Older adults respond differently to these spiritual development tasks
as influenced by their culture, life experiences, and individual
qualities.
● Religion and spirituality may be a source of emotional support, a psychosocial
resource, or a coping mechanism for older adults who experience challenging
 health conditions, losses in personal relationships and fulfilling roles, and
stress.
● Previous studies have found that older adults’ immigration status and
countries of origin influence different religious and spiritual participation
and devotion behavior.
● Some African American female elders have reported higher importance of
religion and spirituality in their lives when compared to younger adults, and
church-based social support was related to positive well-being and life
satisfaction (Krause, 2010).
● Another example of spirituality is evident in older black Caribbean elders with
higher education who were more likely to attend church services, while the
younger and less educated black Caribbeans reported more devotional
nonorganized behaviors (Chatters, Nguyen, & Taylor, 2014).