Increased awareness calls for openness and self-reflection. It is a conscious effort to recognize the bias we express in our interactions with others, especially those who are different than we are (Stone & Moskowitz, 2011). If the nurse is white, especially those who are younger, it is realizing that this means special privilege and freedoms in a predominantly white and youth-oriented society. Those who are especially affected are older adults of color who may not have had the same advantages or experiences as the nurse (McIntosh, 1989). For example, in many regions of the United States, especially in the rural South, the current cohort of African Americans was limited to a fourth-grade education, with far-reaching implications. African Americans who are elders today lived during the time of Jim Crow laws which legalized discrimination and segregation and significantly restricted their lives. Events of the time included numerous murders by lynching (see www.jimcrowhistory.org and Box 4-2). These elders are also aware of the Tuskegee Experiment, in which black men with syphilis were purposely deceived and not treated so scientists could study its effect over time (see www. cdc.gov/tuskegee/timeline.html). For some, this has left a continuing distrust of the health care system and a reluctance to become involved in research.

Cultural awareness means recognizing the presence of the “isms” such as the racism just described. It is imperative to understand how these affect not only the pursuit and receipt of health care, but also the quality of life for older adults (Smedley et al., 2003). Moreover, as older adults they also may have faced sexism, classism, ageism, and so on.

Ageism is a term coined in 1968 by Robert Butler, the first director of the National Institute on Aging, to describe the discrimination and negative stereotypes that are based solely on age. Cole (1997) examined the historic roots of ageism in America. At one time, power in the United States was held almost exclusively by older white males. With the shift to urban industrialism and a growing emphasis on productivity and the ability to withstand the rigors of factory work, power and influence shifted from older to younger white men. With a near cultural obsession with youth today, it is easy to see that ageism is alive and well. Gift shops and department stores are replete with products such as “antiaging” products and graphic portrayals mocking the abilities of those formerly known as elders (Associated Press, 2011). In 2004, Americans spent $45.5 billion on antiaging products, and spending is expected to reach $72 billion by 2009 (International Longevity Center, 2006, p. 28). We often think in personal terms when negative stereotypes are applied to the person due to his or her age, but ageism may also be institutional, such as in mandatory retirement policies or the absence of older adults in research clinical trials. Ageism may be intentional, such as when older workers are targeted in financial scams, but more often in nursing it is unintentional, but nonetheless present and hurtful (Box 4-3). Some health care professionals demonstrate ageism, undoubtedly in part because providers tend to see many frail older persons and fewer of those who are healthy and active. The impact of these perceptions has largely been ignored but almost certainly negatively affects health outcomes.

We now know that ageism is not universal but is most often reflective of the Euro-American culture. In many other cultures, elders are treated with special respect and honor. For example, for the most part, African American elders are respected. They may provide wisdom and insight to younger members of the family. Owing to a number of factors, African American grandparents are increasingly assuming the role of parent, for grandchildren and other teenage and younger relatives (Caminha-Bacote, 2008) (see Chapter 24).

Before the nurse provides quality care to elders, it is useful to self-reflect and consider whether one holds any personal beliefs about such persons and whether these beliefs are negative or positive, how they affect care delivery, and if they are based on facts rather than anecdotal experiences resulting in stereotypes.

Some nurses prefer to use what can be called an “encyclopedic” approach to details of a particular culture or ethnic group, such as proper name usage, touch, greeting, eye contact, gender roles, foods, and beliefs about relevant topics such as health promoting practices, pain expression, death rituals, or caregiving. This information is available in many compendiums of cross-cultural information (see the Evolve website for this book). The work of the Stanford Geriatric Education Center is especially helpful in this area (http://sgec.stanford.edu/training). When working with elders from a specific culture, knowledge about attitudes toward caregiving, decision making, and death rituals are especially important and may be particularly sensitive.

Although cultural knowledge is helpful and essential, caution must be used with regard to the potential for stereotyping. Stereotyping is the application of limited knowledge about one person with specific characteristics to other persons with the same characteristics; negative characteristics are especially prone to this treatment. Stereotyping limits the recognition of the heterogeneity of the group. At the same time, relying on knowledge of a positive stereotype can be useful as a starting point in understanding, but it too can be used to limit understanding of the uniqueness of the individual and impose unrealistic expectations. For example, a common stereotype of the African American culture is to assume that the church is a source of support. The nurse’s assumption can easily have a negative outcome, such as fewer referrals for formal services support (e.g., home-delivered meals).This stereotype can also be used to shortcut conversation about discharge planning. In discussing discharge plans with an African American elder, the non–African American nurse may say, “I understand that the church is often a source of support in the African American community. Is this one of the resources you will be able to depend on when you return home?”

Persons from a specific ethnic group may share a common geographical origin, migratory status, race, language or dialect, or religion. Traditions, symbols, literature, folklore, food preferences, and dress are expressions of ethnicity. These may be particularly seen in older adults who have had no need to leave their culture-specific neighborhoods such as Chinatowns in the major cities, or the barrios of the Southwest. Persons who identify with the same ethnic group may or may not share a common race. For example, persons who consider themselves Hispanic are members of the most diverse ethnic group in the United States and may be from any race and from any one of a number of countries. However, they usually have the Catholic religion and the Spanish language in common.

Health beliefs and practices are usually a mixed expression of life experience and cultural knowledge. In most cultures, older adults are likely to treat themselves for familiar or chronic conditions in ways they have found successful in the past, practices that are referred to as domestic medicine, folk medicine, or folk healing. The basis for much folk medicine was, and remains, to make the most of whatever is available. When self-treatment fails, a person will consult others known to be knowledgeable or experienced with the problem, such as a community or indigenous healer, often an elder known to the community. Only when this too fails do people seek help within the formal health care system.

The culture of nursing and health care in the United States is one that advocates what is called the Western or biomedical system with its own set of beliefs about the cause of illness, the choice of treatments, and so on. In most settings this belief system is considered superior to all others, an ethnocentric viewpoint. However, many of the world’s people have different beliefs, such as those of the personalistic (magicoreligious) system or the naturalistic (holistic) system. Each system is complete with beliefs about disease causation and recommendations for prevention and treatment. It is not uncommon for ethnic elders to adhere to belief systems other than the biomedical system or a combination of systems. Nurses who are familiar with the range of health beliefs and realize their importance will be able to provide more sensitive and appropriate care. In the absence of understanding there is great potential for conflict. This is especially important to remember when working with those who have lived in culturally homogeneous communities.