Imagine being a 76 year old man who is dying of cancer. Your first language is not English, you are in pain, you don’t know who all these people are that are trying to help you, and you are scared. You are informed that you cannot go home because home care services are not able to meet your health needs at this point in your illness. You have been told that you are too healthy for the palliative unit, because all of your presenting symptoms upon admission have been taken care of. Your prognosis is not clear at this point, so you do not fit the criteria of admission into a hospice, but still the doctors insist that the unit is not the best place for you at this point. The only option left is to sign the Application for Long Term Care, and wait to be paneled for a Personal Care Home. When you disagree to dismantle your estate and sign the papers the doctor calls into question your competency.
I find the above scenario frightening. It is frightening because it is a situation that is too common in the hospitals and in-patient facilities. There are a number of factors at work in the situation above. This gentleman is in pain and has reverted back to his native language. He does not necessarily understand all that is happening to him, this is not to say that he does not have the capacity to understand, but that the information is not being presented to him in an understandable fashion. He is not complying with the medical team to sign the papers for long term care, and should he refuse this option than his competency must be called into question and tested. This man was competent, he could make decisions; he was just ill and did not want to accept the options that the medical system was offering. What I saw was a man who refused to comply with what the system felt was best, and as a result of which his competency and capacity to make decisions was called into question. The system was not challenged, but a man’s competency was.
When the masters student came into our class and gave a talk on her thesis project which was focused on competency exams, the above scenario came to mind. I immediately recognized the need for a team of health care professionals who were removed from the situation, but would be the ones to administer a competency exam. Should the doctor from the scenario above be the one to administer the exam on the gentleman than the results would be biased and the validity of the test would be compromised. As social workers it is our job to see the whole picture and to challenge the system when it is apparent that an abuse of power and authority are occurring.
I want to expand on this topic one step further. I want to look at the issue of competency testing and our Aboriginal older adults. How do we actually test a person’s competency? How is a simple 15 minute Mini Mental State Exam able to give enough information about an individual to take away their ability to make decisions for themselves? In the above scenario the older gentleman was not born in Canada, and English was not his first language. Even though Indigenous older adults were born in Canada, their culture and life experiences are vastly different than those of a Euro-Canadian older adult. Indigenous older adults are coming from a collective culture, many of them have grown up on reserve communities, and for some English is not their mother tongue. So how would a 15 minute examination take into account the inherent cultural differences that have shaped this person’s life?
Cattarinich, Gibson, and Cave (2001) examined the cultural barriers present in many of the competency exams administered by health care professionals. The goal of their research was to help health care professionals develop new tools to help in the development and administration of cross cultural competency assessments. What I thought was particularly interesting about this article was that it highlighted the fact that Aboriginal people are over represented in mental health services. This fact supports the article’s importance for furthering research, as it would be unjust to have a certain population over represented as incompetent, due to a lack of cultural awareness when administering a competency exam. The barriers present when administering competency exams to Aboriginal seniors lies in both the content of the exam questions themselves, and in the process’s through which the exams are administered. Neither the content of the questions nor the interview process take into account the older Aboriginal’s life experiences and cultural lens.
The term Degrees of Acculturation was used by Cattarinich et al (2001) in order to determine the varying levels of diversity present within the older Aboriginal community. Four categories of particular life styles were developed to gain an understanding of how Aboriginal people have responded to colonization, the four categories include: traditional, marginal, bicultural, and assimilated. The group most affected by problematic competency exams are those who adhere to a very traditional life style. One of the suggestions that the authors gave was to develop an understanding of how the older Aboriginal person has lived their life, before their cognitive capacities are examined. In this way the tester can develop cultural competency as it relates to this individual, as there are many contradictions between Euro-Canadian conventional ways of testing and traditional Aboriginal life styles.
Cultural considerations should be taken into account when a competency exam is being administered, as such cultural influences will have an effect on the outcome of the exam (Cattarinich et al., 2001). The study found three key areas of cultural “interference” if you will, or better defined as Aboriginal culture that clashed with conventional testing methods. The first is the Aboriginal ethic of non-competiveness. In competency examinations there is a built in tendency in the very process of administering the exam that expects the person taking the exam to demonstrate their knowledge to the full extent. Whereas in Aboriginal culture traditional elders will often down play their knowledge in an act of humility, so as to acknowledge how small they are in comparison to the Creator.
Cattarinich et al (2001) identify the next area of incompatibility between competency exams and Aboriginal culture as it relates to Aboriginal attitudes towards gratitude. The administrator of the competency exam is told to, as part of the process, encourage and praise the individual taking the test. However, in Aboriginal culture displays of gratitude or approval are not commonly shown. It is believed in Aboriginal culture that the intrinsic satisfaction that comes with performing a task is thanks enough, anything above and beyond that is viewed as superfluous. Therefore when the administrator of the examination is encouraging and praising the person taking the exam, the older Aboriginal person may respond by “underachieving” as a way of trying to ease the discomfort they are feeling.
The last area of conflict I am going to discuss is what Cattarinich et al (2001) identifies as communication style and taboos. The authors view the misunderstandings that health care professionals often have of Aboriginal culture as the direct result of cultural incompetence on the part of the health care system as a whole. They state:
Native American Indians emphasize a non-verbal communication style. Moderation in speech and avoidance of direct eye contact are nonverbal communications of respect by the listener, especially for respected elders or authority figures. Traditional Native American Indian people are not rewarded for asking questions or verbally analyzing situations. Rather, they are expected to learn through patience and observation (p. 1472).
In closing, after my own experiences with the possibilities of deeming a man incompetent due to cultural differences, and after reviewing the previously discussed article, I feel that as social workers it is our responsibility to advocate on behalf of older Aboriginal adults who find themselves in a system that does not understand them. Competency examinations do not take into account fundamental historical differences that these individuals have lived through. The question and response format of a competency exam is not compatible with traditional ways of communication that older Aboriginal adults have been socialized with. It is only through open communication with Aboriginal communities, and families of older Aboriginal patients, that one’s true “competency” can be determined. We cannot summarize an individual’s whole life experience into a 15 minute mini mental state exam. I believe that a person’s competency needs to be tested in an appropriate, respectful, and culturally accommodating way in order to truly understand their perspective.
-Michelle K.
References
Cattarinich, X., Gibson, N., & Cave, A. (2001). Assessing mental capacity in Canadian Aboriginal seniors.
Journal of Social Science and Medicine, 53, 1469-1479.
Journal of Social Science and Medicine, 53, 1469-1479.
Michelle,
ReplyDeleteI really enjoyed this blog.
I believe that this is an issue that has been occurring since the beginning of colonization, when the government began to negotiate treaties with Aboriginal people who didn't speak english they would often have them "read" and sign treaty agreements with an "x". Because many Aboriginal people did not read or speak english they were often left with a misunderstanding or misinterpreation of what the treaties actually meant.
I believe that this same sort of thing is happening today with assessing Aborignal seniors mental capacity or competency. How can we address an Aborignal person's capacity or competency when many if not most health care professionals are viewing the idea of competency by their own values and through a eurocentric lense? You are right when you say this is very frightening and I really hope that the work of people such as the Master student who came to our class helps make changes in the way that competency assessment are conducted.
Kendall