DIVERSITY IN DEATH AND DYING:
Cultural Competency in Hospice Social Work
Introduction
I have worked as a volunteer with refugees for several years. After my field instructor at my internship at Hearth Hospice learned this about me, she had the idea for a project on “Diversity in Death and Dying: Cultural Competency in Hospice Social Work”. I agreed that this would be an interesting area in which to do a special project and began researching the topic in February of 2019. Our country as a whole is becoming more and more diverse, and the Chattanooga area is no exception. Hospice social workers need to be culturally competent as they strive to respect the rights and self-determination of clients from diverse backgrounds during their end-of-life. The project was completed by December 1, 2019.
Project Details
I began my special project by researching and writing a literature review on my topic. There is not a lot of empirical research on diversity in death and dying from a social work perspective. Most empirical articles are limited to the variables of ethnicity and religion only. But I found enough sources to conduct a literature review, and this helped in laying the groundwork for the rest of the project. I then met with a funeral home director in Chattanooga who specializes in and is certified in several different cultural types of funeral home clients and gained further knowledge on my topic. Next I created a powerpoint presentation based on all of the data and information that I learned.
I did an assessment of Hearth Hospice based on the cultural variable of ethnicity by looking at their current caseload for the Chattanooga area. On July 1, 2019, Hearth Hospice had a total census of 231 patients. Of this total 96% were Caucasian, 3% were African American, 0.43% were Latino, and 0.43% were Asian. I compared these findings with demographic statistics for Chattanooga as a whole. The latest Census Bureau estimates from July 1, 2018 for Chattanooga’s population were 61% Caucasian, 33.3% African American, 5.6% Latino, and 2.4% Asian. The book Hospice Social Work recommends that hospices annually assess and evaluate both their own census population and their personnel for diversity. Hearth Hospice has a diverse group of employees. But the lack of diversity among their patients reflects national trends and led to an intervention.
After assessing and evaluating the research that I conducted, I did a community intervention, focusing on African American clergy. I learned from my empirical research that African Americans are the most religious ethnic group in our country and sometimes get healthcare advice from their pastors. But they do not use hospice services as much as other cultural groups for a variety of reasons. For an organizational intervention, I engaged with several African American pastors one-on-one to discuss the issue of hospice services and the African American community. In the vast number of cultural variables in death and dying that affect cultural competency among hospices, the ethnicity of African Americans is just one factor- but one that I feel needs to be addressed in the Chattanooga area.
Finally, on September 18, 2019 I presented my powerpoint to employees from the three different locations of Hearth Hospice as a way to improve cultural competency among those who work with hospice patients. At the conclusion of the employee session that I led at Hearth Hospice on cultural competency, I distributed a post-session survey to all those who were present to receive feedback and determine their level of cultural competency in death and dying. On December 1, 2019 I assessed the ethnic makeup of Hearth Hospice’s census of 277 patients. The statistics were very similar to what they were in July and continue to indicate the lack of ethnic cultural diversity among hospice patients.
Theoretical Foundations
This special project was based on systems theory and in particular the different systems that intersect at end-of-life for diverse clients, such as caregivers, the family unit as a whole, the funeral home industry, governmental agencies, and our largely Caucasian healthcare system in the U.S. The family systems theory is also relevant as a terminal illness affects the entire family as it is a crisis and challenge to all of the them. In working with clients from different cultures, the person-in-environment theory is also an important foundation to consider, as hospice patients can be understood by environmental influences from within their particular culture. A strength perspective is necessary when working with hospice patients from all cultural backgrounds, and a knowledge of diverse cultures helps in identifying these strengths. The intrinsic motivation theory also helps explain why a social worker can be motivated by internal factors, such as competence about various cultures, in order to meet the needs of hospice patients from different cultural backgrounds than the dominant culture.
Conclusions
This hands on special project on cultural diversity in death and dying increased my knowledge about different cultures and how they approach end-of-life. It gave me an opportunity to do an assessment, intervention, and evaluation on an organizational and community level. My original plan for the community intervention was to speak to African American pastoral groups, but due to time constraints and some resistance from the community I changed it to meeting with African American clergy members one-on-one. I conducted research and learned about policy. In short, I was able to demonstrate all nine competencies while helping my internship agency with the issue of cultural competency.
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My special project demonstrated all nine competencies required by the CSWE.
Competency 1: Ethics and Professionalism
The research that I conducted was evidence-based and presented without stereotyping cultural groups by recognizing that there are differences within each cultural group. I received supervision and consultation from my field instructor throughout this project. I demonstrated both professional written and oral presentation skills in the literature review paper and powerpoint that I wrote and created. The powerpoint was presented in a cultural competency training session that I gave on “Diversity in Death and Dying: Cultural Competency in Hospice Social Work” to Hearth Hospice staff.
Competency 2: Diversity
My project was all about diversity. I explored cultural groups based on religion, ethnicity, LGBTQ affiliation, inmates, and those hospice patients residing in rural areas. I visited a Muslim mosque, attended a Shabbat service at a Jewish temple in Columbus, GA that had been attacked by white nationalists three days earlier, interviewed a funeral home director in inner city Chattanooga who specializes in diversity, and met with African American ministers.
Competency 3: Human Rights and Justice
I reached out to minority groups to educate them on the benefits of hospice services, emphasizing the right to self-determination and the financial and social benefits of using hospice. The hospice philosophy is for patients to die as peacefully and comfortably as possible and preferably in their own homes. The census population at Hearth Hospice on July 1 was 96% Caucasian and just 3% African American. Many low income residents in our city are not aware of the Medicare hospice benefit, which includes economic benefits. My project sought to increase diversity among low income and minority groups using hospice in Chattanooga, TN.
Competency 4: Research
I purchased a textbook on hospice social work that was invaluable in guiding my research. In addition I researched and wrote a literature review of contemporary best practices based on empirical academic articles. This led me to conducting research on the hospice agency where I interned to find out how ethnically diverse our own client population was. I also did a lot of policy research, including Medicare/Medicaid policies on the hospice benefit to clients.
Competency 5: Policy
I initially set out to learn about federal and state policies that affect diverse hospice clients such as immigrants. A local funeral home director informed me that about 60% of his immigrant clients have the body of the deceased shipped back to their home countries. There are several policies on transporting human remains that influence how this is carried out. My agency last year had a particular case where the office of Sen. Bob Corker had to get involved, and it was good to learn the best way to contact lawmakers if their help is necessary. I researched immigration policies and then went on to research federal and state policies for death certificates, embalming, caskets, burials, cremation, transporting bodies across state lines, and funeral home laws. I attended a local meeting where a case manager from a U.S. Representative’s office spoke about how to best engage with lawmakers in hospice social work practice, including diverse clients such as immigrants.
Competency 6: Engagement
From my research I gained insight into how to best engage with hospice clients from diverse cultural backgrounds and to not assume anything when engaging with a particular cultural group. This engagement also included best practices when working with the family members and caregivers of hospice patients from different cultural groups. In my presentations to hospice employees on cultural competency, I covered information from evidence-based articles on how to best engage with these various individuals and groups, including who to address first when engaging with hospice families from other cultural groups.
Competency 7: Assessment
I learned through this project how to best assess hospice patients from diverse backgrounds and presented this information to groups of hospice employees. It is important for hospice social workers to prepare to ask questions when working with culturally diverse clients rather than to assume to know a client’s views. I also conducted an organizational assessment of the ethnic diversity of current patients of Hearth Hospice where I interned to determine the cultural diversity of our own client population and how that compared to the ethnic make up of Chattanooga. In a survey questionnaire given to the social workers from the three Hearth Hospice offices, I assessed their experiences in working with diverse clients.
Competency 8: Intervention
After doing my organizational assessment of Hearth Hospice, I found that in a city of Chattanooga where 33.3% of the residents are African American, only 3% of our hospice patients on July 1, 2019 were African American. This compares to national data that found that 7.6% of hospice patients in the U.S are African American. Several empirical articles reported that African Americans are more religious and may get healthcare advice and counsel from their pastors. As a community intervention, I met with local African American pastors and talked to them about hospice and tried to dispel any myths that they had heard and pointed out the benefits of hospice that many people are not aware of. I also did an intervention at the organizational level by leading a presentation on cultural competency based on my research for the employees of Hearth Hospice.
Competency 9: Evaluation
I distributed a survey questionnaire to those who attended the cultural competency training session that helped in evaluating the level of knowledge about diverse populations that Hearth Hospice staff has. I evaluated my project with my field instructor throughout this process and particularly at its conclusion. I tried to pay special attention to my wording, both written and spoken, that I did not stereotype or generalize cultural groups, recognizing that there are many differences within a cultural group. The intervention that was done with local African American pastors may not affect the client diversity of Hearth Hospice for awhile, as is was conducted in the fall of 2019. On December 1, 2019, I assessed the racial makeup of Hearth Hospice’s patient population a second time and evaluated the changes from July 1, 2019 by comparing the percentages of the racial diversity among the patients. The percentage of Latino and Asian patients decreased slightly due to a larger patient population in December. The Caucasian percentage stayed the same, and my evaluation concluded that the African-American percentage increased by a quarter of 1%.
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