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Diversity

What is diversity? 

Diversity includes a person’s cultural background, sexual orientation, gender identity, spiritual and religious beliefs, Indigenous identity, among others. [1] These dimensions inform how a person understands themselves, and how they relate to family, community, and society. Cultural identity may include language, religious or cultural practices, celebrations, or other practices specific to a culture or community. [2] 

Intersectionality means that a person may experience more than one dimension of diversity. [1] When multiple marginalised social identities are combined, it can increase the likelihood of discrimination, resulting in additional difficulty receiving respectful, dignified care. [3] 

Cultural awareness is the understanding and sensitivity to the values, beliefs, customs, and traditions of different cultures. Cultural safety is ‘being open-minded and respecting the identities and customs of all people who are culturally different from yourself and/or most of society’. [4] 

Why does this matter for rights-based care? 

Australia’s older population is becoming more diverse, with more than one third of Australians aged 65 and over born overseas. [5] The aged care workforce is also growing, with providers increasingly hiring culturally and linguistically diverse (CALD) workers. [6] 

The Aged Care Act supports ‘accessible, culturally safe, culturally appropriate, trauma-aware and healing-informed funded aged care services’. [7] The strengthened Aged Care Quality Standards reinforce providing good quality, person-centred care that recognises diversity:  

  • Standard 1, Outcome 1.1 focuses on understanding each person’s background, communication needs, and life experiences, and using this information to deliver culturally safe, trauma‑aware and healing‑informed care. [8]
  • Standard 2, Outcome 2.1 describes partnering with people of diverse backgrounds, including First Nations people to ensure accessible and culturally safe services. [9]
  • Standard 3, Outcome 3.2 reiterates that people should receive culturally safe, trauma aware and healing informed funded aged care services that are evidence-based, addresses what they need and prefer, and optimises their quality of life. [10] 

Respect, dignity, and support for older people’s spiritual, cultural, religious and gender identity are central to quality aged care. [11] 

First Nations and Indigenous identity 

First Nations peoples face the ongoing effects of European settlement in many aspects of their lives, including health and wellbeing. [12] For Indigenous older people, ageing in place is a way to fulfil self-determination, so they can keep their connection to their land, communities, and culture. [13] This promotes holistic wellbeing and social supports in place. [13]  

Feeling culturally unsafe can affect Indigenous people’s decision to engage with healthcare services, anticipating that they will experience racial trauma. [14]  

When providing care for Indigenous people, power imbalances can unintentionally be reinforced if healthcare professionals are not aware that their decision-making can be affected by their own racial biases, attitudes, prejudices, and assumptions. [14] Non-Indigenous healthcare professionals can blame patients for health inequalities, rather than recognising harmful systemic and historical factors. [14] 

Read more in the First Nations Hub. 

Cultural and linguistic diversity

People from CALD backgrounds have different languages, experiences, and cultural beliefs. CALD may include people who were born overseas or in Australia, speak a primary language other than English, have different family or community structures, or identify with more than one of these experiences. [5]  

Language and communication norms differ between diverse groups. [15] Language barriers, low health literacy, and a lack of information in their language are barriers for some older people in accessing home care services. [16] Residents from a minority background may find it hard to speak up about their complaints, opting to wait until issues become ‘desperate’ because they worry about being seen as difficult or that they will experience retaliation. [17]

Sexual and gender diversity

Sexual and gender diversity includes people who identify as lesbian, gay, bisexual, trans/transgender, intersex, queer, and other sexuality (including asexual; LGBTIQ+)*, gender, and bodily diverse people. [18] Ageing as an LGBTIQ+ person brings unique challenges, such as reduced social and community supports, and navigating others’ heteronormativity and ageism. [19] 

LGBTIQ+ older people may have different preferences for how they want to be supported and cared for. [20] Responsive, flexible practices that centre the older person’s needs and preferences can help identify how best to support older LGBTIQ+ people in care. Sensitivity training around inclusion and diversity, cultural responsiveness, and inclusive polices that explicitly name transgender and gender-diverse identities are ways that aged care providers can improve workplace culture, resulting in better care for LGBTIQ+ older people. [19, 21]

Bias, discrimination, and exclusion

People from marginalised backgrounds often experience bias, discrimination, and/or exclusion.  

Bias refers to a preference for one group over another. [22] Bias can be external: a negative view held by another person towards a group, or internalised, when a person holds negative attitudes towards the group they are a part of. Bias can be unconscious or a person can be aware of biases they hold. [23]

Discrimination is negative action or behaviour towards a person or group based on a personal characteristic that is protected by the law. [24] One example is refusing to provide care to a resident from a non-English speaking cultural background. 

Ageism is an example of a bias that applies to all older people in our society. [25] However, intersectionality, which refers to ‘ways in which different aspects of a person’s identity can expose them to overlapping forms of discrimination and marginalisation’, [26] means that older people from diverse backgrounds can face more discrimination than those from European backgrounds. 

Exclusion, or leaving people out of an activity or decision, can happen based on cultural identity. While exclusion often happens due to bias, people from diverse groups can be excluded even when there are no bad intentions. For example, CALD residents may not speak English, which can exclude them from receiving good care if translators or materials in their native language are not available. [17, 27] They may also be unable to clearly express their concerns or follow complex complaints processes. [17] 

Exclusion can also happen when designing programs or technology, which can result in products and tools that are harmful to some groups. AI systems can inadvertently encode ageism and cultural bias where when older people, Aboriginal and Torres Strait Islander Elders, and CALD populations are not represented in design and training datasets, the resulting tools may misrepresent their needs. [28]  

Research can also exclude important diverse perspectives. There is a lack of research on cultural safety relevant to Indigenous peoples within a human-rights based framework. [14] Also, while sexual and gender diversity are becoming more accepted in society, there may be bias toward more heteronormative research, which means that these diverse perspectives are missed. [29] 

Racial, ethnic, and socioeconomic disparities 

When there are long-standing biases, discrimination, and exclusion of people from marginalised groups, it results in disparities, or differences in the conditions, access, and outcomes for marginalised groups when compared to groups that do not face these challenges. [22] 

These disparities worsen as people age. For First Nations people, this is demonstrated by the shorter life expectancy of Aboriginal and Torres Strait Islander people when compared to non-Indigenous people. [30] 

These disparities can impact the services that are available to people from marginalised backgrounds. In aged care settings, older people from marginalised groups are disproportionately placed in lower quality facilities. [17, 31]

Workforce diversity

Australia’s diversity means aged care services need to be inclusive and responsive to individual needs. This applies to both older people and the aged care workforce.   

Aged care providers increasingly rely on CALD staff. [6] Service providers should have a non-discrimination culture. [16] Staff who are culturally competent and sensitive are vital. Given that Australia has both a CALD workforce and a CALD older population, cultural differences between staff and older people receiving care need to be considered and navigated. A one-size-fits-all approach to care for diverse people with diverse needs does not work well. Shared values, beliefs, and common goals for the wellbeing of both groups should be the primary focus of interest. [32]

Diversity-affirming practices 

Person-centred approaches 

Person-centred care involves services that reflect what the person wants and needs, and their cultural or religious values. [33] For example, meeting a resident’s request for Halal food respects their religious beliefs. [27] These supports can help provide a better experience in residential aged care for the person and ensure their rights are upheld. 

First Nations organisations have emphasised using decolonising and strength-based approaches grounded in Indigenous world views, to respect the rights, dignity, and cultures of Indigenous people receiving care. [13] 

Cultural beliefs can have an effect on how person-centred care is achieved. [34] For example, community interests are prioritised over individual needs in some Asian cultures, and the right to self-determination [34] and autonomy [35] may look different for those who may not be comfortable with expressing their own needs. 

Increasing cultural knowledge

Learning more about different cultures can help older people feel more known and included.  

Staff may feel uncomfortable or unprepared when interacting with older LGBT+ people. Training on cultural competence, navigating disclosure, LGBT+ affirming language, behaviour change, sensitivity, inclusion and diversity, as well as about history, legislation and rights may help to overcome this. [19] 

Sensitivity towards gender identity and sexual orientation can be demonstrated by using a person’s correct pronouns. [19, 21] Residents are mostly comfortable with sharing their sexual orientation, gender identity, and pronouns when asked. [21] 

Different cultures may have different beliefs about death and dying. Training on cultural beliefs about spirituality, death and dying can help nurses and other staff working in palliative care. [11]

Reflexive education and practice to address bias

Practising self-awareness and cultural humility is a key competency for delivering care services. [36] This involves having cultural awareness and understanding cultural diversity, and being mindful of one’s own privilege, position, and self. [36]

Opportunities for aged care providers and governments to improve communication within aged care settings can include aged care specific communication training for CALD workers and engaging CALD staff to provide care for CALD residents. [37] 

Facilitated staff discussions can be a way to have explore LGBT-related knowledge, attitudes and beliefs in a safe way. [20] These sessions can help staff recognise expressing LGBT identity as a right. [20] Case study discussions can also help uncover issues and strategies, such as co-designing action plans to promote LGBT inclusion. [20]  

Co-design and participation of diverse groups

The values, beliefs, and cultural backgrounds of aged care service users are at the heart of planning and providing services. [16] Including diverse older people, such as through participatory leadership, can be a way to build relationships and change thinking and attitudes to support inclusivity. [20] 

Community gatherings or cultural activities can help support social participation. [37] However, how activities are offered can have unintended impacts for diverse groups. For example, LGBT activities can be empowering however mixed activities may not be as positive for LGBT residents even though they have a role in addressing stereotypes. [11] 

Non-discrimination and inclusion in policy and practice

Organisations can support their diverse clients and workforce by embedding diversity-affirming principles and practices that uphold rights-based care. Providers and other professional organisations should have policies in place to identify and reduce stigma and discrimination. [33] 

Organisations can identify ways to improve services for diverse clients. For example, using data to understand how CALD residents engage with complaints pathways can help identify patterns behind disparities in care. [17]

*LGBTIQ+ is one of several inclusive acronyms used to describe people with diverse sexual orientations, gender identities and sex characteristics. The language is fluid, and terms are often used interchangeably depending on context, preference and community use. It commonly refers to lesbian, gay, bisexual, transgender, queer or questioning, intersex and asexual people, with the plus sign recognising other identities not explicitly listed.

Want to learn more? 

Diverse groups

LGBTIQ+

First Nations

CALD

What can be done?

Clear, culturally safe and inclusive communication

Aged care workers: 

  • Communicate with older people respectfully, taking care to use language that is inclusive, respectful, and culturally sensitive. For example, be sensitive when speaking about gender identity and sexual orientation and avoid using language that reflects assumptions e.g., that the person is heterosexual.  
  • Clarify with the older person and their families about how to best communicate with them and adapt your approach as needed. For example, getting the help of an interpreter or translator when speaking with a CALD older person can ensure that what you need to say is well understood.

Care teams: 

  • Have conversations with older people and within your care teams about the needs and care considerations for LGBTIQ+ older people.

Service providers / organisations: 

  • Consider the profile of older people receiving aged care services and create opportunities for CALD workers to be matched with CALD older people if this is what they prefer.

The evidence:  

  • Language barriers exist between staff and residents which can impact staff ability to understand the resident and their concerns, [17] and provide good care. [27] 
  • Aged care specific communication training for CALD workers and engaging CALD staff to provide care for CALD residents are opportunities for service providers and governments to improve communication. [37] 
  • Communication can be more inclusive for older LGBT+ people if people avoid language that assumes heterosexuality and being sensitive towards gender identity and sexual orientation. [19] Using a person’s correct pronouns can ensure that they feel welcomed. [21] Residents are mostly comfortable with sharing their sexual orientation, gender identity, and pronouns when asked. [21]

Person-centred care approaches embracing diversity

Aged care workers: 

  • Recognise the CALD older people who are part of the community receiving care. 
  • Be self-aware and understand people’s diversity when it comes to cultural identities, preferences, values, priorities, supports, and influences, as a few examples, and how they relate to ageing well. This will help provide holistic, person-centred care. 
  • Respect the older person’s CALD perspectives and experiences, even if you may not agree with them or have different experiences.

Care teams: 

  • Ask the older person about their cultural and linguistic preferences as part of the care planning process so that care can be tailored to meet their needs.

Service providers / organisations:  

  • Review how care is being provided to identify any disparities in care experienced across the diverse groups and address them. This also means considering how services support ageing in place. For example, tools like the Mosaic app are available and can help care teams understand LGBTI residents and provide inclusive care. [38] 
  • Provide opportunities for cultural or community engagement with older people to support social connections, for example through cultural activities. 
  • Engage in meaningful co-design to ensure that older people from diverse groups who are receiving care services have their voices heard and reflected in how care is delivered.

The evidence: 

  • Practising self-awareness, cultural humility, and learning about and considering people’s preferences and trauma experiences within a CALD context are key competencies for delivering care services. [36] This involves having cultural awareness and understanding cultural diversity, and being mindful of one’s own privilege, position, and self. [36]
  • Facilitated discussions with staff can be a way to have conversations about LGBT-related knowledge, attitudes and beliefs in a safe way. [20]  
  • Cultural differences can affect how person-centred care is achieved. [34] For example, in some Asian cultures, the right to self-determination [34] or autonomy [35] may be impacted as older people may not be comfortable with expressing their own needs as community interests are prioritised. 
  • Community gatherings or cultural activities can help support social participation. [37] However, how activities are offered can have different impacts for diverse groups. For example, LGBT activities can be empowering however mixed activities may not be as positive for LGBT residents. [11] 
  • Understanding and collecting data relating to CALD resident profiles and how they relate to complaints received can help identify patterns behind disparities in care. [17]

Training, collaboration, and organisational culture

Aged care workers: 

  • Seek out further training that can help boost understanding and ability to provide culturally safe care. People who work in aged care are diverse, as are the communities of older people that receive care. It is important to have a better understanding of diversity that can improve quality of care.

Service providers / organisations: 

  • Provide training opportunities to upskill staff in understanding and delivery culturally informed, culturally safe and appropriate care. 
  • Engage in participatory leadership to improve cultural competency in delivering aged care services. Work towards enhancing culturally responsive care where the voices of staff are heard and incorporated in a collaborative way to promote inclusive care.

The evidence: 

  • There has been a call for residential aged care staff training on LGBTQ+ issues. [21] Training on cultural competence, navigating disclosure, LGBT+ affirming language, behaviour change, sensitivity, inclusion and diversity, as well as about history, legislation and rights may help staff feel more comfortable or prepared when interacting with older LGBT+ people. [19] 
  • Training is needed when it comes to spirituality and how death and dying is approached in different cultures, [11] as it can be relevant for palliative care. 
  • Participatory leadership can build relationships and change thinking and attitudes to support LGBT inclusivity. [20] Case studies helped uncover issues and strategies, and change and LGBT inclusion can be promoted via co-designed action plans. [20] Tensions between staff religious beliefs in the context of providing LGBT+ care should also be navigated well.

 

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