Case studies

Case study 1: Stroke Care for Mrs Li

Background

Mrs Li is a 70-year-old Chinese woman who had a stroke six months ago.

She came to New Zealand from China five years ago to join her son and his family. Mrs Li speaks Mandarin but not English. After a period of rehabilitation, Mrs Li was discharged to the care of her son’s family. Mrs Li’s son John and daughter-in-law Jenny have three children aged 20, 15 and 12 years of age. Jenny works full time in the family business. Mrs Li is being visited by the District Nurse. She wants to do as much as possible for herself.

While in the stroke unit, the family emphasised their need to be included in their mother’s rehabilitation plan. The stroke team recognised the need to include all the family carers (ie whoever could be present at the rehabilitation sessions) as active participants in Mrs Li’s therapy. All family carers learned how to provide the best support and care for Mrs Li to assist her to achieve her goals on the rehabilitation journey.

When Mrs Li returned home she was contacted by the DHB interpreting service for follow-up appointments. The Interpreting Service provided Mrs Li with a phone number she could contact for help or information at any time of the day or night. The allied health team prepared Mrs Li and her family for ongoing rehabilitation in her home. This is proving successful as Mrs Li continues to work towards maximising her capabilities. She wants to do as much as she can for herself.

Reflection

Stroke survivors, such as Mrs Li, are very dependent on their family for practical, psychological and social support. Migrant families who are coping with settlement stressors are placed under even more pressure when supporting a family member with a stroke. The support provided by the allied health team, not only for Mrs Li but for her family, is critical to the successful outcome of rehabilitation and to her achieving her maximum capacity.

In China, Mrs Li could expect the full support and availability of her extended family and she will expect this level of family support in New Zealand, although she has fewer family members here. As well, her son and daughter-in-law have demanding work commitments and they are not familiar with the New Zealand health and disability system.

Mrs Li will have great difficulty managing all her appointments. To support her adequately, she will need multiple services in place. It is essential to involve Mrs Li’s family members in managing her appointments so the they can incorporate her appointments and activities into their schedules. The Li family as a whole needs to be informed about which services to contact for different types of assistance. Importantly, they will need to use their general practitioner as their liaison person for many services, and to assist them to manage Mrs Li’s changing needs for services over time.

Mrs Li’s care demonstrates how effective services can be when they are culturally and linguistically responsive to the needs of the client, for example through:

• Communication:
  • Mrs Li received phone calls in her own language.
  • She and her family received a phone number to ring for help and information at any time during the day and after hours.
  • The communication with the family was provided in clear, simple English with translated information provided where possible.
• Therapy:
  • Mrs Li felt respected, dignified and in control.
  • Met Mrs Li’s cultural needs, and enabled her to do as much as she was able to do.
  • District Nursing and Allied Health services were culturally sensitive and aware of Mrs Li’s needs.
  • Family members were educated about the health and disability services and support available (including financial support, respite services, community support services (Stroke Foundation), psychological services and additional rehabilitation services).
  • Mrs Li and her family felt informed and empowered.
• Referral appointments:
  • These were received in Mrs Li’s own language.
  • She was cared for by a CALD culturally competent health workforce.
  • She had access to interpreters, or cultural caseworkers.
  • The services provided were responsive.

Case Study 2: Stroke Care for Dr Rajandram

Dr Rajandram is a 64-year-old Sri Lankan man. He is recovering from a stroke which has left him partially paralysed and aphasic.

He was a GP in a busy practice. He lives with his wife and has three adult children. Mrs Rajandram explains that her husband is frustrated because he can only speak a few words of English since the stroke. Dr Rajandram’s mother tongue is Tamil. His wife explains that he still speaks Tamil and uses this when he speaks with family but he wants to be able to speak English again so that he can be independent.

He was in hospital for several months and was helped to mobilise and was assisted with speech therapy. He is very keen to remain independent and has refused help from carers. He attends a day centre once a week. He also attends a support group for people with aphasia and finds it helpful to communicate with others with similar speech difficulties.

Dr Rajandram is assigned a speech language therapist (SLT) as his key worker. The following points outline culturally appropriate approaches to speech, language therapy:

• The designated SLT meets with the client to provide written and pictorial information explaining the family meeting process.
• The SLT then works with the client to identify goals for the meeting, the level of support required, which family members they want present, and any other issues the client wishes to raise.
• Cultural and linguistic considerations are included in planning for and facilitating the meeting with Dr Rajandram and his family (WDHB, Medicine & Health of Older People Service Allied Health/ Speech Language Therapy, 2012).

Family meeting

When addressing Dr Rajandram and his family ask about what names and titles should be used as forms of address.

Speech language therapy

• Tune into multilingual abilities. The nature of language deficits in multilingual adults is complex and not a matter of tuning into the use of each language as a separate ability.
• Talk to the client and their family about language use - the use and importance of each language will vary from person to person. Find out from the client and family which is the most important language to them (Ardila, 1998).
• Seek help in differentiating premorbid and current levels of expressive and receptive competence in each of the client’s languages.
• Be careful to consider dialectic variations. Even when an individual is proficient in English, his or her English may differ from New Zealand English in terms of phonology, vocabulary, grammar, idioms, and pragmatics. What might be considered an ‘error’ or ‘deficit’ on the part of the clinician may actually be due to cultural variations. Extensive variations may also occur in the individual’s first language.
• Be careful to also consider different forms of showing respect and being formal/informal (both verbal and non-verbal) and differences in aspects such as eye contact, body language and facial expression.

Rehabilitation

• Allow Rajandram’s wife to come in each day to bathe and feed her husband. Hospital staff can encourage Mrs Rajandram to let her husband do as much as possible for himself.
• Once home, Dr Rajandram attends a support group for people with aphasia and finds it helpful to communicate with other people with similar speech difficulties.
• Cultural support agencies and community groups could be involved in providing support and social opportunities for  Dr Rajandram and his family. Community therapy staff can liaise to provide advice around communication, mobility and other aspects that will help Dr Rajandram to access these opportunities and events.