Introduction
The present article deals with needs assessment prior to provision of care services to older people (i.e. the assessment process that presumptive elder care recipients go through when they apply for assistance from elder care services). Needs assessment meetings between older citizens and care managers have always been central to the administration of care services in old age. The introduction of needs assessment models in Europe during the 1990s challenged the needs assessment process in numerous ways. These models have brought about the standardisation of both the selection of care services offered (Wrede et al. Reference Wrede, Henriksson, Høst, Johansson and Dybbroe2008) and the way in which the needs assessment process is conducted (Olaison Reference Olaison2009). Standardisation has resulted, for example, in differences between the intentions stated in elder care legislation and how needs assessment is carried out in practice (Challis et al. Reference Challis, Hughes, Jacobs, Stewart and Weiner2007; Chester, Hughes and Challis Reference Chester, Hughes and Challis2010). Endeavours to use existing resources economically have had a clear impact on how assistance is granted (Lymbery Reference Lymbery, Lymbery and Butler2004; Rauch Reference Rauch2007). In a conference presentation we made a couple of years ago, we therefore focused on care managers' experiences of the needs assessment process (Torres, Forssell and Olaison Reference Torres, Forssell and Olaison2011); an angle of investigation that has not received enough research attention. In this article we turn our attention to care managers' experiences of one of the challenges associated with the needs assessment process; i.e. assessing needs across perceived cultural, ethnic, linguistic and/or religious boundaries (referred to as cross-cultural needs assessments in this paper). The problem area dealt with here touches on the dangers of categorisation for the practice of social work (cf. Hall, Slembrouck and Sarangi Reference Hall, Slembrouck and Sarangi2006); that is, how experiences and perceptions of various groups can unintentionally and unconsciously be of great importance to encounters between welfare institutions and clients. For instance, perceptions of this kind may affect how cross-cultural meetings between public welfare representatives and clients are experienced by the former, but they may especially affect what these representatives focus on and what they fail to notice during such meetings.
Research on care managers' experiences
Research focusing on care managers' experiences of needs assessment meetings could be said to be in its infancy, despite the fact that the body of work on the needs assessment process is relatively extensive.Footnote 1 Postle (Reference Postle2001, Reference Postle2002) has studied British care managers' experiences of working according to the care management model, which was introduced during the wave of standardisation that began at the beginning of the 1990s.Footnote 2 Her studies have described care managers' experiences of a decline in the social aspects of their work with older people following implementation of this model. The care managers she interviewed described a situation in which opportunities to take time to engage with individuals about their specific needs and to make well-considered decisions have been lost, and the guidance function has diminished. According to Manthorpe et al. (Reference Manthorpe, Jacobs, Rapaport, Challis, Netten, Glendinning, Stevens, Wilberforce, Knapp and Harris2009), one consequence of the care management model – the introduction of individual budget work – is experienced as an additional complication, as care managers lack the necessary knowledge for this kind of work. Moreover, Gorman and Postle (Reference Gorman and Postle2003) found that care managers often feel their work has become mechanical, in that their time is increasingly devoted to the management of risk rather than to the management of care.
Research on care management as risk management comes from Canada (Ceci and Purkis Reference Ceci and Purkis2009), the United States of America (USA) (Kelsey and Laditka Reference Kelsey and Laditka2009) and Australia (Green and Sawyer Reference Green and Sawyer2010). As the findings section of this article will show, this research offers an interesting point of departure from which we can make sense of the experiences of cross-cultural interaction that the care managers interviewed in this project alluded to. For instance, Ceci and Purkis (Reference Ceci and Purkis2009) looked at the dilemmas that Canadian care managers face in their work, such as the difficulties associated with striving for a balance between, on the one hand, respecting older people's own will and ability to make independent decisions, and on the other hand, ensuring that older people have a tolerable and secure existence. Green and Sawyer (Reference Green and Sawyer2010) presented similar results from Australia, showing that care managers' work is increasingly devoted to risk management. Several British studies have described how care managers find it difficult to deal with their professional role, because the actual meeting with older people has become less central now that their main duties involve administration and decision-making to a greater extent (Jacobs et al. Reference Jacobs, Hughes, Challis, Stewart and Weiner2006; Manthorpe et al. Reference Manthorpe, Jacobs, Rapaport, Challis, Netten, Glendinning, Stevens, Wilberforce, Knapp and Harris2009; McDonald, Postle and Dawson Reference McDonald, Postle and Dawson2008). In the Swedish context, Dunér and Nordström (Reference Dunér and Nordström2006) have drawn attention to the conflicting roles that care managers are expected to play nowadays. In addition to being social workers, they are also administrators, information officers and gatekeepers to the welfare state, i.e. they must take into account the economic resources available to the organisation. The latter role renders decision-making based on individual needs assessment difficult.
The little research there is about care managers' experiences of their work shows that the needs assessment process is filled with challenges. However, the research to date has not taken into consideration the challenges that are presumably presented by increased ethnic, cultural, linguistic and religious diversity among prospective elder care recipients. This, therefore, is the point of departure of this article. The main research question we ask here is: How do care managers experience the cross-cultural meetings that are the basis for assessing care needs prior to deciding exactly what kind of assistance older people with an immigrant background will receive?
Needs assessment in the Swedish context
It is a well-known fact that elder care in Sweden is largely publicly funded. It is also worth noting that the overall responsibility for care of the elderly in Sweden rests with the state and not with the family, as is the case in some European countries. This does not mean that older people in Sweden have all their care needs met by the state. ‘Informal care is the most common form of assistance that older people in Sweden receive; few rely solely on public services’ (Sundström and Johansson Reference Sundström and Johansson2005: S8). All older people in Sweden who have permanent residency and are in need of help and support in activities of daily life can, however, apply for assistance from the elder care services. The decision on whether or not care services will be made available is determined following completion of an individual needs assessment process which is carried out by care managers.
The core of the needs assessment process consists of assessment meetings between the care manager and the older person who is applying for assistance and, in some cases, with his/her relatives. During these meetings, the older person's situation is discussed and his/her needs are assessed. Thereafter, a decision is made on what care services will be made available. Decisions made by care managers can be appealed by older people so care managers handle appeals as well. The actual application for care services (a form that is filled in and signed by the older person) is examined and stored in a needs assessment case file. Continuous notes on what takes place during these meetings (and on the measures that are taken) are collected in a journal. All written documents dealing with the case are saved in the individual's case file. It is worth noting that, in contrast to needs assessment practices in the United Kingdom (UK), which give the relatives of older people applying for services the opportunity to have their own needs assessed during this process (cf. Challis et al. Reference Challis, Hughes, Jacobs, Stewart and Weiner2007), the needs assessment process in Sweden focuses only on the older person's needs. This poses a challenge when dealing with older people who cannot verbalise their needs, as in the case of the older immigrants that will be in focus in the findings section (i.e. those that have immigrated late-in-life, who come from cultures that differ greatly from Swedish culture, and who have not mastered the Swedish language).
The work of care managers in Sweden is guided by legislation but also by organisational and municipal prerequisites (Dunér and Nordström Reference Dunér and Nordström2006). Among them are local guidelines covering not only what care managers can decide upon but also what services can be offered (i.e. the municipality's service catalogues). The legal foundations for the work that care managers carry out are found in the Social Services Act (Socialtjänstlag, SFS 2001:453, Swedish Code of Statutes), which is framework legislation that ‘emphasizes the rights of the individual to receive municipal services’ (Government Offices of Sweden 2007: 1). This legislation does not specify exactly what this right entails. According to the Social Services Act, care for older people should be aimed at promoting a life with dignity and a feeling of wellbeing. But it is up to local municipalities to decide how resources are to be allocated and which services will be made accessible in order to achieve the legislated goals. The framework legislation in question is, in other words, extremely vague since it only states that people have a right to have a ‘reasonable standard of living’, which means that it is up to care managers to decide what ‘reasonable’ means.
As already stated, the assessment of older people's needs is carried out by a care manager, who in most instances is assigned the task of determining what kind of and how much assistance the older person will have access to, and who also makes sure that older people pay the appropriate income-based fee for services. Swedish municipalities often give care managers working in elder care far-reaching investigative and decision-making duties, which ultimately give them great power to make decisions on the use of elder care funds (Dunér Reference Dunér2007). This combination of great power and a loosely defined legislation creates considerable scope for action, but may also lead to difficult dilemmas for care managers when they are faced with individual cases (cf. Torres, Forssell and Olaison Reference Torres, Forssell and Olaison2011).
Studying cross-cultural interaction within the context of Swedish elder care
Over the past few decades, the debate on Swedish elder care has drawn attention to the challenges that increased ethnic, cultural, religious and language diversity could present to the deliverance of high-quality and user-friendly care (Ronström Reference Ronström and Andersson2002). This is the case despite the fact that the number of older people with a foreign-born background is still comparatively small. At the end of 2012, there were 9,555,893 people in Sweden; 19.1 per cent of them were 65+ while 15.4 per cent of them had a foreign-born background. The percentage of the 65+ population that had a foreign-born background was 11.9 per cent at that point in time (Statistics Sweden 2013). The majority of them come from either another Nordic or European country and are people that came to Sweden as labour migrants in the 1950s and 1960s. Despite this, the elder care debate in Sweden has long been concerned with what increased diversity among presumptive elder care recipients could mean for the sector. Part of the reason why this is the case is that the largest increase in the number of older people with this background has occurred in the age category where the need for elder care services is increasing (i.e. 75–84 years of age), and a large proportion of Sweden's foreign-born population is fast approaching retirement age (Socialstyrelsen 2009). Another reason is that the vast majority of older people with a foreign-born background are geographically concentrated, which means that attention is easily drawn to them (most of them live in the larger cities: Stockholm, Gothenburg or Malmö). Another reason why the debate on diversity has been as lively as it has is that the relatively generous family reunification laws that Sweden had for many years made it possible for immigrants to bring over their ageing parents. The latter has meant that a decade or so ago, late-in-life migration became a growing concern for elder care planners in the larger cities.
A review of the Swedish literature on older immigrants has shown that they are regarded as ‘the Others’ by elder care services (Ronström Reference Ronström and Andersson2002; Torres Reference Torres2006) and, as such, as a welfare problem (Torres Reference Torres, Darvishpour and Westin2008). It is worth noting that we have yet to conduct a representative study of older immigrants in this country, which means that most of the assumptions that the debate makes about them are based on qualitative studies with convenient samples that have focused on the ethnic groups that are the largest (i.e. Finns) or the ones that are considered to be the most challenging because of assumed cultural differences (i.e. people with Middle Eastern backgrounds and/or people that have come to Sweden late-in-life). A considerable number of studies have also focused on late-in-life immigrants to Sweden. This is the group that is assumed to be the most vulnerable yet constitutes – statistically speaking – the smallest group within the foreign-born population of older people in Sweden (Torres Reference Torres, Scharlach and Hoshino2013). Thus, despite the fact that most needs assessments in Sweden cannot be described as cross-cultural, there is an increased awareness in Sweden that this is one of the elder care practices in Sweden that could become most challenged as the number of older people with foreign-born backgrounds increases (Forssell and Torres Reference Forssell and Torres2012). It is against this backdrop, and because research in Sweden has shown that the assessment criteria used to determine which older people will be eligible for these resources have become narrower during recent decades (Blomberg Reference Blomberg2008; Rauch Reference Rauch2007), that we designed the project upon which this article is built. Both Swedish and international research has shown restrictions in what needs are actually met through the needs assessment process. It is often the most important and acute medical and care-related needs that are prioritised over social needs (cf. Lymbery Reference Lymbery2010; Olaison Reference Olaison2009; Vabø Reference Vabø2011) even if the legislation, in Sweden at least, does not state that these needs should take precedence over other needs that an older person could have. Thus, the research question that informs this article was posed, in part, because the Swedish debate on older immigrants has mostly focused on their assumed special needs (e.g. culturally adapted daytime activity centres, language-adapted care services or culturally/religiously adapted meals).
An interesting pilot study was conducted by Forssell (Reference Forssell2013) who explored how care managers experience cases involving late-in-life immigrants with transnational ties. She found that these older people's lifestyles and care arrangements can prompt care managers not only to change their practices but also to exploit the grey areas of the framework regulations mentioned earlier. The results of a small survey conducted by Andersson and Johansson (Reference Andersson, Johansson and Johansson2010) in a middle-sized Swedish municipality are relevant here as well. The purpose of their survey was to problematise how the issue of free choice within the Swedish elder care sector is dealt with by care managers. The care managers' ways of dealing with the open-ended questions in the survey give a hint as to why it is important to investigate how these professionals experience cross-cultural interaction within the context of needs assessment. Their responses to these questions suggested that they perceive older individuals with an immigrant background as being more demanding than older people born in Sweden. The former group were ‘judged and described by the care managers as being a problem, because they have not really understood how our system works and because they appear to be very demanding’ (Andersson and Johansson Reference Andersson, Johansson and Johansson2010: 126, our translation). Thus, even though foreign-born older people in Sweden constitute a relatively small group within the 65+ population, there are specific circumstances that make the study of care managers' experiences of cross-cultural needs assessments interesting in this setting.
It is also interesting that the Swedish debate on elder care has, relatively recently, begun to draw attention to the diversity of the elderly care staff. Numerous people with foreign-born backgrounds have been recruited by the elder care sector over the past decade. In one of the most recent publications describing this sector it is stated that ‘among the total number of employees in care of the elderly and disabled, the percentage that are foreign-born increased from 10% to 14% in 2007. The increase consists mainly of people born outside the Nordic region and the EU’ (Swedish Association of Local Authorities and Regions 2009). Diversity is therefore not only something that is on the Swedish elderly care agenda when talking about elder care recipients but is also important when describing the staff. There are, however, no specific statistics on the backgrounds of care managers in Sweden so we do not know how many care managers in Sweden have a foreign-born background.
Methods
The empirical starting point of the article is focus group interviews (cf. Breen Reference Breen2006; Morgan Reference Morgan1997) with 60 care managersFootnote 3 from seven different municipalities and city districts, all of whom worked on a daily basis conducting needs assessments of older people, both with and without an immigrant background. Although we did not ask where the care managers were born, we estimate that around six or seven of them had an immigrant background.Footnote 4 Only two of them were men, which is not surprising considering that elder care is a sector dominated by women in Sweden.
As stated earlier there are no statistics on the backgrounds of care managers in Sweden. Our educated guess is that the background composition of our sample was an accurate representation of the population of care managers in this country.
The reason why we chose to use focus groups to collect data for this project was twofold. First of all, focus group interviews have been found to be an effective way of collecting data about professional practice since such practice is often decided upon through informal talk between peers, and focus groups have been found to be particularly fruitful when trying to bring such talk to light (Vaughn, Schay Schumm and Sinagub Reference Vaughn, Schay Schumm and Sinagub1996). Second, focus groups are known to be particularly propitious for interviews that require informants to open up about practices that they are uncertain about and/or issues that are highly debated and are, as such, deemed to be controversial (Morgan Reference Morgan1997). In accordance with the literature on the ethical dilemmas associated with focus group interviews, which recommends not interviewing work colleagues simultaneously (Hofmeyer and Scott Reference Hofmeyer and Scott2007), the focus groups used in this study were formed so that care managers from the same areas and workplaces were for the most part not interviewed at the same time. The interviews – as well as the documentation study that is also a part of the project but which we are not reporting on in this article – received the ethical approval (Dnr 2011/ 205) of the Regional Ethics Committee in Uppsala.
The first author carried out the interviews. She also conducted the initial analysis of the interview data by organising the material (through coding) with reference to qualitative conceptualisations (Neuman Reference Neuman2011). This means that in the first stage of analysis, we used the topics covered by the interview questions (i.e. where experiences of various kinds, including challenges, were brought up explicitly) as well as the topics that emerged from interpretations and analytical insights drawn in connection with both the data collection itself and repeated listening to the audio-recorded material (cf. Silverman Reference Silverman2001). During the second stage of the analysis, we aimed to identify the themes that the experiences in question tapped into. The themes the analysis generated were: language barriers and the need for interpreters; different demands and expectations; insecurity prior to meetings; dealing with older people who are passive; and the conflict between a reasonable standard of living and equal treatment. The analysis was examined by the second and third authors through peer-debriefing sessions (Creswell Reference Creswell1998), the aim of which was to ensure the trustworthiness of the analysis.
Findings
The first thing to be noted is that the interviewed care managers initially claimed that older immigrants form a particularly broad and multifaceted group. Despite this, most of the focus group interviews contained statements indicating that there may be several reasons for cross-cultural encounters to be perceived as particularly challenging:
You have to be aware … you have to be able … without feeling bad or blaming yourself you have to [say] … now I did something wrong or now I'm not thinking right … you have to be prepared to, you know, face your prejudices … And then recognise the difference between what depends on this person being an immigrant and what depends on him or her being economically disadvantaged. You have to realise that there are, well, several things making their situation difficult … other than just being an immigrant. (Focus group interview 1)
In the excerpt above, we see an example of how the care managers interviewed seemed to be aware that having an immigrant background per se is not always what makes older immigrants different from older Swedes. We also see, however, that the way in which they talked about cross-cultural interaction within the context of needs assessment clearly suggests that they associate this type of interaction with prejudices. This may be why some of them talked about the need to approach cross-cultural needs assessments with an open mind. Doing so enables them to recognise other sources of inequality in addition to those that may stem from an immigrant background (cf. Torres Reference Torres, Scharf and Keating2012).
During the focus group interviews, it was often mentioned that the large number of older people who migrated to Sweden as foreign labour back in the 1960s are now well established in the country and could have the same attitudes toward needs assessment and elder care as do Swedish older people in general. Thus, the group of older people that the interviewed care managers called older immigrants were not such labour immigrants, but primarily non-Swedish-speaking older people who had immigrated late-in-life and came from countries considered to be culturally different from Sweden. This is why we have given the quotes that will be presented in the following sections exactly as they were said (i.e. with references to older immigrants), but we refer to late-in-life immigrants when we analyse what the care managers said. It is also worth noting that we will henceforth use the term ‘older Swedes’ in the relatively loose way in which the care managers interviewed used this term. When they talked about Swedes they seem to have been referring to both people who are part of the ethnic majority in Sweden and people that behave in a way that resembles the norm in this country. As some of the care managers interviewed explained, older people with immigrant backgrounds who came as labour migrants early in life and have aged in Sweden behave – and can therefore be regarded – as Swedes. Both of these clarifications regarding the way in which the care managers interviewed used these terms (i.e. older immigrants and older Swedes) should be kept in mind as we consider the topics addressed in the interviews and presented below.
Language barriers and the use of interpreters
The care managers' duties include giving information about rights, but also explaining how needs assessments are conducted in practice. This includes describing to care recipients what is viewed as a ‘reasonable standard of living’ which is, as stated earlier, the vague guideline on which needs assessment practice in Sweden is based. An additional duty is to inform about the right to appeal, as well as to deal with any appeals that are made. The least controversial challenges associated with assessing the needs of late-in-life immigrants seem therefore to be those concerning language barriers. One of the interviewed care managers expressed this as follows:
Language is really difficult because communication is hard, you can't always call, you don't have … they haven't learned the language at all, they can't communicate in Swedish. And communicating through family and interpreters really isn't … a direct form of communication. As I experience it in my work. (Focus group interview 10)
This excerpt captures one of the greatest challenges that the interviewees associated with cross-cultural needs assessments. In relation to language barriers it is relevant to mention something one of the care managers interviewed noticed when she was collecting documents for the case files study tied to the project on which this article is based.Footnote 5 This care manager had never before considered the fact that the adult children of late-in-life immigrants are much more likely to provide and receive information on behalf of their parents than are the children of older Swedes. The relatives of these immigrants are simply called on more often, frequently due to the older person's poor knowledge of Swedish. This, and similar observations, caused her to wonder whether it might not be the case that late-in-life immigrants are declared incapable because they cannot speak Swedish. In cases when language barriers were so great that an interpreter was required, different and often less positive experiences were reported:
Interviewee 1: Yes, well it's trickier … when you have to have all the conversations with an interpreter. I'm in the middle of two of them now. And it's a bit tricky [because] you have to think about what you're saying because the interpreter, who also has a foreign background maybe speaks several languages and has to translate for a person who … my language has to be translated to [them] … Sometimes it's messy – have I said that the right way? So the interpreter understands what I mean and then…
Interviewer: You mean working with an interpreter leads to some uncertainty and…
Interviewee 1: Yes, it depends on what it's about … it takes a lot of time and it has to, you have to … put yourself in their situation and … you need to make sure that they really understand what you mean…
Interviewee 2: The conversation doesn't flow in the same way, that's the thing. And sometimes you feel [that] … asking sensitive questions is pretty strange with an interpreter. Because you can't … Otherwise you communicate a little more like … it's not like question, answer, question, answer… (Focus group interview 9)
As we see in this excerpt, the use of an interpreter per se was viewed as an important cause of cross-cultural meetings being experienced as more demanding, in terms of both time and the greater pedagogical skills required. The needs assessment process itself must be carefully explained and care managers must continually ensure that the information has been understood. In cases such as this, the workload was often described as both demanding and multifaceted. One simple question may lead to numerous telephone conversations. It is worth noting that making use of one's time – or lack of time – in a wise and efficient manner is always a challenge for care managers, but the interviewees conveyed that it is even more so when dealing with late-in-life immigrants who cannot communicate in Swedish.
Different demands and expectations
Most care managers interviewed were initially careful about discussing the existence of, and their thoughts about, cultural differences. Only one interviewee deviated from this pattern when she said: ‘It's this thing with culture and religion. They have different ideas than we do!’Footnote 6 Interviewees in one of the focus groups had observed that late-in-life immigrants often wished to convey the idea that their identity was different from the Swedish identity. This was compared to the main thrust of meetings with older Swedes, which they described as being more about conveying the nature of their everyday life and needs:
I'm usually pretty sensitive … when they want to talk about their culture … Swedes don't really do that in the same way … [immigrants] talk about their culture and their religion and their homeland … Swedes talk more about their everyday life in another way. And they tell you what the problem is. They are also very eager to talk about their culture and their religion and so on. So you want to emphasise this in those visits … And naturally … you're pretty sensitive to taking it in and like, ‘oh really, that's what you think, what do you think about this’ (and here the interviewee shows the group how she communicates with them when this kind of discussion takes place). (Focus group interview 6)
Thus, the meetings themselves were thought to have different underlying agendas, in that immigrants wished to convey things about their identity, whereas Swedes simply wished to talk about their daily needs. It is worth noting that the care managers who talked about late-in-life immigrants' wish to speak about their culture did not seem to think that this was appropriate even though they also claimed to lack insight into the different ethnic/cultural groups that they met these days. In this excerpt, we also see how experiences of dealing with cases involving immigrant clients were based on distinguishing them from ‘Swedes’ (which was, as already stated, a category that included immigrants who have lived in Sweden for a long time).
Concerning the interviewees' discussion on cultural differences, another aspect was brought to the fore, namely the late-in-life immigrants' expectation – often conveyed while talking about what made their culture different – that they would be assisted with meal preparation. This was something that was regarded as both time consuming and difficult to handle for home help care staff, who were not familiar with culture-specific meal rituals, menus and the like. Therefore, the expectations that were discussed by the care managers involved not only religious customs and culture-specific ways of living, but also dietary requirements that were not based on medical needs but on cultural ones.
The interviewees also mentioned that it was relatively common to encounter insecurity in older people who spoke little or no Swedish (and the same seemed to hold true for their relatives). They often noticed that late-in-life immigrants and their families did not really trust their own ability to deal with the needs assessment process:
Interviewee 1: I've also noticed now in my professional role that they can have a really … they can show a kind of submissiveness, that comes from their culture … they see all authorities as well sort of, stilted and … authorities, you have to watch out for them … [they have] an exaggerated respect for authorities, because there are cultures like that too, that have experienced that. And then of course there are those who think they have their rights. That's just as … difficult…
Interviewee 2: You visit people with an immigrant background who maybe have an enormous respect for people in authority. To go there and to try to solve problems together … it's sort of like well … I think, surprising. That's often the way it is for them.
Interviewer: You mean they don't expect to be invited to have a dialogue?
Interviewee 2: Yes, that a person in authority … it's a bit like … you can get the feeling when you [visit them] … I think that they're overly respectful of authorities… (Focus group interview 6)
This excerpt illustrates several points worth considering. The interviewees suggested that clients with these backgrounds have no understanding of how meetings with a care manager are conducted, of what is expected of clients, or of what clients can expect. The discussion also revealed experiences of cross-cultural meetings in which the clients show a lack of trust in their own ability to influence the needs assessment process itself. In contrast, older Swedes were described as people that find it easier both to pose their own questions and to describe their situation. The excerpt also shows the care managers' awareness – however tacit it may be – of the power imbalance that exists in cases where individuals have no experience whatsoever of the Swedish welfare system.
The focus group discussions often dealt with the notion that immigrant families consisting of several generations constitute more of a unit than do Swedish families in the same situation. According to the interviewed care managers, this is why they must communicate much more often and more intensively with the relatives of late-in-life immigrants. These relatives were often experienced as expecting or demanding extensive care services on behalf of their family member. This seemed to be yet another reason why interviewees found cross-cultural needs assessments particularly difficult. One of the interviewees said the following:
It's a bigger challenge. Certain problems I think. The process itself becomes so tedious, so then the relationship is also tedious somehow … I have a lot of them … who have a different background, or I mean come from different countries. And don't speak Swedish and have completely different customs and live behind them, which makes it much more difficult for me to deal with them. And well … other needs come up, people in many countries live differently, they maybe take for granted that relatives, they'll help you, [will] always be there. And then it's more a question of money than of services from, for example us, the municipality. And then I think it gets to be very tedious all this [talk] about more money. And just the fact that there are problems and that we don't understand each other's culture really. (Focus group interview 5)
In the above excerpt, we see a clear connection between cross-cultural interactions and challenges and/or problems. The interviewed care managers, on the whole, attached great importance to needs they did not feel were legitimate from the perspective of care services. This is particularly noticeable in statements about what late-in-life immigrants are like and what kind of culture they come from, in contrast to what their needs actually are and what kinds of services could meet these needs. The care manager quoted above said that when needs and services are discussed, meetings with late-in-life immigrants tend to be about money. The same interviewee continued:
In Sweden it's maybe more like … well this is my own biased opinion, that people want to manage on their own longer. While they expect something else, many … many I think, in other countries expect to get help with everything and very early. And we're not really used to this, right or wrong, it's not for me to judge, but it feels like that when I meet with many people with different backgrounds. (Focus group interview 5)
Here we see another notion presented: that late-in-life immigrants want to receive help and support earlier in life than older Swedes do. The latter were in turn portrayed as people who do not want as much help, but instead endeavour to manage on their own much longer. Noticeable here is the differentness that late-in-life immigrants were perceived to represent – a differentness that is used to explain why they do not deal with the needs assessment meetings in a ‘Swedish’ manner.
Insecurity prior to meetings
Notwithstanding the interviewed care managers' initial cautious attitudes, as the interviews progressed many of them talked about feelings of insecurity prior to meetings with older people who had immigrated to Sweden late-in-life. The care managers interviewed expressed being afraid of not having sufficient knowledge of these older people's experiences and life conditions. The following excerpt captures this insecurity:
Should I take my shoes off after I come through the door [the most common practice in Swedish homes] or should I? … Are there going to be eight relatives sitting there all talking at once? If it's a Swedish relative then I can say for instance … excuse me, but we have to let your mother speak for herself now. I can talk like that at a meeting [with a Swede] because I have to hear what she says. Should I say the same thing through an interpreter to a son who has called us? … I don't know how it would be perceived … but I do it straight away with Swedes. Because there I feel like, they understand … my role and all that. I base things on my professional role in a different way. So sure, I'm less secure and I feel … at least during the first meetings. (Focus group interview 6)
As we can see, in meetings with Swedes, more is taken for granted, and the care managers described feeling more secure. Greater insecurity was reported prior to meetings with late-in-life immigrants. The care managers described not knowing what is expected of them. The fact that the interviewees felt that the relatives of these immigrants are more prominent than are Swedish relatives also goes against the basic intention of needs assessment practice in Sweden; namely that it is the older person's needs and desires that should be in focus, not the wishes of relatives.
Another kind of insecurity that was clearly expressed in the focus groups concerned what is acceptable to talk about, and with whom. The care managers reported worrying about being perceived as offensive, and avoided asking certain questions to or about late-in-life immigrants. These questions could involve topics or circumstances that are thought to be taboo, but that are also assumed to be necessary to consider when assessing older people's right to assistance. For instance, one of the care managers wondered how one woman had managed to maintain the religious standards of hygiene at home in her mountain village without electricity and running water, considering the fact that here, in her modern apartment, she is applying for ‘a huge amount’ of assistance with ritual washing. She said:
Then I'd like to ask, when she lived in her native country in a mountain village … no running cold water not to mention warm, how do they manage there? When it's time to pray or do they have to skip praying there? Or when there's no way to keep clean … I would just like to know, because I'm curious. Though I do think it's a difficult question. Not that my decision rests on how they do things in their homeland, but … often those kinds of specific question pop up and sometimes they're a bit sensitive and hard to ask about … I mean nobody is completely without prejudice, and in situations like that you think about it a lot more … that you shouldn't sit there and air your biases in a meeting with … with an old person and her relatives. (Focus group interview 4)
The above excerpt shows how some of the experiences described in the focus groups concern the assumptions that non-Swedish-speaking late-in-life immigrants from culturally different countries have lifestyles that are quite different to what is common in a modern Western country like Sweden. What is interesting here is the paralysis that this kind of insecurity seems to bring about. The care managers reported that they do not dare pose their questions for fear they will be perceived as accusatory, but that they also cannot make any decisions until they have ascertained whether there is in fact a need for care. This was described as one of the reasons why decision-making in some cases involving immigrants can take longer. During the interviews, the care managers seldom questioned the notion that there are certain things one can or cannot talk about with immigrants. However, this did not stop the care managers from being worried about possibly missing important information precisely because they were afraid of asking questions about sensitive topics. The situation is further complicated by the fact that the care managers worry about acting in a discriminatory way by drawing attention (unjustifiably) to various circumstances based on older people's background, thereby unintentionally creating differences between immigrants and Swedish older people. One interviewee talked about how she constantly asked herself the following question when she had clients who had immigrated late-in-life: ‘Would I have asked a Swede about this?’
One of the most difficult challenges described by the care managers concerned dealing with cultural expressions or characteristics they did not fully understand or whose scope they did not appreciate. This was often a question of what they perceived to be culture-related demands and expectations. There were also discussions on another kind of challenge, namely determining where the line should be drawn for what a person in their position of authority should accept from clients, interpreters and others in terms of cultural or religious expressions that challenge what the person in authority considers normal. For instance, most of the interviewees felt that not shaking hands with someone who did not wish to do so was reasonable, but they did not seem to want to accept demands for male decision-makers, something that was mentioned, although seldom.
Dealing with older people who are passive
In all of the interviews, there was mention of late-in-life immigrants who lay in bed during the entire home visit, completely quiet and hidden under a blanket. This behaviour was described as something that was often accompanied by a relative saying ‘Mama cannot do anything.’ One of the interviewees provided a lively description of such a scenario:
If you go out on a new case, and if you compare Swedish and immigrant old people … They're often lying down when you arrive. And many of them have pulled their blanket up like this and … (shows by pulling her hands up over her face). And they don't move an inch … or they're sitting on the couch with a blanket over them like this … at the last meeting, when I arrived, I had a colleague with me. And the woman was lying on a mattress on the floor and the man was lying on the couch. And there was a relative there too. And then I said … I asked if … they couldn't sit up, because it would be easier to talk. The man did, but not the woman. But then when the meeting was half over, she sat up sort of spontaneously. Well … you just don't do that in our culture, lie down if you can sit up and have eye contact and talk. I think it's really like … I have colleagues who say the same thing, that they're lying there on the couch or a mattress on the floor, with a blanket… well, pulled up over their faces. (Focus group interview 4)
Lying in bed was perceived as purposefully dissociating oneself from the visiting care manager; something that seemed to annoy care managers. Something else that was mentioned as particularly challenging was the overall ambition of the Social Services Act to promote maintained independence. The care managers' anxiety about not being able to persuade people to talk about their needs and desires reflects a clash between different ways of thinking about assistance, needs and services. In certain cases, the care managers claimed they knew that the person who was lying passively in bed during the home visit took daily walks outdoors with his/her relatives. The person may even have applied for time to take such walks. This caused the care managers to wonder why people would choose to lie in bed during the home visit. Some of the interviewees seemed to feel that this behaviour reflected these older people's desire to show clearly how serious the situation was and how much he/she was in need of help – to emphasise how difficult things were.
In light of the above, one may wonder why this passivity poses a challenge to the needs assessment process. The answer would seem to be that in addition to making it difficult to determine the older person's physical and mental state, it also makes it difficult to know what the care managers' own views are. According to the interviewees, it is common for late-in-life immigrants not to contribute to the assessment at all. From the care managers' perspective, this behaviour seems both incomprehensible and irritatingly difficult to deal with. One of the interviewed care managers had the following to say:
In my city district there aren't so many … cases involving people from other cultures and all, but well I always think …, we think about the Social Services Act, that we should help people, that they should be as independent as possible. But in these cases they often think they should get help with everything: ‘An old woman can't do this and that’ … And you try to get a discussion going: ‘if she gets some help with this, maybe she can do that herself’. So I think this is where we have very different views. They don't really understand, in many cases, the idea … of being as independent as possible. What it means … instead they think the opposite, she's old and she's lived a long life and she has to get help with everything, all the time. She shouldn't have to do anything. (Focus group interview 4)
What we see is different rationalities in conflict with each other, which brings into sharp focus existing power relations between the person in authority, i.e. the care manager, and the client, i.e. the older person. When care managers meet late-in-life immigrants who do not seem to want to strive toward activity and independence, but who instead expect assistance with everything, the entire spirit of the Social Services Act mentioned earlier is challenged. At the same time, the care managers often expressed their doubt as to whether it was legitimate to try to get late-in-life immigrants to actively participate.
The conflict between a reasonable standard of living and equal treatment
There is one overall challenge that was described and discussed in a lively fashion in all of the interviews and that we have so far only touched on in passing. This concerns being able to judge what should be viewed as ‘a reasonable standard of living’ in relation to those who immigrated late in life and in cases when accepted definitions of what constitutes such a standard of living are challenged by other, culturally defined, needs and expectations.
She just turned 65, this woman … And she says [that] she has to go to church four times a week. And well … is that a reasonable standard of living? Has she always done this? … We don't know, you see … Then you have to draw the line at what is reasonable, what should she be granted from these services … Is she really so religious that she has to … or is this something new? … Well I don't even know … what do they do during their visits to the church? What are these needs like? You never get any real … can they practise their religion from home? … if it's a matter of prayers or whatever it's about. No, I mean I'm so unfamiliar. I simply have no knowledge about it and yet I have to decide. (Focus group interview 4)
The question of what constitutes a reasonable standard of living becomes particularly relevant in encounters with older people who have a cultural background that the care managers are unfamiliar with. The above excerpt concerns religious needs that the care manager does not know how to handle. At the core of this excerpt are the implicit questions: Should such needs result in assistance with leaving the home? Is it really impossible to practise one's religion at home? Is it fair to consider the need to attend church as reasonable if such a need emerged during old age?
This excerpt also highlights the clash between different views and practice, when neither the legislation itself nor local guidelines clearly describe what a reasonable standard of living consists of. Several care managers said that they were expected to consider cultural differences when determining what should be judged as reasonable, but that they did not know how they should do this. Curiously enough, a number of interviewees reported that such differences were seldom taken into consideration in practice. The interviewees felt it was much too difficult to get involved in individual considerations such as these because they increase the risk of injustices against other older people who are also trying to access services. The choice then is to take the simplest path: to judge every case in exactly the same way even if the legislation requires them to treat every case in a unique manner.
Certain cases were described as particularly challenging, both in terms of exercising the profession and in terms of understanding and sympathising with needs that are tied to cross-cultural encounters and religion:
They say, in my culture it's like this. And now they live in Sweden and … ‘yes, but in Sweden things aren't the same’, right. I mean … now you're in Sweden. Has this ever happened to you? (she asks the other focus group members) … Now this is just one example, but certain things … that they play on their culture … and then there are also these demands from some people … ‘because we come from this culture we have to maintain this when we come here’. And then I really feel like, what would happen if I went to your country and said the same thing? … that I have to wear traditional Swedish costumes? I mean I really feel that way sometimes. That doesn't mean I'm a racist, it's just that they … They really do have to realise that they're living somewhere else. (Focus group interview 6)
Care managers brought up the fact that it is often difficult to acknowledge cultural differences and at the same time base one's actions on legislation focused on a reasonable standard of living. The excerpt contains questions about what can be considered reasonable in encounters with people who seem to feel they should be able to live in their new country in exactly the same way they lived in their homeland. In this context, it is interesting to note that some care managers seemed to think it is unreasonable to demand to maintain one's old lifestyle when one no longer lives in one's country of origin. It is also worth noting, of course, that the particular care manager quoted above expressed loudly the one question that seemed to be at the core of the interviews, namely: Can one be considered a racist if one feels this way, thinks this way, and/or handles immigrants' requests in this manner? This question seemed, in other words, to be the elephant in the room; the one thing that the care managers interviewed seemed to be wondering about but dared not express out loud that often.
Discussion
The findings resonate well with previous research that has shown that needs assessment is a complex process (cf. Ceci and Purkis Reference Ceci and Purkis2009; Manthorpe et al. Reference Manthorpe, Jacobs, Rapaport, Challis, Netten, Glendinning, Stevens, Wilberforce, Knapp and Harris2009; as well as Dunér and Nordström Reference Dunér and Nordström2006). Therefore, the contribution of this project is not that the findings clearly show this but rather that they shed light on the specific challenges that care managers associate with needs assessments that involve late-in-life immigrants whose cultures differ greatly from the culture of the majority and who have not mastered the language of the societies in which they now live. These are the immigrants that the care managers interviewed described as presenting the greatest challenge. Thus, when the care managers talked about their experiences of cross-cultural needs assessments, it was this specific group of older people that they were thinking of. Worth noting, therefore, is that because the findings tap into understandings of cross-cultural interaction in needs assessment meetings, they have the potential to be of interest beyond the contextual scope in which they were gathered (i.e. focus groups with care managers in Sweden). The findings tap into how care managers' understandings of cross-cultural needs assessment meetings with older people with a particular type of migrant background (i.e. those that have migrated late-in-life) can pose numerous challenges to the needs assessment process. As such, they suggest that the needs assessment process can be challenged by groups that care managers have little information on and/or whose lifestyles they believe they ought to have greater insight into. The findings suggest, in other words, that the interviewed care managers' experiences may resonate well with the experiences of care managers in other parts of the world, where the number of older people with migrant backgrounds is increasing and where there is an elder care debate that makes numerous assumptions about them and takes for granted that some of them are fundamentally different from the majority population.
One of the challenges brought to the fore is related to the concrete problems that language barriers and the use of interpreters pose, because good communication is a prerequisite for needs assessment meetings. Another challenge mentioned was related to the unusual way in which the interviewees felt that late-in-life immigrants behave during the needs assessment process. According to the care managers interviewed, the fact that late-in-life immigrants did not share common cultural frames of reference caused them, for example, to want to explain their own values and daily lives as well as their expectations concerning the care services they have applied for. A great deal of time was spent talking about issues that were not, in their opinion, really related to the needs assessment process, but instead to these immigrants' cultural identity. This was experienced as unusual as well as somewhat inappropriate. The fact that late-in-life immigrants' expectations could be deemed legitimate if the culture-appropriateness of elder care services were to be on the agenda did not, in other words, seem to be part of the interviewed care managers' understandings. This is interesting considering that the care managers interviewed also expressed frustration over not knowing enough about the cultural backgrounds of the immigrants in question. Thus, although they claimed to want to have (and need) more insight into culture-related expectations, needs, ways of living and values, they also described late-in-life immigrants who wanted to talk about these issues as people who took too much time talking about things that were not central to the needs assessment process.
Something else that makes cross-cultural needs assessment meetings involving late-in-life immigrants challenging is that the care managers are faced with what they described as an exaggerated respect for authority, but simultaneously with greater demands and/or expectations on the services that are available. This ambivalent attitude seemed to be regarded as particularly problematic because it is difficult to navigate in conversations marked by uncertainly as to what is going to happen, how it will happen and why. The fact that the interviewees did not feel comfortable posing questions about these older people's cultural characteristics complicates the matter. The care managers' reason for avoiding questions about cultural, ethnic and religious features was that they did not wish to appear to be discriminatory. In other words, uncertainty was found on several levels and seemed to paralyse care managers during the needs assessment process because they knew neither what was expected of them nor what late-in-life immigrants expected of the system.
Cross-cultural needs assessment meetings with late-in-life immigrants were also experienced as particularly challenging by care managers because judging what constitutes a reasonable standard of living is complicated by the fact that the needs that are articulated by these older people (and/or their families) do not always accord with what the care managers are used to and/or find appropriate to address within the framework of Swedish elder care. Here we see indications of different attitudes among the interviewees. Some want to know and understand more about these ‘special needs’ (cf. Torres Reference Torres2006, 2008), while others claim that, regardless of their own level of knowledge, late-in-life immigrants must adapt to what are defined as needs in the new context they live in. Thus, the context in which needs are articulated seems to be of varying importance to the different care managers. It would seem that what is finally judged to be reasonable in such cases depends on the individual care manager's attitudes. In this connection, we note that the legislation that regulates the needs assessment process in Sweden does require the care managers' focus to be on older people's unique individual needs, but with regard to the group of older people in focus here, it seems as though their unique needs were sometimes considered too deviant to be fully taken into account.
The care managers further discussed the consequences of the fact that the reasonable standard of living that they are supposed to ensure is spelled out remarkably plainly in the local guidelines that guide their practice. Sometimes real conflicts develop simply because needs are brought to the fore that do not match the municipal service catalogues that care managers use. One way of dealing with the difficulty inherent in making individual judgements without causing injustices is reflected in descriptions of the division of assessment work into two clearly separate phases. The care managers seem to want, firstly, to create personal encounters where consideration is shown for the individual and where immigrants and Swedes are treated differently in some respects. In the second phase, involving work with documentation and the formulation of decisions, they attempt to achieve (and feel they often succeed in achieving) equality before the law. Many of the care managers indicated that the ideal individual assessment is difficult to attain. They were aware that the existing care services might not always be suitable, but were also uncertain or doubtful about how individual judgements could (or should) be made. Similar results have been reported by Chester, Hughes and Challis (Reference Chester, Hughes and Challis2010) and Challis et al. (Reference Challis, Hughes, Jacobs, Stewart and Weiner2007) in the UK. They have all pointed out that care managers do not always do a needs assessment solely on the basis of older people's needs, they also consider the services that are available and usually aim to match needs to services as opposed to assessing needs per se.
In the review of previous research, we highlighted the fact that the recent debate on needs assessment practice has actually shifted its focus, from identifying needs to judging and dealing with risk (see e.g. Ceci and Purkis Reference Ceci and Purkis2009; Green and Sawyer Reference Green and Sawyer2010). The interviewed care managers expressed the idea that acknowledging late-in-life immigrants' differentness could entail a risk that the care managers themselves might act in what they find to be, in the context, an unreasonable manner. Their line of argument suggests concern that the management of the needs of older people who have immigrated late in life may lead to judgements that other older people may regard as unjust. If judgements of what is reasonable were to include needs that had not previously been acknowledged, then these older people might receive more and/or different care services to those judged to be reasonable for other older people. In other words, reasonable standard of living tends to be interpreted as what is perceived as a typical Swedish standard of living. This is reminiscent of the kind of ‘colour-blind approach’ used in dealing with ethnic ‘Others’ in social work practice, an approach Boushel (Reference Boushel2000) and Dominelli (Reference Dominelli, Williams, Soydan and Johnson1998) have called discrimination.
On the whole, needs assessment is increasingly becoming a matter of risk assessment. Management of risk in relation to the group of older people in focus here – people who immigrated late in life, who do not speak the majority language and who come from cultures perceived as very different from the majority culture – would seem to be, in important respects, a matter of these older people themselves being perceived as a risk, in that they challenge the needs assessment process through their differentness. The very act of judging their needs could also be interpreted as being a ‘risky business’. Thus, the present study highlights what are in part new ways of looking at risk in the context of needs assessment. In this way, it adds to the debate on risk management in social work. In summary, we can say that the partially unknown social landscape inhabited by individuals who immigrate late in life may well be perceived, and was described, by care managers working in elder care in Sweden as a veritable minefield. This is not just because care managers risk putting their foot in it by asking questions that may be perceived as offensive, but also because they are afraid of treating this group of older people differently and in an unjust manner. The care managers interviewed seemed prone to self-criticism because they were not familiar enough with the characteristics (differences) that are assumed to exist, but they seemed also afraid of creating differences themselves, and thereby injustices. In conclusion we can therefore say that the findings presented here show what Hall, Slembrouck and Sarangi (Reference Hall, Slembrouck and Sarangi2006) have referred to as the dangers of categorisation, i.e. that perceptions and experiences of different groups (in this case, late-in-life immigrants) clearly affect the interaction between welfare representatives and their clients. As such, these are findings that are of interest to research on care management and needs assessment in general and not just to those that focus on what happens when the needs assessment process is carried out with migrants.
Acknowledgements
The authors are grateful for the valuable comments they received from the Welfare & Life-course Research Group of the Department of Sociology of Uppsala University, as well as for the ones they received from the anonymous peer-reviewers that read the first version of this article. The data presented in this article come from a project titled ‘Identifying Needs in Elderly Clients with Migrant Backgrounds: Are Understandings of Cross-cultural Interaction, Ethnic ‘Otherness’ and Gender Relevant for Need Assessment Practice?’, which has received funding from the Swedish Council of Working Life and Social Research (grant Dnr 2010-0666). The project received the ethical approval (Dnr 2011/ 205) of the Regional Ethics Committee in Uppsala, Sweden. The first author put together the focus groups, collected the data and conducted the first analysis of it. The second author and primary investigator for this project received the funding for the project, got the ethics approval for it, and manages the project. All three authors have contributed to the writing of the article, including the analysis.
