Homecare in Roma Family

The incident

The narrator tells us:

“As a district and homecare nurse, I was going to visit a young patient, living with his family in the Roma community. The patient had a surgical wound, which was apparently healing very poorly and also very slowly, given the patient´s young age and the normal time for such a healing. The wound was about 15 cm in width and was situated under the navel. I was going to clean it and have a closer look.

My first surprise: when I arrived to the family´s home, almost at the doorstep the little daughter threw herself into my arms and tried to hug and kiss me. I was taken by surprise, while usually patients and their families are not approaching me as if I were a close friend of the family.

My next surprise: when I freed myself from the little girl´s embrace, the patient´s mother came rushing towards me, shouting loudly: “I kill that doctor, I kill that doctor”. I realised that she was referring to the surgeon in the hospital who had operated on her son. It is not unusual that patients and their relatives are complaining about hospitals and treatments. But usually they do not threaten with murder. I was speechless.

My third surprise: when I passed the upset mother and went into the bedroom to see the patient, the whole family followed me and sat on the bed around the patient. I could hardly get close to the patient and his wound. Furthermore, his wife now insisted on giving me my utensils from my nurse´s box, which is completely out of touch with professional precautions. She was concerned about the cleanliness, and I had the impression that she would actually prefer to clean the wound herself. I felt very awkward and also annoyed by her way of acting. But I succeeded in getting the necessary space to give the patient a proper professional treatment, even though the women insisted on being on the bed at the same time.

My fourth surprise: when I finished the treatment, the patient was quite satisfied and the whole family seemed relieved, after all. So, I was going to get away as quickly as possible, feeling somehow uncomfortable and confused about the whole situation. But before I could leave the bedroom, the patient gave me an offer to buy some racks of canned beer to a favourable price. Now I lost my last feeling of normality in the situation, so I just refused this trade deal and rushed out of the apartment…”

1. Identities of the actors in the situation

The narrator is Swedish, but settled down in Denmark with her Danish husband around 35 years ago, parents of 3 grown-up sons. At the time of the incident, the youngest son was still living with them. Originally educated as a psychiatric assistant in the Swedish healthcare system. Later on, after years of practice in the Danish healthcare sector, she was educated as a nurse in the Danish healthcare educational system treating patients in their private homes. At the time of the incident, the narrator was 55 years old and had many years of professional experience as an educated nurse in various sectors of the healthcare system.

The narrator and her family live in the countryside outside the city of Elsinore, where the incident took place. They would regard themselves as humanists with strong values based on simple lives in close contact with nature and outdoor activities. They appreciate close relationships and are not very interested in material values. They would regard themselves as traditional leftist with an open-minded approach to diversity.

The incident involves a Roma family, consisting of:

  • A male patient in his mid-twenties.
  • His wife, also in her mid-twenties.
  • Their little daughter, 5 years old.
  • The patient´s mother in her mid-fifties.

The male patient has recently been in the hospital and is now to be treated in his own home for a surgical wound, that cannot heal.

The whole family lives in the special Roma community, which has been a part of the city of Elsinore for many generations, due to the Roma population´s special history in this corner of the Capital area in Denmark.

The young family in the incident was born and raised in this Roma community. The mother of the patient also lives in the community, but she originally migrated from Ex-Yugoslavia.

The whole family speaks the special Roma community-based accent. This applies also to the patient and his wife, even though they were born and raised in Denmark and have – more or less – been students in one of the local primary schools. Anyway, they are very familiar with the Danish language, and in this particular incident; apparently, the Swedish accent of the narrator would play no particular role for the communication.

The whole family receives social benefits.

A few facts about the Roma population in Elsinore:

The Roma population in Elsinore is estimated to be around 1.200 persons.

It is difficult to give exact numbers for Elsinore as well as Denmark in total, because according to Danish law it is illegal to register people on the basis of ethnicity. Roma associations have indicated that the number of Roma citizens would be much higher than the official estimates, as many Roma people prefer to hide their origins because of fear of being lumped with stereotypes of “thieving gypsies”.
The relative over-representation of Roma people in Elsinore is due to the proximity to Sweden, which is home to a large Roma population. Originally, the Roma history in Elsinore goes back to the sixties, where a number of Roma people from Serbia/former Yugoslavia had difficulties to cross over to Sweden and then settled in Elsinore, where they founded a Roma community.

2. Context of the situation

The incident takes place in the home of a young Roma family. The narrator is visiting the family as part of the homecare for the male family member, who needs special medical care after an operation.

3. Emotional reaction

The narrator felt startled at first and grew speechless over the course of her visit. The situation was becoming ever more awkward for her. She got annoyed and felt relieved when she had finished the homecare and her professional duties, thus she could leave in a hurry.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

The norms and values of the professional identity against norms and values of family unity and integrity:

The incident reflects the clash between a professional expertise-based healthcare on one hand – and the community-based approach and community involvement in all kinds of family matters on the other hand. For the nurse, this would normally be a bilateral matter between the professional person and the patient. In this case, the treatment turns out to be a multilateral matter involving not only the patient, but also the whole family very actively in the treatment process.

One reflection of this dilemma is the wife’s attempt to take over the cleaning of the wound – a task which from the narrator’s point of view should be performed by a professional. There is almost a competition between the professional care and family care. By this action, the wife makes a signal that external authorities do not have the same credibility as internal family and community members.

Because of the unexpected interference from the wife and the whole family, the nurse feels strongly challenged on her professional standards for both treatment procedures and hygiene.

The norms and values of personal distance as part of professionalism distance against norms and values of family’s superior authority and position.

Even though the homecare system is actually taking place in patients´ private surroundings, the nurse, as an authoritative representative of the professional healthcare system, expects to be able to keep a certain personal distance to the patients, not to be confused with a lack of empathy, care, kindness and personal awareness in the situation. But in this case, the nurse feels intimidated at the professional level, while she is being treated as a close family member who is expected to play with the family’s and community´s special cultural rules.

The professional intimidation manifests itself physically as well as emotionally, thereby confusing the nurse on more than one level.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatised", positive, very positive, real, unreal) etc?

Unpredictable – breaking all usual rules and hierarchies between professional and lay people.

Indiscreet, intimidating and transboundary behavior.

Irresponsible in their dealings with disease and infection risk.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

Family values and norms:

Roma people generally have very strong family loyalty, they prefer close contact with family members. They honour older relatives and consult them when making decisions. In time of illness the eldest female member is consulted, because women are supposed to have special medical knowledge. Illness concerns the whole family.

Communicative values and norms:

Roma people normally communicate in a rather animated, loud and argumentative way, especially in critical situations (in this incident: concern over illness). This can also include physical contact.

Roma people can easily be considered aggressive by “external” people, who do not know about their traditions and ways of communication – like the nurse in this incident.

Bodily values and norms:

The body below the waist is traditionally considered impure and is connected with special cleaning procedures (purification). The position of the wound in this incident may influence the reactions of the patient and family: they want the female member to clean it.

Values about public authorities and outsiders:

The local Roma community has quite strong and long-term cultural traditions. This indicates that they are to a certain extent making their own societal and social rules for the community members (we happen to know that from former studies over years in some of these families in Elsinore). Furthermore, this also indicates that strangers and outsiders – especially representatives of authorities – are met with a certain degree of distance and suspiciousness – or they have at least to play by the local rules, as also in this particular case.

In the incident, this is symbolised very clearly by the mother, who threatens to kill the  surgeon, because her son is still sick and in pain after the operation.

Values about labour and self-support:

Some of the local Roma families (rather most of them, but this should be properly documented) are not affiliated with the ordinary labour market. Thus it is not uncommon that they make part of their living on various kinds for barters, thereby the attempt to deal with the nurse. But it should be remembered that as citizens in Denmark they have access to the general social benefits and the relatively high compensation rate. Thus, they are not poor in the general European sense.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

The situation first and foremost highlights the need for intercultural training for healthcare professionals. Especially in this incident, the focus should be on the need for introduction and training in cultural encounters led more or less directly by unfamiliar and unexpected norms and expectations. How do professionals deal with such situations in a way where one takes into account both one’s own as the counterparty needs to feel recognition, respect and responsiveness.

In this incident, the need for such training is especially pronounced, because the professional work is taking place in a private setting and in the patient’s home and domain.  Positionally, this setting is very different from the situation where patients and relatives come to a consultation with a GP or in a hospital ward – ie in the professional domain. Thus, it should be considered, whether homecare requires a special form of intercultural training.