Title Page Full Title: Challenges and Opportunities For The Multi-Cultural Aged Care Workforce: A Systematic

Accepted Article Title page
Full title: Challenges and opportunities for the multi-cultural aged care workforce: A systematic
review and meta-synthesis
A short running title: The multi-cultural workforce
Author details:
Author 1
Li CHEN, RN, BN (Honours), College of Nursing and Health Sciences, Flinders University,
Australia
Email: chen1333@flinders.edu.au
Tel: +61466886722
ORCID: 0000-0001-9817-9771
Author 2
Lily Dongxia XIAO, RN PhD, Professor, College of Nursing and Health Sciences, Flinders
University, Australia
Email: lily.xiao@flinders.edu.au
Tel: +61882013419
ORCID: 0000-0002-4631-2443
Author 3
Weifeng HAN, PhD, Lecturer, College of Nursing and Health Sciences, Flinders University,
Australia
Email: weifeng.han@flinders.edu.au
Tel: +61882015074
ORCID: 0000-0001-5121-8112
Author 4
Claudia MEYER, PhD MPH BAppSci (Physio) Research Fellow, Bolton Clarke Research
Institute, Victoria, Australia & Adjunct Research Fellow, Rehabilitation, Ageing and Independent
Living (RAIL) Research Centre, Monash University, Victoria, Australia
Tel: +61385312500
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JONM.13067
This article is protected by copyright. All rights reserved
Email: cmeyer@boltonclarke.com.au
Accepted Article
ORCID: 0000-0001-5853-6623
Author 5
Amanda MÜLLER, PhD AE Grad Cert TESOL Grad Cert Higher Ed, Senior Lecturer, College of
Nursing and Health Sciences, Flinders University, Australia
Tel: +61 8 8201 3378
Email: amanda.muller@flinders.edu.au
ORCID: 0000-0002-8726-8231
Corresponding author
Lily Dongxia XIAO, RN PhD, Professor, College of Nursing and Health Sciences, Flinders
University, Australia
Email: lily.xiao@flinders.edu.au
Tel: +61882013419
Address: College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide,
SA 5001, Australia
Conflict of Interest Statement: Authors have no conflict of interest to declare.

Funding: Not Applicable

Accepted Article
DR LILY DONGXIA XIAO (Orcid ID : 0000-0002-4631-2443)
Article type : Review Article
Challenges and opportunities for the multicultural aged care workforce: A

systematic review and meta-synthesis
ABSTRACT
Aims: The aims of this review were to identify: (1) challenges for multicultural aged care
teams; (2) opportunities to facilitate teamwork; and (3) strategies to assist team members in a
multicultural work environment.
Background: High-income countries have an increasingly culturally diverse aged care
workforce. Fostering teamwork in such an environment is challenging.
Methods: This systematic review of qualitative studies followed the Joanna Briggs Institute
(JBI) meta-aggregation approach. Six databases were searched. Retrieved articles were
screened by two reviewers. This review identified 111 findings that were aggregated into 15
categories and five themes.
Findings: Aged care workers’ awareness of cultural diversity varies, and their knowledge of
each other’s cultural background is limited. However, cultural skills are demonstrated,
contributing to teamwork. Their experience in cross-cultural encounters is broad and
enhanced team cohesion is desired.
Conclusions: The cultural competence of the aged care workforce shapes team building, peer
support opportunities, and positive cross-cultural experiences.
Implications for Nursing Management: Recommendations are provided for the adaptation
of aged care workers to culturally diverse teams, fostering teamwork to enhance care
outcomes for clients. Interventions for improvements in cross-cultural leadership and
management, and staff experience of cross-cultural encounters are much needed.
Keywords: Aged care, Cultural diversity, Cultural competence, Multicultural team, Nursing
home

1 INTRODUCTION
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The ageing population is a pull factor for migrants from developing countries to work in aged
care in high-income countries, specifically to fill job vacancies (Fujisawa & Colomboand,
2009). In 2017, there were 164 million migrant workers across the world, with 67.9%
employed in high-income countries (International Labour Office, 2018). Moreover, the
population of migrant nurses and doctors in Organisation for Economic Co-operation and
Development (OECD) countries had increased by 60% between 2004-2014, and migrant
nurses in New Zealand, Switzerland, Luxembourg and Australia accounted for more than 30%
of the nurse workforce (International Labour Office, 2015). Simultaneously, older people in
aged care homes in high-income countries have also become culturally and linguistically
diverse (Kim et al., 2015; Xiao et al., 2018). Studies on migrant care workers’ experiences in
multicultural teams in aged care homes in high-income countries are abundant. However,
systematic reviews that synthesise research findings across the globe are scarce. This review
addresses this gap in the literature and promotes evidence-based practice in managing
multicultural teams in aged care homes.
Numerous studies show that cultural diversity of an aged care workforce within
culturally diverse societies has many benefits (Kim et al., 2015). For the aged care workforce,
benefits of a multicultural team include opportunities to upskill in culturally appropriate care
and support each other in cross-cultural client interactions (Xiao et al., 2020). Further, having
aged care workers with fluency in another language benefits cross-cultural communication
between clients and care workers (Kim et al., 2015; Xiao et al., 2018).
It is widely reported that there are challenges with care delivery among multicultural
teams (Nichols, Horner, & Fyfe, 2015; K. Walsh & Shutes, 2013). Cross-cultural
communication can be problematic among teams of aged care workers of diverse cultural
backgrounds (Egede-Nissen, Sellevold, Jakobsen, & Sorlie, 2019; Schilgen, Handtke,
Nienhaus, & Mösko, 2019). Cross-cultural communication difficulties among care workers of
migrant backgrounds can affect their performance and their relationships with clients and
other team members (Bourgeault, Atanackovic, Rashid, & Parpia, 2010; Nichols et al., 2015;
K. Walsh & Shutes, 2013). Aged care workers from a migrant background may also
experience discrimination and racism (Bourgeault et al., 2010; Goel & Penman, 2015;
Stevens, Hussein, & Manthorpe, 2012).

2 AIM
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The aims of this systematic review were to identify: (1) challenges for multicultural aged care
teams; (2) opportunities to facilitate teamwork; and (3) strategies to assist team members in a
multicultural work environment. The review question was: ‘what is the perception of aged
care staff of working in multicultural teams?’
3 METHOD
3.1 Research design
This systematic review applied the JBI meta-aggregation methodology to synthesise
qualitative studies in an area of interest (Lockwood, Munn, & Porritt, 2015). A research
protocol was developed and registered on the PROSPERO website (blinded for peer review).
This review is reported according to the Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA) statement.
3.2 Search strategy

Six electronic databases were searched: MEDLINE; EMcare; CINAHL; Scopus; Proquest;
and Web of Science. An initial scoping search of the literature was conducted to identify
keywords and search terms. Search terms included multicultural caregivers, cultural diversity,
perception, experience, nursing home and aged care facilities. We combined terms using the
Boolean operators AND and OR. An asterisk was used to expand the search and avoid any
omissions. The reference lists of appropriate studies were hand searched for additional
articles. The full search strategy is summarised in Appendix I.
3.3 Eligibility criteria and study selection

Studies were considered eligible when primary studies using a qualitative or a mixed-method
design (wherein qualitative data could be extracted). Studies were required to be published in
English and focused on the experiences of aged care workers in multicultural teams.
Quantitative research or research using a mixed-methods design without extractable
qualitative data were excluded. Publication date was unlimited.
The search strategy yielded 306 articles, with retrieved citations exported to Endnote.
Thirty-eight duplicates were identified and removed. A total of 268 articles were screened by
title and abstract for eligibility, resulting in 26 articles meeting the selection criteria. Full
texts of the 26 articles were exported into Endnote and reviewed. Full-text review resulted in

14 articles selected as eligible. Further manual searching generated another seven eligible
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articles. In total, 21 relevant articles from 17 original studies were included for appraisal. The
screening process was undertaken by three reviewers (LC, LX and WF) without
disagreements. Figure 1 summarises all search results.
3.4 Quality assessment

All articles were assessed for study rigour using the JBI Qualitative Assessment and Review
Instrument (JBI-QARI) checklist (see Table 1) for qualitative research (Joanna Briggs
Institute, 2017). Three articles were excluded, with reasons for exclusion presented in
Appendix II. All reviewers reached consensus on the final appraisal result.
3.5 Data extraction and synthesis

Data extraction was in two stages: (1) the main aspects of the study were extracted from each
article; and (2) a standardised JBI-QARI tool was used to extract findings (author
interpretation of the data), illustrations of findings, and levels of plausibility (a level of
credibility). A level of credibility (one of three possible levels) was attributed to each piece of
evidence by two independent reviewers: (1) unequivocal (U) is evidence without reasonable
doubt; (2) credible (C) is evidence that is plausible from data and theoretical frameworks, but
can be challenged; and (3) not supported (NS) is evidence not supported by the data. Original
texts were repeatedly read by reviewers to ensure correct interpretations. Data synthesis was
through the JBI aggregation process, by aggregating findings to categories and further
aggregating categories to synthesised findings. The JBI ConQual tool (see Appendix III) was
then used to evaluate the dependability and credibility of each finding to establish confidence
in the synthesised findings (Munn, Porritt, Lockwood, Aromataris, & Pearson, 2014).
4 FINDINGS
4.1 Characteristics of the studies
A total of 18 articles from 14 studies were included in this review. Of the 14 studies, three
were of mixed-method design and 11 were of qualitative design. All articles were published
between 2009 and 2019. Of the 14 studies, four studies were conducted in Australia, three in
Norway, two in Ireland, and one each in the Netherlands, Finland, United Kingdom (U.K.),
and the United States (U.S.). The last study was conducted in both Ireland and the U.K..
Detailed characteristics of all 18 articles are summarised in Appendix IV.

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4.2 Meta-synthesis of qualitative data
A total of 111 findings were extracted from the 18 included articles (see Appendix V): 92
articles were ranked as unequivocal and 19 as credible. Fifteen categories were generated
from these findings. Details of the data aggregation are presented in Appendix VI. These
categories were further meta-aggregated into five synthesised findings (see Table 2).
4.2.1 Synthesised finding 1: Various cultural awareness in the multicultural team

Cultural awareness about team members varied. Migrant staff who were culturally aware of
challenges faced by new migrant staff provided peer support for them. They described the
support as “immigrants help immigrants” in adapting to the multicultural team (Goel &
Penman, 2015. p. 6). One explanation given for this kind of peer support was: “We are good
at taking care of those who start working here. I think it's because we work here now, we
were in the same situation before. We also had bad language; we hardly understood anything
ourselves.” (Munkejord & Tingvold, 2019, p. 235). In this instance, cultural awareness
enabled migrant staff to show empathy for others, a key attribute that contributed to a
welcome environment for new migrant staff and an important condition for staff to build
teamwork.
Host staff also showed their awareness of migrant staff: “I find that foreign ones are
very good. Once they know the job well, they're very quick but they're very efficient...I
actually prefer it [to work with overseas born workers]. Because I do think they've got a high
standard work ethic” (Gao, Tilse, Wilson, Tuckett, & Newcombe, 2015, p. 116). Such an
awareness of team members’ strengths contributed to team cohesion.
Managers were aware of migrant staff weaknesses: “when they are communicating with
the residents they have to pick up on other things like non-verbal signs, or, erm, actively
listen to what the resident’s saying or sometimes get the resident to repeat what’s being said”
(Badger, Clarke, Pumphrey, & Clifford, 2012, p. 1731). This awareness allowed managers to
assess the level of migrant staff cross-cultural communication skills.
4.2.2 Synthesised finding 2: Limited knowledge about members in the multicultural

team
Variable staff knowledge about team members’ culture and its impact on care delivery
affected opportunities for offering or seeking peer support. A migrant staff member
demonstrated knowledge of the multicultural team: “There is a huge cultural difference. We

need to give clients what they want, like a simple request for toasted bread. For other nurses,
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individual preferences are not important, but they are.” (Goel & Penman, 2015, p. 7). In this
instance, the staff considered the team to be vital for a person-centred care approach for
clients.
In a Norwegian study, a migrant staff member had no knowledge about Norwegian
clothing culture: “everybody uses a scarf, but we do not use scarf in my country, it is not
necessary, but the old here [older people with dementia], they use scarfs” (Egede-Nissen et
al., 2019, p. 1330). Migrant staff also had little knowledge about traditional celebrations that
were meaningful for clients with dementia: “I did not understand the meaning of celebrations,
it was too much for me, to adapt to culture. In the Norwegian culture, there are many
celebrations, and I did not understand what it all meant, it was very difficult” (Egede-Nissen
et al., 2019, p. 1330). In this example, creating opportunities for migrant staff to learn from
host staff was imperative. Moreover, host staff also showed limited knowledge about migrant
staff cultures:
‘Because, I been talking … with some of the girls from Africa, and … I
thought myself, Africa is a big country and they have … nursing home on
every part, you know. But some of the girls they said, “No, they have to
take care of their elders at home”’
(Nichols et al., 2015, p. 27)
Such misunderstandings, resulting from limited knowledge of cultural differences

among staff and residents, could affect care delivery and wellbeing of staff. An example of a
manager’s unfair treatment of migrant staff was reported: “When I have mentioned
specifically that I need time for prayer, I was refused. But my co-workers go outside quite
often to smoke, and that wasn’t forbidden. Isn’t it unfair and unequal?” (Begum & Seppänen,
2017, p. 67). This example highlights a discrepancy in an individual’s right to exercise their
beliefs.
4.2.3 Synthesised finding 3: Cultural skills in a multicultural team

Multicultural teams demonstrated numerous cultural skills that encouraged an inclusive,
person-centred environment for residents. For example, they acted as interpreters using their
language skills: “We use other staff to help out in language situations. …If we have to ask

them [residents from a migrant background] a menu and they don’t understand what we’re
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saying. We find someone [bilingual staff] that can help” (Xiao et al., 2018, p.7). Evidence
from this study suggested that migrant staff bridged the cross-cultural communication gap
with clients through teamwork and good use of linguistic skills. However, at times, they
demonstrated limited knowledge of the host country’s cultural needs: “She [a host staff]
showed me how to do it, and I am a little ashamed the way it happened, but, yes, I can just
explain that we do not have it at home; we do not need a scarf in my country” (Egede-Nissen
et al., 2019, p. 1330).
Managers were crucial in bringing together a multicultural team evidenced through
pairing experienced staff with new staff of the same cultural background:
we have to do a more intimate training with her [a new migrant staff], so

we always make sure that we’ve got another girl that speaks the same
language and speaks excellent English, that she’s with her… and she can
like to explain to her if there’s a problem.
(Badger et al., 2012, p. 1730)
4.2.4 Synthesised finding 4: Broad experiences in cross-cultural encounters

Cross-cultural encounters for staff and clients were found to be both positive and negative.
Migrant staff felt they could always find someone to assist when they encountered problems
at work: “I think also in our case we have very good help, huge help from other carers”
(Gillham et al., 2018, p. 21). They also appreciated the support from management: “They
described their supervisors as ‘‘good,’’ ‘‘supportive,’’ and ‘‘helpful’’. Monique said ‘‘(t)hey
[the supervisors] are good. They take care of the situation on time. They try to help” (Ryosho,
2011, p. 66).
Challenges in cross-cultural communication were also encountered: “I’ll always sing
the wrong tune. The language stops my wish for further education. I can’t express myself in
Norwegian, must translate all the time” (Egede-Nissen et al., 2019, p. 1332). Some migrant
staff perceived language to be the most challenging part of the job: “The greatest challenge
when I came here was the language, not to be understood and not understanding others”
(Sellevold Gerd, Egede-Nissen, Jakobsen, & Sørlie, 2019, p. 509).

Migrant staff voiced their experience of discrimination: “We work as casual
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employees. We get lousy shifts … They [management] give us difficult tasks, for example,
spring cleaning, but other Australian workers were not given those difficult tasks or shifts”
(Goel & Penman, 2015, p. 6). Racism was evident: “I would say sometimes it's like other
people they don't have confidence in you … I sometimes feel it's about the colour” (Nicols,
Horner, & Fyfe, 2015, p. 27), echoed by another: “Sometimes the way they would talk to you,
the way they would treat you, you would hate yourself. …You say, ‘is it because I am Black
or something?” (Doyle & Timonen, 2009, p. 342).
Extra pressures were felt by some host staff when helping migrant staff: “the Irish
workers were left…on the floor helping [migrant carers] to integrate into it and it was done
very successfully. But with huge challenges and with huge extra pressure on the Irish nurses”
(Kieran Walsh & O’Shea, 2010, p. 29). In this example, support for host staff to team with
migrant staff was much needed to sustain peer support within a multicultural team.
4.2.5 Synthesised finding 5: The desire to enhance teamwork

Opposing views of proactivity or lack of action, dependent upon host staff motivation, was
evident for integration of migrant staff into the multicultural team. Migrant staff desired to be
recognised by the team: “I go step by step. I will get involved in the unit, I’ll learn about the
patients by reading books, by talking with colleagues and with their next of kin…” (Egede-
Nissen et al., 2019, p. 1330). Migrant staff’s motivation to be part of team was recognised by
host staff: “I am impressed how fast they learn … I would never have managed going to [a
foreign country] and working in a nursing home there” (Munkejord & Tingvold, 2019, p.
235). However, humiliation was felt by other migrant staff when host clients were permitted
to make racist remarks:
A patient once said to me: ‘alien, come here’ ... my colleagues heard this
and they laughed and laughed and laughed ... to this date nobody has
apologized [despite complaint to management] ... I don’t care about money,
but I do care about my colleagues giving me respect’.
(Timonen & Doyle, 2010, p. 38)

In this example, a migrant staff’s right to be respected was disregarded through the
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collective action of host staff, managers and clients. This was exacerbated by a lack of
leadership of some managers to combat overt racism:
you can’t really do anything about it [racist verbal abuse], the only thing
that you can do is probably walk away and set up an incident report and
issue an application for a management hearing ... but most of the time
nothing really happens.
(Shutes & Walsh, 2012, p. 97)
In the absence of strong leadership, racism has the potential to be perpetuated in the
workplace. There is an imperative for managers to raise cultural awareness and promote
cultural safety through investigating such incidents, and instigating an action plan to address
serious concerns. There was acknowledgement among staff that cultural safety training would
assist in addressing these issues: “All employees must have some cultural awareness and
sensitivity training in order to work amicably with each other” (Goel & Penman, 2015, p. 8).
5 DISCUSSION
The five synthesised findings show staff cultural competence to be critical for successful
multicultural teamwork. Our findings support the need to improve cultural competence for
staff across the five integrated attributes: cultural awareness, cultural knowledge, cultural
skills, cultural encounters, and cultural desire. These attributes were originally developed by
Campinha-Bacote (2002) and mainly focused on cross-cultural interactions between health
professionals and patients. Our findings extended these attributes to staff cross-cultural
interactions in aged care homes.
The findings from this study support previous work undertaken on innovative models
designed to create positive opportunities and promotion of teamwork among migrant and host
staff members (Munkejord, 2019; Willis et al., 2018; Xiao et al., 2020). Another innovative
model was reported in a Norwegian study, showing similar characteristics (Munkejord, 2019).
Firstly, the organisation promoted egalitarianism across all staffing levels, valuing migrant
staff. Secondly, migrant and host staff were paired as a team, taking responsibility for all
aspects of client care, making best use of both their strengths and enabling collaboration with,

and support of, each other. However, this model may be challenged when accounting for
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mistrust and racism directed toward migrant staff by their clients (Munkejord & Tingvold,
2019). Moreover, aged care homes that employ a large proportion of migrant staff may have
difficulty pairing them to host staff through existing workflow channels. A further innovative
teamwork model may involve strategies such as employing site champions to facilitate
migrant staff and host client cultural exchanges, staff cultural competence development via
education programs, and mentoring new migrant staff to adapt to the multicultural team (Xiao
et al., 2020).
Our findings identified that managers played a crucial role in creating an environment
to enable positive cross-cultural encounters in staff. Cross-cultural communication is
influenced by the cultural values on what information to share or restrain and when and
where to talk with others regarding cross-cultural conflicts (Ting-Toomey, 2010). As this
study has shown, migrant staff fear speaking out in the team, contributing to a negative
teamwork environment (Egede-Nissen et al., 2019; Nichols et al., 2015). A meta-analysis
revealed that elaboration of information held by team members showed a stronger positive
impact on team performance than the frequency of communication (Marlow, Lacerenza,
Paoletti, Burke, & Salas, 2018). Therefore, fostering teamwork requires managers to create a
migrant staff-friendly atmosphere that empowers them to speak out about their opinions
without fear (Willis et al., 2018).
New migrant staff often experience cultural shock and show knowledge and skill
deficits regarding host cultures and traditions (Badger et al., 2012; Nichols et al., 2015; Willis
et al., 2018). Leadership is crucial to support them to adjust to a new cultural environment.
Clinical mentorship programs have been reported in aged care homes for quality
improvement purposes (Liao et al., 2020), yet socio-cultural mentorship programs led by host
staff are scarce. Managers can assist by demonstrating their cultural desire to promote
migrant staff to host staff and host clients, such as through migrant staff sharing their lived
experience of birth country, culture, spirituality and religion, underpinned by a foundation of
social justice, respect for the rights of migrant staff, and working toward combating racism
and discrimination (Douglas et al., 2011).
An important finding from this study is that experiences of racism are often kept quiet
and rarely shared with those in leadership positions (Schilgen et al., 2019). Our findings also
identified inaction from management when receiving incident reports on racism (Shutes &
Walsh, 2012). This situation can have a detrimental impact on the wellbeing of staff and
resources to cope with the challenges. Effective leadership is much needed to create a

culturally safe environment in which migrant staff can speak out about their experiences in a
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formal and informal manner. In a recent leadership study in nursing homes in Sweden, staff
rated the leadership attribute of constructively handling conflicts highly (Backman, Sjogren,
Lindkvist, Lovheim, & Edvardsson, 2017). Findings from our review support that study, but
we elaborate that managers are also required to demonstrate leadership abilities to resolve
conflicts arising from racism and other team frictions. Leadership education and training that
focus on racism, discrimination, unfair treatment, and other issues identified in cross-cultural
interactions are much needed.
The strength of this review is its reinterpretation and syntheses of findings from
rigorous qualitative studies of the multicultural aged care workforce. A further strength is the
enhancement of study rigour through the triangulation of data from different research teams
across different geographic locations across the globe. This review also has limitations. First,
selection bias exists because articles included in the review were published in English only.
This limitation may lead to the omission of relevant articles published in other languages. In
addition, this review did not include articles that reported the perceptions of clients and their
family members on the multicultural workforce.
6 CONCLUSION
This review demonstrated its originality, innovation, methodological rigour, and relevance
across global contexts about how cultural competence in the multicultural aged care
workforce shapes opportunities to build teamwork, peer support, and experiences in cross-
cultural encounters. Managers in aged care homes are in an ideal position to build an
inclusive and egalitarian environment to facilitate staff adaptation to multicultural teams.
Racism, discrimination, and unfair treatment towards migrant staff have detrimental impacts
on their health and wellbeing. In the absence of leadership and effective management, these
issues can be ignored and remain unresolved. There is an imperative to develop human
rights-based policies, standards, protocols, and services at an organisational level, working to
protect staff of diverse cultural backgrounds from all forms of discrimination, including
racism. Developing cultural competence for all staff is a priority to foster workforce
integration.

7 IMPLICATIONS
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The recommendations are presented in Appendix VII. A concerted effort will need to be
made to mobilise resources and scale the findings of this study, to maximise its impact. This
may include engaging with government aged care workforce consultations, submitting the
report to government and aged care industry associations, and educating institutions that
provide management and leadership training for aged care nurses. There is an urgency to
enhance staff adaptation to multicultural teams. This can potentially be achieved through the
creation of resources for cross-cultural leadership and management, use of anti-racism and
discriminations toolkits, or utilisation of internationally recognised resources (Transcultural
Nursing Society, 2020).
ETHICAL APPROVAL
No ethical approval was required for this review paper.
REFERENCES
Backman, A., Sjogren, K., Lindkvist, M., Lovheim, H., & Edvardsson, D. (2017).
Characteristics of highly rated leadership in nursing homes using item response theory.
Journal of Advanced Nursing, 73(12), 2903-2913. doi:10.1111/jan.13353
Badger, F., Clarke, L., Pumphrey, R., & Clifford, C. (2012). A survey of issues of ethnicity
and culture in nursing homes in an English region: nurse managers' perspectives.
Journal of Clinical Nursing (John Wiley & Sons, Inc.), 21(11-12), 1726-1735.
doi:10.1111/j.1365-2702.2011.03880.x
Begum, S., & Seppänen, M. (2017). Islamic Values in Elderly Care in Finland: The
Perspective of Muslim Women Caregivers. Journal of International Women's Studies,
18(2), 59-73.
Bourgeault, I. L., Atanackovic, J., Rashid, A., & Parpia, R. (2010). Relations between
Immigrant Care Workers and Older Persons in Home and Long-Term Care. Canadian
Journal on Aging, 29(1), 109-118. doi:10.1017/S0714980809990407
Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare
services: A model of care. Journal of Transcultural Nursing, 13(3), 181-184.
doi:10.1177/10459602013003003

Douglas, M. K., Pierce, J. U., Rosenkoetter, M., Pacquiao, D., Callister, L. C., Hattar-Pollara,
Accepted Article M., . . . Purnell, L. (2011). Standards of practice for culturally competent nursing care.
Journal of Transcultural Nursing, 22(4), 317-333. doi:10.1177/1043659611412965
Egede-Nissen, V., Sellevold, G. S., Jakobsen, R., & Sorlie, V. (2019). Minority healthcare
providers experience challenges, trust, and interdependency in a multicultural team.
Nursing Ethics, 26(5), 1326-1336. doi:10.1177/0969733017752546
Fujisawa, R., & Colomboand, F. (2009). The Long-term care workforce: Overview and
strategies to adapt supply to a growing demand. OECD Health Working Papers, No.
44. Retrieved from http://www.oecd-ilibrary.org/social-issues-migration-
health/international-migration-outlook-2015_migr_outlook-2015-en
Gao, F. S., Tilse, C., Wilson, J., Tuckett, A., & Newcombe, P. (2015). Perceptions and
employment intentions among aged care nurses and nursing assistants from diverse
cultural backgrounds: A qualitative interview study. Journal of Aging Studies, 35,
111-122. doi:10.1016/j.jaging.2015.08.006
Gillham, D., De Bellis, A., Xiao, L., Willis, E., Harrington, A., Morey, W., & Jeffers, L.
(2018). Using research evidence to inform staff learning needs in cross-cultural
communication in aged care homes. Nurse Education Today, 63, 18-23.
doi:10.1016/j.nedt.2018.01.007
Goel, K., & Penman, J. (2015). Employment experiences of immigrant workers in aged care
in regional South Australia. Rural and Remote Health, 15(1). Retrieved from
https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84928997182&partnerID=40&md5=df3f6fbb7b33405f8577aa017ff2cb06
International Labour Office. (2015). Global estimates of migrant workers and migrant
domestic workers: Results and methodology: Special focus on migrant domestic
workers. Retrieved from Geneva:
International Labour Office. (2018). Global Estimates on International Migrant Workers –
Results and Methodology. Retrieved from Geneva:
Joanna Briggs Institute. (2017). Checklist for qualitative research. Retrieved from
https://joannabriggs.org/sites/default/files/2019-05/JBI_Critical_Appraisal-
Checklist_for_Qualitative_Research2017_0.pdf
Kim, H., Woods, D. L., Phillips, L. R., Ruiz, M. E., Salem, B., Jeffers-Skrine, K., & Salem,
N. (2015). Nursing Assistants' Communication Styles in Korean American Older
Adults With Dementia: A Review of the Literature. Journal of Transcultural Nursing,
26(2), 185-192. doi:10.1177/1043659614547200

Liao, L., Xiao, L. D., Chen, H., Wu, X. Y., Zhao, Y., Hu, M., . . . Feng, H. (2020). Nursing
Accepted Article home staff experiences of implementing mentorship programmes: A systematic
review and qualitative meta-synthesis. Journal of Nursing Management, 28(2), 188-
198. doi:10.1111/jonm.12876
Lockwood, C., Munn, Z., & Porritt, K. (2015). Qualitative research synthesis: methodological
guidance for systematic reviewers utilizing meta-aggregation. International Journal
of Evidence-Based Healthcare, 13(3), 179-187. doi:10.1097/xeb.0000000000000062
Marlow, S. L., Lacerenza, C. N., Paoletti, J., Burke, C. S., & Salas, E. (2018). Does team
communication represent a one-size-fits-all approach?: A meta analysis of team
communication and performance. Organizational Behavior and Human Decision
Processes, 144, 145-170. doi:10.1016/j.obhdp.2017.08.001
Munkejord, M. C. (2019). Challenging the ethnic pyramid: Golden rules and organisational
measures towards a more inclusive work environment. Journal of Nursing
Management, 27(7), 1522-1529. doi:10.1111/jonm.12838
Munkejord, M. C., & Tingvold, L. (2019). Staff perceptions of competence in a multicultural
nursing home in Norway. Social Science & Medicine, 232, 230-237.
doi:https://doi.org/10.1016/j.socscimed.2019.04.023
Munn, Z., Porritt, K., Lockwood, C., Aromataris, E., & Pearson, A. (2014). Establishing
confidence in the output of qualitative research synthesis: the ConQual approach.
BMC medical research methodology, 14(1), 108.
Nichols, P., Horner, B., & Fyfe, K. (2015). Understanding and improving communication
processes in an increasingly multicultural aged care workforce. Journal of Aging
Studies, 32, 23-31. doi:10.1016/j.jaging.2014.12.003
Ryosho, N. (2011). Experiences of Racism by Female Minority and Immigrant Nursing
Assistants. Affilia, 26(1), 59-71. doi:10.1177/0886109910392519
Schilgen, B., Handtke, O., Nienhaus, A., & Mösko, M. (2019). Work-related barriers and
resources of migrant and autochthonous homecare nurses in Germany: A qualitative
comparative study. Applied Nursing Research, 46, 57-66.
doi:10.1016/j.apnr.2019.02.008
Sellevold Gerd, S., Egede-Nissen, V., Jakobsen, R., & Sørlie, V. (2019). Quality dementia
care: Prerequisites and relational ethics among multicultural healthcare providers.
Nursing Ethics, 26(2), 504-514. doi:http://dx.doi.org/10.1177/0969733017712080

Shutes, I., & Walsh, K. (2012). Negotiating User Preferences, Discrimination, and Demand
Accepted Article for Migrant Labour in Long-Term Care. Social Politics, 19(1), 78-104.
doi:10.1093/sp/jxr025
Stevens, M., Hussein, S., & Manthorpe, J. (2012). Experiences of racism and discrimination
among migrant care workers in England: Findings from a mixed-methods research
project. Ethnic and Racial Studies, 35(2), 259-280.
doi:10.1080/01419870.2011.574714
Timonen, V., & Doyle, M. (2010). Migrant Care Workers’ Relationships with Care
Recipients, Colleagues and Employers. European Journal of Women's Studies, 17(1),
25-41. doi:10.1177/1350506809350859
Ting-Toomey, S. (2010). Intercultural conflict interaction competence: From theory to
practice. In M. Guilherme, E. Glaser, & M. a. d. C. M. García (Eds.), The
intercultural dynamics of multicultural working (pp. 21-40). Bristol: Multilingual
Matters.
Transcultural Nursing Society. (2020). Transcultural Nursing Resource Links. Retrieved from
https://tcns.org/resources/
Walsh, K., & O’Shea, E. (2010). Marginalised Care: Migrant Workers Caring for Older
People in Ireland. Journal of Population Ageing, 3(1), 17-37. doi:10.1007/s12062-
010-9030-4
Walsh, K., & Shutes, I. (2013). Care relationships, quality of care and migrant workers caring
for older people. Ageing & Society, 33, 393-420. doi:10.1017/s0144686x11001309
Willis, E., Xiao, L., Morey, W., Jeffers, L., Harrington, A., Gillham, D., & Bellis, A. (2018).
New Migrants in Residential Aged Care: Managing Diversity in Not-for-Profit
Organisations. Journal of International Migration and Integration, 19(3), 683-700.
doi:10.1007/s12134-018-0564-2
Xiao, L. D., Ullah, S., Morey, W., Jeffers, L., De Bellis, A., Willis, E., . . . Gillham, D.
(2020). Evaluation of a nurse-led education program to improve cross-cultural care
for older people in aged care. Nurse Education Today, 87, 104356.
doi:https://doi.org/10.1016/j.nedt.2020.104356
Xiao, L. D., Willis, E., Harrington, A., Gillham, D., De Bellis, A., Morey, W., & Jeffers, L.
(2018). Improving socially constructed cross‐cultural communication in aged care
homes: A critical perspective. Nursing Inquiry, 25(1), 1-1. doi:10.1111/nin.12208

Appendix I: Searched databases
Accepted Article
Search strategies used for finding qualitative research articles about aged-care staff members’
perceptions of multicultural teamwork in aged care facilities. The number of retrieved articles
is given in the right-hand column.
Medline (OVID)
S1 assisted living facilities/ or homes for the aged/ 14523
S2 Nursing Homes/ 33606
("nursing home*" or "aged care" or "housing for the elderly" or "old aged home*" or "home*
S3 52630
for the aged").mp.
S4 1 or 2 or 3 53497
S5 Cultural Diversity/ 11037
health personnel/ or allied health personnel/ or caregivers/ or medical staff/ or nurses/ or nursing
S6 220263
staff/ or physicians/
S7 5 and 6 809
((multiculture or "cultural divers*" or "cultural and language divers*" or CALD) adj5
S8 (caregiver* or "care giver*" or healthcare or "health* personnel*" or staff or team or 497
organisation* or "health* provider*" or migrant*)).mp.
S9 7 or 8 1176
S10 Perception/ 33015
S11 "Attitude of Health Personnel"/ or Attitude/ 161801
S12 Knowledge/ 10678
(knowledge* or perception* or attitude* or belief* or barrier* or enabler* or facilitator* or
S13 2746361
experience* or perspective* or opinion* or views or belief*).mp.
S14 10 or 11 or 12 or 13 2746361
S15 4 and 9 and 14 20
EMcare (OVID)
S1 nursing home/ or health care facility/ 45745
("nursing home*" or "aged care" or "housing for the elderly" or "old aged home*" or "home*
S2 29805
for the aged").mp.
S3 1 or 2 53147
S4 cultural diversity/ 515
S5 health care management/ or health care personnel/ or health workforce/ 95783
S6 4 and 5 26
S7 ((multiculture or "cultural divers*" or "cultural and language divers*" or CALD) adj5 150

(caregiver* or "care giver*" or healthcare or "health* personnel*" or staff or team or
Accepted Article
S8
organisation* or "health* provider*" or migrant*)).mp.
6 or 7 175
S9 perception/ 62847
physician assistant attitude/ or physician attitude/ or attitude/ or health personnel attitude/ or
S10 49391
nurse attitude/
S11 knowledge/ 13232
(knowledge* or perception* or attitude* or belief* or barrier* or enabler* or facilitator* or
S12 1021275
experience* or perspective* or opinion* or views or belief*).mp.
S13 9 or 10 or 11 or 12 1021275
S14 3 and 8 and 13 7
CINAHL (EbscoHOST)
S1 (MH "Gerontologic Care") OR (MH "Gerontologic Nursing") OR (MH "Housing 33601
for the Elderly")
S2 (MH "Home Nursing") OR (MH "Nursing Homes") OR (MH "Long Term Care") 42,667
S3 "nursing home*" or "residential facilit*" or "aged care" or "housing for the elderly" 45,228
or "old aged home*"
S4 S1 OR S2 OR S3 85,538
S5 (MH "Cultural Diversity") 11,553
S6 (MH "Allied Health Personnel") OR (MH "Faculty, Medical") OR (MH "Faculty, 127,113
Nursing") OR (MH "Health Personnel, Minority") OR (MH "Nurses, Minority")
OR (MH "Medical Staff") OR (MH "Nurses") OR (MH "Nursing Assistants") OR
(MH "Nursing Home Personnel") OR (MH "Health Facility Administrators") OR
(MH "Health Personnel")
S7 TX ((multiculture or "cultural divers*" or "cultural and language divers*" or 390
CALD) N4 (caregiver* or "care giver*" or healthcare or "health* personnel*" or
staff or team or organisation* or "health* provider*" or migrant*))
S8 S5 AND S6 803
S9 S7 OR S8 1,175
S10 (MH "Perception") 27,062
S11 62,011
(MH "Faculty Attitudes") OR (MH "Employee Attitudes") OR (MH "Attitude of
Health Personnel") OR (MH "Attitude")
S12 (MH "Knowledge") 10,797
S13 knowledge* or perception* or attitude* or belief* or barrier* or enabler* or 985,945
facilitator* or experience* or perspective* or opinion* or views or belief*

S14 S10 OR S11 OR S12 OR S13 985,945
Accepted Article
S15 S4 AND S9 AND S14 30
Scopus
S1 ("nursing home*" or "aged care" or "housing for the elderly" or "old aged home*" or 89
“home* for the aged”) AND ((multiculture or "cultural divers*" or "cultural* and
language* divers*" or CALD) W/4 (caregiver* or "care giver*" or healthcare or "health*
personnel*" or staff or team or organisation* or "health* provider*" or migrant*)) AND
(knowledge* or perception* or attitude* or belief* or barrier* or enabler* or facilitator*
or experience* or perspective* or opinion* or view* or belief*)
Proquest
S1 ("nursing home*" or "aged care " or "housing for the elderly" or "old aged home*" or 1340
“home* for the aged”) AND ((multiculture or "cultural divers*" or "cultural and
language divers*" or CALD) NEAR/4 (caregiver* or "care giver*" or healthcare or
"health* personnel*" or staff or team or organisation* or "health* provider*" or
migrant*)) AND (knowledge* or perception* or attitude* or belief* or barrier* or
enabler* or facilitator* or experience* or perspective* or opinion* or views or belief*)
S2 Source type included “Scholarly Journals” OR “Trade Journal” 150
Web of Science
S1 TS=("nursing home*" or "aged care" or "housing for the elderly" or "old aged home*" or 10
“home* for the aged”) AND ((multiculture or "cultural divers*" or "cultural and language
divers*" or CALD) NEAR/4 (caregiver* or "care giver*" or healthcare or "health*
personnel*" or staff or team or organisation* or "health* provider*" or migrant*)) AND
(knowledge* or perception* or attitude* or belief* or barrier* or enabler* or facilitator*
or experience* or perspective* or opinion* or views or belief*)
TOTAL FOUND: 306

Appendix II: List of excluded studies
Accepted Article Study Reasons for exclusion
1 Dahl, K., Dahlen, K. J., Larsen, K., & Lohne, V. (2017). No statement on philosophical
Conscientious and proud but challenged as a stranger: orientation or analysis method;
Immigrant nurses' perceptions and descriptions of the no demonstration of addressing
Norwegian healthcare system. Nordic Journal of the influence of researcher and no
Nursing Research, 37(3), 143-150. evidence of ethics approval; and
doi:http://dx.doi.org/10.1177/2057158517690952 the participants’ views are rarely
represented.
2 Shutes, I. (2012). The Employment of Migrant Workers No statement on philosophical
in Long-Term Care: Dynamics of Choice and Control. orientation or analysis method;
J. Soc. Pol., 41(1), 43-59. did not locate the researchers and
doi:10.1017/S0047279411000596 no demonstration of addressing
the influence of researcher; and
no evidence of ethics approval.
3 Walsh, K., & Shutes, I. (2013). Care relationships, No statement on philosophical
quality of care and migrant workers caring for older orientation; did not locate the
people. Ageing and Society, 33(3), 393-420. researchers and no demonstration
doi:10.1017/S0144686X11001309 of addressing the influence of
researcher; and no evidence of
ethics approval.

Accepted Article
Appendix III: ConQual summary of findings
Systematic review title: Aged care staff members’ perceptions of working in multicultural teams: a systematic review and qualitative meta-synthesis.
Population: All employees that worked in a nursing home with staff from different cultural backgrounds.
Phenomena of interest: Experiences of staff regarding multicultural teamwork.
Context: Homes for the aged including nursing homes, residential aged care facilities, long-term care.
Synthesized finding Type of research Dependability Credibility ConQual score
Various cultural awareness in the Qualitative High Downgrade Moderate
multicultural team 1 level**
It is acknowledged that staff was aware of the
different cultures in the multicultural team,
and CALD staff members’ weaknesses and
strengths. Staff recognised the key factors
affecting teamwork and the importance of
working with a good colleague and providing
constructive feedback to others during
teamwork. CALD staff were inclined to
support staff from the same background.
Some CALD staff also noticed the cultural
awareness of management, which was a
reason for them to stay in the workplace.
Managers and local staff found that CALD
staff were good colleagues and had good
work ethics, and they could bridge the cross-
cultural communication gap, however, they
needed to improve their language skills.

Accepted Article
Meanwhile, awareness of cultural diversity in
the team was perceived to be inadequate.
These inadequacies came from clients, co-
workers and managers.
Limited knowledge about members in the Qualitative High Downgrade Moderate
multicultural team 1 level**
Managers acknowledged that CALD staff had
some advantageous characteristics and the
impact of cultural events that might contribute
to teamwork. It is identified that the
management had insufficient knowledge
about the Muslim staff members’ religion,
and local staff lacked knowledge about
CALD staff members’ cultural characteristics.
Cultural skills in the multicultural team Qualitative High Downgrade Moderate
It is found that cultural skills were 1 level**
demonstrated in the multicultural team.
Managers were able to implement effective
strategies to improve teamwork, including a
buddy system, assessing CALD staff
members’ English ability, balancing the
relationship between team members. Staff
succeeded in fostering teamwork through
cooperation and support. Local staff protected
CALD staff from prejudice. It is also
suggested there was a lack of some skills in

Accepted Article
the multicultural team. CALD staff felt that it
was hard to keep rapport with clients.
Management was unable to take effective
action to prevent mistreatment from clients.
Broad experiences in cross-cultural Qualitative High Downgrade Moderate
encounters 1 level**
Multicultural team members experienced
support from co-workers and management,
communication barriers and discrimination.
Staff received support from co-workers and
management, they enjoyed the positive and
open environment. However, both local and
CALD staff experienced communication
barriers in the multicultural team, including a
lack of language and communication skills.
CALD staff experienced discrimination,
racism, exploitation, distrust, and disrespect.
Different performances of staff also led to
some tension.
The desire to enhance teamwork Qualitative High Downgrade Moderate
It is noticed that the staff expected to get 1 level**
involved in the process to become culturally
competent. They tried to be open and learn
from each other and fit into the team. Staff
expected more communication and
mentorship and supervision. Training and

Accepted Article
education on communication skills and
cultural diversity were also expected by
multicultural team members.
*Downgraded one level due to common dependability issues across the included primary studies (the majority of studies did not present a
statement locating the researcher culturally or theoretically and no acknowledgment of their influence on the research).
**Downgraded one level to a mix of unequivocal and credible findings.

Accepted Article
Appendix IV: QARI data extraction of included studies
Author(year) Methodology Method Phenomena of Setting Geographical Cultural Participants Data Author’s conclusion Reviewer’s
interest analysis comments
Badger et al. Mixed methods Semi- Explore managers’ Nursing One English British 13 managers Thematic Managers must Show the
(2012) Exploratory structured perceptions of homes in the region in the (11 British, 2 analysis consider the delivery managers’
telephone diverse cultures UK UK black and of culturally perceptions of
interviews minority competent services CALD staff
ethnic) due to the increasing
number of black and
minority ethnic
clients.
Begum & Qualitative Discussions Explore Muslim Nursing Helsinki, Finland Eight care Thematic There is a need for Show the
Seppanen Ethnography and women’s homes and Finland professionals analysis health sectors to Muslim health
(2017) interviews experiences of hospitals in from Islamic accommodate professionals’
working as Finland origin (six Muslim cultural perceptions of
healthcare work for both norms in many their cultural
professionals settings) respects. needs in the
workplace
Celik et al. Mixed methods Semi- Investigate how Mental Not clear Netherland 31 Content The training program Show aged-
(2012) structured effective diversity health s professionals analysis can help participants care staff
interviews awareness training practices, (eight from to take actions to members’
Observation is in promoting hospitals and mental health enhance diversity perceptions of
notes diversity sensitivity nursing practice, 12 sensitivity. the diversity
homes in the from hospitals, awareness
Netherlands 11 from training.

Accepted Article
nursing
homes) All
participants
had a
Dutch
background,
except for one
psychiatrist in
the mental
hospital was
born in
Suriname)
Doyle & Qualitative Semi- Explore migrant Long-term Not clear Ireland 40 migrant Framewor Negative experiences Show migrant
Timonen structured carers’ experience care sector carers (Africa, k analysis concentrate on aged care
(2009) interview of work and in Ireland South Asia, (Pope et specific immigrant workers’
differences among and Europe) al., 2000) groups and the negative
different groups understanding of it is experiences in
limited workplaces
Egede-Nissen Qualitative Narrative Explore the A nursing Not clear Norway Five minority a Cooperation in Identify the
et al. (2019) Phenomenologi interviews minority health home in healthcare phenomen multicultural teams is challenges
cal-hermeneutic providers’ Norway providers ological– important and minority
experiences of (Africa, Asia, hermeneuti facilitate a high healthcare
challenges in a Europe) c analysis quality of care for professionals
multicultural team people with dementia confronted
with
Gao et al. Qualitative Semi- Understand direct An aged care An urban area Australia 16 participants Thematic It’s important to Identify

Accepted Article
(2015) Descriptive structured care workers’ facility in of (ten nursing analysis understand DCWs’ negative
interviews perceptions of the Australia Queensland, assistants and perceptions and factors from
difficulties and Australia six nurses) intentions in working migrant aged
rewards of care in aged care sectors care workers’
work, and how it perceptions in
differs between working in
native and migrant multicultural
workers teams
Gillham et al. Qualitative Focus group Identify what staff Four South Australia 56 care Thematic An education Identify staff
(2018) Interpretive Interviews need to overcome residential Australia workers (40 analysis package was created members’
and what can help aged care native workers to access cultural perceptions of
staff to improve facilities in and 16 CALD diversity and gave teamwork and
cross-cultural care, South workers) insights for evidence- training in the
and identify Australia informed education multicultural
approaches to context.
enhance learning
Goel & Qualitative Focus group Investigate Three South Australia Seven Thematic Some reforms can be Identify
Penman (2015) Interpretative immigrant workers’ residential Australia immigrant analysis made to enhance the positive and
phenomenologi working experience aged care workers (five positive working negative
cal approach in aged care facilities in personal experience of perceptions of
South carers, one immigrant workers immigrant
Australia home support workers in the
worker and workplace
one allied
health
assistant)

Accepted Article
Munkejord Qualitative Interviews Investigate how A nursing Not clear Norway 22 healthcare Content Rules and measures Identify useful
(2019) An managers can home in workers (11 analysis can facilitate measures to
interpretative enhance connection Norway Norway, 5 connection and promote
constructivist and ethnic equality Asia, 2 Africa, collaboration among workers’
grounded in the multicultural 3 Europe, 1 staff to promote care competences
theory approach context Russia) quality in the
multicultural context
Munkejord & Qualitative Interviews Examine staff’s A nursing Not clear Norway 22 healthcare Thematic Factors including Identify staff
Tingvold interpretative perceptions of home in workers (11 analysis education, race, and members’
(2019) constructivist competence in the Norway Norway, 5 language can perceptions of
grounded multicultural Asia, 2 Africa, influence the competence in
theory approach nursing home 3 Europe, 1 perception of the staff the
Russia) multicultural
context
Nichols et al. Exploratory Semi- Explore how culture Six aged Metropolitan Australia 46 staff (11 Thematic A cohesive Identify staff
(2015) structured shapes the care homes Perth, Western native analysis multicultural members’
questionnair relationship of the in Australia Australia workers, 14 (NVivo) workplace needs to perceptions of
es/interviews multicultural Asia, 12 be improved by working in the
workforce and how Africa, 7 multiple respects multicultural
the aged care sector western including beliefs, context
supports the Pacific, 2 culture, education
workforce Europe), seven and social
managers and circumstance.

Accepted Article
five family
members
Ryoscho Qualitative Semi- Explore perceived A large for- Virginia US Eight minority Not clear Immigrant workers Identify
(2011) structured racism and conflicts profit and immigrant frequently migrant
interviews among immigrant nursing CNAs experienced racism workers’
workers in the home in and cultural conflicts perceptions of
nursing home Virginia working in the
multicultural
context
Sellevold et al. Qualitative Meeting Explore the One nursing Not clear Norway 25 multi- Dialectic It’s important to give Identify
(2019) Phenomenologi notes, experience of home unit in ethnic analysis space and time for migrant staff
cal- discussions minority healthcare Norway healthcare multi-ethnic staff to members’
hermeneutical in seminars, providers toward providers discuss experience to perceptions of
interpretation dialogue- their working (America, improve care quality working in the
based relationship, and its Africa, multicultural
lectures significance to care Europe, Asia) context
for people with
dementia

Accepted Article
Shutes & Comparative Surveys and Explore who are Residential Not clear UK & 46 providers A Providers prefer Identify
Walsh (2012) telephone preferred to provide care homes Ireland (30 UK, 16 framework migrant workers due providers’
interviews care according to in the UK Ireland) by to their “care ethic” perceptions of
and in-depth employers and and Ireland 90 migrant Williams and “work ethic” migrant care
interviews clients regarding care workers (2011) workers
race and ethnicity; (56 UK, 34
how institutions Ireland,
balance the including
preference and Asia, Africa,
discrimination and Europe)
30 elderly
people in the
UK
Timonen & Qualitative Interviews Examine Three long- Not clear Ireland 40 migrant Framewor There was a generally Identify
Doyle (2010) relationships term care care workers k approach positive relationship migrant care
between migrant sectors in (Africa, Asia, (Pope et between workers and workers
carers and care Ireland Europe) al., 2000) clients; racism and perceptions of
recipients, cultural tensions were working with
employers/managers obvious in the multicultural
and colleagues workplace team members

Accepted Article
Walsh & Mixed methods Semi- Explore perceptions Voluntary Not clear Ireland 40 migrant Thematic Migrant care workers Identify the
O’Shea (2010) Frameworks structured of migrant workers institutions workers from analysis faced with many experience of
from Peck interviews, care provision and home Asia, Europe, (Altas IT challenges in the migrant
(1989) and focus group, within the ageing care settings and Africa (17 analysis aged care sector workers in the
O’Doherty survey sector from older RN and 23 software) workplace
(2006) people, migrant care
workers and assistants), 25
employers old adults, 16
employers
Willis et al. Qualitative Management Demonstrate how Residential South Australia 16 CALD staff Thematic Human resource Identify
(2018) Interpretive documents organizations aged care Australia (Asia and analysis strategies worked as CALD staff
focus support CALD staff organization Africa) vehicles in supporting members’
groups, within the s in CALD staff to perceptions of
semi- workplace Australia integrate into the management
structured workplace strategies
interviews
Author et al. Qualitative Semi- Examine actions Four aged South Australia 30 residents Critical Residents and staff Identify the
(blinded) Double structured that have been taken care homes Australia 56 care hermeneuti found strategies to staff
(2018) hermeneutic interviews, to improve cross- in Australia workers (40 c analysis facilitate members’
focus group cultural non-CALD, communication perceptions of
communications 16 CALD) communicatio
n in the
multicultural
context
DCW: Direct Care Worker; CALD: culturally and linguistically diverse; CNAs: Certified Nursing Assistants, RN: Registered Nurse

Accepted Article
Appendix V: Finding and illustrations
Badger, F., Clarke, L., Pumphrey, R., & Clifford, C. (2012). A survey of issues of ethnicity and culture in nursing homes in an English region:
nurse managers' perspectives. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 21(11-12), 1726-1735.
Finding Illustration from the study Evidence
CALD staff members’ English all our overseas staff have very good English, when we interview them, we have Unequivocal
proficiency was assessed by to make sure that they…have a good understanding of the English language,
managers as part of selection because of the nature of the business (p. 1730)
criteria in job interview
CALD staff needed to use non- when they are communicating with the residents they have to pick up on other Unequivocal
verbal communication strategies things like non-verbal signs, or, erm actively listen to what the resident’s saying
to overcome communication or sometimes get the resident to repeat what’s being said (p. 1731)
difficulties with clients
CALD staff acted as interpreters Erm, if somebody has a different language, erm then if we’ve got one of our own Unequivocal
staff members that can interpret we do that, but then if not, we’ll get outside
interpreters to come in… (p. 1730)
Managers signed staff who spoke When we do training, what we have to do is, we have to do like a more intimate Unequivocal
the same language with the new training with her, so we always make sure that we’ve got another girl that speaks
staff to help new staff to improve the same language and speaks excellent English, that she’s with her… and she can
English like explain to her if there’s a problem (p. 1730)
White family members were we took an agency man, a staff nurse in and err, the family turned around and said Credit
hesitant to have a black man to ‘it comes to something when my mother has to be cared for by a black man’ (p.
care for their relatives 1731)
Local staff protected CALD staff we had one resident that took umbrage to the person and we had to be very Credit
from racial prejudice from clients careful and we had to ask her not to go in to that resident. A lot of elderly people
can be very racially prejudiced erm about erm black people and so we sometimes

Accepted Article
have problems with the residents who are very erm discriminatory, erm, so we,
…we try and work around it so that resident might – we have to say ‘Well don’t
go in to that resident, you go in to all the others, but not that resident’ and we, we
work around it (p. 1731)
Managers had to persuade clients I have a word with them (resident) and I say ‘Well it’s either that or nobody, err, Credit
to accept CALD staff we can’t just send white people in to you because we haven’t got that many, so
it’s either that or you don’t get taken care of, we’ll have to move you to a home
that…’ it’s not a direct threat, you know, but we do, we do have to speak to them
and speak to their family if it’s quite a constant refusal (p. 1731)
Note: CALD= Culturally and linguistically diverse
Begum, S., & Seppänen, M. (2017). Islamic values in elderly care in Finland: the perspective of Muslim women caregivers. Journal of
International Women's Studies, 18(2), 59-73.
Finding Illustration from the study Evidence
Muslim staff experienced “Nowadays, the acceptance of Muslim values and culture are positively Unequivocal
improved understanding of recognised by many if I compare the present situation to the earlier one. I must,
Muslim values in culture in the however, mention that in every culture there are both positive and negative sides.
workplace in Finland We should not be distracted by negative examples only; we should also value the
positive ones. Promotion of this understanding will certainly offer a better
understanding amongst the professionals who are from a different culture by
origin.” (p. 65)
Muslim staff expected to have “Even though the events for Muslim celebration are easily traceable from the Credit
flexible and alternative working calendar, in Finland there is no common holiday. Some of us can manage a day
arrangements to accommodate off from work, though, but that does not work equally for all. Moreover, as there
events in the Muslim Calendar is no common holiday for celebration, children of school age may not have a
chance to spend time with their family, as they may have important lessons or

Accepted Article
examinations at school.” (p. 67)
Muslim staff experienced unmet “When I have mentioned specifically that I need time for prayer, I was refused. Unequivocal
needs to pray to workplace But my co-workers go outside quite often to smoke, and that wasn’t forbidden.
Isn’t it unfair and unequal?” (p. 67)
Celik, H., Abma, T. A., Klinge, I., & Widdershoven, G. A. (2012). Process evaluation of a diversity training program: the value of a mixed
method strategy. Evaluation & Program Planning, 35(1), 54-65.
The content of education and To improve the training we need more leeway to understand the concept of Unequivocal
training needed to be improved diversity and to make it less difficult. (p. 60)
Doyle, M., & Timonen, V. (2009). The different faces of care work: understanding the experiences of the multi-cultural care workforce. Ageing
and Society, 29(3), 337-350.
Discrimination towards to CALD You meet a lot of them that would make you hate this job, that you can sit down Unequivocal
staff was the reason for them to and say, ‘oh my God, I hate doing this job’... You say, ‘ is it because I am Black
hate the job or something?’ Sometimes the way they would talk to you, the way they would
treat you, you would hate yourself. (p. 342)
CALD staff experienced I’m a psychologist, and because I couldn’t work in my profession in Ireland, I Credit
discrimination insecurity in wanted to work with people, so I said, why not? This kind of job, it’s some kind
employment of psychology as well, you have to work with different people, with different
mentalities, and it’s good experience actually. (p. 346)
Egede-Nissen, V., Sellevold, G. S., Jakobsen, R., & Sorlie, V. (2019). Minority healthcare providers experience challenges, trust, and
interdependency in a multicultural team. Nursing Ethics, 26(5), 1326-1336.
CALD staff learned to adapt to In my own country, a nurse who needed help was ignorant. Now I must learn to Unequivocal

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the team approach in the care of ask for assistance, to say, I need help. In the beginning I thought I can do this
clients in the host country and nursing alone, but now I ask for assistance. When we cooperate, the work is going
embraced the positive working faster, it takes only a minute to help to move a patient from bed to chair, and the,
environment it is all finished and better for the patient. They expressed that ... Here, you can do
mistakes, you can tell everybody about it, and no one will bully you. (p. 1331)
CALD staff experienced I’ll always sing the wrong tune. The language stops my wish for further Unequivocal
difficulties when communicating education. I can’t express myself fin Norwegian, must translate all the time. (p.
with others in the dominant 1332)
language of the host country
CALD staff felt comfortable to One MHCP (Minority Healthcare Providers) does not understand the written Credit
approach CALD peer for patient documentation. Instead of going to a Norwegian, she comes to me and ask
language support what those words mean, or how you spell words ... Some of the health care
providers try to pretend they possess good language qualifications, and you
Norwegian do not see the trouble I prevent ... .You Norwegian are blind ... they
come to me and ask because I am both a foreigner and a Norwegian ... (p. 1332)
Newly employed CALD staff In the beginning, it was very difficult. I did not know the language, did not know Unequivocal
experienced difficulties in the words. Ohhh, the first morning report, the nurse in charge, it was awful, I
understanding the handover from didn’t recognize one single word, and as soon as I recognized one, she had gone
the local nurse further, a new sentence, and then came the next sentence. (p. 1332)
CALD staff tried to improve One MHCP (Minority Healthcare Providers) told how she had made endeavors to Unequivocal
communication skills in order to understand prattle in staff meetings. In the beginning, she had tried to make
fit into the team herself small and invisible. She used to sit very quietly and listen carefully to the
small talk of the others traveling experiences, new places to go, dinner menu, and
so on, until she herself made a change. She decided to come forth to tell about her
experiences from her own country and travels, what I have in my head and heart

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... Must tell ... must bring it forth ... (p. 1330)
CALD staff strived to learn to fit They expressed to their surprise that in taking their place in the group and telling Unequivocal
into the team about experiences to colleagues, they got friendly attention and interest: I go step
by step. I will get involved in the unit, I’ll learn about the patients by reading
books, by talking with colleagues and with their next of kin ... (p. 1330)
CALD staff experienced I will never become Norwegian; you will always be one coming from abroad ... I Unequivocal
homesick in the host country can go back, but I won’t, even if I miss my family every day. I’m longing for my
home every day. (p. 1332)
CALD staff tried to overcome the To cooperate and be in a team meant to overcome challenges such as the feeling Unequivocal
feeling of strangeness in order to of strangeness and linguistic challenges, but also to overcome the feeling of being
fit into the team a stranger. (p. 1332)
Gao, F. S., Tilse, C., Wilson, J., Tuckett, A., & Newcombe, P. (2015). Perceptions and employment intentions among aged care nurses and
nursing assistants from diverse cultural backgrounds: A qualitative interview study. Journal of Aging Studies, 35, 111-122.
The management’s cultural Some overseas born DCWs (Direct Care Workers) expressed intentions to stay in Unequivocal
awareness was a key factor for the facility because of cultural awareness of the management: "this is a
CALD staff to decide to stay in multicultural community. People understand different culture. It is easy for
the nursing home migrant workers. (p. 117)
Working with a good colleague (The most rewarding parts of my job) Firstly is the resident... Secondly is the Unequivocal
was rewarding for CALD staff colleague... If you work with a good colleague, you're happy too. (p. 117)
Tensions existed in the We often have people saying - working with another staff member, she's too slow Unequivocal
multicultural team due to different or he's too slow... You sometimes find the person that's a bit slower is the person
working experience and patterns that's doing the job very well... Sometimes people who have been in the industry
for a long time are resistive to any changes. When new staff come in with new
ideas, they feel a bit a threatened. (p. 117)

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Communication in English was All nine overseas born participants reported that English Unequivocal
the most challenging between communication was the most challenging part of their job. The English native
native English speakers and speaker workers also expressed communication difficulties with their non-native
CALD staff speaker colleagues. (p. 116)
If they (non- native English speakers) speak quickly, I have no idea what they
asked me and I'm in trouble. (p. 116)
Staff felt reluctant to Sometimes, (I) feel very tired and feel incapable to handle it. I am not Unequivocal
communicate with supervisors comfortable to talk to my supervisor. Often time, your boss will think you are
about the stress that might incompetent. It is very difficult to work in aged care for a long time. (p. 117)
contribute to staff turnover
Local staff preferred to work with I find that foreign ones are very good. Once they know the job well, they're very Unequivocal
CALD staff due to their high quick but they're very efficient...I actually prefer it (to work with overseas born
standard work ethic workers). Because I do think they've got a high standard work ethic. (p. 116)
Management played a key role in She (the general manager) always makes us feel that we are a team... Nobody is Unequivocal
enabling the team approach to the more important than the other... it's important that we can cope with our job.
care of clients in reducing work- Otherwise, you have injuries; you have a lot of sickies that kind of thing happens.
related injuries for staff Here, we don’t have a lot. (p. 117)
Senior staff members’ valuable When I just entered aged care, I felt it was stressful, because you don’t know Unequivocal
support was crucial for new routine. I lost two kilogram. There was a senior staff member who provided on-
CALD staff to reduce their stress the-job support. One month later, I can manage very well. (p. 117)
and adapt the practice
CALD staff enjoyed various I get access to a lot of education. I was privileged to be able to go on a study tour. Unequivocal
professional development I was sponsored to go to a wound care conference. It's continual. The actual
opportunities provision for ongoing education is very good here. (p. 117)
An onsite English teacher helped We have an English teacher on site. That helps to keep migrants. (p. 117) Unequivocal

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CALD staff retention
CALD staff demonstrated Even though I know I’m very busy, I can still make 10 minutes with somebody Credit
improved skills to cope with without feeling that overwhelming pressure to get back into routine or say if
stress after learned from others in somebody gets sick, I have to send them to the hospital or the doctor comes. I just
staff meetings and seminars cope with that. I’m reasonably happy with my job. I would tend to stay at the
same place, if I’m happy there. (p. 118)
Gillham, D., De Bellis, A., Xiao, L., Willis, E., Harrington, A., Morey, W., & Jeffers, L. (2018). Using research evidence to inform staff learning
needs in cross-cultural communication in aged care homes. Nurse Education Today, 63, 18-23.
Intolerance and insensitivity were I think we do have a very multicultural workforce here, and I think also people Unequivocal
two key factors affecting that tend to work in aged care are sort of coming from a beginning point of
teamwork in a multicultural team sensitivity. So I think we're probably perhaps more sensitive and aware of people
than probably the average cross section because I really don't think you'd be able
to function and do this work at all if you were intolerant and insensitive. (p.21)
CALD staff brought their unique Because in my culture we respect elders way too much, like we'd never cross our Credit
cultural care skills to the team to feet in front of them; we never talk – at least they let us to talk … they ask us to
enhance the care of clients sit down. (p. 21)
Respecting team members’ We give an example like if I don't respect you – your culture you won't be happy Unequivocal
culture was a condition to work in with me and you will feel bad... So you need to accept everything like open heart
the team – and just respect them – respect their culture …. (p. 21)
Staff enjoyed working in a team I worked in the government before, but this is one of the nicer cultures here, Unequivocal
that was supportive people are more open. (p. 21)
I think also in our case we have very good help, huge help from other carers. (p.
21)
To me group works because we have this on-line whatever training it is; I don't

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really like it, I mean I'll do it but it's diff erent when you're in group because … if
you don't understand … I could ask what's that supposed to mean, so yeah. Learn
better when interacting with others in the group. (p. 21)
CALD staff preferred to engage To me group works because we have this on-line whatever training it is; I don't Unequivocal
in learning activities that had really like it, I mean I'll do it but it's diff erent when you're in group because … if
interactions with team members you don't understand … I could ask what's that supposed to mean, so yeah. Learn
better when interacting with others in the group. (p. 21)
According to my experience, I think face to face is the best thing and then it's not
only one person is talking then is discussion … to get more knowledge. (p. 21)
I would say combination. Face to face we speak about our experience and then if
you need to find out something more we can access something on the internet,
learn something online. But mainly face to-face I think is more important. (p. 21)
Goel, K., & Penman, J. (2015). Employment experiences of immigrant workers in aged care in regional South Australia. Rural and Remote
Health, 15(1).
CALD staff identified care We get emotionally involved with clients, but some workers are so mechanical... Unequivocal
approaches were different among Asians are different in their approach to clients. (p. 7)
staff from different cultures
Understanding clients’ care There is a huge cultural difference. We need to give clients what they want, like a Credit
preferences were important for simple request for toasted bread. For other nurses, individual preferences are not
CALD staff important, but they are. (p. 7)
CALD staff experienced Language is such a barrier for us. They [other staff members] cannot understand Unequivocal
communication difficulties with us. Some just refuse to understand you. One said, ‘I understand your sign
local staff language’. (p. 8)

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CALD staff experienced There is direct and indirect discrimination. We work as casual employees. Some Unequivocal
discrimination regarding shifts, people, however, are given preferences in shifts. We [immigrant workers] get
tasks, and workload assigned to lousy shifts. (p. 6)
them They [management] give us difficult tasks, for example, spring cleaning, but other
Australian workers were not given those difficult tasks or shifts. (p. 6)
Immigrants helped immigrants in One participant highlighted the support provided by co-immigrant workers, Unequivocal
the team explaining that ‘immigrants help immigrants’, presumably because they share
common hardships and empathise with each other. (p. 6)
CALD staff expected to have It would be good to have a supervisor, one who would oversee the team and take Unequivocal
supervision and mentorship interest in each worker’s performance. (p. 6)
CALD staff expected teamwork Team work must be emphasised. While we use our own initiative in carrying out Credit
in the workplace for improved our duties, working with others is very important. (p. 8)
care for clients Good handovers will help you know about the client. (p. 8)
CALD staff identified training on Management must invest in training staff on effective communication, language. Unequivocal
effective communication for them (p. 8)
was imperative
CALD staff identified training on All employees must have some cultural awareness and sensitivity training in Unequivocal
cultural awareness and sensitivity order to work amicably with each other. (p. 8)
for all staff was imperative
CALD staff expected a way to and a way by which we might air our grievances, voice our concerns, that should Unequivocal
express their concerns and stress be profitable… (p. 8)
Munkejord, M. C. (2019). Challenging the ethnic pyramid: Golden rules and organisational measures towards a more inclusive work
environment. Journal of Nursing Management, 07, 07.
CALD staff identified that local I was so annoyed when I saw that. ‘Why is she eating in the living room? Look – Unequivocal

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staff did not follow the care plan she does not even eat!’ And that was a Norwegian nurse! (going back to the
which was the source of tension conversation with Gina:) ‘What? Why is the food not mashed?’ We started to give
in the team her mashed food since she lost so much weight (…). What’s the point of making a
diet plan if you don’t follow it? (…) You have to read the plan.
Fair treatment for team On the researchers’ question of how the staff decided who should take which Unequivocal
members regarding workload group, foreign-born Frida answered: ‘We circulate. And if we don’t agree, then we
was achieved through consensus flip a coin. Usually, that goes all fine’
A sense of team was achieved When it is like that, it is more intimate or a little more like belonging. It’s a little Unequivocal
through cooperation and support more like – then they know. It’s not vague. Then they know that they’re a team and
in the team that they have to take care of each other’s duties and each other’s patients. Like, if
someone is on holiday and she forgot to do certain tasks before she left, then the
other (her partner in the pair) has to take care of those things. (…)
Munkejord, M. C., & Tingvold, L. (2019). Staff perceptions of competence in a multicultural nursing home in Norway. Social Science &
Medicine, 232, 230-237.
Experienced CALD staff helped We are good at taking care of those who start working here. I think it's because we Unequivocal
new CALD staff based on their who work here now, we were in the same situation before. We also had bad
empathy language; we hardly understood anything ourselves. (p. 235)
Local staff were impressed by I am impressed how fast they learn. (…) I would never have managed going to (a Unequivocal
CALD staff for their quick foreign country) and working in a nursing home there. But (talking about a specific
learning and work colleague) she really wants to succeed. She is genuinely interested in the people
ethics/motivation of work here. That is important, too, that you don't come to work here just for the money.
(p. 235)
CALD staff perceived that other I don't think it's about the language. (…) You can't just say (to a new colleague) Unequivocal

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methods were required to ‘Can you prepare a piece of bread with raspberry jam?’ without showing them, and
facilitate communication with then, if they don't react immediately, you conclude that her language skills aren't
new CALD staff good enough. I think that's the wrong conclusion. I'm looking for something else (in
new colleagues). I consider how much they are interested in working here. (…) (p.
235)
New CALD staff with low (When asked if she experienced lower skills in the Norwegian language as a Unequivocal
language skills were accepted problem when communicating with newly recruited colleagues from a migrant
by other CALD staff if they background, Frida replied) Researcher: you look at their motivation? Yes, their
demonstrated the desire to learn motivation. Because if they want to learn, they learn fast. So, I don't think (initially
to improve their skills low) language skills are a barrier. Of course, you need to learn the language to work
here, but in the beginning, it's about your willingness to learn. You see it
immediately as they enter the room. (p. 235)
A supportive environment was a You can always ask for help, and you get help, if you are unsure about something. Credit
key factor for CALD staff We often discuss professional stuff . We have a good atmosphere here. (…) We
retention know each other. We trust each other. That's important. Because sometimes you
have a bad day, but when you get support, things become easier. (p. 233)
CALD staff experienced open There's one thing: we have a good time at work. Even though we might disagree Unequivocal
conversations in the team that sometimes, in general, we have a good time. We are not serious all the time; we are
improved team cohesion joking with each other. We can be open about everything, problems and stuff .
That's why I like working in this unit. (…) If we don't agree, we talk about it. We
don't keep it inside. Because if you keep it inside, you'll explode, and you'll be sick.
Here, we talk, and then we move on. (p. 233)
Having a local staff to explain I have not experienced discrimination from colleagues but from patients and Credit
clients’ relatives regarding the relatives. (p. 234)
lack of trust in CALD staff was When I feel it, I tell them they can speak to one of my colleagues. Perhaps I do not

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an effective strategy use the right words, perhaps they do not understand what I say (…) Anyway, when
that happens, we can talk with our colleagues about how we feel, and they are there
to comfort you. We really take care of each other here. (p. 234)
Nichols, P., Horner, B., & Fyfe, K. (2015). Understanding and improving communication processes in an increasingly multicultural aged care
workforce. Journal of Aging Studies, 32, 23-31.
CALD staff was unable to “I'm an Adventist so we don't eat pork, and … on Sundays the residents eat … Unequivocal
provide care for clients due to bacon and egg. At one time I was supposed to be doing the breakfast and I just
food taboos in their culture couldn't touch the pork and that was a problem”. (p. 28)
Managers identified that CALD One manager believed that cultural forms of communication were implicated in Unequivocal
staff were doing tasks without some of the barriers with residents. “They don't talk to the resident, so they just
communication with clients come, the individuals just come in and do the work and walk out so there's no
communication whatsoever.” (p. 28)
Cultural events like Ramadan One manager explained how a CaLD worker had found it difficult to explain to her Unequivocal
affected CALD staff members’ work colleagues that she was observing Ramadan. “We had a lady who was fasting
fitness to work and often felt quite faint and dizzy because, obviously she hadn't eaten all day, and
the staff ganged up on her because she was lazy”. (p. 27)
Local staff disliked CALD staff “One problem I had is that people from different cultures started talking in their Unequivocal
to talk in their first language as own language … and those people that didn't come from those cultures started to
they did not know what they complain that ‘it's not fair, we don't know what they are talking about’”. (p. 28)
were talking about
Local staff expressed “I know that I sometimes personally have issues with language barriers, it's very Unequivocal
communication difficulties with difficult if you need something done and you're having a problem getting that
CALD staff that affect the through” (p. 28)
productivity of teamwork
CALD staff expected local staff “We don't speak English in our country — that is a problem to understand people Unequivocal

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to have sympathy for them speaking English, so I think if our colleagues can understand our … language
regarding communication problem, they can speak slowly, they can speak clearly”. (p. 28)
challenges they experienced and
spoke to them slowly and
clearly
CALD staff experienced that “I would say sometimes it's like other people they don't have confidence in you Unequivocal
local staff did not trust them due thinking you know, even whether you experienced … I sometimes feel it's about
to racial differences the colour”. (p. 27)
Local staff identified different “… the way they work, some staff don't feel like they keep their side of doing the Unequivocal
working approaches in CALD caring as good as what they could do … I think it causes a bit of friction”. (p. 27)
staff that led tensions in the
team
The local staff took advantage “… because in our culture if somebody is, like, older than you, if they tell you to do Unequivocal
of CALD staff members’ something you just do it, you don't question … But sometimes they take advantage
culture relating to respecting of that”. (p. 27)
seniority
Newly employed CALD staff “The others, [from countries where migration patterns are longer established] … Unequivocal
from African countries they feel you are from Africa, you have come to take the jobs here in Australia, and
experienced tensions with other especially these jobs”. (p. 27)
CALD staff due to competition
for the job.
CALD staff experienced CaLD participants talked about the culture shock they personally faced when they Unequivocal
cultural shock at the beginning first entered the workforce. One described feeling like a “fish out of water”.
Another described “the work culture … it's already a culture... very difficult. We
learn to accept it”. (p. 27)

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Managers considered some “But you do have people from other parts of Africa that are not as gentle, they are Credit
African staff as not gentle or not more bombastic I suppose if you like, they are a heftier build, they are a darker
suit for carer’s job colour, and I am not being discriminatory here, this is just as it is”. (p. 27)
Managers identified CALD “it's my preference now to take on people from different cultures, they work Unequivocal
staffs were patient staff and extremely well together, they are very patient, they are good mentors as well”. (p.
good mentors 27)
Staff embraced multiculturalism “Because over here, all the staff here are all multicultural … and it's really Unequivocal
in the team interesting, because that's what I like”. (p. 27)
Local staff were lack of “Because, I been talking … with some of the girls from Africa, and … I thought Unequivocal
knowledge about the countries myself, Africa is a big country and they have … nursing home on every part, you
that CALD staff were from know. But some of the girls they said, ‘No, they have to take care of their elders at
home’”. (p. 27)
CALD staff realized that “People coming from the different countries they have many other languages so Unequivocal
training on communication was they might be having difficulty in talking communication, so there should be some
imperative training or something for that. Like you know, even they speak English but the way
of talking is different”. (p. 28)
Ryosho, N. (2011). Experiences of racism by female minority and immigrant nursing assistants. Affilia, 26(1), 59-71.
Local staff asked CALD staff to ‘‘Sometimes it’s hard to understand them. But I just ask them to write it down. It’s Unequivocal
use written communication to not a big deal. We get along well.’’
overcome communication
barriers
CALD staff experienced Sometimes they treat me like I am dumb. Just because I cannot express myself in Credit
discrimination in employment English, people think I don’t know anything. They laugh at my accent. English is
not my native language, so, of course, I have an accent. But they don’t seem to

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understand that. They don’t know how hard [it is] to learn another language. Most
of them never have been outside of this country. It’s always a battle. (p. 66)
CALD staff were satisfied with They described their supervisors as ‘‘good,’’ ‘‘supportive,’’ and ‘‘helpful.’’ Unequivocal
the support from their Monique said, ‘‘They [the supervisors] are good. They take care of the situation on
supervisors who were local time. They try to help.’’ (p. 66)
people
Sellevold Gerd, S., Egede-Nissen, V., Jakobsen, R., & Sørlie, V. (2019). Quality dementia care: prerequisites and relational ethics among
multicultural healthcare providers. Nursing Ethics, 26(2), 504-514.
Multicultural team members ‘We must give each other enough time to show what we can do and who we are’. Credit
spent additional time and made (p. 507)
efforts to know team members
in order to work with them
Multicultural team members ‘The new ones need time, not pressure; it is unethical to prevent them from growing Unequivocal
supported new members to their potential’. (p. 507)
‘In the beginning, you have to form short sentences and give the healthcare
provider time to understand’. (p. 507)
Multicultural team members ‘Give each other both criticism and praise’ which had to be done in a polite and Credit
provided constructive feedback considerate way, and the healthcare providers reflected on their way of guiding
to members in a polite and colleagues. (p. 508)
considerate way
Openness was a condition for ‘To learn about others’ cultures; we must open up to other cultures’. (p. 508) Unequivocal
multicultural team members to
learn each other’s culture

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Multicultural team members ‘Habits from other cultures must not be unlearnt; rather we must understand and Unequivocal
learned each other’s cultures accept each other’s habits’. (p. 508)
We are different, we are unique, each in our way’. (p. 508)
Communication with team ‘The more you talk together, the more you have the experience of not being alone Unequivocal
members was crucial for in thinking like this’. (p. 508)
members to support and learn ‘One has to open up for a discussion if one is uncertain about what to do’. (p. 509)
from each other in the ‘To agree on who has the responsibility for what. Cooperate of prioritize’ (p. 508)
multicultural team ‘Discuss there and then when something acute happens in a particular situation’ (p.
508)
‘To work together when caring for the patient’ and ‘be role models for each other
and guide each other’ (p. 508)
CALD staff were afraid of They were, therefore, afraid that colleagues should see them as incompetent. ‘In our Unequivocal
expressing their thoughts in the culture, we are not supposed to say what we think, particularly not to people above
team us in status’. (p. 509)
‘I don’t dare to talk about what feels uncertain or speak up when the responsibility
feels uncomfortable’. (p. 509)
The greatest challenge for ‘The greatest challenge when I came here was the language, not to be understood Unequivocal
CALD staff was the proficiency and not understanding others’. (p. 509)
of dominant language ‘I become afraid to use words when I am uncertain about the language and may be
too scarce and direct’. (p. 509)
CALD staff experienced stress ‘I get frightened when I get more responsibility than I can cope with’. (p. 509) Unequivocal
if they were assigned to a job
that they felt incompetent to do
CALD staff experienced ‘I experience being vulnerable in a new job in a new country where my potential is Credit
discrimination in employment not seen’. (p. 509)

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Communication with team ‘How we as healthcare providers talk together filters through to the patient. The Credit
members was crucial for respect we show when we instruct one another filters through to the patient’ (p.
members to achieve quality care 507)
for clients in the multicultural ‘To develop quality care is to use the time to talk together about what is worthwhile
team and about the challenges met in achieving quality care. Good attitudes spread’. (p.
508)
Multicultural members were ‘I wonder how I can tell the other that she makes mistakes and explain it in a way Unequivocal
concerned about the proper way that creates understanding and change? (p. 508)
to provide constructive
feedback to members
Shutes, I., & Walsh, K. (2012). Negotiating user preferences, discrimination, and demand for migrant labour in long-term care. Social Politics,
19(1), 78-104.
CALD staff expected the You can’t really answer back (regarding racist verbal abuse), you can’t really do Credit
management to take action to anything about it (eg. Migrant care workers who had vocalized those rights by
prevent them from racist verbal reporting to their managers their experiences of racist verbal abuse), the only thing
abuse from clients that you can do is probably walk away and set up an incident report and issue an
application for a management hearing ... You can report it to management, but most
of the time nothing really happens. (p. 97)
CALD staff had lower rates of The biggest advantage is that they turn up for work. Their absenteeism is very, very Unequivocal
absenteeism compared to local minimum. It is the exact opposite with Irish workers . . . Very reliable. (p. 89)
staff
CALD workers had better work To be honest with you, migrant workers, particularly the Filipinos and Chinese, Unequivocal
ethos compared to local staff have a better work ethos than the majority of British people. They are more inclined
to buckle down and get on with it . . . whereas some British people will just take the

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job because they need to get off the dole and for them it is a stepping stone. (p. 89)
Timonen, V., & Doyle, M. (2010). Migrant care workers’ relationships with care recipients, colleagues and employers. European Journal of
Women's Studies, 17(1), 25-41.
The local staff could not [The agency] employ people to the management that don’t speak English clearly, Unequivocal
understand CALD staff they employ foreigners but for example I don’t understand people from Nigeria . . .
members’ oral English it’s not that I am racist, I just don’t understand their English, if they want something
from me I usually have to say, listen, text me [send a text message to my mobile
phone], I don’t really understand what you are saying. At this moment it’s getting
more and more culturally diverse. (p. 35)
CALD staff experienced A patient once said to me: ‘alien, come here’ . . . my colleagues heard this and they Unequivocal
humiliation by clients and local laughed and laughed and laughed . . . to this date nobody has apologized [despite
staff due to their accent complaint to management] . . . I don’t care about money, but I do care about my
colleagues giving me respect. (p. 38)
CALD staff perceived harsh When she comes you think what will be wrong this time, you’re a kind of criminal Unequivocal
treatment and lack of support every time, you never hear good words . . . you still need to do more because this
from managers and local staff and that . . . with the owner, there is no hello, how are you, is there any problem
you would like to share . . . when we go home we have back pain and yet we
receive this kind of treatment, it’s very upsetting. (p. 34)
CALD staff perceived . . . it’s a good thing that the nurse in charge is Irish, in the private nursing home, Unequivocal
competent management of staff there was an Indian nurse in charge, and she couldn’t manage this part
relationships from a local [relationships between Irish and non-Irish workers]. (p. 35)
manager

Accepted Article
Walsh, K., & O’Shea, E. (2010). Marginalised care: migrant workers caring for older people in Ireland. Journal of Population Ageing, 3(1), 17-
37.
CALD staff needed to learn I think that anybody coming into this country needs to know the cultural Unequivocal
culture in the host country differences. The cultural Ireland…They are coming to Ireland; they need to know
the cultural differences, they need to know the nuances, they need to know the
colloquialisms, you know. (p. 25)
CALD staff experienced For a patient-centred approach to care you have to know where the patient is Unequivocal
challenges to provide person- coming from, you have to know the culture of the patient. Irish workers find that
centred care for clients difficult not to mind migrant workers…Promoting evidence-based personcentred
care for older people is a huge challenge in itself and bringing migrant workers into
it adds to that challenge enormously. (p. 25)
Language skills were the I think communication skills are the biggest concern I would have. Because they Unequivocal
biggest challenge for CALD [migrant carers] speak too low, the residents are half deaf and they’re nervous when
staff they come in and I think the communication really would be the major thing. (p.
25)
CALD staff experienced Because I just see it’s pointing to one direction, and it hurts, it hurts so badly Unequivocal
difficulties in gaining that…we’re here not to… like live on the welfare… but I want to work… why do
employment they not sit down and see I want to do it. But the people should please open up,
accept us. We can do the same thing, we can do it. Just give us a chance. (p. 26)
Local nurses experienced extra It was a learning process…The staff on the ground, the Irish workers were left…on Credit
pressure when helping CALD the floor helping [migrant carers] to integrate into it and it was done very
staff to successfully integrate successfully. But with huge challenges and with huge extra pressure on the Irish
into the system nurses. (p. 29)

Accepted Article
CALD staff offered a lot to the I feel that they have an awful lot to offer us. I wouldn’t be afraid of having migrant Unequivocal
aged care sector care workers in this country at all. I think we have an awful lot to learn. Their work
ethic you know…Like it’s simple things. They have got skills like phlebotomy
skills…they do IV…They would be likened to a CNS [clinical nursing specialist].
The people I am coming across are highly skilled. (p. 28)
Willis, E., Xiao, L. D., Morey, W., Jeffers, L., Harrington, A., Gillham, D., & De Bellis, A. (2018). New migrants in residential aged care:
managing diversity in not-for-profit organisations. Journal of International Migration and Integration, 19(3), 683-700.
CALD staff were supported in a …this is one of the nicer cultures here, people are more, what do you call – more Unequivocal
positive work environment open, and then when you do something and you’re not sure about things, they say,
okay this is normally like this, but if you’re not sure, check in the care plan, and no,
no, can I have problem – not can I have – not, always not – no problem here at all
with how we deliver the care. (p. 691)
CALD staff were supported by And I can ask, can you swap, do you want to swap… And you always find Unequivocal
colleagues somebody that will say yes. (p. 691)
Managers were very And also the management… if you have a problem, be sure that you are going to Unequivocal
approachable for CALD staff in talk to them and they can help you… their open door approach. (p. 691)
a positive work environment
CALD staff were comfortable to So culturally I like this system much more, very frank, and it is a free culture... I Unequivocal
work in a positive work feel comfortable that – you know talking with my boss. (p. 691)
Managers created a positive …also we have lots of Asian people here, like fifty-fifty… Yeah they [the Unequivocal
work environment for staff from management group]’re putting us in a good mood to deliver our service, yeah and
all cultural groups that’s important, because when you are loving what you’re doing, and you have a
reward it’s easy. (p. 692)

Accepted Article
Author et al. (blinded) (2018).
CALD staff experienced …Because they [CALD staff] do not understand the difference between cheeky and Unequivocal
difficulties to build rapport with banter or having the rapport with someone before you can be banter. … For
clients example, I could say something like, if someone was naked, the things you say
when you don’t have a gun. I could say that and the resident will laugh. If a young
Asian male came in and said that they’d probably want to hit him because they
would be very affronted by that. (p. 8)
Local staff experienced They [CALD staff] do have to have the skillset. I do have a staff member here Unequivocal
difficulties in understanding that’s very hard to understand… Trainings always important’ (p. 8)
CALD staff so that training on
communication in staff was
required
The language was the main ‘Well I think the main obstacle is it was about language and then if that one is fixed Unequivocal
obstacle for CALD staff I think every other thing will come in place’ (p. 8)
Bilingual staff acted as ‘We use other staff to help out in language situations. …If we have to ask them Unequivocal
interpreters in cross-cultural [residents from a CALD background] a menu and they don’t understand what we’re
communication saying. We find someone [bilingual staff] that can help’ (p. 7)
Management suggested support We need to provide ongoing support for those people [CALD staff] through that Unequivocal
for CALD staff through the buddy element. We need to have some champions in the workplace’ (p. 8)
buddy system

Accepted Article
Appendix VI: Results of meta-synthesis
Finding Category Synthesised finding
Muslim staff experienced improved understanding of Muslim values Synthesised finding 1: Various cultural
in culture in the workplace in Finland (U) awareness in the multicultural team
CALD staff felt comfortable to approach CALD peer for language It is acknowledged that staff was aware of the
support (C) different cultures in the multicultural team and
The management’s cultural awareness was a key factor for CALD CALD staff members’ weaknesses and strengths.
staff to decide to stay in the nursing home (U) Staff recognised the key factors affecting
Intolerance and insensitivity were two key factors affecting Awareness of team members’ teamwork and the importance of working with a
teamwork in a multicultural team (U) cultures good colleague and providing constructive
Multicultural members were concerned about the proper way to feedback to others during teamwork. CALD staff
provide constructive feedback to members (U) were inclined to support staff from the same
Working with a good colleague was rewarding for CALD staff (U) background. Some CALD staff also noticed the
Immigrants helped immigrants in the team (U) cultural awareness of management, which was the
Experienced CALD staff helped new CALD staff based on their reason for them to stay in the workplace.
empathy (U) Managers and local staff found that CALD staff
New CALD staff with low language skills were accepted by other were good colleagues and had good work ethics,
CALD staff if they demonstrated the desire to learn to improve their and they could bridge the cross-cultural
skills (U) communication gap, however, they needed to
CALD staff was unable to provide care for clients due to food taboos improve their language skills. Meanwhile, it is
Awareness of CALD staff identified some inadequate awareness of cultural
in their culture (U)
members’ weakness and strengths diversity in the team. These inadequacies came
Managers identified that CALD staff were doing tasks without
from clients, co-workers and managers.
communication with clients (U)
CALD staff had lower rates of absenteeism compared to local staff
(U)

Accepted Article
CALD workers had better work ethos compared to local staff (U)
Managers identified CALD staffs were patient staff and good
mentors (U)
CALD staff needed to use non-verbal communication strategies to
overcome communication difficulties with clients (U)
Local staff asked CALD staff to use written communication to
overcome communication barriers (U)
Local staff preferred to work with CALD staff due to their high
standard work ethic (U)
CALD staff acted as interpreters (U)
Bilingual staff acted as interpreters in cross-cultural communication
(U)
White family members were hesitant to have a black man to care for
their relatives (C)
Muslim staff expected to have flexible and alternative working
arrangements to accommodate events in the Muslim Calendar (C)
CALD staff experienced cultural shock at the beginning (U) Lack of awareness of cultural
CALD staff perceived harsh treatment and lack of support from diversity
managers and local staff (U)
CALD staff experienced difficulties in gaining employment (U)
Newly employed CALD staff from African countries experienced
tensions with other CALD staff due to competition for the job (U)
CALD staff identified care approaches were different among staff Synthesised finding 2: Limited knowledge
from different cultures (U) Understanding different cultures about members in the multicultural team
Cultural events like Rmandan affected CALD staff members’ fitness Managers acknowledged that CALD staff had

Accepted Article
to work (U) some advantageous characteristics and the impact
Understanding clients’ care preferences were important for CALD of cultural events that might contribute to
staff (C) teamwork. It is identified that the management had
Muslim staff experienced unmet needs to pray in the workplace (U) insufficient knowledge about the Muslim staff
Local staff were lack of knowledge about the countries that CALD Lack of knowledge about different members’ religion, and local staff had a lack of
staff were from (U) cultures knowledge about CALD staff members’ cultural
characteristics.
CALD staff members’ English proficiency was assessed by managers Synthesised finding 3: Cultural skills in a
as part of selection criteria in a job interview (U) multicultural team
Managers signed staff who spoke the same language with the new It is found that cultural skills were demonstrated in
staff to help new staff to improve English (U) the multicultural team. Managers were able to
Local staff protected CALD staff from racial prejudice from clients implement effective strategies to improve
(C) teamwork, including applying a buddy system,
Managers had to persuade clients to accept CALD staff (C) assessing CALD staff members’ English ability,
CALD staff learned to adapt to the team approach in the care of balancing the relationship between team members.
clients in the host country and embraced the positive working Skills demonstrated in the Staff succeeds in achieving teamwork through
environment (U) multicultural team cooperation and support. Local staff protected
Management played a key role in enabling the team approach to the CALD staff from prejudice. It is also suggested the
care of clients in reducing work-related injuries for staff (U) lack of some skills in the multicultural team.
Fair treatment for team members regarding workload was achieved CALD staff felt that it was hard to keep rapport
through consensus (U) with clients. Management was unable to take
A sense of team was achieved through cooperation and support in the effective action to prevent mistreatment from
team (U) clients.
CALD staff experienced open conversations in the team that

improved team cohesion (U)

Accepted Article
Having a local staff to explain clients’ relatives regarding the lack of
trust in CALD staff was an effective strategy (C)
Multicultural team members spent additional time and made efforts
to know team members in order to work with them (C)
Multicultural team members supported new members (U)
Multicultural team members provided constructive feedback to
members in a pilot and considerate way (C)
CALD staff perceived competent management of staff relationships
from a local manager (U)
CALD staff brought their unique cultural care skills to the team to
enhance the care of clients (C)
CALD staff demonstrated improved skills to cope with stress after
learned from others in staff meetings and seminars (C)
CALD staff experienced homesick in the host country (U)
CALD staff expected local staff to have sympathy for them regarding
communication language challenges they experienced and spoke to
them slowly and clearly (U)
CALD staff expected the management to take action to prevent them
from racist verbal abuse from clients (C) Lack of skills in the multicultural
CALD staff experienced challenges to provide person-centred care team
for clients (U)
Local staff disliked CALD staff to talk in their first language as they
did not know what they were talking about (U)
CALD staff experienced difficulties to build rapport with clients (U)
Managers considered some African staff as not gentle or not suit for

Accepted Article
carer’s job (C)
CALD staff were afraid of expressing their thoughts in the team (U)
Senior staff members’ valuable support was crucial for new CALD Synthesised finding 4: Broad experiences in
staff to reduce their stress and adapt practice (U) cross-cultural encounters
CALD staff enjoyed various professional development opportunities Multicultural team members experienced support
(U) from co-workers and management, communication
An onsite English teacher helped CALD staff retention (U) barriers and discrimination. Staff received support
Staff enjoyed working in a team that was supportive (U) from co-workers and the management, they
Local staff were impressed by CALD staff for their quick learning enjoyed the positive and open environment.
and work ethics/motivation of work (U) However, both local and CALD staff experienced
A supportive environment was a key factor for CALD staff retention communication barriers in the multicultural team,
(C) including lacking language and communication
Support from co-workers and
CALD staff were satisfied with the support from their supervisors skills. CALD staff experienced discrimination,
management
who were local people (U) racism, exploitation, distrust, and disrespect.
CALD staff offered a lot to the aged care sector (U) Different performances of staff also led to some
CALD staff were supported in a positive work environment (U) tension.
CALD staff were supported by colleagues (U)

Managers were very approachable for CALD staff in a positive work
environment (U)
CALD staff were comfortable to work in a positive work (U)
Managers created a positive work environment for staff from all
cultural groups (U)
Staff embraced multiculturalism in the team (U)
CALD staff experienced difficulties when communicating with Communication barriers in a
others in the dominant language of the host country (U) multicultural team

Accepted Article
Newly employed CALD staff experienced difficulties in
understanding the handover from the local nurse (U)
Communication in English was the most challenging between native
English speakers and CALD staff (U)
CALD staff experienced communication difficulties with local staff
(U)
CALD staff perceived that other methods were required to facilitate
communication with new CALD staff (U)
Local staff expressed communication difficulties with CALD staff
that affect the productivity of teamwork (U)
The greatest challenge for CALD staff was the proficiency of
dominant language (U)
The local staff could not understand CALD staff members’ oral
English (U)
Language skills were the biggest challenge for CALD staff (U)
The language was the main obstacle for CALD staff (U)
Discrimination towards to CALD staff was the reason for them to
hate the job (U)
CALD staff experienced discrimination regarding shifts, tasks, and
workload assigned to them (U)
Discrimination and racism
CALD staff experienced that local staff did not trust them due to
experienced by CALD staff
racial differences (U)
CALD staff experienced bullying by local staff due to
communication difficulties in the dominant language used in the
country (U)

Accepted Article
CALD staff experienced humiliation by clients and local staff due to
their accent (U)
CALD staff experienced discrimination insecurity in employment (C)
CALD staff experienced discrimination in employment (C)
CALD staff identified that local staff did not follow the care plan
which was the source of tension in the team (U)
The local staff took advantage of CALD staff members’ culture
relating to respecting seniority (U) Tensions in the multicultural team
Local staff identified different working approaches in CALD staff due to the variations of performance
that led tensions in the team (U)
Tensions existed in the multicultural team due to different working
experience and patterns (U)
CALD staff experienced stress if they were assigned to a job that
they felt incompetent to do (U)
Local nurses experienced extra pressure when helping CALD staff to Stress from cross-cultural
successfully integrate into the system (C) interactions
Staff felt reluctant to communicate with supervisors about the stress
that might contribute to staff turnover (U)
CALD staff expected to have supervision and mentorship (U) Synthesised finding 5: The desire to enhance
CALD staff expected teamwork in the workplace for improved care the teamwork
for clients (C) It is noticed that the staff expected to get involved
Expectations of a better
CALD staff expected a way to express their concerns and stress (U) in the process to become culturally competent.
multicultural team
Openness was a condition for multicultural team members to learn They tried to be open and learn from each other
each other’s culture (U) and fit into the team. Staff expected more
Multicultural team members learned each other’s cultures (U) communication and have mentorship and

Accepted Article
Communication with team members was crucial for members to supervision. Active training and education on
support and learn from each other in the multicultural team (U) communication skills and cultural diversity were
Communication with team members was crucial for members to also expected by multicultural team members.
achieve quality care for clients in the multicultural team (C)
CALD staff needed to learn culture in the host country (U)
Management suggested support for CALD staff through the buddy
system (U)
The content of education and training needed to be improved (U)
CALD staff preferred to engage in learning activities that had
interactions with team members (U)
CALD staff identified training on effective communication for them
was imperative (U)
Expectations of training and
CALD staff identified training on cultural awareness and sensitivity
education
for all staff was imperative (U)
CALD staff realized that training on communication was imperative
(U)
Local staff experienced difficulties in understanding CALD staff so
that training on communication in staff was required (U)
CALD staff strived to learn to fit into the team (U)
Respecting team members’ culture was a condition to work in the
team (U)
The desire to be a valuable member
CALD staff tried to overcome the feeling of strangeness in order to
of the team
fit into the team (U)
CALD staff tried to improve communication skills in order to fit into
the team (U)
Note: CALD= Culturally and linguistically diverse

Appendix VII: Recommendations for practice
Accepted Article
Recommendation Joanna Briggs Institute
Grade
The nursing home should develop human right based policies, A
standards and protocols to protect staff from migrant and ethnical
minority backgrounds from discrimination and racism and to
ensure their cultural rights.
The nursing home should develop items in the ‘Charter of A
Clients’’ Rights and Responsibilities’ to ensure clients respect
staff from migrant and ethnical minority backgrounds.
The nursing home should develop regular education activities for A
clients and staff to reinforce respect for staff from migrant and
ethnical minority backgrounds.
The nursing home should provide counselling services for aged A
care workers from a migrant background who experience
psychological destress dye to discrimination, racism or other
negative cross-cultural encounters.
The nursing home should provide language training to assist aged A
care workers from a migrant background in improving
communication skills. The nursing home should also encourage
host staff to assist aged care workers from a migrant background
to adapt their communication into the host country.
The nursing home should provide training and education about A
cultural differences and their impact on care activities, teamwork
and communication. The training should have proper length and
intensity and encourage.
The nursing home should develop a more effective policy A
relating to the buddy system, for example, assigning staff who
have the same mother tongue to help new staff to adapt to
practice.
The nursing home should create a standard rule to divide tasks A
into proper groups and allocate shifts equally.
Managers should assign mentors to staff who need additional A
help.
The nursing home should deliver education using multiple A
approaches according to different preferences, for example,
learning through interactions with others, and learning by a
combination of face-to-face and online modes.
The nursing home should hold team-building activities regularly A

to encourage staff to familiarise themselves with different
Accepted Article
cultures and personalities, and thus enhance their relationships.
Managers should acknowledge aged care workers’ cultures and A
allocate shifts considering their religions and cultural events.
The nursing home should provide training on cultural A
competence in a multicultural aged care workforce.

Accepted Article
TABLE 1 Evaluation of Qualitative Studies Included for Review
Q1. Q2. Q3. Q4. Congruity Q5. Q6. Q7. The Q8. Q9. Research is Q 10.
Congruity Congruity Congruity between Congruity Statement influence of Participants ethical according Conclusions
Question
between between between methodology between locating the the are to current criteria drawn flow
philosophical methodolo methodolo and the methodology researcher researcher, adequately or, for recent from the
Author perspective gy and gy and representation and the culturally and vice- represente studies, and analysis
/Year and research data and analysis interpretatio and versa, d there is evidence and
methodology question/o collection of data n of results theoretically addressed of ethical interpretati
bjectives method approval on of data
Badger et al., √ √ √ √ √ √ X √ √ √
2012
Begum & √ √ √ √ √ √ X √ X √
Seppanen,
2017
Celik et al., X √ √ √ √ √ √ √ X √
2011
Doyle & X √ √ √ √ √ X √ X √
Timoen, 2009
Egede-Nissen √ √ √ √ √ √ √ √ √ √
et al., 2019
Gao et al., √ √ √ √ √ √ √ √ √ √
2015

Accepted Article
Gillham et al., √ √ √ √ √ √ X √ √ √
2017
Goel & √ √ √ √ √ √ X √ √ √
Penman, 2015
Munkejord, √ √ √ √ √ √ √ √ √ √
2019
Munkejord & √ √ √ √ √ √ X √ √ √
Tingvold, 2019
Nichols et al., √ √ √ √ √ √ X √ √ √
2015
Ryoscho, 2011 X √ √ √ √ √ √ √ X √
Sellevold et √ √ √ √ √ X X √ √ √
al., 2017
Shutes & √ √ √ √ √ √ X √ X √
Walsh, 2012
Timonen & X √ √ √ √ √ X √ X √
Doyle, 2010
Walsh & √ √ √ √ √ X X √ X √
O’Shea, 2010
Willis et al., √ √ √ √ √ X X √ √ √
2018

Accepted Article
Author et al., √ √ √ √ √ X X √ √ √
(blinded) 2018
Adapted from JBI critical appraisal checklist for qualitative research (2017)

Accepted Article
TABLE 2 Synthesised findings and categories
Synthesised Category Badger Begum & Celik et Doyle & Egede- Gao et Gillham Goel & Munkejord
findings et al. Seppanen al. Timonen Nissen et al. et al. Penman (2019)
(2012) (2017) (2012) (2009) al. (2019) (2015) (2018) (2015)
Various cultural Awareness of √ √ √ √ √
awareness in team members’
the multicultural cultures
team Awareness of √ √
migrant staff
members’
weaknesses and
strengths
Lack of √ √
awareness of
cultural diversity
Limited Understanding √
knowledge different cultures
about members Lack of √
in the knowledge about
multicultural different cultures
team

Accepted Article
Cultural skills in Skills √ √ √ √ √
a multicultural demonstrated in a
team multicultural team
Lack of skills in a √
multicultural team
Broad Support from co- √ √
experiences in workers and
cross-cultural management
encounters Communication √ √ √
barriers in a
multicultural team
Discrimination √ √
and racism
experienced by
migrant staff
members
Tensions in a √ √
multicultural team
due to variations
in performance
Stress from √ √

Accepted Article
cross-cultural
interactions
The desire to Expectations of a √
enhance better
teamwork multicultural team
Expectations of √ √ √
training and
education
The desire to be √ √
a valuable
member of the
team
Continued TABLE 2
Synthesised Category Munkejord Nichols Ryoscho Sellevold Shutes & Timonen Walsh & Willis et Author et
findings & Tingvold et al. (2011) et al. Walsh & Doyle O’Shea al. al.
(2019) (2015) (2019) (2012) (2010) (2010) (2018) (blinded)
(2018)
Various cultural Awareness of √ √

Accepted Article
awareness in the team members’
multicultural team cultures
Awareness of √ √ √ √ √
migrant staff
members’
weaknesses and
strengths
Lack of √ √ √
awareness of
cultural diversity
Limited Understanding √
knowledge about different cultures
team members’ Lack of √
cultures knowledge
about different
cultures
Skills √ √ √
demonstrated in
Cultural skills in a
a multicultural
multicultural team
team
Lack of skills in √ √ √ √ √

Accepted Article
a multicultural
team
Broad Support from co- √ √ √ √ √
experiences in workers and
cross-cultural management
encounters Communication √ √ √ √ √
barriers in a
multicultural
team
Discrimination √ √ √
and racism
experienced by
migrant staff
members
Tensions in a √
multicultural
team due to
variations in
performance
Stress from √ √
cross-cultural

Accepted Article
interactions
The desire to Expectations of √ √ √
enhance a better
teamwork multicultural
team
Expectations of √ √
training and
education

jonm_13067_f1.pdf
Accepted Article
Items located from databases and other sources (N=306)
Identification
MEDLINE (n=20), EMcare (n=7), CINHAL (n=30), Scopus (n=89), ProQuest (n=150),
Web of Science (n=10)
Duplicated items removed (N=38)
Browse title and abstract of each item (N=268)

Screening
Items excluded (N=242)
Full-text articles evaluated for eligibility (N=26)
Full-text articles excluded (N=12)

Eligibility
Quantitative studies (n=6); Not primary studies (n=3);
Not perceptions from aged care staff (n=2);
Not aged care setting (n=1)
Manual search (N=7)

Included
Full-text articles included for review (N=21)

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Conflict of Interest Statement: Authors have no conflict of interest to declare.

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Article type : Review Article

Challenges and opportunities for the multicultural aged care workforce: A

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3.2 Search strategy

3.3 Eligibility criteria and study selection

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3.4 Quality assessment

3.5 Data extraction and synthesis

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4.2.1 Synthesised finding 1: Various cultural awareness in the multicultural team

4.2.2 Synthesised finding 2: Limited knowledge about members in the multicultural

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(Nichols et al., 2015, p. 27)

Such misunderstandings, resulting from limited knowledge of cultural differences

4.2.3 Synthesised finding 3: Cultural skills in a multicultural team

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we have to do a more intimate training with her [a new migrant staff], so

(Badger et al., 2012, p. 1730)

4.2.4 Synthesised finding 4: Broad experiences in cross-cultural encounters

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4.2.5 Synthesised finding 5: The desire to enhance teamwork

(Timonen & Doyle, 2010, p. 38)

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(Shutes & Walsh, 2012, p. 97)

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TOTAL FOUND: 306

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This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved