Building transcultural skills for professional contexts


what people do every day: how they behave, speak, relate and make things

It is important to be aware that our personalities also influence how we communicate. Chapter 6 explains how personality or individual differences can affect communication. Across cultures too there are many similarities in experiences around life, work, change and death. It is therefore also important to appreciate that cultures often have more in common than they do differences.

Defining culture

The concept of culture has a range of everyday and technical uses and meanings. Lankshear et al. (1997, cited in Kossen, Kiernan & Lawrence, 2013) describe these different meanings:

  • culture as artefacts (e.g. ‘early Aboriginal culture is displayed at the museum’)
  • culture as visible displays (e.g. ‘the cultural dances of the Pacific’)
  • culture as ethnic or racial identity (e.g. ‘there are 60 cultures represented at the University of Southern Queensland’)
  • culture as ‘class’ (e.g. ‘they have culture and style’)
  • culture as ‘high’ or ‘low’, or ‘elite’ (e.g. ‘the opera is an example of high culture’)
  • culture as exotic or different (e.g. ‘Indigenous culture is “raw”’)
  • culture as explicit rather than implicit (i.e. you can see it, touch it, hear it, taste it and perhaps smell it).

These definitions of culture are ‘narrow’ in that they associate culture with material objects (dance, drama, diet and dress), visible displays (ceremonies and festivals) and other tangible features, such as language or dialect. They understand that culture is what you can see, touch, hear, smell and taste. These narrow definitions imply that culture belongs to others, and that ‘we’ don’t have culture; they infer that our behaviour is ‘normal and natural’, and it is the cultural behaviours of others that are different.

It is not that these narrow definitions of culture are incorrect; rather, this chapter argues that there are wider, more productive ways of thinking about culture that are more appropriate in our contemporary world. This wider concept of culture suggests that we all have culture – that culture is reflected in our everyday activities, relationships and social processes, our values, beliefs, norms, customs, possessions, rules and codes, and our assumptions about life. Shor (1993, p. 30, cited in Lankshear et al., 1997) argues that ‘culture is what ordinary people do every day, how they behave, speak, relate and make things. Everyone has and makes culture … culture is the speech and behaviour of everyday life’. For example, while eating is seen as a biological process, the foods we eat and the ways in which we prepare and consume them are examples of cultural activities. Eating with chopsticks, knives and forks, with our hands, around a table, in front of the television, in a hotel, or at a fast food restaurant or a dumpling stall are all examples of cultural practices (Kossen, Kiernan & Lawrence, 2013). In Lawrence (2014), a nursing student notes that:

My culture and Australian culture have many differences. First, in Australia they eat at the table with knife and fork but in my country we eat by hand and from one plate.

As Chapters 2 and 3 have already discussed, this wider concept of culture is confirmed by its presence in many different theoretical perspectives. In anthropology or ethnography, culture is a central concept. Words and phrases like ‘way of knowing’ and ‘world-view’ are also key to the theoretical perspectives of social science and critical theory (see Kossen, Kiernan & Lawrence, 2013). Communication theory uses words like ‘perception’ (outlined in Chapter 2), ‘interpersonal communication’ (outlined in Chapter 6) and ‘organisational communication’ (discussed in Chapter 7).

The wider concept of culture can also be applied to more specific groups within societies. Each of us belongs to a range of cultural groups and sub-groups – a family group or groups, social groups, friendship groups, work groups, sporting groups, religious groups, gender groups and so on.

Learning activity

Think of your groups of friends. Are there differences in the ways the members of each group relate to or communicate with each other?

We are simultaneously members of many cultural groups, each of which may have different cultural practices and/or share common practices. We are also members of the cultures that are emerging from globalisation – for example, Facebook, Twitter and other social media (see Chapter 7).

There is also a national culture or identity. Australia is a multicultural country. Aboriginal and Torres Strait Islander peoples have been here continuously for 60 000 years (Hazelwood & Shakespeare-Finch, 2010), but everyone else is an immigrant of less than 250 years’ heritage. Australia has a high level of first- and second-generation immigrants. In 2006, for example, 25 per cent of Australians were born overseas (ABS, 2006, cited in Hazelwood & Shakespeare-Finch, 2010). However, the numbers of migrants and Aboriginal and Torres Strait Islander people vary across Australia. For example, only 1.6 per cent of the South Australian population identify as Aboriginal and Torres Strait Islander people compared with 27.8 per cent of people in the Northern Territory (ABS, 2006, cited in Hazelwood & Shakespeare-Finch, 2010). International students are surprised by the diversity of cultures they encounter at university (Lawrence, 2014):

I found it shocking that Australia is a multicultural country as Australia has got mixed cultures and is not limited to one specific culture.

When I came to Australia I was very surprised to see that Australia is a multicultural country. Many people came from different countries with different languages, different beliefs, different values and different cultures.

Despite this diversity, Western ideas of communication are the norm in Australia. For example, English is used as the standard language, written communication is valued (particularly in legal matters) and the accessibility of ideas (especially through the internet) is a taken-for-granted notion reflecting the individualised Western way of communicating. The next section discusses how cultural differences operate in our professional lives in academic, nursing and healthcare contexts.

Cultural difference

Identifying how cultural difference can arise is important if we are to act professionally in all the contexts with which we engage. If we have not been exposed to different cultures and to different ways of understanding and knowing, we might not understand the uncertainty posed by wider concepts of culture. Here we introduce the ideas that each cultural group communicates using specific verbal and non-verbal behaviours and that the same act can have different meanings in different cultures. We also describe the ways individually and collectively orientated cultures differ in their approaches to life, and acknowledge the cultural differences inherent in the way men and women communicate.

Verbal and non-verbal differences

Each cultural group communicates using specific verbal and non-verbal behaviours. According to Kossen, Kiernan and Lawrence (2013), these include greeting people, eye contact, personal space, silence, dress, use of time, taking turns in conversations and speaking. Our body language, our gestures, the way we eat and our ‘naming’ practices can differ between cultural groups. When we greet people, for instance, we might shake hands or bow, or envelop the newcomer in a bear hug, or kiss them on either cheek or exchange business cards (Kossen, Kiernan & Lawrence, 2013). The most appropriate behaviour is finely tuned to the particular cultural context we are in at the time. Likewise, the use of eye contact differs from culture to culture. In white Australian culture, direct eye contact is interpreted as a sign of confidence and honesty. In some Asian and African cultures, direct eye contact is a sign of disrespect, or possibly challenge. Calling people who are in a more senior position or older by their given name is seen as disrespectful. Lawrence (2014) presents the following anecdote from a nursing student:

At higher education boys and girls are together and they can call their teacher by their first name and they speak with me like their friends. However, in my country when we call our teachers we say ‘teacher’ and when we answer a question we should stand.

The same act can have different meanings in different cultures. For example, speaking in a quiet voice is a sign of respect in some cultures, but a sign of concern or shyness in others. Waiting for others to finish their sentence is a sign of courtesy in some cultures but is not valued and accorded little respect in others – for example, Australian culture. These differences relate to our behaviours (our cultural practices). In discussing how health practices can differ between cultural groups, Hazelwood and Shakespeare-Finch (2010) provide examples related to the Xhosa people in South Africa and Aboriginal and Torres Strait Islander peoples in Australia. The Xhosa people train people who hear voices to be healers and look up to their prowess in this regard while in Western medicine people who hear voices are perceived as being in need of medication. In their traditional law, Aboriginal and Torres Strait Islander peoples perceive mental illness as external to the individual and perhaps the result of an offence against traditional law. Health professionals need to be aware that such differences exist and should be mindful of them in the clinical context.

Individualist and collectivist cultural differences

Hofstede (2001, 2014) was a seminal cultural researcher who identified four dimensions to cultural difference: power distance, uncertainty avoidance, masculinity-femininity and individualist-collectivist. Power distance refers to the ways people in various cultures react to status differences and social power. Uncertainty avoidance refers to how cultures adapt to change and cope with uncertainty. Masculinity-femininity refers to the way cultures prefer assertiveness and achievement (masculinity) or nurturance and social support (femininity).

This section focuses on individualist and collectivist cultural differences, which are particularly relevant to assumptions or ways of thinking that are intrinsic to both Western academic and healthcare cultures. For example, differences between individualist and collectivist cultures emerge in relation to referencing conventions. In Western academic culture, there is an understanding that ideas (and words) belong to individual people. Therefore, it is important to acknowledge the owner of the idea (words) explicitly in an in-text reference. Not to do so is labelled plagiarism and is considered stealing or cheating. Some other cultures do not share this view; in these cultures, it is respectful if you quote the idea but not the source. Another way in which these differences can cause confusion is in relation to setting out the complete bibliographic reference. In individualist cultures, it is the individual’s name that is expressed first – for example, I write my name as Jill Elizabeth Lawrence. However, in collective cultures the surname (family name) is written first – for example, Yang Hwei-Jen. So an international student coming from a collective culture may have difficulty deciding which name to reference as the surname in a bibliographic reference.

According to Hofstede (2001, 2014) individualist cultures, such as Australia, New Zealand, Canada, Britain and the United States, are more likely to pursue individual activities and agendas than to contribute to the success and well-being of the larger group. In these cultures, a high degree of independence/self-reliance/individual problem-solving is valued (Hofstede, 2001). It is reflected in the use of individual desks in education, the use of individual cars rather than public transport (despite the negative effects of urban sprawl, air pollution and highway/parking congestion), the notion of individual ownership, and the concept of control over one’s personal property. Privacy is important, and life choices – such as those concerning marriage, jobs and children’s names – tend to be made individually.

In a collectivist culture, people tend to view themselves as members of groups (families, work units, tribes or clans, and nations) and usually consider the needs of the group to be more important than the needs of individuals. There is an emphasis on collective well-being (the well-being of a group) and social harmony (Hofstede, 2001). Most Asian cultures (for example, China) and some European and African cultures tend to be collectivist. While in individualist cultures people are permitted to speak out and challenge ideas being put forward by other group members (Hofstede, 2001), collectivist cultures tend to reach decisions through careful consensus, and there is a tendency to avoid conflict and speaking out against issues. Given the emphasis placed on harmony and conformity, collectivist cultures tend to communicate less directly and much more politely than individualist cultures, in which communication tends to be more direct or ‘to the point’. An example of this kind of indirectness is a library sign in South Korea that reads, ‘There is much laughter and fun in our trees and park outside’. A cultural translation in many English-speaking countries would be, ‘Silence in the library’. This shows how cultural norms relating to manners can require a substantial shift in the way we think about and approach communication, as there can be large differences in people’s cultural sensibilities.

Collectivist and individualist approaches are not better or worse than each other; rather, they have different underlying taken-for-granted assumptions about life, which can in turn provide us with different perspectives. These ways of behaving or knowing can be beneficial in some situations. For example, people from collectivist backgrounds can be well suited to teamwork and averting group conflict. Yet the tolerance of group conflict in individualist cultures promotes competition between ideas, which can also help to produce effective outcomes.

It is also important to understand that our cultural orientation can sometimes inhibit our use of productive communication strategies. Scott, Ciarrochi and Deane (2004) suggest that people with strong individualist views have smaller social support networks, are less likely to seek support for personal problems and have less skill in dealing with emotional well-being than others whose views are not so strong. In an Australian rural setting, this may mean that supposedly self-reliant farmers or teenagers may be less likely to ask for help when experiencing suicidal thoughts or if they are overwhelmed by adversity. That is why organisations as varied as Beyondblue and Men’s Sheds Australia explicitly talk about joining groups and asking for help.

Cultural stereotyping

There is considerable intellectual discussion about the way in which cultural stereotypes develop. Socialisation, early carer influence and the media are implicated in the way we perceive and categorise people who are from a particular group. McGarty, Yzerbyt and Spears (2002) note that shared stereotyping is useful (but often not accurate) in understanding or predicting the behaviour of a particular group. Hofstede’s (2001, 2014) value orientations predicting the way in which members of a particular cultural group may act or communicate are a type of stereotyping. So there always needs to be an understanding that there will be individual differences within any cultural group. As students and healthcare professionals, we need to examine our own socialised cultural stereotypes to ensure that any personal negative stereotypical views do not negatively impact on either the quality of care we are able to provide or the cultural safety of our patients. It is vital that nurses suspend any negative judgements of any people under their care (Andrews & Boyle, 2002).

Within broader national cultures, there are smaller subcultural groups called microcultures, with their own power structures, rituals, beliefs and rules. The next section applies the more general cultural understanding perspectives outlined above to the healthcare culture.

Healthcare culture

Healthcare culture is one example that has clearly defined hierarchy, behavioural differences, distinct style of dress (uniform), a unique language and a number of rules about social interactions that differ significantly from the national culture in which they are embedded. For nursing students, the new healthcare microculture can present some unique challenges as they negotiate the typically unwritten rules of the new culture. Suominen, Krovatin and Ketola (1997) observe that there is very little written about healthcare culture, and there continues to be very little formal study of this area. It is wise to have some ‘pre-travel’ or preliminary information from others familiar with the new culture. This is where your lecturers and clinical preceptors can assist you. Using the practices outlined in Chapters 2 and 3 can also be helpful here.

Negotiating healthcare culture

Historically, the shift from hospital to higher education nursing education has involved the role of the registered nurse requiring a greater knowledge base and a more autonomous and respected healthcare practitioner. There has also been an increase in the amount of respect and autonomy accorded the role of the registered nurse in Australia and other developed countries. From a cultural perspective, the power distance or hierarchical structure within healthcare settings is much more structured and more clearly defined than it is in the wider Australian community. Similarly, the need for clear lines of authority and the call to minimise ambiguity in all communication to safeguard patient safety means that communication within healthcare settings tends to be much more direct than it is in the broader population.

The non-verbal element of personal space is another area of significant difference between broader Australian culture and healthcare culture. For example, when providing treatment, nurses need to be physically closer to patients than is usual outside a healthcare setting. Although healthcare professionals are accustomed to close physical and often intimate personal interactions, we still need to gain consent from our patients and explain what we are planning to do and why it is important. The need for this consideration is even greater in cultural groups where higher levels of personal modesty are the cultural norm (see later in this chapter for a discussion of particular cultural groups).

Negotiating unfamiliar language

When first entering a healthcare context or workplace, it is important to recognise that there will be a new or unfamiliar language. To further challenge you in the new healthcare culture, the new complex language is filled with multiple acronyms and commonly used healthcare jargon. This language use can lead to semantic barriers (see Chapter 2), and generate difficulties in your interactions with healthcare professionals. Therefore, it is vital that students studying nursing have a foundational knowledge of basic healthcare terminology prior to their first clinical placement as part of their undergraduate nursing degree.

A number of healthcare acronyms are used as common language in a healthcare setting. To complicate matters, there are also many commonly used healthcare acronyms related to medication and treatment that are specific to specialised areas. Many are Latin, and their full meanings not intuitive – particularly for students whose first language is not Latin-based like English. Examples include mane (morning), nocté (night), prn (when required), stat (immediately), tds (three times a day) – there are many others.

The Australian Commission on Safety and Quality in Health Care (ACSQHC, 2006) has published a list of acceptable commonly used abbreviations/acronyms and identified a number of abbreviations that have caused adverse patient events due to the acronym being mistaken for something different. For example, the abbreviation/acronym CA can be written to represent carbohydrate, (cancer) antigen, cancer, cardiac arrest or community-acquired. ACSQHC recommends writing the full medical term in patient charts, followed by its acronym, in the first instance to ensure patient safety.

Despite these recommendations, it is common in healthcare settings to hear sentences constructed almost entirely of healthcare jargon and acronyms. The following sentence would be easily understood by most healthcare professionals, but might terrify a patient.:

When the MVA gets back from MRI he should have his PRN stat, and then set up an IV with a PCA and check his MCS on his micro-urine – I think he has a UTI.

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Jan 30, 2017 | Posted by in NURSING | Comments Off on Building transcultural skills for professional contexts

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