Vocabulary.

Even though people may speak the same language, establishing communication is often difficult because word meanings for both the sender and the receiver vary according to past experiences and learning. Words have both denotative and connotative meanings. A denotative meaning is one that is in general use by most persons who share a common language. A connotative meaning usually arises from a person’s personal experience. For example, although all Americans are likely to share the same general denotative meaning for the word pig, depending on the occupation and cultural perception of the person, the connotation may be entirely different and precipitate completely different reactions. The word pig will invoke either negative or positive reactions from certain people on the basis of occupation and culture. For example, an Orthodox Jew’s reactions will differ from those of a pig farmer. For an Orthodox Jew, the word pig is synonymous with the word unclean or unholy and thus should be avoided. On the other hand, for a pig farmer the word pig implies a clean, wholesome means of making a living. Numerous conflicts resulting from differences in word meaning among various ethnic and racial groups are reported in the literature. Among her many famous cultural studies, Margaret reported on the different meanings that the word compromise carries for an Englishman and an American:

In Britain, the word compromise is a good word, and one may speak approvingly of any arrangement that has been a compromise, very often including one in which the other side has gained more than 50% of the points at issue. Whereas, in Britain, to compromise means to work out a good solution, in America it usually means to work out a bad one, a solution in which all the points of importance are lost.

Often people who have learned a language have learned the meaning for the word in only one context. For example, reported that a Hispanic person who was told he was going “to be discharged tomorrow” somehow interpreted this to mean that he was going to develop “a discharge from below.” Díaz-Duque also indicated that for Hispanics, problems arise with cognates such as constipation because for Hispanics this term generally refers to nasal congestion rather than intestinal constipation. recounts the story of Xial Ming Li, now a college teacher, who came to the United States from China where she had been a good writer. However, in college in the United States she struggled to understand what faculty expected of her writing. Although she used appropriate words and sentence grammar, she needed tutors to assist her to write in the “U.S.A. style” that was expected.

Although barriers exist when people speak the same language, more profound barriers are present when different languages are spoken. Each language has a whole set of unconscious assumptions about the world and life. Understanding differences in the meaning of words can provide insight into people of different cultures. For example, many English-speaking Americans are puzzled by what seems to be a different time orientation among Hispanic peoples. An understanding of the meaning of the word time helps provide insight into this different orientation. In Spanish, time is defined as “passing”—a clock “passes time” or “moves,” whereas in English a clock “runs.” If time is moving rapidly, as English usage declares, we must hurry. On the other hand, the Spanish definition allows for a more leisurely attitude ( ). Such cultural understandings can provide insight into the reasons why Spanish individuals are often late for health care appointments.

Language reflects the dominant concerns and interests of a people, which can be noted in the number of words for certain things. Some classic studies have reported that certain cultures use many words to describe a particular object of importance. For example, Eskimos have 20 or so words for snow depending on consistency and texture ( ). The language of a people is a key that unlocks their culture. A nurse who is familiar with the language of clients will have the best chance of gaining insight into their culture.

Names.

Names have a special psychological and cultural significance. All people have names, and in every culture naming a newborn is considered important. The considerations that go into the naming process vary greatly from culture to culture. For example, in Roman tradition there is a given name for boys; a family name, which is second; and a third name that specifies an extended family unit. The name Caius Julius Caesar illustrates the importance of tribal connections as well as male chauvinism ( ). In Roman times, girls had only one name, the female version of the family name; for example, Caesar’s sister was Julia, as were his father’s sister and other relatives. During the early Roman times, women lacked individuality and thus in Roman society were not worth being named.

The Hebrew tradition has a patrilineal way of looking at names—that is, a given name plus “son of.” Mothers’ names are not included. A spiritual and traditional continuity is evidenced in this system of naming. The Hebrew tradition can be seen today in Iceland, where all males have their given names, followed by their father’s given name, ending in “son.” In contemporary Western society as well, there are systems of naming. The most common one in the dominant culture in the United States is a patrilineal succession plus one or more given names. In the United States, the middle name is often one that relates to the family, such as the mother’s maiden name.

The Russian system of naming provides a clue to the significance placed on relating son and father, as well as daughter and father. The mother is left out, with Russians habitually addressing each other by the individual’s given name together with the patronymic. The family name is omitted. Spaniards and Latin Americans include women more than other cultures, with children carrying their father’s name first and their mother’s name second. The mother’s name usually appears only on documents and for formal occasions because the addition of the mother’s name makes the name quite long. Another variation is seen in the Dutch, who have the option of using both the husband’s and the wife’s family names jointly. Among the various cultures, the most common theme of naming is pride in lineage ( ).

Grammatical Structure.

Cultural differences are reflected in grammatical structure and the use and meaning of phrases. “That’s all right” is a phrase frequently used by African-Americans when they actually mean “I have some plans, but I am not telling you what they are” ( ). In another example, for some Hispanic-American women, having a stillborn baby or a miscarriage does not equate with a pregnancy—rather, pregnancy is equated only with a successful live birth ( ). It is important for nurses to keep in mind that there is little validity in generalizations about the meaning of phrases by persons in varying cultures.

Length of sentence and speech forms may vary not only with culture but also with social class. For example, noted that persons from the lower class commonly use short, simple sentences and are more direct than are persons with more education. Word choice, grammatical structure, speech fluency, and articulation provide cues to social status and class. Jargon is also a speech variation that may prove to be a barrier to communication. Nurses frequently have difficulty expressing things in simple, jargon-free language (without medical terms) that clients can understand. On the other hand, a nurse who does not know the jargon used by the clients served may have a difficult time relating to them.

For some cultures, patterns of social amenities can create communication problems. Small talk, social chitchat, and discussion of mundane topics that may appear to “kill time” are sometimes necessary as preliminaries for more purposeful discussion. Yet the busy nurse seeking short, succinct answers to questions may be annoyed by the amount of anecdotal information that a Hispanic-American client, for example, gives. Many clients tend to add irrelevant material because it lessens embarrassment. They may be more comfortable if attention is not focused on their medical problems, and so they may intersperse actual symptoms with other biographical data. Cultural factors may also play a role in what seems to be verbal rambling. Patients who are used to folk healers believe that information on the weather, the environment, and eating habits are really important pieces of information for the health professional.

Voice Qualities.

Paralinguistics, or paralanguage, refers to something beyond the words themselves. Voice quality, which includes pitch and range, can add an important element to communication. The commonly used phrase “Don’t speak to me in that tone of voice” indicates the significance of this aspect of the communication message.

The softer volume of Asian-American or American-Indian speech may be interpreted by the nurse as shyness. On the other hand, the nurse’s behavior may be viewed as loud and boisterous if the volume is loud and if there is a deliberate attempt to accent particular words. Sometimes people who speak softly, slowly, and without emphasis on particular words are viewed as wishy-washy. When the nurse cannot hear what the client is saying, there is a tendency for the nurse to speak louder. It is important to remember that amplifying the volume does not necessarily equate with being understood or understanding. Nurses must remember when they are assessing the client that paralinguistic behavior is an important cultural consideration. The nurse can recognize this behavior by listening to tone of voice, quality of voice, and nonword vocalizations, such as sobbing, laughing, and grunting.

Intonation.

Intonation is an important aspect of the communication message. When people say they feel “fine,” they may mean they genuinely do or they may mean they do not feel fine but do not wish to discuss it. If said sarcastically, it may also mean they feel just the opposite of fine. There is often a latent or hidden meaning in what a person is saying, and intonation frequently provides the clue that is needed to interpret the true message.

Techniques of intonation vary among cultures. For example, Americans put commands in the form of suggestions and often as questions, whereas Arabic speech contains much emphasis and exaggeration ( ). Some cultures value indirectness and subtlety in speech and may be alienated by the frankness of Western health care professionals. Asian clients, for example, may interpret this method of communication as rude, immature, and lacking finesse. On the other hand, health care professionals may label Asian clients as evasive, fearful, and unable to confront problems ( ).

Rhythm.

Rhythm also varies from culture to culture; some people have a melodic rhythm to their verbal communication, whereas others appear to lack rhythm. Rhythm may also vary among persons within a culture. For example, some African-American ministers use a singsong rhythm to deliver fiery sermons.

Speed.

The rate and volume of speech frequently provide a clue to an individual’s mood. A depressed person will tend to talk slowly and quietly, whereas an aggressive, dominating person is more apt to talk rapidly and loudly.

Pronunciation.

Persons from some cultural groups may be identified by their dialect, such as Black dialect or Black English, Irish brogue, or a Brooklyn accent. Black English includes words and expressions not commonly found in Standard English and is sometimes spoken by African-Americans. It ranges on a continuum from being more to less Africanized, with the mild end of the continuum being much like Standard English ( ). However, even persons with dialects at the mild end of the continuum may have a “Black sound” that identifies them as African-American. A person may hear a boil called a “raisin” or difficult breathing called “the smothers” ( ); dentures may be called “racks” ( ). Some African-Americans speak in dialect when they do not want others to understand what is being said. One function of the Black dialect may be to enhance the in-group solidarity of African-Americans ( ).

Utterances of “ahs,” “ers,” and grunts also provide important dimensions to communication. Although hesitations may indicate a person who is unsure and slow to make a commitment, for some cultures this can have the opposite meaning.

Silence.

The meaning of silence varies among cultural groups. Silences may be thoughtful, or they may be blank and empty when the individual has nothing to say. A silence in a conversation may also indicate stubbornness and resistance, apprehension, or discomfort. Silence may be viewed by some cultural groups as extremely uncomfortable; therefore, attempts may be made to fill every gap with conversation. Persons in other cultural groups value silence and see it as essential to understanding a person’s needs. Many American Indians have this latter view of silence, as do some traditional Chinese and Japanese persons. Therefore, when one of these persons is speaking and suddenly stops, what may be implied is that the person wants the nurse to consider the content of what has been said before continuing. Other cultures may use silence in yet other ways. For example, English and Arabic persons use silence for privacy, whereas Russian, French, and Spanish persons may use silence to indicate agreement between parties. Some persons in Asian cultures may view silence as a sign of respect, particularly toward an elder. Mexicans may use silence when instructions are given by a person in authority rather than showing the disrespect of disagreement ( ).

Nurses need to be aware of possible meanings of silence so that personal anxiety does not promote the silence to be interrupted prematurely or to be nontherapeutic. A nurse who understands the therapeutic value of silence can use this understanding to enhance the care of clients from other cultures.

Touch.

Touch, or tactile sensation, is a powerful form of communication that can be used to bridge distances between nurse and client ( ; ; ). Touch has many meanings ( Box 2-3 ). It can connect people, provide affirmation, be reassuring, decrease loneliness, share warmth, provide stimulation, and increase self-concept. Being touched can be highly valued and sought after. On the other hand, touch can also communicate frustration, anger, aggression, and punishment; invade personal space and privacy; and convey a negative (such as a subservient) type of relationship. In certain situations touch can be disconcerting because it signals power. In a study reported by , higher status individuals were found to enjoy more liberties concerning touch than their lower status associates. It is generally considered improper for individuals to put their hands on superiors.

Touching or lack of touch has cultural significance and symbolism and is a learned behavior. Cultural uses of touch vary. Each culture trains its children to develop different kinds of thresholds to tactile contacts and stimulation so that their organic, constitutional, and temperamental characteristics are accentuated or reduced. Some cultures are characterized by a “do not touch me” way of life. These persons may view fondling and kissing as embarrassing. Some cultures include every possible variation on the theme of tactility. In the United States, the dominant culture generally tolerates hugs and embraces among intimates and a pat on the shoulder as a gesture of camaraderie. The firm, hearty handshake is symbolic of good character and a sign of strength. In some American-Indian groups, however, the hand is offered in some interpersonal interactions, but the expectation is different. Rather than a firm handshake, there is a light touch or grasp or even just a passing of hands. Some American Indians interpret vigorous handshaking as an aggressive action and are offended by a firm, lengthy handshake ( ).

Americans often give a lingering touch a sexual connotation. For some Americans, even casual touching is considered taboo and may be a result of residual Victorian sexual prudence ( ). Other cultures also consider touching taboo; the English and Germans carry untouchability further than Americans do. On the other hand, highly tactile cultures do exist, such as the Spanish, Italians, French, Jews, and South Americans ( ). However, generalizations about diverse national or ethnic groups in the area of touch can be problematic. For example, reported on studies of touch in Costa Rica, Colombia, and Panama. Findings from this study indicate that Latin Americans are commonly oriented toward high contact. also compared couples in Costa Rica, Colombia, and Panama and found that partners in Costa Rica were touched and held more often than partners in the other two countries.

Most cultures give touch different rules and meanings depending on the sex of the persons involved. reported that women in a hospital study had a strikingly positive reaction to being touched, with subsequent lowered blood pressure and anxiety before surgery, whereas men found the same experience upsetting, with a subsequent increase in blood pressure and anxiety. reported on a study at the Kansas City International Airport that found women greeted women and men more physically, with lip kisses, embraces, and more kinds of touch and holding and for longer periods than did men. For men, a more common greeting was to shake hands. Regardless of sex, some research has shown that people who are most uncomfortable with touch are also uncomfortable with communicating through other means and have lower self-esteem ( ). Other studies have shown that people who touch more are less afraid and suspicious of other people’s motives and intentions and have less anxiety and tension in their everyday lives. In some cultures, leaning back, showing the palm of the hand, and fussing with the other person’s collar may be perceived as possible courting behaviors because they may convey an invitation for closeness or affiliation. Touching behaviors such as reaching out during conversation to poke the other person in the chest may be viewed as domineering behavior. However, laughing while being poked may be a way to submit to and at the same time trivialize or eliminate the other person’s aggressive intent ( ).

In some cultures touch is considered magical and healing ( ). For example, some Mexican Americans and American Indians view touch as symbolic of “undoing” an evil spell, as a means for prevention of harm, or as a means for healing ( ). On the other hand, Vietnamese Americans may find touching shoulders with another to be anxiety producing, since they believe that the soul can leave the body on physical contact and that health problems may result ( ). The Vietnamese regard the human head as the seat of life and therefore highly personal. Procedures that invade the surface or any orifice of the head can frighten the Vietnamese, who fear that these procedures could provide an escape for the essence of life ( ).

Nurses must be alert to the rules of touch for individuals encountered in the work role. found that nurses perceive male clients as being less receptive to touch and closeness than their female counterparts, which could be attributed to the fact that males generally have a larger personal space than females. Thus it is believed that people generally maintain a greater distance from males ( ; ). concluded that there may be a double standard concerning touch because of societal norms and expectations: male clients may be more receptive to touch than are female nurses, but female nurses are perhaps more comfortable with the closeness and touch of female clients.

Although the rules of touch may be unspoken and unwritten, they are usually visible to the observer. A nurse should stay within the rules of touch that are culturally prescribed. It is essential that the nurse uses touch judiciously and avoids forcing touch on anyone. Nurses must keep in mind that the message conveyed through touch depends on the attitude of the other person involved and on the meaning of touch both to the person touching and to the person being touched. Generally, the need for intimacy and touch is so strong that the satisfaction of that need is a greater influence on behavior than fears about its inappropriateness ( ). A momentary and seemingly incidental touch can establish a positive, temporary bond between strangers, making them more compliant, helpful, positive, and giving. In all cases, touch needs to be applied deliberately, with empathy, and with close attention to the person’s particular needs. All cultural groups have rules, often unspoken, about who touches whom, when, and where. To avoid being perceived as intrusive, the astute nurse must be mindful of the client’s reaction to touch.

Facial Expression.

Facial expression is commonly used as a guide to a person’s feelings. Research shows that generally, in Americans, facial expression is used as a part of the communication message. A constant stare with immobile facial muscles indicates coldness. During fear, the eyes open wide, the eyebrows rise, and the mouth becomes tense with the lips drawn back. When a person is angry, the eyes become fixed in a hard stare with the upper lids lowered and the eyebrows drawn down. An angry person’s lips are often tightly compressed. Eyes rolled upward may be related to tiredness or may show disapproval. Narrowed eyes, a curled upper lip, and a moving nose commonly signal disgust. A person who is embarrassed or self-conscious may turn the eyes away or down; have a flushed face; pretend to smile; rub the eyes, nose, or face; or twitch the hair, beard, or mustache. A direct gaze with raised eyebrows shows surprise ( ; ).

Facial expression also varies with culture. Italian, Jewish, African-American, and Hispanic persons smile readily and use many facial expressions, along with gestures and words, to communicate feelings of happiness, pain, or displeasure. Irish, English, and northern European persons tend to have less facial expression and are generally less responsive, especially to strangers. Facial expression can also be used to convey an opposite meaning of the one that is felt; for example, in Asia negative emotions may be concealed with a smile ( ).

Eye Movement.

Research on eye movement has vastly increased as a result of the development of computer-based data collection and analysis routines. Recording techniques for eye movements provide a vast array of data to the researcher ( ; ; ).

Eye movement is an important aspect of interpersonal communication. Generally, during social interaction, most people look each other in the eye for short periods ( ; ). People use more eye contact while they are listening and may use glances of about 3 to 10 seconds. When glances are longer than this, anxiety is aroused.

Eye contact is an important tool in transcultural nursing assessment and is used both for observation and to initiate interaction. In the United States, those of the dominant culture (predominantly Whites) value eye contact as symbolic of a positive self-concept, openness, interest in others, attentiveness, and honesty. Eye contact can communicate warmth and bridge interpersonal gaps between people. A nurse who wears glasses and wants to make a point may increase the intensity of eye contact by taking off the glasses. The removal of glasses has also been cited as a technique that can humanize an individual’s face, since barriers to eye contact are removed (

Lack of eye contact may be interpreted as a sign of shyness, lack of interest, subordination, humility, guilt, embarrassment, low self-esteem, rudeness, thoughtfulness, or dishonesty. In social interaction the speaker glances away from the listener to indicate collecting of thoughts or planning of what is to be said. If contact is not resumed, lack of interest may be interpreted. Pupil dilation and constriction can also be a clue to anxiety level and positive response ( ).

Most Mexican-American and African-American clients are comfortable with eye contact ( ; ). In contrast to this view, others have suggested that through a process of socialization in a “minority status” of relative powerlessness, some African-Americans have learned to deliberately avoid eye contact with others ( ). In fact, in the United States avoidance of eye contact is sometimes considered rude, an indication of lack of attention, or a sign of mental illness ( ; ). On the other hand, reported that, for some Filipinos, eye contact that turns away is associated with the possibility of being a witch. Other groups who find eye contact difficult include some Asian people and some American Indians, who relate eye contact to impoliteness and an invasion of privacy. Many American Indians regard eye contact as disrespectful because it is believed that “looking in an individual’s eyes” is “looking into an individual’s soul” ( ; ; ; ).

Persons in certain Indian cultures avoid eye contact with persons of a higher or lower socioeconomic class. The Vietnamese generally practice less eye contact ( ), and prolonged eye contact is also avoided by some African-Americans ( ). In some Indian cultures eye contact is given a special sexual significance. Some Orthodox Jews also attribute a sexual significance to eye contact by an elderly man with a woman other than his wife ( ). Some Appalachian people tend to avert their eyes because for them eye contact is related to hostility and aggressiveness ( ). Certain cultures place more focus on the eyes than others; for example, in India and Greece the use of the eyes is all important ( ).

Body Posture.

Communication is also affected by body posture. A nurse can bridge distance in an interaction by placing the forearms on the table, palms up. In Western culture, palms up can send a message of acquiescence even while disagreeing. However, the nurse should also recognize that palms up in other cultures may have a sexual implication. Therefore, the decision to use this gesture should be weighed carefully.

Body posture can provide important messages about receptivity. In some Western cultures, such as among Whites in the United States, the closer a listener’s overall posturing matches the posture of the speaker, the higher the likelihood of receptivity. If the individuals’ unconscious gestures differ, probably their perspective on the matter at hand is also different. Matching body movements to those of another person can communicate a sense of solidarity, even if solidarity is not present. Body posture can also communicate attitude toward a person. For example, within the dominant culture of Whites in the United States, an attentive posture is indicated by leaning toward a person. Attentive posture is used toward people of higher stature and toward people who are liked ( ). An American man may indicate sexual attraction by placing his arms in front of his body with his legs closed. An American woman, on the other hand, indicates attraction by a more open posture, that is, arms down at the side ( ). Physical pain is communicated by rigid muscles, flexed body, and cautious movements. reported that in England dominance is communicated when the dominant person stands or sits more erectly than the compliant or submissive person. Knowledge of sociocultural heritage is essential in interpreting body language, since various body parts are used differently in different cultures.

Warmth.

Warmth is a quality or state that promotes feelings of friendship, well-being, or pleasure. Warmth can be communicated verbally (“You really lay still during the procedure, and that helped us to do it as quickly as possible”) and may also be communicated nonverbally, as by a pat on the shoulder or a gentle smile.

Although warmth is also a matter of perception, communication that focuses on human needs is more likely to be related to warmth in the speaker. Statements that show respect, address the human need to be needed, and promote self-acceptance will usually be interpreted positively and can increase motivation, morale, and cooperation. Personal recognition and concern also communicate warmth. Verbal recognition (for example, a hello on meeting) or a statement of genuine concern (for example, “How are you feeling?”) can convey interest and may facilitate a positive relationship between client and family and the nurse ( ).

The nurse’s communication of warmth is an important and dynamic aspect of a therapeutic nurse–client relationship. If the client is from another culture and is having difficulty with understanding communication, the nurse’s warmth may be vital to promoting a positive relationship. suggests that the healing process is promoted by the interrelation between the nurse and the client and that without this relationship the client from another culture may not be engaged in the healing process.

Humor.

Humor is a powerful component of verbal and nonverbal communication. Humor can create a bond of shared pleasure between people, decrease anxiety and tension, build relationships, promote problem solving and learning, provide motivation, and enable personal survival. As a healthy and constructive coping mechanism, humor can provide a discharge for aggressive feelings in a more or less acceptable way and can enable management of stressful situations ( ). Humor that is therapeutic does not ridicule and rarely uses cynicism ( ). Personality, culture, background, and levels of stress and pain may influence reactions to humor. When people are from a different culture, humor must be used in a limited and deliberate manner since humor can be an obstacle to a relationship if it is misunderstood. The nurse must carefully assess the individual client and the situation to decide if humor is appropriate. Humor not only can improve communication when used appropriately but may also affect the immune system by promoting the body’s ability to combat such problems as cancer and diseases of the connective tissue, such as arthritis and lupus ( ).

When the individual spoken with does not have a full grasp of the language and the nuances and puns that are often involved in humor, jokes and statements meant humorously may not be understood or may be misinterpreted. It is also important for an individual who tries to speak in another language to be prepared to precipitate laughter. A statement meant to be serious may be perceived as comical. The ability to laugh at oneself and with others can ease the anxiety that may be present in an intercultural situation.