After reading this chapter, the nurse will be able to:
Describe the importance of communication as it relates to transcultural nursing assessment.
Delineate barriers to communication that hinder the development of a nurse–client relationship in transcultural settings.
Understand the importance of dialect, style, volume, use of touch, context of speech and kinesics and their relationship to transcultural nursing assessment and care.
Describe appropriate nursing intervention techniques to develop positive communication in the nurse–client relationship.
Understand the significance of nonverbal communication and the use of silence, and their relationship to transcultural nursing assessment and care.
Explain the significance of the structure and format of names in various cultural groups.
Explain the significance of variations in word meanings across and within various cultural and ethnic groups.
The word communication comes from the Latin verb communicāre , “to make common, share, participate, or impart” ( ; ). Communication, however, goes further than this definition implies and embraces the entire realm of human interaction and behavior. All behavior, whether verbal or nonverbal, in the presence of another individual is communication ( ; ; ).
As the matrix of all thought and relationships among people, communication provides the means by which people connect. It establishes a sense of commonality with others and permits the sharing of information, signals, or messages in the form of ideas and feelings. Communication is a continuous process by which one person may affect another through written or oral language, gestures, facial expressions, body language, space, or other symbols.
Nurses have long recognized the importance of communication to health. Effective communication of health care information motivates individuals to work with their health care providers to manage their health. notes that individuals who have had effective health care communication are better informed and more confident in pursuing health care. Communication received increased visibility nationally with the inclusion of an entire chapter on health communication in Healthy People 2010, and this trend continues in the new Healthy People 2020 ( ). In Healthy People 2010, among the six national objectives were increased access to the Internet from home, increased satisfaction by individuals in the communication skills of their health care providers, and increased research on health communication. Effective communication of health care information is critical if individuals are to take action on behalf of their own health, the strategic goal of Healthy People 2010 . For Healthy People 2020, the communication objective is centered on health communication and health information technology ( ).
Communication is the core of most nursing curricula. However, if effective communication is to occur in today’s multicultural setting, nursing curricula not only need to provide skills in communication but also must teach diversity as a value ( ). To accomplish this, nursing curricula are increasingly reflecting integration of culture as a central concept ( ; ; ). Furthermore, to promote effective communication, health care settings are modifying the climate of units and organizations to accommodate multiculturalism ( ; ; ; ; ).
Nevertheless, communication frequently presents barriers between nurses and clients, especially when the nurses and the clients are from different cultural backgrounds. If the nurse and the client do not speak the same language or if communication styles and patterns differ, both the nurse and the client can feel alienated and helpless. When communication is impaired, the physical healing process may be impaired. Nurses may also feel angry and helpless if their communication is not understood or if they cannot understand the client. With ineffective communication, certain physiological problems such as pain may not be controlled ( ). Nurses need to have not only a working knowledge of communication with clients of the same culture but also a thorough awareness of racial, cultural, and social factors that may affect communication with persons from other cultures. Communication with family members is also crucial to client and family satisfaction. When interviewed family members in four countries, all the respondents identified the importance of communication with family members in the provision of care.
Nurses must have an awareness of how an individual, although speaking the same language as the nurse, may differ in communication patterns and understandings as a result of cultural orientation. Nurses must also have communication skills in relating to individuals who do not speak a familiar language ( ; ; ). Nurses generally assume that their perceptions and assessment of the client’s health status are accurate and congruent with those of the client. However, there is evidence that discrepancies in perceptions persist and may interfere with the provision of care to special populations with higher-than-average risk of developing health problems ( ). Many factors obstruct high-quality client care, including cost, fear, poor communication, noncompliance with the treatment regimen, inadequate or unnecessary treatment, and ethical problems. All these factors combine to create discrepancies in perceptions between nurse and client ( ; ; ; ).
Communication and Culture
Communication and culture are closely intertwined. Communication is the means by which culture is transmitted and preserved ( ; ; ). Culture influences how feelings are expressed and what verbal and nonverbal expressions are appropriate. Americans may be more likely to conceal feelings, and the United States is generally considered a low-touch culture, whereas a member of an Eastern culture may be open and loud with expressions of grief, anger, or joy and may use touch more ( ; ; ; ). Other cultural variables, such as the perception of time, bodily contact, and territorial rights, also influence communication. The cultural differences in contact can be quite dramatic. In a classic study, Sidney reported that when touch between pairs of people in coffee shops around the world was studied, touch occurred more in certain cities. For example, touch occurred as frequently as 180 times an hour between couples in San Juan, Puerto Rico, and 110 times an hour in Paris, France. In other cities there was less touch; specifically, touch occurred twice an hour between couples in Gainesville, Florida, and zero times an hour in London, England.
Cultural patterns of communication are embedded early, typically by age 5, and are found in child-rearing practices ( ; ). In a classic study, studied the playgrounds and beaches of Greece, the Soviet Union, and the United States, and compared the frequency and nature of touch between caregivers and children ranging from 2 to 5 years of age. The analysis of data indicates that although rates of touching for retrieving or punishing the children were similar, rates of touching for soothing, holding, and playing were dissimilar. American children were less likely to be touched than children from other cultures. The communication practices of persons in different cultural groups affect the expression of ideas and feelings, decision making, and communication strategies. The communication of an individual reflects, determines, and consequently molds the culture ( ; ). In other words, a culture may be limited and molded by its communication practices. As early as 1929, proposed that individuals are at the mercy of the particular language that has become the medium of expression of their society. Experiences are determined by language habits that predispose the individual to certain conceptions of the world and choices of interpretation. noted that educational programming that is provided to children of different cultural and linguistic backgrounds is critical for the successful implementation of language interventions. Focusing on English-language development while minimizing learning opportunities limits children who do not speak English as their first language from the development of higher-level cognitive skills.
Variations in communication may be limited to specific meanings for a few individuals in a small group, such as a family. On the other hand, unique communication patterns are frequently found among persons from the same ethnic and cultural group, such as the Gypsies or the Amish ( ; ). Some persons consider the deaf a cultural group. In any case, persons who are deaf have a unique language and communication patterns that require nurses to use special communication approaches ( ). However, the nurse must be cautious about assuming that a certain communication pattern can be generalized to all persons in a designated cultural group because communication patterns are often unique. In assessing the client, the nurse should keep in mind common cultural patterns and approach the client as an individual who should not be categorized because of cultural heritage.
Because communication is a broad concept and encompasses all human behavior, it has been conceptualized in many ways. One way is to consider the structure of communication, as in linguistics. Linguistics is the area within anthropology concerned with the study of the structure of language. Linguistic patterns represent more than the use of grammatically nonequivalent words; these patterns can create real disparity in social treatment. The major focus on the structure of communication has been developed within the fields of ethnomethodology in sociology and of linguistics in anthropology. Structure may be perceived as a form of language and the use of words and behaviors to construct messages. The role of ethnomethodologists is to consider the structure and effects of communication and to look at rules of communication and the consequences of breaking these rules. Ethnomethodologists not only have emphasized the study of the structure and rules of language but also have studied the structure and rules of nonverbal communication ( ; ).
Functions of Communication
Another way to think about communication is to consider what it achieves or accomplishes in human interaction. Consideration of the functions of communication refers to examining what the communication accomplishes rather than how the communication is structured. A relationship exists between communication structure and communication function in the sense that structure does affect function.
As a part of human interaction, communication discloses information or provides a specific message. Messages can be sent with no expectation of a response. Included in the disclosure of information may be an element of self-disclosure. Communication may or may not be intended as a method of self-disclosure or a means to provide information about the self or the individual’s perception of self ( ; ; ). Perceptions of self include acts that describe the self and estimations of self-worth. In some situations self-awareness may be achieved through communication; this function of communication involves interaction with people ( ). Through communication with others, an individual may become more aware of personal feelings. Communication can also serve the important interpersonal functions of conveying respect and giving or taking away power ( ; ; ).
Process of Communication
Communication may be conceptualized as a process that includes a sender, a transmitting device, signals, a receiver, and feedback ( ). A sender attempts to relay a message, an idea, or information to another person or group through the use of signals or symbols. Many factors influence how the message is given and how it is received. For example, physical health, emotional well-being, the situation being discussed and the meaning it has, other distractions, knowledge of the matter being discussed, skill at communicating, and attitudes toward the other person and the subject being discussed may all affect the communication that takes place ( Box 2-1 ). In addition, personal needs and interests; background, including cultural, social, and philosophical values; the senses and their functional ability; a personal tendency to make judgments and be judgmental of others; the environment in which the communication takes place; and experiences that relate or are related to the present situation may all affect the message that is received. The receiver then interprets the message. Feedback is given to the sender about the message, and more communication may occur. If no feedback is given, there may be no reciprocal interaction. Cultures such as the mainstream U.S. culture may be low context whereas the Asian cultures are high context; that is, very little of the message is the coded, explicit, transmitted part of the message. Members of individualistic cultures have a tendency to communicate in a more direct manner that has relatively low dependence on context, whereas members of collectivistic cultures use high-context messages in a more indirect fashion ( ).
Physical health and emotional well-being
The situation being discussed and its meaning
Distractions to the communication process
Knowledge of the matter being discussed
Skill at communicating
Attitudes toward the other person and toward the subject being discussed
Personal needs and interests
Background, including cultural, social, and philosophical values
The senses involved and their functional ability
Personal tendency to make judgments and be judgmental of others
The environment in which the communication occurs
Experiences that relate to the current situation
Although the process of communication is universal, nurses should be aware that styles and types of feedback may be unique to certain cultural groups. For example, before the assimilation of the Alaskan Eskimo into the American culture, the Alaskan Eskimo would indicate that a message was received by blinking rather than by making a verbal response ( ). Nonverbal responses are also found in the Vietnamese. Vietnamese persons may smile, but the smile may not indicate understanding. A Vietnamese person may say yes simply to avoid confrontation or out of a desire to please. A smile may cover up disturbed feelings. Nodding, which nurses commonly interpret as understanding and compliance, may, for a Vietnamese individual, simply indicate respect for the person talking ( ; ). The nurse may be surprised later when the Vietnamese client who smiled and nodded does not follow through with the instructions given.
In today’s health care system, optimal communication includes use of technology. E-mail, cell phones, voice mail, and PDAs have greatly improved timeliness in communication ( ). E-mail messages can be printed to provide hard copy for documentation purposes. Notebook computers with cell phone modem connections to access clinical information can be used in a client’s home in a rural setting to give clients more efficient service. Past health records can be accessed via the computer to be viewed by health professionals. Nurses can use the Internet and search Web sites to keep up-to-date on health care information and to print health education material for clients. Clients can be assisted to find age- and language-appropriate TV programs as well as Web sites for health information ( ). Health promotion strategies can include CD-ROMs, health consumer e-journals, toll-free telephone numbers, and DVDs.
Linguistic Isolation in the United States
In the United States, some 43 million adults are linguistically isolated, do not speak English well, or speak a language other than English at home ( ). Table 2-1 shows some of the languages spoken in the United States.
|Language Spoken at Home for Persons Over 18 Years of Age||Number|
|Spanish or Spanish Creole||34,560,000|
|French (including patois, Cajun)||1,979,000|
Verbal and Nonverbal Communication
Another way to conceptualize communication is in terms of verbal and nonverbal behavior ( Box 2-2 ). Communication first of all involves language or verbal communication, including vocabulary or a repertoire of words and grammatical structure ( ; ).
Although foreign-born persons need to demonstrate English proficiency to obtain U.S. citizenship, the nurse may encounter many persons in the United States who are not fluent in English. In 2009, 38.5 million members of the U.S. population were foreign born, representing 12.5% of the total U.S. population. It is interesting to note that between 2000 and 2009, the foreign-born population increased by 11.3 million people. This figure represents a percentage of change of 23.5% and a share of change of 28.6%. Among the foreign-born in 2009, 53.7% were born in Latin America, 28% were born in Asia, 13.1% were born in Europe, 2.2% were born in other regions of North America, and 4.3% were born in Africa and other regions of the world. In fact, among the foreign-born, the top four countries representing the greatest number were Mexico (11.5 million; 29.8%), China (2 million; 5.2%), the Philippines (1 million; 4.5%), and India (1 million; 4.3%). As previously indicated, of the total number of foreign-born, 43.7% are U.S. citizens, and 17.9% live in poverty ( ; ). In fact, in 2009, of the number of foreign-born, 56.2% were not U.S. citizens and only 43.7% had obtained citizenship through naturalization ( ).
Among the foreign-born, four of every five speak a language other than English at home. This translates roughly to 83% of the foreign-born older than 5 years of age who speak a language other than English at home. This figure includes 52.3% who speak Spanish, 21.9% who speak other Indo-European languages, and 21.6% who speak Asian or Pacific Island languages. In 2008, of the number of foreign-born who spoke a language other than English at home, only 38.5% spoke English “very well,” whereas 12.2% of the foreign-born did not speak English at all. Among the foreign-born who speak Spanish at home, only 48% speak English very well ( ; ; ). In 2008, 283,150,000 persons older than 5 years of age spoke English at home; 34,560,000 spoke Spanish; 1,979,000, French; 782,000, Italian; 2,466,000, Chinese; 1,488,000, Tagalog; and 620,000, Polish. Vietnamese was spoken by 1,225,000, Portuguese by 661,000, Japanese by 440,000, Greek by 337,000, Arabic by 786,000, and Hindi by 560,000. Russian, Yiddish, Thai, Persian, French Creole, Armenian, Navajo, Hungarian, Hebrew, Dutch, Khmer (Cambodian), and Gujarati were all spoken by at least 100,000 people ( ). In addition to these persons registered as living in households, many other non–English-speaking persons are in the United States as visitors, on temporary visas, or illegally. Approximately one sixth (31,845,000) of the population reported that they spoke another language besides English in the home, yet only a small minority of caregivers speak a language other than English ( ).
It is important to appreciate that along with language, significant communication cues are received from voice quality, intonation, rhythm, and speed, as well as from the pronunciation used. Dialect may differ significantly among persons both across and within cultures. Silence during communication may itself be a significant part of the message.
Communication involves nonverbal messages, which include touch, facial expressions, eye behavior, body posture, and the use of space ( ). Spatial behavior also affects communication and encompasses a variety of behaviors, including movement and proximity to others and to objects in the environment (see Chapter 3 ). Although nonverbal communication is powerful and honest, its importance and meaning vary among and within cultures; therefore, it is essential that the nurse have an awareness and appreciation of the role that body language may have in the communication process. In addition, some communications combine nonverbal and verbal components in the message that is sent. Two examples of combination messages are warmth and humor.
Language, or Verbal Communication
Language is basic to communication. Without language, the higher order cognitive processes of thinking, reasoning, and generalizing cannot be attained. Words are tools or symbols used to express ideas and feelings or to identify or describe objects. Words shape experiences and influence cultural perceptions. Words convey interpretations and influence relationships ( ; ; ). Although words provide a special way of looking at the world, the same words often have different meanings for different individuals within cultural groups. In addition, word meanings change over time and in different situations. It is important to ascertain that the message is received and understood as the sender intended. As early as 1954, emphasized the importance of ongoing validation in a therapeutic relationship to verify interpretations made on the behavior and words of another. Even today, this validation remains relevant in a nurse–client relationship in which many experiential, educational, and cultural differences are present. reported a study comparing the effect of personal questions and physical distance on anxiety rates. Pulse rates were higher when the investigator asked personal questions, regardless of the physical distance from subjects. Although the data from this study indicate that the most important part of a message may be verbal, the opposite has also been found to be true. Thus, both verbal and nonverbal communication must be considered before a conclusion about the true meaning of a message can be determined.
To provide culturally appropriate nursing care, nurses must separate values based on their own cultural background from the values of the clients to whom care is given. Transcultural communication and understanding break down when caregivers project their own culturally specific values and behaviors onto the client. has suggested that projection of values as well as hindering care may actually contribute to noncompliance.
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 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 ( ).
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.
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 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 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.
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.
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.
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.
suggested that 65% of the message received in communication is nonverbal. Through body language or motions (kinetic behavior), the person conveys what cannot or may not be said in words. For a message to be accurately interpreted, not only must words be translated but also the meaning held by nuances, intonation patterns, and facial expressions. Just as verbal behavior may undo nonverbal behavior, nonverbal behavior may repeat, clarify, contradict, modify, emphasize, or regulate the flow of communication. Nonverbal behavior is less significant as an isolated behavior, but it does add to the whole communication message. To understand the client, the nurse may wish to validate impressions with other health team members, since different people often interpret nonverbal behavior differently. It is important for the nurse to be aware not only of the client’s nonverbal behavior but also of personal nonverbal behavior that may add to, undo, or contradict verbal communication ( ).
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.
Connect one individual with another, both literally and figuratively, by indicating availability.
Provide affirmation and approval.
Be reassuring by providing empathy, interest, encouragement, nurturance, caring, trust, concern, gentleness, and protection.
Decrease loneliness by indicating a relationship with another.
Share warmth, rapport, love, intimacy, excitement, and happiness.
Provide stimulation by being a mode of sensation, perception, and experience.
Communicate frustration, anger, aggression, or punishment.
Invade personal space and privacy by physical and psychological assault or intrusion.
Convey a negative type of relationship with another.
Cause sexual arousal.
Allow a person to perform a functional or professional role, such as a physician, barber, or tailor, and be devoid of personal message.
Reflect cordiality, such as a handshake by business associates and among strangers and acquaintances.
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 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 ( ).
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 ( ).
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.
Communications That Combine Verbal and Nonverbal Elements
Many interpersonal communications combine both verbal and nonverbal elements. Warmth and humor are two of these.
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 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.