Irene’s story demonstrates that while a great deal has been written about culture, the concept is not well understood outside the discipline of sociology, yet its influence is pervasive. Nurses may be unaware of their own culture or the degree to which their cultural influences affect the way they view people or how they expect them to act in various situations. Culture influences what we expect of our patients as well as what we expect of ourselves as nurses.

While some aspects of culture are acquired through education, much of it is learned unconsciously through contact with other members of the society or group, and especially through childhood experiences with family, friends and school. As cultural values and beliefs tend to be learned unconsciously, the expectations that individuals place on other peoples’ behaviour are ingrained and equally unconscious. Irene, for instance, expected her nurses to understand that she needed to learn about her treatments at a different pace and in a different way to Anglo-Celtic people. Similarly, her nurses expected that the way they traditionally taught self-management of dialysis to non-Indigenous people would suffice for an Indigenous woman like Irene. As a result, when the behavioural expectations of people are not met, the reaction of the individual tends to be emotional, automatic, and judgmental. The example given earlier about eye contact is a good case in point. In Anglo-Celtic cultures, there is an expectation that people will look each other in the eye when speaking to them. If this doesn’t happen, there is a tendency to suspect that the person is being dishonest based on the assumption that ‘one can’t look someone in the eye and lie’. Many other cultures however, including many Indigenous Australian communities, consider it rude, disrespectful or even aggressive to look someone directly in the eye, so when people with these different cultural values meet both are likely to feel uncomfortable with the other.

While the existence of culture is universal, all groups tend to have a specific view of the world, and that worldview can vary a great deal between cultures. This fact is one that few individuals are instinctively aware of. Because of the unconscious nature of cultural learning, group values and beliefs tend to be seen as universal; that is, not specific to the individual’s own culture. Hence when people from other cultures are met, there is no recognition of the fact that their behaviour is determined by a different set of equally valid rules. Their behaviour is in fact judged unconsciously by the cultural rules of the observer.

An individual’s values, which are the basis of judgments that they make to determine whether they perceive something as good, bad, desirable or undesirable, are also culturally determined. These values, while often unconscious, play a major role in deciding what behaviours are acceptable and what are not. Society develops rules from these values, which in turn determine behaviour that is rewarded if it complies with the rules, or punished if it does not. To disobey a culture’s rules of behaviour invokes a judgment and usually a negative emotional response by members of that culture, often without awareness of the values underlying it, and rarely is there recognition that those values are culture specific. Values also affect the individual’s perceptions of others, so that once a person has transgressed a cultural rule, there is a tendency to develop an overall view of that person as deviant, leading to a biased judgment of any future behaviour.

Another aspect of culture is that of symbolism. Over time, all societies develop symbolism in which concepts become value-laden. Symbols developed in past times represent deep-seated values that are rarely understood by the present members of the society. Because these symbols are covert, there is a tendency to assume that they mean the same to everyone regardless of cultural background. This mistaken belief makes cross-cultural understanding especially difficult. A powerful symbol in Anglo-Celtic cultures is that of Christmas. The origin of this symbol is in Christian religion, but most Anglo-Celtic Australians, even those who do not consider themselves to be practising Christians, would consider it unthinkable that they should be expected to work on Christmas Day and not spend it at home with their family.

Within a multicultural society, such as that found in Australia, there are many groups of people who come from non Anglo-Celtic cultural backgrounds. Members of these groups share a common culture, to the extent at least that they have more in common with each other than they have with members of other groups or with the dominant Anglo-Celtic group. While members of a group have much in common, like all members of all cultures, there are individual differences and considerable variation can occur within a society. People from a particular group may have had very different experiences and/or backgrounds. Over time they will also be influenced by their interaction with the dominant culture, as well as other groups that they come in contact with.

The host country’s health care system will be based in that country’s culture. Australia’s system, for example, is based on Anglo-Celtic cultural beliefs about health, health-related behaviours and health care. As a consequence, there are enormous cultural differences in the perceptions of health and illness, as well as of health care services including: