Understanding each other: communication and culture

Lois O. Gonzalez, PhD, ARNP, BC and Julia Balzer Riley, RN, MN, AHN-BC

1. Define culture, ethnicity, and ethnocentrism

2. Discuss reasons why nurses need to become informed about the healthcare beliefs and behaviors of diverse cultures

3. Discuss two common American values that may interfere with nurses’ recognition and appreciation of the healthcare beliefs and behaviors of diverse cultures

4. Describe your own cultural background and its influence on your healthcare beliefs and behaviors

5. Identify the components of communication suggested for assessment in Purnell’s model for cultural competence

6. Discuss techniques that enhance communication with clients from diverse cultures

7. Apply communication techniques to improve the care of clients from diverse cultures

8. Discuss how the variables of age and gender relate to culture and communication

9. Participate in exercises to build skills in understanding each other

The tongue slow and the eyes quick.

Mexican proverb

Cultural competence is a major component in the quality and safety of care (Larson et al, 2010; Frohlich and Potvin, 2008). According to the Quality and Safety Education for Nurses (QSEN) Initiative, an understanding of how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values, is vital for today’s future nurses (QSEN, 2010a). QSEN calls patient-centered care, which includes diversity, one of the six pillars of safe and effective nursing care, recognizing this competency as a required Knowledge, Skills, and Attitudes (KSAs) needed to promote patient safety (QSEN, 2010a). According to their definition, nurses should be able to

“Provide patient-centered care with sensitivity and respect for the diversity of human experience. Seek learning opportunities with patients who represent all aspects of human diversity. Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds. Willingly support patient-centered care for individuals and groups whose values differ from own” (QSEN, 2010b).

Being culturally aware takes a great deal of commitment and effort on the part of the nurse. Merely talking about culture does not necessarily mean that you have translated knowledge into action. Individuals are not likely to translate cultural knowledge into behavior until they experience direct contact with people from other cultures. This exposure is becoming more and more inevitable in the United States.

Data from the 2010 census provide evidence that America is becoming even more racially and ethnically heterogeneous. Considerable growth among the Hispanic and Asian populations due to increased immigration and the decline of growth in the non-Hispanic White alone population are indications that America is becoming a nation with no ethnic majority (Humes et al, 2011). Recent projections indicate that by 2020 the white population will decrease by 53%, while the number of African Americans will double, and the number of Hispanic and Asian Americans will triple (Giger and Davidhizar, 1999). By 2050, no group will constitute more than 50% of the population (RAND, 2006). This multiracial, ethnically complex population will challenge U.S. healthcare providers who are attempting to offer culturally driven client care. Changing demographic trends indicate that America is making progress in efforts to reduce inequalities and barriers to opportunities. Unfortunately, despite improvements in access to healthcare across U.S. ethnic populations, disparities between the majority population and most ethnic groups still exist. Intercultural knowledge, communication, and competence will become necessities in almost every occupation (Weaver, 2000).

Eliminating racial and ethnic healthcare disparities is urgent, and our efforts must focus on social, cultural, and environmental factors that reach far beyond the traditional medical model. Effective communication between and among cultures is essential because it is the way that we interact globally. In the American healthcare setting, nurses indicate an understanding of the importance of communication and demonstrate awareness of the need for cultural awareness, but many have not operationalized into their practice the significance of culture. Because nurses spend more time with clients than do most other healthcare professionals, it is particularly important that nurses realize that both communication and culture are inextricably connected to healthcare. Nurses need to know about culture—their own and their clients’—because it influences both nurses’ and clients’ healthcare perceptions and behaviors.

The impact of culture and communication-related issues can be life threatening, particularly in cases in which there are differing perceptions and descriptions of pain. For example, an assessment of the quality of chest pain is a critical piece of data so that an acute myocardial infarction can be distinguished from other conditions causing pain in the chest or epigastric area. Missed diagnoses and delayed treatments occur when responses to pain are culturally dictated and an individual may delay coming for treatment because of fear, stoicism, or meanings attributed to pain. Such delays can be life threatening (Sobralske and Katz, 2005).

Negotiating a larger, white-dominated culture can be painful for minorities, particularly when people in the majority are not aware of cultural differences. After living for an extended period of time in a majority culture, a minority person can choose one of two paths. He or she can either become acculturated or live apart in isolation or within the safe boundaries of a familiar cultural neighborhood. The latter prevents participation in and enrichment of the larger culture, thwarting the development of increased multiculturalism in the community.

We are experiencing a nationwide increase in our multicultural society due to immigration migration within the United States because of posthurricane displacement to other areas of the country. When nursing experts are asked to predict the skills, education, and perspectives that nurses will need to prosper in the coming era, they suggest that nurses will need to demonstrate transcultural competence to employers and consumers (Alexander et al, 1998; Reeves and Fogg, 2006). However, some nurses still ask, “What’s culture got to do with it?” After all, according to many Americans, healthcare is healthcare and we’ve got the best in the world. This ethnocentric attitude interferes with nurses’ recognition and appreciation of a broad view of culture and communication. Everyone is familiar with the meaning of communication, but what is culture?

Definition of culture, ethnicity, and ethnocentrism

Madeline Leininger defines culture as the learned and shared beliefs, values, and lifeways of a particular group that are generally transmitted intergenerationally and influence one’s thinking and actions. For three decades, Leininger has emphasized the need for nurses to become informed about other cultures’ healthcare beliefs and practices. Ethnicity also needs to be defined because some confuse its meaning with that of culture. According to Leininger, ethnicity refers to the social identity and origins of a social group due largely to language, religion, and national origin; for example, the Amish are an ethnic group. Sociologists and psychologists are more likely to use the term ethnicity. The term culture is used more frequently by anthropologists and transcultural nurses. Culture is a broader term because it refers to the holistic, patterned lifeways of a group rather than to selected ethnic features or origins (Leininger, 2002).

The term ethnocentrism was coined by William Graham Sumner, a social evolutionist and professor of political and social science at Yale University. He defined it as the universal tendency of people to believe that one’s own race or ethnic group is the most important and/or that some or all aspects of its culture are superior to those of other groups (Salter, 2002). Furthermore, ethnocentrism perpetuates the attitude that beliefs differing greatly from one’s own are strange, bizarre, or unenlightened, and therefore wrong (Purnell and Paulanka, 1998). Within this ideology, individuals will judge other groups in relation to their own particular ethnic group or culture, especially with concern to language, behavior, customs, and religion. These ethnic distinctions and subdivisions serve to define each ethnicity’s unique cultural identity.

Reasons why nurses need to be culturally informed

There are several compelling reasons why nurses need to be informed about culture. First, shifting demographics will call for dramatic changes in the U.S. healthcare industry. The proportion of white Americans will significantly decrease by the mid–twenty-first century to approximately 51% of the total population. The literature suggests that Hispanics and nonwhites have much different patterns of healthcare than do non-Hispanic whites, with disparities in healthcare access accounting for a large portion of differences in use. It is projected, however, that demand for healthcare services by minorities is increasing as percentages within the population increase. Moreover, between 2000 and 2020, the percentage of total patient care hours that providers spend with minority clients will increase from 31% to 40% (Health Resources and Services Administration, 2006). With the increase in nonwhite clients, it is imperative that healthcare professionals understand the importance of culture and its relationship to clients, their families, and the community (Zoucha, 2000).

Second, care is central to the concept of nursing. As technology becomes an increasingly important part of healthcare, the essence of human caring becomes the most valued aspect of nursing. The diversity of populations and the uniqueness of the caring phenomenon in these diverse practice settings provide the cultural basis of human caring (Brown, 2001).

Third, although the United States has always been a diverse society, this diversity has not always been recognized by healthcare providers, because they have long had the attitude that newcomers should adapt to “us.” We as a society are beginning to recognize that this is not desirable, and it will not work in a heterogeneous society. As our patients become increasingly diverse, it is imperative that nurses be capable not only of understanding but also of working with those diverse groups in a productive (health-producing) way (Chrisman, 1993).

Furthermore, there are serious concerns that, overall, nursing education does not adequately prepare nurses to work with diverse populations. The teaching of cultural competence to nursing students commonly emphasizes cultural beliefs, values, and practices, rather than issues of race, gender, class, or sexual orientation. Although this approach has been somewhat successful in increasing practitioners’ awareness of and sensitivity to cultural groups, it does not address other problems related to the nursing care of nondominant people. Culturally competent care cannot be provided unless underlying issues of discrimination are confronted (Abrums and Leppa, 2001). A study designed to uncover racial bias in nursing fundamentals textbooks found minimization of the effects of racism (Byrne, 2001). There is a concern about this educational omission because it limits students’ understanding of the implications of racism to those inherent in power dynamics, namely oppression and subordination. In addition to implications for patient care such as delivery and disparity, nursing curricula typically do not include content on racism, oppression, and group dynamics within the nursing profession. When such controversial topics are omitted or minimized, students do not fully comprehend nor do they have the information necessary to detect, understand, and, therefore, change circumstances reflecting lack of cultural awareness.

Fourth, this is an age of economic imperatives. Our healthcare system is evolving toward an integrated system combining hospital and community facilities as well as physical health and mental health services, Western and traditional medicine, primary and tertiary care, technology and clinical practice, and so on. As providers and systems strive to gain market share, competition for clients increases. Regional systems, alliances, mergers, and networks have become commonplace (Chin, 2000). The increasing diversity of the overall population forces healthcare plans and organizations to ask whether their employees reflect the communities they serve. If they do, their ability to deliver culturally competent care is enhanced. If they do not, then a chance to improve the care experience for a large portion of their members is being lost, and the organization is missing an opportunity to gain a competitive edge in the marketplace.

The provision of publicly financed healthcare services is now being delegated to the private sector. Issues of concern in the current healthcare environment include the marketing of health services and the cost-effectiveness of healthcare delivery. The potential for improved services lies in state managed-care contracts that can increase retention and access to care, expand recruitment, and increase the satisfaction of individuals seeking healthcare services. To reach these outcomes, managed care plans must incorporate culturally competent policies, structures, and practices to provide services for people from diverse ethnic, racial, cultural, and linguistic backgrounds.

Finally, the issues of working with older clients and with the chronically ill are of immense importance. Chrisman (1993) suggests that there is an increasing number of cases in which healthcare personnel need to work in community settings and with whole families and in which the outcomes are not (and cannot be) the standard medical outcome of cure. Clearly, the achievement of nursing outcomes requires working with (versus working on) humans in settings in which the nurse has less control. Consequently, the client and family have more control than does the nurse, and culture has a strong effect on how people act.

In summary, nurses need to know about culture because it influences both nurses’ and clients’ healthcare perceptions and behaviors. Also, with healthcare moving into the community, if nurses expect to be part of this movement, they must know about the culture of diverse clients and communities. To achieve this outcome, nurses must first recognize and then overcome certain attitudes basic to the American culture.

Barriers that interfere with nurses’ recognition and appreciation of diverse cultures

Despite notable progress in the overall health of Americans, there are continuing disparities in health status among African Americans, Hispanics, Native Americans, and Pacific Islanders, compared with the U.S. population as a whole. In addition, the healthcare system is becoming more challenged as the population becomes more ethnically diverse. Therefore, the future health of the U.S. population as a whole will be influenced substantially by improvements in the health of racial and ethnic minorities.

Cultural, ethnic, linguistic, and economic differences impact how individuals and groups access and use health, education, and social services. They can also present barriers to effective education and healthcare interventions. This is especially true when health educators or healthcare practitioners stereotype, misinterpret, make faulty assumptions, or otherwise mishandle their encounters with individuals and groups viewed as different in terms of their backgrounds and experiences. The demand for culturally competent healthcare in the United States is a direct result of the failure of the healthcare system to provide adequate care to all segments of the population.

Ethnocentrism interferes with the appreciation of diverse cultures and their accompanying beliefs and behaviors. On an international basis, the United States is considered to have the best healthcare system in the world. Western healthcare is traditionally seen as delivering topnotch high-technology care, yet being lacking because the care is reductionistic rather than holistic. Furthermore, the cost of the care is considered exorbitant relative to the outcome. Recognition of ethnocentrism is necessary to develop an appreciation of diverse cultures. One nurse put it this way:

I always thought of myself as open, flexible, and reasonably unprejudiced; but I am not always! When caring for my friend from Saudi Arabia, I realized that, without knowing, I made value judgments. These judgments reflected my inability to accept that others handle the same data differently; and their perspectives are as important as mine.

We as nurses recognize that we need to know about delivering care to diverse clients, but how do we go about it? First, nurses need to become familiar with their own healthcare beliefs and behaviors, because without self-awareness, nurses cannot recognize that their beliefs and behaviors are not necessarily common to all. Nurses’ lack of knowledge about their own culture can distort their perceptions of the beliefs and behaviors of clients from diverse cultures. It is logical that if a nurse does not understand the reasons for a client’s behavior, then it is impossible for the nurse to implement appropriate interventions.

Your answers to the following questions are both interesting and important. For example, consider your answer to the question, “What did your family do to stay healthy?” If your family advocated taking a daily vitamin to stay healthy, how do you view a client who daily drinks a small amount of his own urine to promote health? How do you perceive the Cuban mother who tells you her child is very beautiful and healthy because he is fat?

“What did your family believe caused illness?” If you grew up in the United States, your family probably thought that illness was caused by germs and bacteria. This way of thinking contrasts greatly with that of a client from Thailand, who might believe that her liver cancer is a punishment for a wrongdoing, or that of a Mexican American client, who might believe his illness is a result of witchcraft.

“How were specific illnesses treated?” Americans use medication—over-the-counter or physician prescribed—to treat illnesses. Asian clients often prefer meditation rather than medication to treat illness. They believe that illness is a sign that the body is out of balance, and meditation helps restore the body’s balance. How do you react when a client refuses morning care or breakfast because it is time to meditate?

“Who was responsible for deciding the appropriate treatment?” Because most Americans place a high value on individualism, the individual adult client usually decides what treatment he or she deems to be most appropriate. How do you perceive a female Hispanic client whose husband decides the preferred treatment for his wife? A nurse notes, “I had always thought the patient was the one making his decision but now I realize that many families, particularly Hispanic and Asian ones, think these are family affairs and not individual choices.”

“What healthcare practitioners outside of the family were used to treat illness?” Most American families eventually consult a medical doctor if illness persists and if home remedies do not work. How do you perceive a Mexican American client who prefers that a curandero (folk practitioner), not a physician, treat his liver disease?

It is interesting to compare the healthcare beliefs and behaviors of your family of origin with those of friends or other healthcare professionals. It often becomes apparent that your family’s ideas and behaviors are not necessarily common to all. This recognition is an important step in not only identifying but also appreciating the healthcare beliefs and behaviors of diverse cultures.

Because cultures are so diverse, no one can possibly know all the unique aspects of each client’s cultural healthcare beliefs and behaviors. To address this need, nurses and other healthcare professionals began to develop conceptual and theoretical frameworks for assessing, planning, and implementing culturally appropriate interventions. One of the most popular transcultural theoretical and conceptual frameworks is Leininger’s sunrise model, which was designed for nursing (Leininger, 1988). Tripp-Reimer and Afifi (1989) suggest two processes that nurses may use to communicate with clients from diverse cultures: cultural assessment and cultural negotiation. Cultural assessment refers to the appraisal of a client’s health beliefs and behaviors. The information is then used to determine appropriate nursing interventions. Cultural negotiation refers to the process of negotiating with the client regarding differences in the lay and professional belief systems concerning appropriate care.

Since Leininger’s “first” cultural theory in nursing (1988), several transcultural frameworks or models have been proposed for nurses, including cultural assessment frameworks and models (Giger and Davidhizar, 1999; Purnell, 2002). Research suggests that culturally competent care brings positive health outcomes (Leininger, 1988; Smith, 1998; Zoucha, 1998). With the movement of healthcare to more community-based settings, nursing researchers have expanded on these models in order to predict public health outcomes of culturally competent care. Bernal (1993) suggested a framework for community-based care including the concepts of cultural self-awareness and self-efficacy. Kim-Godwin and colleagues (2001) proposed the Culturally Competent Community Care (CCCC) model built around three constructs of cultural competence, the healthcare system, and health outcomes. Four interdependent dimensions of cultural competence are caring, cultural sensitivity, cultural knowledge, and cultural skills. In the healthcare environment calling for more evidenced-based practice, the CCCC model provides specific guidelines for community-based nurses in developing and assessing cultural competence and meeting the healthcare needs of a diverse patient population.

With increasing frequency, a cultural assessment has become a standard of care in the initial client assessment in both acute and primary care settings. Consider reviewing the assessment tool that you use when you admit a client. How is the client’s culture addressed in the tool? The model for cultural competence developed by Purnell and Paulanka (1998) provides you with ideas about other cultural components that may need to be addressed. The 12 domains essential for assessing the ethnocultural attributes of an individual, a family, or a group are as follows: overview, inhabited localities, and topography; communication; family roles and organization; workforce issues; biocultural ecology; high-risk health behaviors; nutrition; pregnancy and childbearing practices; death rituals; spirituality; healthcare practices; and healthcare practitioners. The domains are interconnected and have implications for health. Box 4-1 details the communication component of the model for cultural competence.

Box 4-1 Assessment of Characteristics of Clients’ Communication

Dominant language and dialects