transcultural nursing: overcoming obstacles to effective communication

AORN JOURNAL - ~ _ _ _ ~ MAY 1990, VOL. 51, NO 5

Transcultural Nursing OVERCOMING OBSTACLES TO EFFECTIVE COMMUNICATliON

Ruth Lahde Rothenburger, RN

ranscultural nursing has developed in the United States as increasing numbers of T patients come from other cultures. Partic-

ularly on the West Coast, microcosms of other countries have not been fully assimilated into the cultural melting pot. In San Francisco, for example, there are mini-countries such as Chinatown, little Vietnam, Japantown, and small enclaves of Central and South American natives. Some city blocks resemble Ireland, the Philippines, Italy, Portugal, and other European countries. Each of these areas has so many characteristics of the country itself that you feel as though you are actually in the native country. Physicians, grocers, and others transact business in their native language. Elders can live within such a community and never learn English.

It is becoming more common for perioperative nurses to encounter communication barriers that stem from different cultural backgrounds. When the cultural values of nurse and patient clash, the potential increases for inferior nursing care and, ultimately, for poor patient outcomes. When nurses who deal with transcultural patients develop a respect for those patients’ cultural beliefs, as well as a strong insight into their own attitudes and values as health care providers, the effectiveness of nursing intervention is amplified.

Nurses often are unaware of the dynamics behind blocks in communication and transcultural nursing in general. In a recent informal survey, West Coast perioperative nurses were asked: what is transcultural nursing? Some of the varied responses follow.

Transcultural nursing is nursing between

two cultures. Traveling would entail transcultural nursing. There is no application here-only in the sense that people from here go to Guam and South America to do volunteer work.

I t involves nurses who come from one culture and go to mother to practice nursing. It is a sharing of ideas and ways of doing things.

It’s about caring forpeople ofmany different cultures, bur you do not have to . . . go from here to there.

Ruth Lahde Rothenburger, RN, BA, is the principal of Portojino Nursing Associates, Foster CiQ, Calij and staff nurse at the University of California, Sun Francisco, Operating Rooms. She earned her ussociate degree in nursing from Fayetteville (NC) Technical Institute, and her bachelor of arts degree in Spanish from Seattle Universio.

1349

AORN JOURNAL MAY 1990, VOL. 51, NO 5

Maxwell Ibsen, MD, caring for an Ecuadorian baby.

It is the adapting of two cultures, so that they are agreeable, so that you give a level of care that you can live with and that they are happy with.

All of the respondents were OR nurses with extensive experience in dealing with patients and colleagues from multiple ethnic origins. It is evident from this small sampling that many nurses are unaware of the importance of transcultural nursing in daily nursing practice regardless of the setting.

I have defined transcultural nursing as the systematic comparative study of values, beliefs, and patterns of caring behaviors in nursing practice, as applied to patient care assessments and interventions, intracollegial relationships, and attitudes of the care giver.

In this country, transcultural nursing is receiving more attention from nurses than in the past. This is partly because of the large influx of immigrants, the pride they have in their culture, and their

determination to preserve that culture. Although there always will be the Ugly American stereotype, we are getting to know our international neighbors and starting to accept what seems strange to us. As a result, people from the United States are slowly evolving into a people of greater sensitivity and awareness.

Nurses are beginning to recognize transcultural differences. In 1980, Madeleine Leininger, RN, PhD, founded the Transcultural Nursing Society, which focuses on research, workshops, and networking. Her work has led to the recognition of transcultural nursing as a vital area of study and practice in the United States and overseas. Universities in San Francisco, Salt Lake City, Miami, Detroit, and Alberta, Canada, now offer graduate programs in transcultural nursing.

With increased opportunities to learn the lessons of transcultural nursing, nurses can amplify their practices. The study of specific cultural differences can provide a resource for understanding patient behaviors that relate to ethnicity. An examination

1350

AORN J O U R N A L MAY 1990, VOL. 51, NO 5

of care givers’ responses adds further insight. This is an important area in which nurses have the power to apply information and create change.

Getting to Know Someone Different

ifferent cultures exist side by side in the world, and each has its own pace and D guidelines. They are completely separate

from one another in many ways. In most parts of the United States, culture is characterized by adherence to the clock and deadlines. There are high expectations and demands of society, and considerable inflexibility. Despite convictions about legitimate injustices in the United States, we still have it far better than most of the world. In the United States, there are opportunities for and access to change. This is in strong contrast to centuries-old philosophies that argue that whatever is supposed to happen will happen, and that acceptance is the universal solution to most problems. In many other places, change is not a right. This is vividly apparent only to people who experience life in a Third World culture.

The process. When two people from diverse cultures meet without any understanding of each other, I believe they go through seven stages of adjustment. These stages are

fear, dislike, distrust, acceptance, respect, trust, and like.

On first encounter, these two strangers may react immediately with fear. With no input other than the foreignness of the other person, each perceives the other as a threat to his or her own safety or way of doing things. This fear slowly dissipates. When consistencies in the stranger’s behavior begin to appear, the feeling of outright threat gives way to dislike. It is a human characteristic to dislike things that make us uncomfortable. As dislike slowly fades, simple distrust emerges as the stronger feeling.

As time passes in this relationship and more

information becomes available, acceptance begins to set in. This is especially true if these people have to get along, such as in a work situation or for survival. If there is enough time, and if these individuals have open minds, they eventually begin to recognize qualities in one another, and respect follows. Finally, when enough shared events have occurred, they begin to trust one another’s behaviors. They see that they have more basic things in common than not, and the result may be that they like one another.

Many motion pictures have been made about these stages of adjustment in war. One vivid example is Hell in the Pacific, a John Boorman film made in 1968. Lee Marvin and Toshiro Mifune portray two World War I1 soldiers, one American and one Japanese, who are marooned on an island. Neither speaks the other’s language. Because of the confines of the island, the threat of a war that might encroach upon them again at any time, and their common need for the food, shelter, and weapons available on the island, the protagonists are forced to work through their differences in a short time. If they do not, neither one will survive. The screenplay gives an excellent illustration of the characters going through the stages of adjustment. They work through prejudice and instinct, resist change, and finally work together and develop a friendship.

In the nursing profession, the clear-cut parameters of time and motivation usually are not as apparent as in a wartime situation. Survival usually is not an issue. Because pressure to rapidly grow and change is not a factor, two people can cautiously move through the process and not get past the first three steps. This can happen between colleagues, particularly in a larger hospital where they might not work together again for several weeks. It can happen between a US nurse and a patient from any of a multitude of cultures. It can occur in any combination where two people are not forced to grow through changes.

One vivid way of learning this is being the minority patient, dealing with medical personnel in a foreign country in which you have fallen ill. A useful exercise is to picture yourself in the following scenario.

You are traveling alone in the mountains of

1352


Author with Ecuadorian mother and child one year after successful cleft palate repair on child.

some distant country, for our purposes called Swangihili. You have sudden acute pain in the substernal area. You feel faint. Because you are at high altitude in a Third World country with suboptimal sanitation, you attribute the pain to food and altitude problems. You continue on, but several days later, in a lower elevation and on an improved diet, you still have the pain. In addition, there is gastrointestinal bleeding, you can hardly open your eyes or stand up, and you may have a fever. There are no English-speaking people

available. You speak no Swangihilian. As things begin to progress rapidly, you are aware of being rushed off in a car. Suddenly, you are horizontal looking up at old green tiles and hospital lights, smelling unfamiliar smells.

There are people poking and prodding. Are they taking vital signs? Is somebody ordering laboratory studies? Why don’t they just ask me what’s wrong, you wonder. Someone with black, horn-rimmed glasses leans over you and asks you a question. You are unable to read his lips, and

d) 1354

MAY 1990, VOL. 51, NO 5 AORN JOURNAL

Body language is an excellent tool when spoken language

is a barrier.

you hear nothing familiar. Thoughts rattle through your mind my chest hurts; I can barely breathe; I am bleeding; and they do not seem to be interested in understanding. In frustration that you are not responding appropriately, the man with black horn-rims shouts a question, perhaps thinking that you are deaf instead of merely stupid. Finally, he throws up his hands, mumbles something to an associate, and suddenly someone starts an intravenous line in your arm. She is giggling and will not make eye contact with you. Another person removes the sheet guarding the last vestiges of your privacy and begins to scrub your abdomen with what smells like antiseptic. What are they doing, you wonder. You feel out of control and deeply scared.

In this scenario, the medical personnel are stuck between dislike and distrust. There is no compelling need for them to grow toward acceptance because they will take care of you, and you will be out of their lives soon.

In US hospitals, we often encounter patients who do not communicate in our language. Excessively compliant or combative behavior are mechanisms patients may employ in a frustrating situation with no communication in which they may fear for survival. The nurse can deal with this patient successfully with nonconventional means. Body language is an excellent tool when spoken language is a barrier. The nurse can use his or her hands and tone of voice to effectively convey inquiries about pain and give reassurances about safety.

There is pressure on US nurses to expedite room turnover, meet complicated team needs in minutes, and save the organization money. Even though nurses are trained to use all of their senses to make assessments, they can fall into a routine in which they do not take time to recognize and sift through all the variables a patient can present. At that point nurses get stuck in the stages of adjustment, and the process of getting to know

someone different is impeded.

Blocks to Communication

everal factors block communication and complicate transcultural nursing. These S include the stereotype of Western medicine,

language barriers, expected roles of care givers, and ethnic beliefs.

Stereotype of Western metdicine. One of the biggest blocks to communication between cultures is the misconception that Western medicine is omniscient and omnipotent. ‘The myth is that Western medicine has the answer to everything or is in the process of developing it and that there are no alternative ways of healing.

For example, my friend has two Ecuadorian exchange students in her home. When they begin to get colds, she finds them cutting up lemons into small pieces and putting them in their noses. One of the students put a cabbage leaf on a bruised hand. The bruise disappeared. For the most part, the attitude in the United Sta.tes is that if you can not find a scientific basis for this type of occurrence, it is shelved as a diubious old wives’ tale.

Most nurses are educated to believe that the science of Western medicine is the answer to all of humankind’s needs. Miracles bolstering this belief abound. A heart, which some cultures argue is where the soul resides, can be transplanted into another person’s chest. Three months later, the person who was almost dead is; back playing the piano at the local pizza parlor. P,atients are brought back from the brink of death. We pound on their chests, administer medications and therapy in the textbook manner, and often succeed.

Beyond our understanding are people who do not militantly fall in with our beliefs in this system. There are consumers who do not see Western medicine as the be-all and end-arll. There are those who drift away from follow-up attendance at a

1357


In many Far Eastern cultures, it is inappropriate for a woman to discuss ‘female matters’

with a male stranger.

clinic without apparent reason. There are those who hear logical and rational instructions and still are noncompliant.

What is this divergence from all that appears to be rational? In many cross-cultural exchanges, it is not the absence or inadequate delivery of information that results in lack of confidence in Western medicine. It is that the information is delivered with the attitude that there are no alternatives and that the patient’s ingrained concepts of health care are incorrect. The individual’s concepts of health and illness are developed at a prejudicial level; they are ingrained and not easily changed. They are expressed in areas such as perception of pain, susceptibility to disease, severity of a condition, and effectiveness of available remedies. The patient’s responses and beliefs are strongly colored by his or her background. Our system of medical care may not fit into the patient’s.

Language barriers and patterns of communication. Another block to transcultural communication is increased stress brought about by language barriers. The patient is nearly naked in the operating room, wearing only a flimsy hospital gown. He or she may be without teeth or glasses, which normally help define him or her as an individual. With no common language, there is no way for the patient to communicate with strangely dressed, rushed individuals who are “taking care” of him or her.

I encountered a situation in which a young Vietnamese patient was scheduled for hysterec- tomy because of a tumor. My initial interview went well. She nodded, occasionally said an appropriate “yes,” and showered me with thanks when I brought her a warm blanket. I went into greater detail to see if she understood the implications of sterilization. Suddenly, I realized that all of her responses were positive regardless of the question, and that her understanding was minimal.

I summoned a business office employee who was fluent in Vietnamese. She performed the check-in interview and assessment with greater accuracy. The patient’s facial expression, one of wide-eyed compliance, changed very little. I did not feel successful in alleviating her fears through verbal communication. Body language was effective in conveying empathy.

Subsequently, the translator told me that this was a typical response of the Indo-Chinese culture to Western medicine. The patient probably felt that if she “rocked the boat” in any way, by responding negatively or expressing true feelings, the quality of her care would be affected adversely. She may have felt that we were in a position to punish her for being noncompliant. She probably felt powerless and without rights.

The stress this woman already felt about her surgery was magnified and distorted by the language barrier. I encouraged her to have input into her own care by providing choices about positioning and comfort measures. I introduced her to other surgical team members, which made her feel like part of the team and less the victim of it. All of these things were accomplished without verbal language.

Even with a translator, verbal exchanges may not be completely satisfactory. A translator may come from a different educational or social stratum than the patient. A well-educated or highly acculturated member of an ethnic group may be embarrassed or reluctant to report patients’ statements accurately if he or she thinks they reflect what would be regarded as ignorance or superstition.

There also may be cultural taboos about the situation being discussed. In many Far Eastern cultures, for example, it is inappropriate for a woman to discuss “female matters” with a male stranger. Much valuable information and insight can be lost by using the wrong translator. In many instances, it may be best to use a bilingual

1358


Shirley Rodriguez, RN, with 12-year-old Ecuadorian burn patient one year after successful scar revision surgery.

adolescent or adult relative to translate. Expected roles and responsibilities of care

givers and support systems. The expectations patients have of medical personnel can lead to another major barrier in communication. In Arab families, for example, patients’ beds are described as

. . . invariably surrounded by relatives and friends, The health care providers are amazed at the number of persons who are constantly in the way of the hospital routine and who seem to interfere with the kind of care the health care personnel prefer to give.

Relatives and close friends are expected to be present to provide emotional support, take care of special needs, such as special foods, herbal medicines, and massage, and monitor the medical treatment. When these familial roles are neither understood nor accepted by medical personnel, conflicts arise.

In older Japanese cultures, the physician is not even in charge. He or she is a “skilled and sympathetic technician” whose job is to help with the cure, not to manage it. The responsibility for the patient’s recovery remains with the family and the patient.

Ethnic beliefs and customs. Other blocks to communication are apparent in major ethnic groups. Filipino patients tend to have their families hovering.2 A sick child is lost without his or her mother; an ill grandparent always has someone keeping him or her company. Single adults have numerous visitors. They tend to attribute illness to God‘s will. They do not complain and frequently suffer in silence. A silent nod may be a defense. If a nurse gives instructions and the Filipino patient nods, it could be that he or she understands. It also could be that the instructions were inadequate but the patient wants to spare the nurse’s feelings.

In some Hispanic cultures, all family members must approve of a surgical procedure.3 It is vital to the patient’s recovery that the entire family be present, and this may create delays before surgery. The Hispanic patient is regarded as an innocent victim of external forces. Acceptance is the secret of life, and the patient prays for acceptance.

In her book Cultural Diversity in Health and Illness, Rachel Spector, RN, PhD, describes the relationship of hot and cold and the four humors, a theory that was brought to Mexico by Spanish priests, became fused into Aztec beliefs, and became the basis for much traditional thinking today.

The theory states that there are four body fluids or humors: (1) blood, hot and wet; (2) yellow bile, hot and dry; (3) phlegm, cold and wet; and (4) black bile, cold and dry.4 When all four humors are balanced, the body is healthy. When any imbalance occurs, an illness is manifested. These concepts provide one way of determining the remedy for a particular illness. For example, if

1360


Some Native Americans believe that technical medicine is not part of man’s

harmonious balance with nature.

an illness is classified as hot, it is treated with a cold substance. A cold disease must be treated with a hot substance.

In some Black American cultures, a patient may be afraid of the loss of “self” or “soul” while under anesthesia. A prevalent religious belief is that God sends illness as a punishment for sin5

To many Soviet emigrants, hand-shaking and smiling signify frivolity and immaturity.6 The nurse who tries to put a new patient at ease by smiling and touching may be surprised when these things do not convey the warmth and confidence he or she intended.

Some Native American Indian tribes believe that man lives in a harmonious balance with nature and that technical medicine is not a part of this harmony.7 Body language is important. Native Americans can be very quiet and observant, preferring to listen rather than speak. They are seemingly unassuming. Accommodating behavior helps them fit into the balance of things. They do not write wills, and when a person dies, they save all parts of the body, even the umbilical cord, so that the body passes on in its entirety.

Native Americans may believe they have come to the hospital to die, even if they are not ill enough to die. In the phenomenon known as medical pluralism, the family may seek a physician for the “immediate” cause of illness and a native healer for the “ultimate” cause. The physician is the obvious choice to set and cast a fractured leg, but only a medicine man can determine why the patient was so out of harmony with the environment that he or she fell and broke the leg.

It must be noted that these traditions are, in many cases, either extremely general or extremely traditional. They do not describe every individual in that cultural group. Researchers believe that there may be greater discrepancies among people of different educational and class levels within an ethnic category than there are across ethnic

boundaries with people of similar social class and education who are familiar witih Western life.8

In the United States, many immigrants have been assimilated into the larger culture, where there is greater opportunity for education, change, and upward class mobility. Some of these characteristics may not be applicable. The modern Hispanic patient faced with an enthusiastic nurse who intently discusses the effect of the imbalance of hot and cold on his or her clinical condition may wonder if the nurse is microcephalic. It is important not to generalize.

Application to Practice

he lessons of transcultural nursing, applied to perioperative nursing practice on a daily T basis, will result in improved patient care,

better relationships with colleagues, and increased personal satisfaction. Several specific applications follow.

Develop the awareness that every person perceives things through several sets of variables. Some of these come from the care giver’s background; some come from the background of the person with whom interaction is taking place. The environment presents yet another set of variables. Ona: you realize that there are different ways of relating to you and the Western medical system, you open yourself to many possibilities for meeting patient needs, perhaps by incorporating elements of the patient’s own system. The first step in accomplishing this is to cultivate awareness as you interview your patient.

Learn to use all your senses. Notice when touch is not working and perhaps is even offending or intimidating your patient or colleague. Notice also when it might be appropriate and helpful. Listening cannot be used enough. Sometimes by being quiet and avoiding leading questions, you learn more than from the responses to direct

1361


questions. Does the patient look apprehensive? Is he or she glancing frequently at family members for validation or deferring to them for decision making? Is there an unusual degree of compliance? Is there flushing, diaphoresis, embarrass- ment, and avoidance of the subject? These may be clues to culturally derived behaviors that require a different kind of response.

You might select a more appropriate interpreter, or different interventions might be more effective. By listening, you show the patient that you are interested in him or her as an individual and that you respect him or her. You establish a basis for trust.

Learn to ask the right questions. You are never going to know all of the background details about every culture, and there is no way to anticipate all of the other variables that form attitudes. By asking the right questions, however, you can draw out important information about this individual’s way of thinking.

Specific group information is important because it increases awareness of the need to be open, and it may provide clues to specific behaviors. It should be a springboard from which our growing sensitivity to the differences takes over. By using it in this way, we realize that we are equals, and that someone else’s concept of truth is just as valid as ours even if it is I80 degrees apart in meaning and origin. Mutual respect can grow, and our patients will get the best results possible from medical and nursing interventions.

Conclusion

ultural differences affect every aspect of patient-nursing interaction. The tendency C in Western medicine is to create routines

and rituals, with the intent of achieving safety through standardization. Unfortunately, a by- product of this practice is disregard for cultural variations that seem bothersome or irrelevant, rather than appreciation for greater insight and resources for creative nursing intervention.

More important than examining larger cultural groups and their characteristic traditional responses to health care is examining our own attitudes toward other ethnic groups. Basically,

all people have the same needs for self-esteem, validation, and love of family. Once we can assimilate this knowledge, much of the fear of the unfamiliar vanishes. Progress can then begin through the stages of adjustment, and the quality of our perceptions and interactions changes as

0 though from black and white to color.

Notes 1. R E Spector, Cultural Diversity in Health and

Illness, second ed (East Norwalk, Conn: Appleton- Century-Crofts, 1985) 16 1 - 162.

2. I D Wood, The Need for Transcultural Nursing Awareness, (undergraduate paper) College of San Mateo, Calif, 1985); Rev A L Galloway, Jr, “Diverse cultures in the OR,” AORN Jou,ral 27 (June 1978) 1296-1301; L J Davitz, Y Sameshima, J Davitz, “Suffering as viewed in six different cultures,” American Journal of Nursing 76 (August 1976) 1296-1297; J Glittenberg, “Cultural values conlionting OR nurses,” AORN Journal27 (June 1978) 1391-1295.

3. Ibid. 4. Spector, Cultural Diversity in Health and Illness,

5. Wood, The Need for Transcultural Nursing Awareness.

6. M E Wheat et al, “Aspectci of medical care of Soviet Jewish emigres,” Cultural Diversity in Health and Illness, second ed (East Norw,alk, Conn: Appleton- Century-Crofts, 1985) 98.

7. M M Clark, “Cultural context of medical practice,” Western Journal of Medicine 139 (December 1983) 4.

161- 162.

8. Zbid, 2.

Suggested reading Leininger, M. Transcultural Nursing: Concepts,

Theories, and Practices. New York City: John Wiley & Sons, Inc, 1978.

Miller, S H; Mason, E D, eds. Contemporay Minority Leaders in Nursing. Kansas City, Mo: American Nurses’ Association, 1983.

1363

transcultural nursing: overcoming obstacles to effective communication

Documents