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Unit 1
Contemporary concepts in nursing
may hold the balance of power within the client–nurse thera
peutic relationship provides for the beginning basis of power
sharing and empowerment of the client, which is a crucial step
towards culturally competent nursing care.
Cross-cultural communication
Establishing an environment of culturally congruent care
and respect begins with effective communication through
speech, body language, and other nonverbal cues. Person
to person interactions between nurse and patient as well as
those between members of a multicultural healthcare team are
dependent on the ability to understand and be understood.
In New Zealand two official languages are spoken—Ma¯ori
(variations in dialect from
iwi
[tribe] and in some cases
hapu
[subtribe] may exist) and English—with English predominat-
ing. However, at least 12 other identified languages are spoken
(Statistics New Zealand, 2006), including New Zealand sign
language. In Australia, there are 97 major language groups
(Australian Bureau of Statistics [ABS], 2011). Although
nurses cannot become fluent in all the languages they may
encounter, they can employ strategies to foster effective
cross-cultural communication. For example, an interpreter
can be employed. However, cultural issues, including the
interpreter’s social position relative to the patient, should be
considered in their selection. If the clinician, or the manager,
has a role in employing the interpreter (which is often not
the case), the interpreter’s voice quality, pronunciation, use
of silence, use of touch, and use of nonverbal communica-
tion should also be assessed as part of the selection process.
It is useful for clinicians to discover the culture/subculture
to which the patient belongs so they can alert interpreter
services when booking an interpreter. In addition to language
differences, communication may be further impaired by
the person’s state of health. The nurse should also assess
the patient’s and the family’s understanding of the nurse’s
intended communication. The following behaviours may
signal lack of effective communication:
•
Efforts to change the subject
. This action could indicate
that the patient does not understand the nurse and so is
attempting to talk about something familiar.
•
Absence of questions
. Paradoxically, a lack of questioning
often means that the listener has not grasped the message
and so has difficulty formulating questions.
•
Inappropriate laughter
. A self-conscious giggle may signal
poor comprehension and may be an attempt to disguise
embarrassment.
•
Nonverbal cues
. Although a blank expression may signal
poor understanding, among certain Asian peoples, for
example, it may reflect a desire to avoid overt expression
of emotion.
Similarly, avoidance of eye contact may indicate an expres-
sion of respect for the speaker; many Ma¯ori and Pacific peoples
adopt this behaviour.
Culturally appropriate communication may also influ-
ence what is communicated as well as how it is done. Nurses
educated in Australia or New Zealand may believe in the
ethical efficacy of their care if they attend to various patients’
rights. However, this view may not accord with the beliefs of
the patient and their family (Johnstone, 2009). For example,
in relation to valid consent (informed consent) and full
disclosure, a nurse may believe that patients have the right
to full disclosure about their disease and prognosis and may
feel that advocacy means working to provide that disclosure.
This stance may conflict with the cultural practice of family
members who believe that it is their responsibility to protect
and spare the patient from the knowledge of a terminal illness.
Similarly, patients may not want to know about their condi-
tion and may expect their family members to ‘take the burden’
of that knowledge and related decision making. The nurse
should not decide that the family or patient is ‘wrong’ or that
the patient must know all details of his or her illness. Similar
issues may arise when patients refuse pain medication or treat-
ment because of cultural beliefs regarding pain, belief in divine
intervention, or faith healing.
Determining the most appropriate and ethical approach to
patient care requires an exploration with the patient and their
family of the cultural aspects of these situations (Johnstone,
2009; Wilson, 2013). When the most appropriate approach
deviates from the requirements on the nurse about valid
consent (informed consent) and full disclosure, it is important
that the nurse document the outcomes and process of working
with the patient and their family. The nurse must promote
open dialogue and work with the patient, family, doctor, other
members of the multidisciplinary team and other healthcare
providers to reach the culturally appropriate practice or
strategy for the person.
Space and distance
The amount of space people need between themselves and
others to feel comfortable is a culturally determined phenom-
enon. Misunderstanding of a nurse’s motives may manifest in
patient withdrawal, noncompliance, or aggression; alterna-
tively, the nurse may react negatively to ‘unwanted’ behaviours
exhibited by the patient that could be an expression of part-
nership or gratitude. For example, one patient may perceive a
nurse sitting close as an expression of warmth and care, while
another may perceive it as a threatening invasion of personal
space. People from rural areas, including traditional Aboriginal
and Torres Strait Islander people, may, for example, require
more personal space between themselves and others, whereas
those from urban areas may need less space and feel comfort-
able standing close to others. If patients appear to position
themselves too close or too far away, according to the nurse’s
cultural conception of personal space, the nurse should
consider cultural preferences for personal space and distance.
Ideally, patients should be permitted to assume a position that
is comfortable for them.
Eye contact
Eye contact is also a culturally constructed behaviour. Although
most nurses have been taught to maintain eye contact when
speaking with patients, some people from certain cultural
backgrounds may interpret this behaviour differently. People
from certain cultures consider direct eye contact impolite or
aggressive and regard a lack of eye contact as a sign of respect.
They may avert their own eyes when talking with nurses and
others whom they perceive to be in positions of authority.
Consequently, some Ma¯ori and Pacific peoples may stare at the
floor during conversations, a cultural behaviour that conveys
respect and indicates that the listener is paying close attention
to the speaker. Being aware that making eye contact may be
a culturally specific practice will help the nurse to understand
a patient’s behaviour and so promote an atmosphere in which
the patient and the nurse can feel comfortable.
