Textbook of Medical-Surgical Nursing 3e

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Unit 1 Contemporary concepts in nursing

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.

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