Intercultural Communication in Health Care Settings –

Problems and Challenges

Ingrid Hanssen RN, Dr.Polit.Sci.

”One’s culture gives an individual the beliefs and values that support a sense of identity and security, as well as providing a prescription for behaviours about how one is to conduct life and approach death” (Sherman 2001, p. 4).

Communicative problems and Communicative problems and challenges in health-care praxischallenges in health-care praxis

Different illness aetiologiesDifferent illness aetiologies Individualistic versus collectivistic coping Individualistic versus collectivistic coping

stylesstyles Language and communication Language and communication Interpreters and interpretingInterpreters and interpreting AutonomyAutonomy

Different illness aetiologiesDifferent illness aetiologies

Examples Examples of illness aetiologies:of illness aetiologies:

Being in unbalance with natureBeing in unbalance with nature

Body fluidBody fluid CharacteristicCharacteristic

Black bileBlack bile Cold and dryCold and dry

Mucus Mucus Cold and whetCold and whet

Blood Blood Hot and whetHot and whet

Yellow bileYellow bile Hot and dryHot and dry

Warm foodsWarm foods Cold foodsCold foods

All meets and fishAll meets and fish

Carrots, aubergines, onion, Carrots, aubergines, onion, chilli peppers, yamschilli peppers, yams

Apples, bananas, mango, Apples, bananas, mango, melon, olivesmelon, olives

Most nuts, currants, raisins, Most nuts, currants, raisins, dates, figsdates, figs

maize, peas, wheatmaize, peas, wheat

Butter, oilButter, oil

Sugar, honeySugar, honey

Tea and coffeeTea and coffee

Spices, except corrianderSpices, except corriander

Cabbage, coliflower, Cabbage, coliflower, cucumber, potatoes, cucumber, potatoes, pumpkin, lettuce, spinachpumpkin, lettuce, spinach

Citrus, peach, pear, Citrus, peach, pear, pineapple, plums, lychies, pineapple, plums, lychies, watermelon, grapeswatermelon, grapes

Oatmeal, yoghurt, milkOatmeal, yoghurt, milk

VinegarVinegar

Egg whitesEgg whites

Yin = feminine Yin = feminine energyenergy

Yang= masculine Yang= masculine energyenergy

ColdCold

DarkDark

WetWet

EmptyEmpty

BitterBitter

External External

PassivePassive

WarmWarm

LightLight

FullFull

SweetSweet

InternalInternal

ActiveActive

Examples Examples of illness aetiologies:of illness aetiologies:

Being in unbalance with natureBeing in unbalance with nature Sickness as punishment from God/the Sickness as punishment from God/the

godsgods

The evil eye or the evil mouthThe evil eye or the evil mouth MagicMagic Being possessed by devils or evil spiritsBeing possessed by devils or evil spirits The body having lost its soulThe body having lost its soul

It is not always enough that the health services offered are efficient. They also must be acceptable and meaningful to the recipient of care.

Individualistic versus Individualistic versus collectivistic coping stylescollectivistic coping styles

Individualistic societies focus among other things on ‘I’ consciousness, autonomy, independence, individual initiative, and right to privacy, while collectivistic societies tend to focus on ‘we’ consciousness, collective identity, emotional dependence, group solidarity, duties, obligations, and group

decision (Kim et al. 1994).

Western societies exhibit significant individualistic Western societies exhibit significant individualistic traits. Hofstede defines ‘individualism’ as pertaining traits. Hofstede defines ‘individualism’ as pertaining to societies “in which the ties between individuals to societies “in which the ties between individuals tend to be loose: everyone is expected to look after tend to be loose: everyone is expected to look after himself or herself and his or her immediate family” himself or herself and his or her immediate family” (1991, p. 51). (1991, p. 51).

In contrast, in collectivist societies people tend to be In contrast, in collectivist societies people tend to be “integrated into strong, cohesive ingroups, which “integrated into strong, cohesive ingroups, which throughout people’s lifetime continue to protect them throughout people’s lifetime continue to protect them in exchange for unquestioning loyalty” in exchange for unquestioning loyalty” (ibid: 51). (ibid: 51).

While the Western focus on independence tends to create an orientation towards self-care and a basically self-reliant, independent, and assertive coping style, the family-care perspective of collectivistic societies tends to lead to an other-reliant coping style, where patients turn to “others for help and advice. In doing so, the need for others’ help is not directly communicated; rather, it is understood and acted upon without being verbally articulated” (Meleis et al. 1983: 892).

”We Iranians, who value our family more than anything else and spend our entire lives within its warm, protective walls, know that from there comes our very being, our innermost and most meaningful feeling of existence. Through it we define who we are, to the world and to ourselves. As long as the family is intact, safe and complete we know that we are somebody instead of nobody” (Farmanian 1993, p. 134).

”We live in a culture where our dependence on others is played down and partly denied and camouflaged. People are expected to manage on their own as long as possible, and people are to a large degree responsible for their own health and for the circumstances under which they live. This is demanding regarding the individual’s ’self care’ and ’assisted self help’ (Moen 2002, s. 76)

Language and Language and communicationcommunication

Culture will influence relationshipsCulture will influence relationships

• The person’s thoughts about why he/she has become ill/handicapped and what treatment(s) is/are suitable and expected

• How the person perceives him/herself and the world, and his/ her role when ill and as family

• The person’s linguistic communication

A patient’s communication with the health care personnel depends on:

• Personality, experience, social background, education etc.

When it comes to communication of symptoms, it is important to realise that:

• All symptoms, perhaps except pain, are learned

• How symptoms are communicated is among other things dependent on:

One’s belief concerning the causes of symptoms/health problems

How serious one believes the symptoms to be

How one has learned to communicate symptoms

Communication of painCommunication of pain

A person who is independent and self-relient A person who is independent and self-relient tends to value self-disicpline and complain less tends to value self-disicpline and complain less about pain and discomfort than do other-about pain and discomfort than do other-dependent, collectivisticly oriented patients, dependent, collectivisticly oriented patients, who tend to express pain more freely.who tend to express pain more freely.

Communication of pain isCommunication of pain is• Learned and culture specificLearned and culture specific• Depends on the individual’s socialisation,Depends on the individual’s socialisation, personality, and experiencespersonality, and experiences

My nurse respondents claim that non-Western patients have ”a totally different tolerance of pain” in the sense that ”some [people] express their pain more loudly” and ”that they have … a very expansive way – the entire bodily expression and that kind of thing.”

Bowler (1993: 167) found in her study of British midwives’ view of Asian women in labour, that

”noise during labour and low pain thresholds were mentioned in interviews by all the midwives who worked in the labour ward. In response to a question about whether there were different sorts of patients who needed different sorts of treatment a typical response … was: Well, these Asian women … have very low pain thresholds. It can make it very difficult to care for them”.

Linguistic challengesLinguistic challenges

The patient and the health care worker do The patient and the health care worker do not have a common languagenot have a common language

The patient is able to cope linguistically at The patient is able to cope linguistically at work/in school, but does not have the work/in school, but does not have the vocabulary required to communicate vocabulary required to communicate bodily symptoms, worries etc.bodily symptoms, worries etc.

”They do not understand what we really try to express” (Nurse P).

”Sometimes I feel that one is butting one’s head against a brick wall … that

they do not understand what I am saying” (Nurse C).

“When they are to be ‘nil by mouth’ before having blood sugar drawn, it is very clear to me that it is from midnight, but it is not clear to them, for they often fast from sunup, and that makes it … 6 a.m. And then it happens that the blood sugar [results] turn out wrong because they have been drinking grape juice” (Hanssen 2002, p. 153).

“When I go to see a Norwegian speaking physician and start telling about my illness, I find that I suddenly have two different illnesses: First the one I went to see the physician about, and then, the one I acquire while sitting there. I lose my self-confidence and I become frightened. I cannot explain in Norwegian what is the matter with me, and I am afraid that he will misunderstand me” (Utsi 1986, s. 73).

Linguistic challengesLinguistic challenges

The patient and the health care worker do The patient and the health care worker do not have a common languagenot have a common language

The patient is able to cope linguistically at The patient is able to cope linguistically at work/in school, but does not have the work/in school, but does not have the vocabulary required to communicate vocabulary required to communicate bodily symptoms, worries etc.bodily symptoms, worries etc.

The patient and the health care worker do to The patient and the health care worker do to a certain extent speak a common language, a certain extent speak a common language, but the connotation of their words may differ.but the connotation of their words may differ.

Communication difficulties also stem from the use of colloquial language. It is common for health care workers “to use culturally specific lay terms for symptoms and euphemisms for parts of the body that confuse the [patients]. Terms such as ‘waterworks’, ‘down there’, ‘the other end’, ‘tummy’, and ‘dizzy’ are difficult even for [patients] who are competent in English” (Bowler 1993, p. 162).

High context/low context High context/low context communicationcommunication

Collectivistic societies tend to develop a highly contextual, implicit form of communication, while individualistic societies tend to lean towards low context, explicit communication.

Traits to be Traits to be comparedcompared

IndividualisticIndividualistic CollectivisticCollectivistic

DefinitionDefinition Separate from social context Separate from social context Connected with social contextConnected with social context

ObligationObligation Be unique.Be unique.

Express one’s feelings and Express one’s feelings and thoughts. thoughts.

Realise one’s inner self.Realise one’s inner self.

Further one’s personal Further one’s personal goals.goals.

Be direct; ’speak one’s Be direct; ’speak one’s mind’.mind’.

Belong, fit in.Belong, fit in.

Find one’s proper place.Find one’s proper place.

Participate in fitting Participate in fitting activities/actions.activities/actions.

Further other’s goals.Further other’s goals.

Be indirect, ’read the other Be indirect, ’read the other person’s mind’.person’s mind’.

Others’ Others’ rolesroles

Self evaluation:Self evaluation: others are others are important for social important for social comparison; reflect values.comparison; reflect values.

Self evaluation:Self evaluation: one’s self is one’s self is defined by relationships to others defined by relationships to others in spesific contexts.in spesific contexts.

Basis for Basis for self esteem self esteem

Ability to suppress thoughts Ability to suppress thoughts and feelings, validation of and feelings, validation of one’s inner self.one’s inner self.

Ability to adapt, restrain oneself, Ability to adapt, restrain oneself, preserve social harmony in social preserve social harmony in social contexts.contexts.

”It is not only the patients, since they have such a lot of contact with everyone else in the family, one has to try to get

everyone to understand, and that makes it more problematic” (Nurse W).

Interpreters. InterpretingInterpreters. Interpreting

““Interpreting is not about the transference of Interpreting is not about the transference of a set of words from one language to a set of words from one language to another. Rather, it is about the another. Rather, it is about the conveyance of oral communication within conveyance of oral communication within a particular context and then translating a particular context and then translating things into another language in a way that things into another language in a way that leaves an identical understand and effect leaves an identical understand and effect with the listener” with the listener” (Nilsen 2000, p. 37).(Nilsen 2000, p. 37).

Failing to use a trained interpreter is an abuse of power, as through using an incompetent interpreter –or neglect to use an interpreter all together – one:

Exercise power by frustrating the patient’s

self-expression.

Exercise power by not bringing about linguistic

understanding.

Exercise power by not bringing about

understanding of the material content.

And, when using family interpreter(s), the interpreter(s) may

Exercise power through shielding measures.

”I am thinking about this Pakistani lady; she was quiet – very quiet. But, when we had this interpreter here, the words just welled forth. (…) Because she smiled and did not speak, it was easy for people to think that she had had a stroke, she is a little stupid, she is inattentive. But, when she had an interpreter, and the words just welled forth, I realised … And when I saw her facial expression while she talked, you saw … She was totally with it, intellectually adequate – it had no connection with that at all. (…) But I did not realise this until the interpreter came” (Nurse P).

• Has the patient linguistically understood the information given him/her?

• Is the information given within the patient’s understanding of cure and healing?

• Has the patient’s personal, cultural, or religious background prepare him/her for having to make autonomous choices?

Important questions:

‘Autonomy’ may be defined as

“a capacity for self-rule, a quality inherent in rational beings that enables them to make reasoned choices and actions based on a personal assessment of future possibilities evaluated in terms of their own value

system” (Pellegrino 1990, pp. 4-5).

“Nurse ethicists are fairly consistent in their view of the guiding moral principles, which are usually identified as respect, beneficence, and justice. The ethical principles of autonomy and veracity tend to be incorporated under respect” (Kelly 1990, p. 72).

”Nurses must be aware that cultural values must be evaluated in the cultural context they exist in. Prematurely to force one’s own actions and values on an individual from another culture, may cause a serious imbalance in that person. This imbalance may result in poor communication between the patient and the practitioner and, as a final consequence, to the patient turning away from the health personnel” (Thiederman 1986, p. 56).

”Multiculturalism as a value involves an understanding, appreciation and valuing of one’s own culture, and an informed respect and curiosity about the ethnic culture of others. It involves a valuing of other cultures, not in the sense of approving of all aspects of those cultures, but of attempting to see how a given culture can express values to its own members” (Blum 2002, p. 14-15)