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3. THE CULTURALLY COMPETENT NURSE: COMMUNICATION SKILLS

With any theory the theorist formulates assumptions to guide the research as a basis for the theory and draws upon the theorist's conceptual and philosophical perspectives. The theoretical assumptive premises of the theory of Culture Care Diversity and Universality Theory areas follows:

The importance of self-knowledge is essential to working effectively across cultures. Unconscious feelings and attitudes become activated in interracial, as well as, culturally diverse situations and relationships. Nurses not only bring academic knowledge and past experiences to bear in their relationship with the culturally diverse client, they also bring themselves. How this self interacts within the nursing situation will determine how successful the encounter will be. Awareness of self on an honest level involves recognizing one's own values and assumptions about people and life, and emotional reactions to culturally diverse clients. This knowledge is essential towards training culturally competent nurses. Awareness of self as a cultural being is most important in transcultural nursing. Nurses need to "know thyself before they can start the process of overcoming the tendency to look and act toward culturally diverse patients on the basis of their own cultural framework and imperatives. Nurses need to understand themselves as cultural beings very much like the culturally diverse patient in their care.

When attempting to understand the dynamics of transcultural care it would be well to consider the nurses own culture to determine similarities and differences across cultures.

Dimension I

The first level of dimensions of one's personal identity would include; personal history (including family of origin and early childhood experiences), age, culture, ethnicity. gender, language, physical disability, race, sexual orientation, social class.

Dimension II

The second level dimensions are; income, educational background, geographical location, marital status, religion, work experience, citizenship status, military experience, hobbies/recreational interests.

Dimension III

The third level includes the historical and political elements that influence personal identity. For example, Welfare Reform or an on-going struggle with another country that leads to war (as with Iraq during the Gulf War and the negative reaction of many Americans towards Arabic populations during that point in history).

A health and illness questionnaire can be used to facilitate this process starting with the nurse's family of origin and early childhood experiences. Below are questions that can help define our view of illness, and healthcare.

  1. Who makes the healthcare decisions in your family?
  2. When you are ill, who do you tell?
  3. What do you expect from the person(s) you tell?
  4. Think of the last illness you had: how did you know that you were ill? How would you describe the symptoms?
  5. In your opinion, what caused the illness? In your opinion, what made you well again?

Upon evaluation of responses given to the questions listed above, one may discover that persons coming from Western society and health-care system will usually reflect an individualistic perspective whereas persons diverse cultures may view their illness in relation to all other members of both their nuclear and extended family. Social explanation of the nature and cause of disease is often very different than that offered by medical textbooks and nurses need to continue to explore cultural differences throughout their career.

Below are personal history questions that can lead to cultural self-awareness:

  1. What messages did I get growing up from my parents about my own culture?
  2. What group of persons in our community faced discrimination and prejudice by the majority? Include religious, socio-economic class, and those who might be excluded for reasons other than race and ethnicity.
  3. What were the views of my family (including extended family members) concerning persons from diverse cultures?
  4. How do I feel when I am working with a culturally diverse client whose value system is the opposite of my own?
  5. What have I done to overcome uneasy feelings that I might have when working with culturally diverse clients?

These questions are simply stated, yet if answered honestly, can make us painfully aware of early childhood experiences that contribute to the way in which we communicate across cultures. Self-awareness is both a cognitive and emotional process. Through the process of self-examination, the nurse can achieve a sense of self and can become more aware of self-attributes that may create barriers to effective communication across cultures.

Problems can also arise when nurses attempt to function in their own value system while at the same time identify with another value system. This needs to be addressed in learning about diverse cultures. Through such knowledge, the nurse can develop the flexibility to allow an easy adaptation to fresh and different perspectives on die issues of values. Using Leininger's theory as a basis of training the culturally competent nurse, other areas that lead to the use of effective communication across cultures include:

  1. Knowledge of the role of language, speech patterns, and communication styles in culturally distinct communities.
  2. Knowledge of the ways that professional values may conflict with or accommodate the needs of culturally diverse patients.
  3. Knowledge of the power relationships in institutions that impact on clients across cultures.
  4. Knowledge of resources that can be utilized on behalf of the culturally diverse client.

In addition to becoming sensitive to cultural issues the following skills need to be developed in order to communicate effectively with culturally diverse patients.

  1. Explaining or presenting a concern from someone else's perspective.
    Chances are, the nurse already has this skill because of his or her role as a client advocate. This takes an ability to listen carefully at what is being said within the framework of the culturally diverse client's experience and relay the information to those who are able to meet his or her needs. The communications and counseling field refers to this skill as empathy (putting oneself in another's shoes). The art of being empathic takes practice since we are all inherently self-centered and tend to see things from our own worldview. Looking at the situation from the client's point of view can open communication on all levels. For example, an elderly Hmong male who did not speak English refused to go to the hospital for his emphysema until he could hardly breathe because he believed that when a person went to the hospital, they died. Many of his friends were elderly, and some of them did spend their last days in the hospital. It was left up to his granddaughter to go with him to the emergency room stay with him during the total procedure, explaining in great detail what technology was being used and what results the client could hope for (improved breathing). The nurse, who was willing to openly listen to the client in a non-judgmental manner, was able to work effectively with him and saw his anxiety and fear dissipating. By the time they were finished he was smiling. By putting herself in his place, the nurse was able to understand the client s fear, and empathize with his situation.
  2. Knowing how to reduce resistance and defensiveness.
    Ethnocentric statements such as "We do it this way here." can make culturally diverse patients and families defensive and mistrust the delivery of health care. But less obvious behaviors can also cause patients and families to resist care. For example, a direct approach is considered to be rude when speaking to many Asian and Hispanic clients. When we lack knowledge of the patient's culture, we may judge their behavior. It is important to learn the cultural variations in verbal and non-verbal communication patterns among clients. The transcultural nurse can start with the generalities inherent in cultural definitions, yet allow for individual differences.
    The first step is to recognize resistant or defensive behavior then take steps to address it. First, give the client a sense of psychological safety by providing a quiet space and spend time listening to his or her concerns. It would be helpful to use basic active listening skills that are referred to in the counseling field by the acronym SOLER and can readily be applied to nursing interactions with culturally diverse clients.
    S - Squarely facing the client gives the client a message that the nurse is available to work with the client.
    0 - Open posture (as well as an open mind) suggests to the client that the nurse is ready to listen without judgment to what is being said.
    L - Leaning forward allows the client to know that what is being said is important to the nurse and can underscore the listening and responding process.
    E - Eye contact that is comfortable for the client can relay the message that the nurse is interested in what is being said. R - Relaxed position is an indicator that the nurse is willing to take the time to truly listen to the client's concerns.
    The client responds to both the verbal and nonverbal messages being sent by the nurse. It is important that the messages are congruent and that the nurse's body cues match the words or the nurse will be perceived as non-caring and the message is likely to be ignored.
    One of the best indicators of resistance and defensiveness are body cues. For instance, Asians and Native Americans consider direct eye contact to be rude and invasive. The nurse needs to observe the client's level of comfort when attempting to converse in the same style as one would use with a client who is of the same cultural background as the nurse. It is also important to also listen to how the patient is expressing their concerns. The level of trust may be so low that the client will distance themselves from the conversation by acting aggressively when speaking their mind or speaking in a manner that is devoid of any affect. For example, an African American woman of low income who was treated poorly when she delivered her last baby, may show animosity towards the nurse and be less likely to cooperate when she has another child. It's important that this mother be treated with respect.
    When there is resistance, the nurse first needs to ask if their actions would warrant that reaction. If not it's important not to take the incident personally. Make an attempt to "win the patient over" with an understanding and respectful attitude. Reacting to resistance with resistance will only escalate the problem. As professionals, it is up to us to model acceptable behavior.
  3. Accepting mistakes in communication
    Mistakes are inevitable, especially when trying to communicate with the culturally diverse patient It is better to risk making a mistake than not communicating at all. When members of different cultures first try to communicate, they are tolerant and forgiving, as long as they respect each other. If in doubt, ask. Persons from diverse cultures are often willing to explain their cultural beliefs and values if given a psychologically safe space to share this information with the nurse. If a mistake is made, apologize. If the patient seems upset by something the nurse has said or done, ask what changes need to be made. If the nurse observes a ritual or activity that is culturally defined take the time to ask in a respectful manner what is the cultural significance. An example would be the burning of sage as a manner of healing for Native Americans. The client (and family) will often be pleased by the nurse's inquiry and willing to explain the significance of the ritual.

FACTORS INFLUENCING COMMUNICATION

  1. Physical health and emotional well-being.
    When a patient is in pain they are less able to communicate or listen to what is being said. In this case, it is important to get the pain under control before attempting to communicate. As a person becomes depressed over the state of their health, they are less able to process or comprehend what is being said. It is better to allow the person the opportunity to speak by letting them know you care enough to truly listen.
  2. The situation being discussed and its meaning.
    Words may impact the statement differently, depending on who is hearing the message. For instance, the word cancer may mean impending death to one person, while another may hear the prognosis with a hopeful outlook. An African American client who went for a breast biopsy was so agitated that she had to be subdued by a calm nurse who was willing to ask what was causing the client to overreact with such a high degree of anxiety. In speaking with the client, it was discovered that her mother had died of breast cancer many years ago when she was about the same age as the client. The nurses reassurance helped the client go through the procedure without the extreme level of distress first exhibited when entering the reception area. Taking time to listen to the client can be the first step towards forming a working relationship with him or her.
  3. Distractions to the communication process.
    Communicating with the patient needs to be timed when distractions are less likely to interfere with communication-If there are distractions, acknowledge them then continue the conversation with the same focus as before. Studies show that when one is truly listened to, they are less likely to exhibit attention getting behaviors. For example, an elderly female Alzheimer client in a nursing home continued to loudly repeat the same sentence over and over again. The nurse asked another client what he thought could be the matter. He responded, "I think that she wants attention." Upon taking the time to talk to the woman about her past the client calmed down and responded with more clarity than she had previously exhibited.
  4. Knowledge of the matter being discussed.
    Remember that patient is not familiar with the professional language learned in nursing school. They may have little knowledge of a recent diagnosis and will want a clear understandable explanation of the implications upon their life. For example, an African American client was hospitalized with congenital heart failure although she originally came to the emergency room because she was having a great deal of problems breathing. She was quite fearful and asked for an explanation of her diagnosis. The nurse responded with professional jargon that left her anxious and frustrated. A simple explanation would have alleviated her fears.
  5. Skill at communicating.
    Communicating takes practice. The nurse can consistently work on using active listening skills, but the patient may not be adept at communicating in a style that is comfortable for the nurse, especially if the patient is from a different culture or socio-economic background than the nurse. As a professional, it is up to the nurse to adjust for discrepancies in communication. Body cue observations are the key to reading whether the client is "in tune" with the nurse's verbal and non-verbal communication. Adjustments must be made accordingly in order to meet the client's needs.
  6. Attitudes toward the other person and toward the subject being discussed.
    We cannot hide our attitude towards others, especially culturally diverse patients. They have learned to read body language cues over the years as a means of protecting themselves from painful discrimination and prejudicial actions. It is important to put judgments aside in order to open our minds and our hearts to what the patient is trying to communicate to us. If an attempt is made to be open and honest, and the patient is still reluctant to cooperate, one might conclude that this is a result from past painful experiences with the health care system.
  7. Background, including cultural, social, and philosophical value.
    The nurses background is likely to be dramatically different from the culturally diverse patient. Understanding the background, including the ethnohistory of the cultural group of the patient will help foster trusting, open communication between nurse and patient. This is the area in which knowledge in cultural, social and philosophical values of the patient is essential to communicating effectively. The nurse working in a South Texas hospital, needs to do some reading, personal inquiry, and perhaps take some specialized training in Mexican American history and culture. This is just a beginning. A conversational Spanish course would also be helpful to open the gates of communication and trust between nurse and patient.
  8. The senses involved and their functional ability.
    When any of the senses are affected, communication may have to take a different form. Do not be afraid to make a mistake. The patient will respond favorably if they perceive that you care enough to make an attempt to communicate. Nurses need to tune their ears to accents and dialects. They need to become comfortable with using an interpreter for language barriers including working with persons who are deaf. Nurses need to address the patient, not the person who is interpreting. The same holds true when dealing with the mentally ill, physically disabled, developmentally delayed, or the elderly. It's important to respectfully address the client rather than the interpreter, attendant or guardian.
  9. Past experiences that relate to the current situation.
    This is where assessment is important. Below are some exploratory questions that could be asked during the initial assessment with a culturally diverse patient. The client's response to these simple questions can lead to understanding of how the culturally diverse client perceives their illness and what attempts have been made to heal before entering the health care system.

    A few questions that could be added to this base are the following: