4. COMMUNICATION GUIDELINES: VERBAL AND NONVERBAL

Language or verbal communication include factors such as: vocabulary, grammatical structure, voice quality, intonation, rhythm, speed, pronunciation, and silence. We make distinctions between angry silence and a quiet moment of processing what has been said by observing body cues. Non verbal communication involves facial expression, eye movement, body posture, gestures, and the use of touch. A communication pattern that combines verbal and nonverbal elements are warmth and humor. While it is important to show interest and warmth in interacting with clients, too friendly or casual a manner may be interpreted as rude and intrusive. Many feelings are conveyed through the way we say something as well as what is being said. The nurse who is upset, or frustrated will convey these feelings through nonverbal signals. It would be best to acknowledge the feeling before attempting to converse with the patient. For example, relating the frustration to another nurse before entering the patient's room.

Language is basic to communication. Words are tools or symbols used to express ideas and feelings, or to identify or describe objects. Even though people may speak the same language, establishing communication is often difficult, because word meanings for both the sender and receiver may vary based on past experiences and learning. Cultural differences can often reflect grammatical structure and the use and meaning of words in phrases. For instance, "That's bad." or "She's bad." is a phrase often used by African Americans to say that an experience or person was better than could be expected.

Misreading the way something is said may occur by the voice quality of the sender, the receiver, or both. For example, the softer volume of Asian American or Native American speech may be interpreted by the nurse as shyness. On the other hand the nurse’s vocal quality may be viewed as boisterous if the volume is loud and there is a deliberate attempt to accent particular words. It would be a mistake to assume that because the client speaks with an accent or dialect, that he or she does not understand ft hat is being said. Nurses who respond by raising their voice could set up barriers to communication since the client could easily misinterpret this behavior as disrespectful.

Intonation is also an important aspect of communicating across cultures. There may be a latent or hidden meaning in what a person is saying, and intonation frequently provides the clue that is needed to interpret the message. For example, when the patient says they feel "fine," they may mean they genuinely do or the do not feel fine and don't want to discuss it. If said sarcastically, it may also mean they feel the opposite of fine. It's important to hear what is being said, how it is being said and what topics cause a change in conversation on the part of the client. An area of discomfort will often result in an attempt to avoid the topic.

Cultures also vary with the use of rhythm and speed in communication. Rhythm may differ among those who have English as a second language or within English speaking persons as well. Those with a dialect may use a rhythm that is not familiar to a well-educated nurse who has been imbedded in the majority culture's style of communication. It is imperative that the nurse trains her or his ear to the nuances, rhythm and speed in which the client is speaking. Rate speed can also provide a clue to an individual’s mood. A depressed person will tend to talk slowly and quietly, whereas an aggressive, dominating client will talk rapidly and loudly. Neither pattern can be interpreted without understanding the cultural perspective of the patient. For example, Native Americans often think before responding to a question and respond slowly with a quiet voice, whereas an African American from an urban area may sound aggressive and angry to the nurse who grew7 up in a small midwestem town. In both these cases, culture shock may lead to misinterpretation of the client's communication.

In regards to nonverbal communication, facial expression is commonly used as a guide to a person's feelings. In general, Americans from the majority culture use facial expression as a part of communicating expression although facial expression varies with culture. For example African-Americans and Spanish-speaking persons smile readily and use many facial expressions, along with gestures and words, to communicate feelings of happiness, pain, or displeasure while Northern European persons tend to use less facial expression and are generally less responsive, especially to strangers. Facial expression can also be used to convey an opposite meaning of the one that is felt, for example. Asians may conceal negative emotions with a smile.

Facial expression is highlighted by the use of eye contact which is a considered to be an important tool in transcultural nursing assessment. Nurses use eye contact for both observation and to initiate interaction. The dominant American culture values eye contact as symbolic of a positive self-concept, openness, interest in others attentiveness, and honesty. Lack of eye contact may be wrongfully interpreted as a sign of shyness, lack of interest, subordination, humility, guilt, harassment, low self-esteem rudeness, thoughtfulness, or dishonesty. It is essential mat the nurse does not judge the culturally diverse client. Knowledge of the client’s culture can help bridge the gap when communicating across cultures. For example, it would be helpful to understand culturally diverse variations in eye-contact such as: most African-American and Mexican-American patients are comfortable with eye-contact whereas Native Americans and Asians may interpret prolonged eye-contact as intrusive.

Body posture can also provide important messages about receptivity. In the United States, the closer a listener's overall posturing matches the posture of the speaker, the higher the likelihood of receptivity. Matching body movements to those of another person can communicate a sense of solidarity and can also communicate the attitude held towards both the persons sending and receiving the message. Knowledge of sociocultural heritage is essential in interpreting body language, since various body parts are used differently in different cultures. For example, African Americans and Mexican Americans may readily use gestures to convey their distress in the healthcare setting, whereas the Asian or Native American will tend to under represent their distress by using a stoic body response.

A number of interpersonal communications combine both verbal and nonverbal elements. The communication of warmth and caring is essential to healing. Warmth and caring are qualities or states that promote feelings of well-being. Statements that show respect, address the human need to be cared about, and promote self-acceptance will usually be interpreted positively and can increase motivation, morale, and cooperation. Verbal recognition or a statement of genuine concern can convey interest and facilitate a positive relationship between patient and family and the nurse.

Humor can also be used as a healing tool. As a healthy and constructive coping mechanism, humor can provide a powerful bond of shared pleasure between people, decrease anxiety and tension, build relationships, promote cohesiveness, elicit learning, provide motivation, and enable personal survival. Humor that is therapeutic does not ridicule nor use cynicism. Personality, culture, background, and levels of stress and pain may influence reactions to humor. Thoughtful consideration needs to be given when attempting to use humor with the client who is culturally different from the caregiver. The nurse must carefully assess the individual client and situation to decide if humor is appropriate. When used wisely, humor not only improves communication, but may also be a factor towards healing.

COMMUNICATING ACROSS CULTURES GUIDELINES

1. Assess personal beliefs of culturally diverse patients.
   Self awareness is the key towards understanding cultural bias. Set aside any values, biases, ideas, and attitudes that are judgmental and likely to interfere with the relationship between nurse and culturally diverse patient.
2. Assess communication variables from a cultural perspective.
   Determine the ethnic identity of the patient and assess cultural factors that may affect the nursing relationship with the patient. Transcultural nurses who have a background in cultural diversity and are willing to view their relationships with cross cultural clients as an opportunity, can gain a valuable source of learning through the experience.
3. Plan care based on communicated needs arid cultural background.
   Knowledge of the patient's cultural customs and beliefs is needed in order to evaluate the effectiveness of nursing actions and modify nursing care plans when necessary. As part of this process, the nurse can encourage the client to reveal cultural interpretation of health, illness, and health care.
4. Modify communication approaches to meet cultural needs.
   The transcultural nurse needs to be attentive to signs of fear, anxiety, and confusion in the patient and respond in a reassuring manner in keeping with the client's cultural orientation.
5. Understand that respect/or the client and communicated needs is contralto the therapeutic relationship.
   The nurse can use appropriate active listening techniques to learn how listening is communicated in the client's culture and adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture. It is important to validate the client's concerns and communicate respect by using active listening skills in an understanding, attentive and non-judgmental manner.
6. Communicate in a nonthreatening manner.
   The interview needs to be conducted in an unhurried manner, following social and cultural expectations of me diverse population that is being interviewed. A trusting relationship can be formed by listening carefully, allowing time for digression from the information requested, and giving the client full attention during the interview process.
7. Use validating techniques in communication.
   The nurse must be alert for feedback that the client is not understanding what is being communicated and not assume that the meaning of what is being said will not be distorted by the client. This is especially important when the client is from a different culture than the nurse.
8. Be considerate of reluctance to talk when the subject involves sexual matters.
   For some cultures such as; Spanish-speaking and Native American individuals tend to be hesitant when discussing sexual matters with members of the opposite sex. It would be a respectful consideration for the nurse to arrange for a same-sex nurse to interview culturally diverse clients when they appear to be reluctant about discussing sexual matters.
9. Adopt special approaches when the patient speaks a different language than the nurse.
   Special approaches may be used to enhance understanding such as; speaking slowly and distinctly using gestures, pictures, and play acting when necessary, and repeat messages in different ways until it is certain that the patient understands what is being said. Use a caring tone of voice and facial expression to help alleviate the patient's fears. Keep messages simple and avoid using medical terms and abbreviations that the patient may not understand.
10. Use interpreters to improve communication.
    The nurse can improve communication when using an interpreter by asking for translation of the message as well as the individual words being stated by the culturally diverse patient. It is best to use an objective interpreter who is familiar with medical terminology and procedures. If one is not available, the interpreter may either be a family member, friend, a person from the community or a representative from an agency who can act as an advocate for the patient. The interpreter who is able to translate not only the literal meaning of words but the nonverbal cues that accompany the messages are most likely to be effective communicators. Asking for feedback to confirm understanding is essential when attempting to ensure that accurate communication has been accomplished.