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When working with persons of color, it would be well to consider the stage of cultural awareness of the client. The Racial/Cultural Identity Development Model was originally developed by Sue and Sue (1990), as a conceptual framework to aid counselors understand culturally different client's attitudes and behaviors. This model can also be used by healthcare providers to assess the level of acculturation in the healthcare setting and the implications of providing services at various levels of cultural identity.
The model defines five stages of development that oppressed people experience as they struggle to understand themselves in terms of their own culture, the dominant culture, and the oppressive relationship between the two cultures. The five stages of the Cultural/Racial Identity Model are: (1) conformity, (2) dissonance, (3) resistance and immersion, (4) introspection, and (5) integrative awareness. At each level of identity, four corresponding beliefs and attitudes can be seen as an integral part of the person's identity and are manifest in how he or she views the self, others of the same minority, others of the another minority, and majority individuals. Sue and Sue referred to diverse populations as minorities and this chapter will use the terminology presented in the conceptual framework developed by the authors.
At this stage, minority persons are distinguished by their preference for dominant cultural values over their own. This stage is characterized by a belief that the majority cultural, social, and institutional standards are superior. Members of the dominant group are admired, respected, and emulated. The majority culture represents the individual's frame of reference and attitude towards self is self-depreciating as comparisons are made over lifestyles, value systems, and cultural/physical characteristics. This stage is characterized by a belief that the majority cultural, social, institutional standards are superior. Members of the dominant group are admired, respected, and emulated.
Individuals in the conformity stage often internalize the majority of stereotypes about their group. Physical and cultural characteristics such as; skin color, shape of the eyes, or hair texture, and cultural characteristics such as; traditional modes of dress and appearance, and behavioral characteristics are viewed negatively. For example, the second generation Southeast Asian may be embarrassed by the fact that his or her parent used a Shaman in an attempt to recover from an illness. At this stage, there is a tendency to deny one's own culture and deny membership in his or her cultural group. They are likely to internalize the message that "I'm not like them, I'm Americanized".
Minority groups most similar to White cultural groups are viewed more favorably. Such distinctions often manifest themselves in debates as to which group is more oppressed and which group has done better than others. This tends to pit one group against the other by holding one group up as an example to be obtained. For example, as a group, Asians are considered to be the "model minority" valuing education and pooling their resources to take advantage of business opportunities. They have recently become targets of conflict and hostility because of their noteworthy achievements and a proliferation of small business ownership in Latino and African-American communities.
No mater how much an individual attempts to deny his or her own racial/cultural heritage, they will encounter information or experiences inconsistent with culturally held beliefs, attitudes, and values. Movement into the dissonance stage is a gradual process since the individual is in conflict between disparage pieces of information or experiences that challenge his or her self-concept. The individual has a growing sense of personal awareness that racism does exist and that one cannot escape one's cultural heritage.
Dominant-held views of minority strengths and weaknesses begin to be questioned, as new contradictory information is received. A growing sense of comradeship with other oppressed groups is shared. The person experiences a growing awareness that not all cultural values of the dominant group are beneficial to him or her. This is especially true if the minority person experiences personal discrimination which may result is some distrust of certain members of the dominant group. In this case, the diverse client may question the interaction of the majority culture practitioner, viewing a hurried encounter as a sign that the healthcare professional is reluctant to provide the same type of caring services that they would with someone from mainstream society.
During this stage, the culturally diverse individual tends to completely endorse minority-health views and to reject the dominant values of society and culture. The person seems dedicated to reacting against the majority social, cultural, and institutional standards as having no validity for him or her. The individual may also feel an inward sense of guilt and shame over previous rejection of their own cultural/racial values. On the other hand, anger may be directed outwardly in a strong way towards the oppression suffered at the hands of the majority population.
Movement into this stage seems to occur because resolution of the conflicts and confusions of the previous stage allows greater understanding of the social forces (racism and oppression) that have contributed to the victimization of his or her cultural group by members of the majority culture. At this point, individuals may start to question on a personal basis of why they previously felt shame over their cultural identity.
During this stage the minority individual is oriented toward self-discovery of one's own history and culture. There is an active seeking out of information and artifacts that enhance the person's sense of identity and worth. Cultural and racial characteristics that once elicited feelings of shame and disgust become symbols of pride and honor. The home health care nurse may encounter this client in an environment that is immersed with traditional artifacts and quite resistant towards forming a relationship that can lead to an accurate assessment and health care plan. Communication is essential towards reconciliation and if this fails, a same-culture health care professional may have to mediate the process.
There is a feeling of connectedness with other members of the racial and cultural group and strengthening of new identity begins to occur. Member of one's own group are admired, respected, and often viewed now as the new ideal. Cultural values of the minority group are accepted without question. An example of this is the case in which a Native American male had been removed from his reservation as a young child and placed in a boarding school as part of the assimilation project sanctioned by the United States. An angry, identity confused, young man, he fell into the trap of alcoholism. After various attempts to get sober, he sought out the guidance of a chemical dependency counselor on his reservation. He was admitted to a culture specific treatment center on the reservation that combined Western practice with Indian spirituality concepts. While in treatment, he was able to deal with his Indian identity issues and get culturally appropriate services that ensured a greater chance of successful treatment outcome.
Several factors work in unison to move the individual from the resistance and immersion stage into the introspection stage. First, the individual begins to discover that this level of intensity of negative feelings directed toward the dominant society is psychologically draining and does not permit one to devote crucial energies to understanding themselves or their own cultural group. Second, the minority individual experiences feelings of discontent and discomfort with group views that may be quite rigid in the resistance and immersion stage. Often, the individual is asked to submerge individual autonomy in favor of the group good. However, personal experiences of the individual may not support this group view.
Increasingly, the individual may see his or her own group taking positions that might be considered quite extreme. In addition, there is now increasing resentment over how one's group may attempt to influence the individual into making decisions that may be inconsistent with his or her values, beliefs, and outlook. There is now greater uneasiness with an ethnocentric position taken by members of their own racial/cultural group. Internal conflict is most likely to occur at his stage because the person begins to recognize that many elements in American culture are highly functional and desirable, yet there is confusion as to how to incorporate these elements without losing his or her racial or cultural identity.
Culturally diverse persons at this stage have developed an inner sense of security and can now own and appreciate unique aspects of their culture as well the majority culture. Conflicts and discomforts experienced in the previous stage become resolved, allowing greater individual control and flexibility. There is now the belief that there are acceptable and unacceptable aspects in all cultures, and that it is important for the person to examine and accept or reject those aspects of a culture that are not seen as desirable. At the integrative stage, there is a strong commitment and desire to eliminate all forms of oppression.
The culturally diverse individual begins to perceive his or her self as an autonomous individual who is unique (individual level of identity), a member of one's own racial-cultural group (group level of identity), a member of a larger society, and a member of the human race (universal level of identity). The individual begins to experience a strong sense of pride in his or her racial/cultural group without having to accept group values unequivocally. The individual may also experience an openness to the constructive elements of the dominant culture and develop selective trust and appreciation towards members of the dominant group who seek to eliminate oppression across cultures.
Sue and Sue (1990) warn that one of the major dangers that helping professionals can fall into is to use the stages of the Racial/Cultural Identity Development model as fixed entities. Most culturally different clients may evidence a dominant characteristic, but there are mixtures of the various stages as well. The second limitation is that the model involves interaction with an oppressive society that may not hold true across all cultures. For example, recent Asian immigrants tend to hold positive and favorable views of their own culture. Third, it is clear that all cultural identity development models assume that some cultural resolutions are healthier than others. For example the integrative awareness stage represents a higher form of functioning than the previous stages. Fourth, identity transformations can be seen as being triggered by social movements (such as the Black power movement) can have powerful effects on the culturally different individual's identity. Fifth, there is a strong need to understand and refine models taking into account issues of class, age, gender, educational level, etc. Last, there is a need to look more closely at the possible combinations between helping professionals and clients.
Keeping these limitations in mind, most models can be used as a framework towards understanding the client's response towards receiving care. Differences are not the problem. Being Asian American is not the problem. Being American Indian is not the problem. Being African-American is not the problem. Being Hispanic is not the problem. The problem lies in the perception of what differences mean in an individual's (as well as society's), perception of the attributes attached to being a minority group member. Persons who are willing to address cultural differences directly and view these differences as positive attributes will most likely meet and resolve the challenges that arise when working across cultures.
Oppressed groups have much in common; disenfranchisement, barriers to political and economic power, assignment to marginal status in the larger society, internalization of oppression, and daily struggles for dignity and pride. In order to work effectively with oppressed groups, the nurse needs to accept the fact that there is no single cause for discrimination, prejudice, racism, and classism, among any group.
To eliminate oppression, changes need to occur at the personal, social, political, and economic levels. On a personal and professional level, the process of change requires that we learn to think differently about ourselves and others and to make an attempt to see the world from the client's point of view. This process begins when the nurse becomes keenly aware of how his or her language, attitudes and behaviors affect clients, and works towards treating every client with respect regardless of race, gender, ethnicity, or socioeconomic status
Self-reflection is needed by the transcultural nurse in order to understand the dynamics of privilege, power, and prejudice on one's worldview. Below are some questions that may lead to greater understanding and empathy when working across cultures.
On a continuum of awareness, the helping professional can exhibit a variety of characteristics from dysfunctional to ideal. The first levels represent attitudes that would lead to inappropriate nursing care to diverse clients and the individual on level one or two needs to stay out of professional care service occupations. Level three and four represent attitudes that can be changed through education, only if the individual is open to revising their belief systems. The final stage is an ideal and a process to strive for through education and experience.
The five styles listed above is a result of early childhood experiences and can be evaluated through self-examination. It would be helpful to first summarize briefly those attitudes and feelings toward people of another race or ethnic group which began with the early childhood messages given by significant adults (and the community) regarding race, ethnicity, class, religion, or any perceived difference that would cause negative or positive descriptors. Honestly assess any stereotypical attitudes that are part of your world view and ask the following question. What do you like least about your feelings and attitudes toward others, what do you like most? What attitudes and behaviors would you like to change? How can you start the process?