Transcript Document

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
challenges in health-care praxis
 Different
illness aetiologies
 Individualistic versus collectivistic coping
styles
 Language and communication
 Interpreters and interpreting
 Autonomy
Different illness aetiologies
Examples of illness aetiologies:
 Being
in unbalance with nature
Body fluid
Characteristic
Black bile
Cold and dry
Mucus
Cold and whet
Blood
Hot and whet
Yellow bile
Hot and dry
Warm foods
All meets and fish
Carrots, aubergines, onion,
chilli peppers, yams
Apples, bananas, mango,
melon, olives
Most nuts, currants, raisins,
dates, figs
maize, peas, wheat
Butter, oil
Sugar, honey
Tea and coffee
Spices, except corriander
Cold foods
Cabbage, coliflower,
cucumber, potatoes,
pumpkin, lettuce, spinach
Citrus, peach, pear,
pineapple, plums, lychies,
watermelon, grapes
Oatmeal, yoghurt, milk
Vinegar
Egg whites
Yin = feminine
energy
Cold
Dark
Wet
Empty
Bitter
External
Passive
Yang= masculine
energy
Warm
Light
Full
Sweet
Internal
Active
Examples of illness aetiologies:
 Being
in unbalance with nature
 Sickness as punishment from God/the
gods
 The evil eye or the evil mouth
 Magic
 Being possessed by devils or evil spirits
 The 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
collectivistic 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
traits. Hofstede defines ‘individualism’ as pertaining
to societies “in which the ties between individuals
tend to be loose: everyone is expected to look after
himself or herself and his or her immediate family”
(1991, p. 51).
In contrast, in collectivist societies people tend to be
“integrated into strong, cohesive ingroups, which
throughout people’s lifetime continue to protect them
in exchange for unquestioning loyalty” (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 communication
Culture will influence relationships
A patient’s communication with the health care
personnel depends on:
• Personality, experience, social background, education etc.
• 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
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 pain
Communication of pain is
• Learned and culture specific
• Depends on the individual’s socialisation,
personality, and experiences
A person who is independent and self-relient
tends to value self-disicpline and complain less
about pain and discomfort than do otherdependent, collectivisticly oriented patients,
who tend to express pain more freely.
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 challenges
 The
patient and the health care worker do
not have a common language
 The patient is able to cope linguistically at
work/in school, but does not have the
vocabulary required to communicate
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 challenges
 The
patient and the health care worker do
not have a common language
 The patient is able to cope linguistically at
work/in school, but does not have the
vocabulary required to communicate
bodily symptoms, worries etc.
 The patient and the health care worker do to
a certain extent speak a common language,
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
communication
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
compared
Individualistic
Collectivistic
Definition
Separate from social context
Connected with social context
Obligation
Be unique.
Express one’s feelings and
thoughts.
Realise one’s inner self.
Further one’s personal
goals.
Be direct; ’speak one’s
mind’.
Belong, fit in.
Find one’s proper place.
Participate in fitting
activities/actions.
Further other’s goals.
Others’
roles
Self evaluation: others are
important for social
comparison; reflect values.
Self evaluation: one’s self is
defined by relationships to others
in spesific contexts.
Basis for
self esteem
Ability to suppress thoughts
and feelings, validation of
one’s inner self.
Ability to adapt, restrain oneself,
preserve social harmony in social
contexts.
Be indirect, ’read the other
person’s mind’.
”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. Interpreting
“Interpreting is not about the transference of
a set of words from one language to
another. Rather, it is about the conveyance
of oral communication within a particular
context and then translating things into
another language in a way that leaves an
identical understand and effect with the
listener” (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).
Important questions:
• 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?
‘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)