Culture and Nursing

Introduction: The Concept of Culture
Culture is the way of life for a person, society or group of people. It embodies the soul of the community and the heart of a team; it is seen in the way its members express themselves, communicate, think, feel, and believe. It determines what they value and how they honor the principles that guide them. It is different for every society, as Hofstede (1980) showed—and yet there are universal elements to every culture that allow people from different backgrounds to understand one another and rise above their differences to find common ground. Culture shapes the way people, families and communities communicate, perceive the self, think about sexuality, express spirituality, manage stress, cope with less, and deal with death and grief. Some cultures are open and indulgent about individuals’ choices, spirituality, sexuality and how they choose to communicate themselves. Others are more restrained and promote a collectivist approach to community, putting the needs of the group before the desires of the individual. Nurses can use and understand culture by utilizing models like Leininger’s transcultural model of nursing, by adopting a patient-centered care strategy, or simply by developing their cultural competencies. In doing so, nurses can promote safe, effective, and quality personalized care for patients, their families, and for the communities they serve within the realm of nurses’ care. To promote cultural awareness among nurses, one of the best places to start is Hofstede’s research on cultural dimensions.
Literature Review
What is Culture?
Culture has been defined in terms of the values that it promotes, as Hofstede (1980) shows. Hofstede’s (2011) 6d model of cultural dimensions has helped to advance the discipline of cross-cultural awareness among nurses by identifying half a dozen different criteria for understanding and evaluating the psychology of individuals from different cultures. These criteria are: 1) power distance, 2) uncertainty avoidance, 3) individualism vs. collectivism, 4) masculinity vs. femininity, 5) long vs. short term orientation, and 6) indulgence vs. restraint (Hofstede, 2011). Hofstede’s model teaches what values to look for when interacting with people of other cultures and provides nurses with a framework for discerning these values. As Orr and Hauser (2008) note, “Hofstede’s seminal work has been the benchmark for cultural analysis for the last three decades” (p. 15). Hofstede showed that every culture has its own set of social values that can be broken up into those six categories.
Power distance refers to the relation of people or groups to one another in a person’s society. It determines the way people talk, communicate, and show respect (Hofstede Insights, 2019). For example, in very hierarchical societies, the power distance ranking is much higher than in societies where equality is considered an important ideal. A person from a country like Saudi Arabia will have a psychology that is more informed by a strong power distance ratio because of the culture in which he has grown up. The same goes for China. China has a high power distance score, meaning that in the Chinese culture people accept that power is distributed unequally: it is a hierarchically organized society with power concentrated in the hands of those at the top. In America the power distance score is much lower, with American society believing more in the equitable distribution of power (Hofstede Insights, 2019). American nurses will thus have different attitudes than Chinese nurses, and American nurses will communicate with more openness than nurses or patients in a culture that is more restrained.
Individualism vs. Collectivism is another dimension of culture and it refers to the extent to which the society has respect for the freedom of the individual or for the collective. America, for instance, has a high individualism score, while China, to use the example of the same nation again, has a high collectivism school (Hofstede Insights, 2019). In this way, the two nations’ cultures are very different on this particular value. American nurses will thus be more likely to respect the individual choices of patients and other people in terms of their sexual orientation, religious and political beliefs, and their ideas about death and dying. Indeed, this is the essence of person-centered care (Davidson, Tondora, Miller & O’Connell, 2015). Because of their strong cultural value of individualism, Americans tend to be tolerant and respectful of individual choices, whereas other cultures expect conformity from people and do not tolerate deviation from the norm.
In terms of masculinity, which is defined as working for the sake of achieving success, China and the U.S. have similar scores: both are devoted to working (Hofstede Insights, 2019). Neither has a high femininity score. In the model, femininity is defined as working for the enjoyment of the work—i.e., people do not work because they have to if they want to achieve success but rather because they want to as they enjoy it. The feminine dimension of culture focuses on doing things because it is pleasing.
Another dimension of culture is one’s tolerance for uncertainty. This means that some cultures are okay with ambiguity and do not mind if communication is unclear or if there is little understanding between people: they see each other as knowing their own mind and that is what matters (Hofstede Insights, 2019). If something needs to be communicated, it will be said. China has a low tolerance for uncertainty—lower at least than in the U.S. (Hofstede Insights, 2019). In the Chinese culture, the preference is to avoid uncertainty, but Americans are a little more comfortable with ambiguity if it arises. For nurses, this is a dimension of culture that will impact how comfortable patients, families and communities are with knowing (or not knowing) about health related issues, but increasing health literacy depends on communicating well and eradicating ambiguity, which can be an obstacle for many nurses (Noel et al., 2019).
The short- vs. long-term orientation dimension of culture is another aspect to consider. The Chinese have a very high long-term orientation score (Hofstede Insights, 2019). This means they focus on doing what is best for themselves in the long-term rather than in the short-term. Americans are a bit more short-sighted in that they tend to focus on the near-term, appreciating that events and factors can change over the long-term and that planning for the long-term can be too presumptuous. As for the dimension of indulgence vs. restraint, this refers to how tolerant a culture is. China has a low cultural score here and is seen as a very restrained society, unwilling to break conventions or to tolerate those who do (Hofstede Insights, 2019). It is rigid and formal and disciplined. The U.S. on the other hand is highly self-indulgent and allows people freedom to personalize, choose their own path, leave the beaten path if they prefer, and to be different if that is what they want to be.
Hambrick, Davison, Snell and Snow (1998) point out that in today’s globalized world, there are bound to be environments where there are multiple people from different social and cultural backgrounds—so it is important for nurses to understand these dimensions and to increase their understanding by developing their cultural competencies. Thus, the use of Hofstede’s model in today’s nursing environment can assist nurses in adopting a cultural approach to managing their environment. Some contend, however, that that Hofstede’s model is too simplistic and that many individuals are shaped by other factors outside of those of their cultural origins. Hambrick et al. (1998) argue for instance that while “individuals may have psychological characteristics that deviate from the central tendencies of their nationalities, we do not mean to imply that nationality imprinting is easily erased” (p. 184). Rather, cultural imprinting largely occurs without an individual even realizing it. Cultural imprinting on a person’s psychology does not even become discernible until one is engaging with people of another culture and experiencing what is known as culture-clash. This is where cultural norms and expectations of two or more different people or groups come into contact with one another and fail to mesh. In today’s global society it is important that the risk of culture clash be mitigated by developing cultural competencies within leaders of groups and nursing organizations.
Cultural Perceptions
With Hofstede’s model in mind, the way that people perceive the self, identify sexuality, express spirituality, manage stress and coping and respond to loss, death, and grief can be better understood. The environment, where cultural values are communicated, shapes an individual’s perception. These perceptions are formed by various determinants external to one’s self. Bandura (2018) notes that the three big determinants of perception are peers, groups and media: peers would be one’s family and friends; groups would refer to organizations such as churches or schools; and media would refer to anything from TV to music to Internet sites. All of these determinants will shape a person’s perception. Moreover, each of them can have their own culture. Sub-cultures within cultures exist (Oyserman, 2017). Thus, schools can have their own culture. Workplaces can have their own culture. Families can have their own culture, and churches can have their own culture. There is a subculture for music, for films, and so on. To be truly transcultural, nurses have to maintain a cultural knowledge of all these determinants (Leininger, 2008).
In doing so, nurses can better understand how individuals identify themselves and their sexuality, which is important because nurses have to show respect for the individual and his or her choices. Determinants that often influence perception of sexuality include religion, peers, media and other subcultures, and the more nurses are aware of these determinants, the more responsive they can be to a patient’s or family’s or community’s needs (Hogan, 1982). As Shell (2007) notes, many patients will be concerned about how treatment will impact their sexuality, so nurses must be ready and able to discuss this issue with them in a culturally-sensitive manner.
The same goes for managing stress and coping with grief or death and dying. Nurses who are culturally incompetent will not be a very good emotional support for patients and families in difficult times. McNamara, Woddell and Colvin (1995) point out that nurses have to perceive stress, coping and death not through their own cultural lens but rather through the cultural lens of the patients, families and communities they are serving. Nurses have to disappear in terms of what their culture tells them about these experiences and they have to put themselves in the shoes of the other, which, again, is the essence of person-centered care (Davidson et al., 2015). It is also the essence of transcultural care, wherein the nurse focuses on asking the right questions of a patient to better understand the patient’s cultural background and using knowledge of that culture to provide the patient with better care and support (Leininger, 2008).
Cultural Competence
In the field of nursing, developing cultural competencies is a recommended strategy by transcultural nursing theory. Noel et al. (2019) recommend cultural-specific interventions to help facilitate better communication between care provider and patient. Likewise, Leininger’s (2008) theory of culture of care is that the patient’s culture, values, beliefs and expectations with regard to care have to be considered by the nurse in order for quality care to be delivered. In other words, the nurse must be culturally competent. The nurse should be culturally sensitive, i.e., aware of issues and values, beliefs and expectations that a person will have as a result of his or her culture.
Every patient’s psychology will be informed or influenced to some extent by the person’s culture (Leininger, 2008). As nurses are tasked with providing quality care to all patients, it behooves them to know what the cultural inputs of a variety of nationalities is going to be so that they do make mistakes in assuming that a person who is of a particular ethnicity will have the same expectations as a person from a quite different one. The nurse should take time to consider whether one’s cultural psychology is likely to be more masculine or more feminine, whether it is likely to have a high uncertainty avoidance threshold or a low one (Hofstede, 2011). This will allow the nurse to determine the right way to approach the patient with empathy, information, care, treatment, questions, and support.
Communication
Communication is a big part of cultural competence. Therefore, it is crucial for nurses to possess communication skills and cultural competencies when dealing with any population (Leininger, 2008). Listening well is the first step to communicating well (Davidson et al., 2015). One should never appear distracted when a patient, family member or coworker is talking. They deserve the nurse’s full attention, and the nurse must be mindful to give it. The nurse should also refrain from saying one thing with her face and another thing with her body language, eyes, and hand gestures. They are all clues about what one is really thinking, and people can pick up on these clues easily (Davidson et al., 2015). Nurses should be calmly positioned, not fidgeting, listening with eyes attentive and connecting to the speaker’s, and pen in hand ready to take notes if necessary.
To maximize cultural care, the four elements of communication that nurses should be mindful of are: encoding, medium of transmission, decoding and feedback. Encoding is the process of inputting meaning into a message. The sender is the one who inputs the meaning into the message, and all communication begins with a sender (Burnett & Dollar, 1989). The medium of transmission is the tool used to convey that message (oral communication, written communication, video, text message, etc.). Decoding is the process of interpreting the message and distilling the essential information. Feedback is the process of returning a response to the sender (Bovee & Thill, 1992). Part of listening well is the process of giving feedback. Feedback lets the sender know that the message has been received and understood. The nurse should always give feedback to the let the sender see that the sender’s words have been received. The nurse can do this by repeating out loud what the sender has said or by asking for more information on a point. This shows the sender that receiver is listening and is interested in what is being said. This can be an effective way to show support during emotionally trying times, such as when patients are dealing with stress or grief (Davidson et al., 2015).
The methods for effectively communicating with others include always conveying a professional manner—i.e., having clean hair, nails and clothing; wearing professional attire, and avoiding the usage of slang or profanity when talking (Bassert, 2017). One should always be “honest and forthright in communications with coworkers and clients” (Bassert, 2017, p. 20). The nurse, therefore, should never make an attempt to fake listening if she is actually busy recording notes into a computer or preparing for the next patient. Time should be set aside simply to listen. A positive attitude should be maintained at all times, and tact and care should be shown when communicating both orally and in written exchanges. Sarcasm and cynicism should be avoided. Attention to others should always be shown, and communication should always be clear and exact and responses given in a prompt manner. People should never be kept waiting for long when a response is expected, and the more immediately one can respond the better(Bassert, 2017). Communications should always be respectful, courteous, pleasant, and positive when exchanged with patients and colleagues. Professionalism should be the rule and practice at all times, and one should never assume familiarity with either a colleague or a patient.
The importance of using and observing verbal and nonverbal communication is absolutely essential, as both are forms of communication that can convey meaning (Bassert, 2017). Thus, one should be mindful about body language, making eye contact, and using hand gestures; however, one should also consider that there will be cultural differences when it comes to using body language and making eye contact. For example, in some Asian cultures, eye contact is not a custom between bosses and lower level workers as it is considered a sign of disrespect (Bovee & Thill, 1992). One should thus develop a cultural competency with respect to communicating verbally and nonverbally. Tones of voice and body language can provide clues as to whether a person is annoyed, happy, upset, anxious, and so on. Understanding verbal and nonverbal expressions can facilitate the nurse’s communication. To clarify what a patient or coworker has said, it is best to repeat back to the sender the words that were sent or to paraphrase them and then ask for more information by saying something like, “Could you explain what you mean?” or “Tell me more about that, ” or something of that nature (Bassert, 2017).
Summary
The Hofstede model of cultural dimensions shows that different cultures around the world mold people, families and communities in different ways depending on how the society considers various concepts such as power, work, leisure, and planning. The model of cultural dimensions provides insight into how people of different cultures view power structures, gender roles, and the meaning of life (Hofstede, 1998). Nurses must be culturally competent in order to provide patients with the best care possible. Every culture differs in terms of beliefs, expectations, values and desires. Subcultures within cultures exist and should be understood by the nurse. The nurse must learn to communicate in a way that is culturally sensitive and culturally aware. Body language is just as important at sending messages as tone of voice, facial expression and words. Every culture also will have its own understanding of these forms of language. To promote safe, effective, personalized care for the person, for families, and for communities, nurses must develop cultural competencies by learning and applying Leininger’s transcultural theory, person-centered care approach, and Hofstede’s model of cultural dimensions.
References
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