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Section three: Supervision in a multicultural context
This section specifically looks at the challenge of providing appropriate and sensitive supervision in a cross-cultural context that is not only supervision between a supervisor/mentor and a practitioner in the general context of multiethnic Britain; where, for example, issues of cultural diversity amongst the client population would be expected to be relevant. More particularly this section addresses the challenge of maintaining open and professionally sensitive supervision in a situation where the supervisor/mentor and the practitioner have different ethnic identities. The supervisory relationship, in such cases, is always an exercise in transcultural communication.
See section six of the Module Transcultural Communication and Nursing Practice by Charles Husband and Edwin Hoffman for a description of transcultural communication
In this section the discussion draws heavily upon the considerable body of work that has been done on transcultural supervision in the area of counselling and clinical psychological practice. Whilst there are real differences between these professional domains of health care and nursing, the core features of the supervisory process remain comparable in their essentials.
No two people are identical. Therefore, we cannot avoid the issue of difference if we are to approach the tasks of care and supervision seriously. Yet until recently, our training as practitioners, and our melting pot society, have reinforced a particular understanding of difference, one reflecting an individualistic bias (Bellah, Madsen, Sullivan, Swidler & Tipton, 1985). We have been trained to focus our attention on individual differences. Helping professionals have just begun to struggle with the larger and more subtle (for some) force of group identity. For those who were brought up not to notice group identity, it can still feel like prejudice to address the issue directly. We are in the midst of a paradigmatic shift that often leaves us awkward and inadequately prepared to address group identity. The decade of the '80s marked a serious attempt by mental health practitioners and writers to catch up with social changes. In true Western, linear fashion, the literature first addressed client characteristics based on group identity, moved on to practitioner characteristics that were culturally sensitive, and, for the most part, only recently addressed cross-cultural supervision.
In part this chapter will mirror the progress that the field as a whole has witnessed; that is, we will rely on concepts offered by authors concerned with therapy as some basis for our discussion of supervision. We will, of course, additionally stress the current understanding of multicultural supervision. As another parallel to the field, we will use the terms multicultural and cross-cultural interchangeably.
This chapter is limited by the relatively few empirical examinations of multicultural therapy and supervision. Most contributions to date that address cultural issues have been theoretical in nature. We approach our topic, therefore, with an awareness that
- future research efforts may challenge, if not discount, some of our present assumptions because
- cultural bias can be extremely subtle and has infiltrated our cognitive constructs in ways of which we are only partially aware.
Before we consider some of the supervision issues with persons who have different group identities, it is important to realise that there is an up side and a down side to our topic. The up side can be described (albeit simplistically) by the word pluralism, whereas the down side focuses on the concept of discrimination. To embrace the assumptions of pluralism is to affirm "the dominant culture benefits from coexistence and interaction with the cultures of adjunct groups" (Axelson, 1985, p13). From the standard point of pluralism, helping professionals celebrate diversity and welcome the viewpoints from different groups because they recognise the gain for themselves. This perspective recognises the naturalness of difference and the legitimate claims of persons from minority ethnic communities that their identity and culture should be explicitly recognised and respected.
See section five of the module The Politics of Diversity by Charles Husband for a discussion of pluralism in multicultural societies.
The discrimination, which many members of minority ethnic communities experience, is a very real 'down side' to multiethnic Britain. The values inherent in transcultural nursing explicitly require practitioners to challenge such discrimination where it occurs. This is a logical consequence of respecting difference, and it is a requirement of professional practice within the NHS.
See section two of the module Race Equality Management by Karen Chouhan and Dave Weaver for a discussion of managing ethnic diversity in the NHS.
Many professional helpers are more accustomed to fighting discrimination than celebrating pluralism. This has led, unfortunately, to the reinforcing of social stereotypes that it is bad or unfortunate to be a minority. For this and many other reasons, helping professionals have been criticised for contributing to the one-down position many minorities continue to experience in this culture. But it is our belief that the pluralistic view alone also is flawed because it can be construed as a "Pollyanna" position that diminishes the real hardships encountered by minorities when they attempt to prosper in this society. The only desirable option as we see it, is to adopt a position that keeps both the up and down sides in focus. When working with trainees or when helping practitioners to work with their clients, supervisors must look for opportunities to enrich each other by a sharing and accepting different perspectives; however, they must also stand guard lest a person's group identity becomes a rationale for less than acceptable treatment.
There is no basis for the argument that one can ignore differences. Allport (1958) postulated over thirty years ago that the mind is prone to categorise and to group in order to reduce the stress on the brain in its attempt to comprehend its surroundings. Therefore, there is a "normality of prejudgment" (p19). But this is not the problem. The problem, as Allport understood it and as we understand it, is that we become 'partisan'. We start to attach "rightness", or in our profession, normality, to the group of which we are members. In order to feel safe by virtue of group membership, we determine that other groups must be somehow defective. The overall task, then, if we are to support pluralism, is to redefine safety to include a pluralistic orientation. Otherwise we are only fooling ourselves in our attempts to be more aware.
Definitions and issues
Definition of minority
Before we attempt to understand different, we must identify same. This is crucial because it affects our definition of minority. The beginning of a definition of majority is often considered to revolve around the overrepresentation of white males from European descent in positions of relative power in our society. Minorities, therefore, can be defined in terms of power, not numbers. One central feature to being a minority is the potential of being stigmatised. Therefore, women can legitimately be included as a minority in this country whereas the very wealthy cannot, regardless of the number in each group. A poignant example of this concept is South Africa, where blacks have been the numerical majority but are minorities by this definition because of their reduced status.
Myth of sameness
One of the many factors that contribute to the complexity of appreciating difference and sameness is that each is a partial truth. Smith (1981) referred to the "myth of sameness" as the error of most helping professionals who were convinced that their skills were generic and could be applied to individuals of varying backgrounds. The lack of appreciation for the different aspects of 'identity', including individual identity, group identity or a wider universal identity can result in stereotyping.
There is another way that helping professionals deny difference, and this can be seen among those who are white and share a professional identity. Because most helping professionals continue to represent the dominant culture, it is easy to adopt an us-them mentality regarding minority clients.
The training exercise below is an example of how multi-cultural issues have been introduced within group situations; this is a relevant exercise for all participants in a clinical supervision group.
Exercise 3.1 Group training exercise
It is very important in training activities to discourage this 'us-them' mentality when introducing multicultural issues. When classes or supervision groups are composed of persons who appear more similar than dissimilar, it is useful to begin by taking time to study the group participant's own ethnic and regional differences as a backdrop to exploring the cultures of others. We use McGoldrick's (1982) outline and ask our group supervisees to
- describe themselves ethnically;
- describe who in their family experience influenced their sense of ethnic identity;
- discuss which groups other than their own they think they understand best;
- discuss which characteristics of their ethnic group they like most and which they like least;
- discuss how they think their own family would react to seeking the services of a helping professional (p27).
Often the answers to these items are stilted at first and become more animated, as more participants get involved, beginning to compare and contrast experiences. The wide diversity of assumptions and opinions, use of food and drink, acceptance or rejection of religion, regard for education and upward mobility, etc, among white middle-class helping professionals is an eye-opening experience for may supervisees. Therefore, the myth of sameness is challenged within the majority culture group before it is seen as wanting in the work with minority clients. Additionally, it is helpful to have participants discover and react to differences among themselves as a way to desensitise them to making similar observations about cultures they see as further away from their experience. Where several ethnic groups are well represented in a training situation, the relativity of ethnic characteristics can be observed, some following traditional patterns more than others. This serves as a reminder of levels of acculturation and intra-group differences when we attempt to examine cultures with only a single representative or no representative in the training group.
World group
Ibrahim (1985) and Sue (1981) stressed the importance of worldview as the basis for relating to each other.
Ibrahim asserted that understanding of our own worldview and that of others is key to enhancing multicultural effectiveness. Structures of reasoning are central to one's worldview. Ibrahim and Kahn (1987) incorporated into their model an investigation of one's ideas about human nature, human relationships, the relationship between people and nature, time orientation, and level of activity. Ibrahim and Kahn challenged the assumption of pronounced inter-group differences and minimal intra-group differences. Their research supported both inter-group and intra-group differences.
Therefore in a country, such as the UK, with perhaps the greatest cultural complexity and variety on earth, helping professionals must be adept at refining and redefining generic knowledge. Furthermore, practitioners and supervisors must be willing to discard hard earned cultural knowledge when it is not a good fit for the client or supervisee being encountered. They require intercultural competence in being creatively open to cultural difference.
See section six of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman for a discussion of intercultural competence.
Mokuau (1987) also explored the worldview theme. Analysing the results of a study where no differences were found when Asian American and white American social workers evaluated counselling effectiveness where there was variation of ethnicity, counselling style, and the presenting problem, Mokuau concluded that what seemed to be critical was an understanding of the client's world view and values. Mokuau noted that "ethnic similarity between counsellor and client does not ensure attitudes, and ethnic dissimilarity does not preclude a mutual understanding of another's value and cultural orientation" (pp334-335).
One of the paradoxes of worldview theory is that it is best applied as an overlay to sound cultural information. In other words, an appreciation of the idiosyncratic nature of worldviews does not negate the need to understand cultural differences among groups. It is rather, the interplay of these complementary positions that puts helping professionals in a position to react astutely and knowledgeably to their clients. There is no easy way to become more culturally sensitive. The place to begin, however, is to understand what the literature has come to call the majority culture.
Assumptions of the majority culture
The majority ethnic population lives in a world where their culture has a taken-for-granted normality. The majority frequently has difficulty in seeing itself as an ethnic group. For them 'ethnic fashion' or 'ethnic food' means exotic; different and strange. It is easy for the majority to take their culture as being the norm against which others are measured.
Refer to section two of the module The Politics of Diversity by Charles Husband for a discussion of ethnocentrism.
Pedersen (1987) identified 10 common assumptions that reflect a Western bias in the helping professions. These, he argued, help to reinforce "institutional racism, ageism, sexism, and other forms of cultural bias" (p16), and are as follows (the italicised material is Pedersen's):
- Assumptions regarding normal behaviour. What we define as normal is culturally, politically, and economically defined.
- Emphasis on the individual, as opposed to emphasis on family, community, and/or society.
- Fragmentation by academic disciplines. We tend to identify the problem differently based on whether we are psychologists, anthropologists, sociologists, priests, or physicians. Clients don't necessarily experience their problems in such compartmentalised ways.
- Dependence on abstraction. The dominant culture in this country has relied heavily on abstract concepts without reference to a context. As a result, there is a false assumption that these words mean something to most other persons regardless of their cultural identity. As we have become more aware of context in recent years, we have become more appreciative of the relativity of all cognitive constructs.
- Overemphasis on independence. Our strength and weakness as a culture is our confidence in the individual. This makes us disregard the opinions of others who seem to be overly dependent on family, community, church, etc. Lee (1984) also addressed this issue and pointed to our sophistication in the area of individual development as one indication of our bias.
- Neglect of client's support systems. One of the strange idiosyncrasies of our profession is that we are often more comfortable with the concept of paid friendship than of deliberately involving the client's natural group, familial or social, in treatment.
- Dependence on linear thinking. Systematic therapies have become more sensitive to interactive paradigms that revolve around cause-effect thinking. Other cultures appreciate far more the interconnectedness of seemingly separate events.
- Focus on changing the individual, not the system. As a profession, we are still more in the camp of person-blame, than system-blame. We tend not to challenge institutions and we accept as necessary that the client must accommodate the system.
- Neglect of history. As an uninspired part of our here-and-now philosophy, we tend to neglect the historical context of our clients. If we collect data on the client's immediate family, we believe we have been thorough.
- Dangers of cultural encapsulation. Pedersen highlighted all of his previous insights by reminding the helping professional that the most dangerous assumption is 'that one is already aware of all of one's assumptions'. We are only at the edge of the frontier of appreciating cultural diversity. We needn't be concerned about admitting our ignorance. On the other hand, we communicate a much more uniformed posture if we become self-satisfied with our cultural awareness prematurely.
Pedersen's 10 cultural pitfalls are as important to keep in mind in supervision as in practice. For example, the supervisor is guilty of fragmentation when multicultural information that is offered in a didactic course is not integrated into work with clients. The supervisor can be critical of a practitioner's intervention because it is unorthodox (not "normal") although it is highly effective with a minority client. Furthermore, there is the additional danger in supervision of making one or several of these assumptions because supervisors tend to view their supervisees as extensions of themselves, even if their cultural identity is different. By virtue of the practitioner's identification with the profession, supervisors can mistakenly assume that their common professional identity implies that they share a common cultural identity as well.
The professional culture
Not only is practice reflective of the majority culture, it makes up a culture in and of itself with professional values and belief systems, a code of language, professional norms and behaviours.
In a therapeutic interaction client-centred practice is perhaps far more difficult to achieve than is commonly assumed because of the practitioner's enmeshment with the professional culture. Thus cross-cultural misunderstandings are likely to arise when working with all clients. The simple assessment that someone is behaving defensively is an example of the therapy culture at work in that this commonly used term is rooted in Freudian psychodynamic theory. Therefore, we are all in the business of cross-cultural practice regardless of whether our clients represent a different group identity from ourselves.
It is not only therapy that has a distinctive professional culture; and a professional culture that reflects the values and priorities of the majority ethnic culture. Nursing too has a very strong professional identity and a heavily entrenched institutional structure that shapes practice. As Burkitt et al (2001) have shown the 'communities of practice', which shape the actual delivery of health care in Britain, are constructed from a powerful interaction of nurses subjective identification with the profession of nursing, and the resources and power relations determined by the specific institutional context.
Refer to section three of the module The Politics of Diversity by Charles Husband re the importance of communities of practice.
Additionally, the work culture of the nursing profession has been demonstrated to strongly reflect the values of the majority ethnic community (Gerrish et al 1996, Beishon et al 1995). Thus the institutional ethos and managerial priorities of health care systems in Britain are not culturally neutral. The values of nursing as experienced and practised have been acquired through a professional socialisation in a particular dominant culture.
The issue of the many nuances of culture brings us to our last point before we address specific minority groups. McGoldrick et al. (1982) used the metaphor of a snapshot to describe the kind of information we may gain about another culture. It is an image of the real thing, not the real thing itself. In addition to the quality of the focus (fuzzy or sharp), the snapshot can be a good or a distorted image of a person within a culture. (Think of all the perfectly clear photos we have described as not a good likeness of so and so.) The snapshot is also frozen in time, as can be our understanding of another's culture; that the real client (or supervisee) is someone different from the hypothetical model that exists in our minds. Just as we are prone to categorise, we are prone also to simplify. This is true not only for diagnostic categories but also for cultural phenomena. Therefore, our understanding of disabled becomes a cognitive shorthand for a variety of constructs. To return to a metaphor, we can find ourselves working with a variety of negatives as we attempt to discern what the picture really looks like. But even when we have developed our negatives, our pictures of our clients and the cultures they represent are no more who they are than the pictures of a wonderful vacation are the vacation itself. The danger, of course, is for us to stop searching for new perspectives, to stop updating snapshots, and to close the album on ourselves, or the people we serve.
For the remainder of this chapter, we will be considering several distinct minority groups. One insight we have encountered is that issues relating to one minority group often relate to others as well. This, of course, makes intuitive sense because a society that is intolerant of any minority will be predisposed to be intolerant of all minorities. Therefore, many comments made to underscore one group's obstacles could be made about other groups as well. We appeal to our readers to see the following sub-sections as overlapping and not discrete. Many points that are made about practice with minority ethnic groups, for instance, also can be made about practice across generations or sexual orientations. We have focused on the literature specific to each group and have attempted not to repeat issues within the chapter. We hope, however, that the reader will feel the permission to expand upon statements made about one minority and to look for applications for all minority groups.
Supervision issues
There is only modest attention given in the literature to the dynamics and experiences of multicultural supervision. In contrast, there is a sizeable body of information that describes training criteria to prepare (presumably) white, middle-class students to work with minority ethnic groups. We will begin with the latter.
If supervisors are working independently of a training programme, they might wish to consider ways in which they can incorporate the information offered in the following paragraphs for their supervisees.
Training for cross-cultural practice
What types of experiences will prepare the health care professional to work effectively with a minority population? As Ponterotto and Casas (1987) asserted, practitioners will not become culturally sensitive until training programmes are culturally sensitive. Christensen (1989: 270-287) described five stages, shown in the table below, that both majority and minority practitioners will experience as they develop in cross-cultural awareness.
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As a means to achieving cross-cultural awareness, the following foci represent the collective opinions of several authorities in the field:
1. A pluralistic philosophy
(Ponterotto & Cass, 1987). No amount of training will undo the determined or frightened supervisee who is not willing to discard the 'melting pot' myth.
Refer to section six of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman re the relationship between intercultural and cultural communication.
2. Cultural knowledge
(Parker, Valley & Geary, 1986; Ponterotto & Casas, 1987; Sue, Akutsu & Higashi, 1985). Being open-minded is not enough when we are ignorant of the basic underpinnings of a particular minority culture, and it is deeply unhelpful when educational programmes are inadequately prepared to dispel these myths. The criticism of learning about the culture is that it clouds individuality, that it is closely related to stereotyping.
Again, refer to section six of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman re the relationship between intercultural and cultural communication.
3. Consciousness raising
(Parker & McDavis, 1979). Being open-minded and welcoming diversity are imperative preconditions to consciousness-raising, but they are not the same thing. Unless the practitioner is a minority, many of the experiences of minorities in the society will be out of the practitioner's awareness. In effect, we must know ourselves, including our learned cultural reactions, before we can attempt to understand another from a different culture.
4. Experiential training
(Parker et al., 1986). Cognitive learning cannot be bypassed, but it should be complemented with some trial-and-error opportunities prior to direct work with minorities. Use of videotape and role-plays to monitor communication patterns that might hinder cross-cultural practice are quite useful. It a practitioner has an opportunity to observe their supervisor working with a patient from a minority ethnic group with whom the student is preparing to work it is important to remember that each person is an individual with individual ways of interfacing the culture. Therefore, the types of techniques that are important for the supervisor to model include; ways of addressing culture and ethnicity in the clinical context, and ways for checking out information about an individual's culture that is relevant to the assessment and the health care to be provided.
Neimeyer and Fukuyama (1984) proposed another type of experiential learning. They developed the Cultural Attitudes Repertory Test (CART), which can be used for practitioner self-exploration of private knowledge about a number of different minority groups. CART allows practitioners the opportunity to appreciate cultural variations among groups (differentiation) and aids practitioners in bringing variations together into a more comprehensive understanding of their private understanding of a particular ethnic community (integration).
5. Contact with minorities
(Parker et al., 1986; Parker & McDavis, 1979; Sue et al., 1985). In a pluralistic society it is less and less acceptable for a practitioner to work with a minority when the practitioner has had no social experience with members of the minority person's cultural group. Ethnic neighbourhoods abound, and some training programmes require that their students spend some time in such neighbourhoods, or in minority clients' homes.
6. Practicum or internship with minorities
(Sue et al., 1985). Prior to leaving a training programme the student should have supervised, direct contact with minority ethnic patients. Even if solid cognitive content is presented and appropriate attitudinal changes occur, when students work only with members of their own culture during practicum they cannot be considered trained as a multicultural practitioner. Therefore, supervised experience is imperative to help students integrate their new knowledge with actual experience, sometimes in a trial-and-error fashion. Of course, the student's experience will be partially determined by the cross-cultural expertise of the supervisor. With so few minority supervisors in the clinical setting, this in itself can be a precarious situation.
Nagging problems
Even the most progressive programmes (Ponterott and Casas, 1987) cannot undo social ills. Among our nagging problems in multicultural training are the following:
1. Our training programmes in nursing are still culturally constrained by the fact that most nurse educators and mentors represent the majority culture. In addition, the nursing and health care professions are only just beginning to seriously address the under-representation of minority ethnic personnel in the training programmes.
2. It is important to recognise that cross-cultural training has the potential of missing two important groups; namely:
- people who are marginal and who identify with neither the dominant culture or a particular minority culture
- and individuals who are given more than one label, e.g. a person from a minority ethnic group who also has a disability.
Awareness of differences between cultures should not be allowed to obscure the complex differences within cultures.
See chapter two of the module The Politics of Diversity by Charles Husband re hybrid identities.
3. Ironically, cultural knowledge, used simplistically, may be a dangerous thing. As the curricula in nursing and health care increasingly contain some element of instruction in transcultural care it is possible that nurses may respond to the ethnic identity of a patient, but in a stereotypical way. They may attribute cultural values to someone on the basis of an ethnic label which mistakenly assumes that general cultural insights apply in every instance. The ability to be appropriately sensitive to ethnic identities among apparently similar persons requires experience and more than a superficial grasp of cultural differences.
4. Until all minority ethnic communities have equal access to power and influence real pluralism in society and health care delivery will not be easily attained. Consequently, nursing and health care staff need to be aware of the political environment that shapes health care. An understanding of the constraints built into their own community of practice should allow nurses to accept the necessity of retaining a political agenda as part of their professional role.
Refer to section three of the module Politics of Diversity by Charles Husband for details regarding Communities of Practice.
The supervision process
Although there is a general acceptance of the need to recruit minority ethnic staff into the nursing and health care professions this is not necessarily matched by an ability to provide appropriate mentoring for staff in training or practice. In addressing the agendas of The Vital Connection: An Equalities Framework for the NHS (Department of Health, 2000) and other current policy statements within the NHS it is essential that experienced practitioners are appropriately prepared to supervise colleagues from different ethnic backgrounds. Such supervision, across a cultural boundary, always carries the potential for anxiety and misunderstanding that is intrinsic to any cross-cultural interaction. Such misunderstanding can occur for either, or both, the trainee and the mentor.
Refer to section six of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman for a discussion of the challenge of intercultural communication.
In the contemporary British situation there is widespread evidence of racism and discrimination in society at large. And, there is ample evidence of racism and discrimination in the NHS and caring professions.
Refer to section three of the module The Politics of Diversity by Charles Husband for a discussion of racism and discrimination.
Consequently, it is reasonable to assume that minority ethnic nurses may be legitimately sensitive to any racialised content of their interaction with supervisors and mentors. Equally, majority ethnic nurses live in a professional environment which has only relatively recently begun to meaningfully address issues of equal opportunities among staff and transcultural competencies in health care delivery. This is a policy change for which perhaps the majority have not been professionally prepared in their own training. Not surprisingly, very many nursing staff feel professionally exposed in this situation. This professional anxiety can amplify the personal anxiety that may be engendered in any cross-cultural supervisory relationship.
See section six of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman for a discussion of nurses' fear of being perceived as being racist.
Thus, cross-cultural supervision in the current context of health care practice in Britain may reasonably be assumed to require sensitivity to ethnicity and 'race' as powerful potential variables in the interpersonal interaction. This is a challenge for both partners but clearly the onus is upon the supervisor to have the personal and professional competence to manage this situation sensitively and appropriately. A commitment to equal opportunities and ethnically sensitive supervision is no guarantee of inoculation against the stresses of cross-cultural supervision.
Supervisors may inadvertently put minority ethnic supervisees in a double bind by being over solicitous on the one hand and never addressing the supervisee's ethnicity on the other hand. Such behaviour effectively isolates the supervisee, even if the supervisor's intention is very different. As with gender, the requirement is to recognise the appropriate relevance of ethnicity for the supervisor's understanding of the supervisee's learning trajectory. To always explicitly engage with a female colleague as a woman, rather than as a professional peer is a sexist reduction of them to being defined solely through their sex. Equally to, as a matter of principle or ignorance, fail to engage with this peer's gender is hardly likely to promote sensitive shared learning. Thus, in the prior paragraphs there has been a reference to the potential relevance of ethnicity within supervision. Its relevance is not routinely self-evident, but must be revealed in each situation as part of the process of supervision. This in itself is sufficient to underline the importance of continuity and commitment in supervision; for both are required to build the trust in which the potential relevance of ethnicity, for both partners, can be explored with sensitivity and safety.
An ability to provide sensitive and appropriate supervision in a cross-cultural relationship requires the supervisor to have competence in transcultural communication skills. They need the openness and moral imagination of the generic intercultural communicative competence which provides a flexible and sensitive disposition toward recognising cultural differences. And, it requires the development of specific cultural competence which will provide the supervisor with a baseline knowledge of the cultural values and behavioural practices of their supervisee.
Refer to sections six and seven of the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman for an introduction to transcultural communicative competence.
In an excellent review of salient issues in cross-cultural supervision of Asian and Hispanic social workers by majority ethnic supervisors, Ryan and Hendricks (1989) identified five characteristics that may become sources of conflict: cognitive orientation, motivational orientation, communication styles, value orientations and sensory orientation.
- in relation to cognitive orientation Ryan and Hendricks noted that in some cultures more trust is placed in non-verbal information than verbal analysis in solving a problem. Ways of accessing and processing 'relevant' information may differ significantly from culture to culture
- In relation to motivational orientation Ryan and Hendricks provide a reminder that Western European beliefs in the power of individual agency are not universal. In some cultures degrees of fatalism and acceptance of the status quo may have a greater relevance. Assuming a common motivational agenda can create serious difficulties in evaluating the impact of guidance for the mentor and confuse the supervisee
- communication styles have received a great deal of attention in the literature on interpersonal communication. Everything from the distance maintained between self and others, and the use of facial expressions may differ dramatically from one culture to another. A failure to allow for such differences can generate real misunderstanding and frustration for both the mentor and supervisee
- the value orientations that are embedded in each culture underpin the individual's orientation to their world. For example, in British higher education it is normal to encourage the student to be critical. The lecturer may be an expert but that does not mean that they are right. In some other cultures explicitly challenging a 'superior' would feel a shocking breach of social convention. Consequently, for example, a quiet supervisee may be saying more about their respect for the mentor, than non-verbally demonstrating a lack of interest in the supervision
- and finally, sensory orientation reflects the range of differences between cultures in reliance upon particular sensory modalities. Touch and smell, for example, are not significant elements in contemporary professional interactions in the United Kingdom. Being denied the use of a familiar modality, like touch, may be quite disruptive of communication in a cross-cultural interaction.
These five characteristics highlighted by Ryan and Hendricks clearly interact with each other in complex ways. They serve as a reminder of the need to pay attention to the process of communication in any cross-cultural supervisory situation. Cross-cultural supervision requires more than an ethical commitment to equality and an empathetic openness to cultural diversity. It necessarily requires a willingness to acquire the necessary transcultural communication skills.
Robinson (1998) provides a valuable and detailed review of relevant literature in her text Race, Communication and the Caring Professions, Buckingham: Open University Press.
In supervising minority ethnic nurses in the context of the current policy commitment to developing transcultural nursing competence it is quite possible that the majority ethnic supervisor may feel that the minority ethnic nurse has a privileged knowledge of ethnic difference. They might even slip into assuming that the minority ethnic nurse is an 'expert' in relation to all members of their minority ethnic group. Although the minority ethnic nurse's perspective is certainly valuable, to assume that they understand all patients from that ethnic background is another form of "all xxx's are alike". The minority ethnic nurse is likely to know that they cannot fulfil this role and wish to resist it. But, they may also feel reticent about explicitly rejecting it given the necessary implicit criticism of their mentor this will invoke.
It is useful to unpick this dynamic a little more fully. In any supervisor/mentor- supervisee relationship there is a real power relationship. The supervisor may not only be providing professional support, but may be simultaneously assessing the supervisee's progress. Either by virtue of their formal role in assessment or through their status as professional 'expert' the supervisor is in a position to claim authority. Where the supervisor is a member of a minority ethnic community, and the supervisee is a member of the majority ethnic group, this authority may not be readily or fulsomely recognised by the supervisee. The powerful assumptions of cultural racism in British society may operate in subtle ways to hinder the development of an open and equitable supervisory relationship.
Please refer to section three of the module The Politics of Diversity by Charles Husband for a discussion of cultural racism.
In the more likely circumstances of a majority ethnic nurse supervising a minority ethnic nurse then it is equally possible that culturally racist assumptions may inadvertently, and unintentionally, pollute the supervisory relationship. One means whereby this may occur is through the routine exaggeration of the relevance of the supervisee's ethnicity. They may become essentialised, for example, as 'Black', 'Asian' or Chinese. The unique complexity of the supervisee in this way becomes buried through the primacy given to their ethnicity. An important feature of this process resides in the process of who ascribes the ethnic label to the supervisee. Routinely, it is the supervisor. And, it is from the ascription of this label that the supervisor may generalise the assumed cultural expertise of the minority ethnic nurse.
Thus, a valuable and necessary element in the process of cross-cultural supervision is the careful and explicit exploration of ethnicities: both that of the supervisor and of the supervisee. Ethnicity is not a fixed property of an individual but is a dynamic negotiation of identities. And, ethnic identities are most concretely realised as the boundaries between ethnic identities are negotiated. Thus, the process of recognising the relevance of ethnicity in a supervisory relationship is not a simple matter of the supervisor 'identifying' the supervisee's ethnicity. It is necessarily a more dynamic negotiation of the nature of the ethnic boundary between the supervisor and supervisee: what values and behaviour do they share and which set them apart.
Please see section two of the module The Politics of Diversity by Charles Husband for a discussion of the nature of ethnicity.
Nursing has a core commitment to delivering individualised holistic care; and nurses are familiar with the engagement of themselves as emotional and complete persons in delivering that care. As a recent ENB Report (Burkitt et al, 2001) underlined, the negotiation of 'emotional labour' is a key element of professional nursing practice. Thus, a mutual exploration of the nature of ethnicity for both partners in a cross-cultural supervisory relationship provides an important route into addressing the personal dynamics that are integral to professional practice.
However, the same report echoes other current research in revealing the highly pressured circumstances under which nurse educators and nurse practitioners currently operate. Both have very considerable difficulties in controlling the demands made upon them, and the conditions under which supervision takes place are very far from ideal. Very often inadequate time is allocated for supervision. The time once allocated can prove difficult to protect, and continuity of supervision may prove difficult to sustain. Such pressures can only amplify the ambiguity and tension that may be present in cross-cultural supervision. Consequently, a central task for the supervisor in cross-cultural supervision is to seek to ensure the existence of a stable supervisory relationship.
It is clearly implicit in this discussion of the supervisory process that the exploration of the potential relevance of ethnicity in the learning trajectory of the supervisee is double edged. It requires the supervisee to be willing to explore a critical element of their identity. And if, as is likely for a minority ethnic nurse, their ethnicity has been made a powerful and sensitive source of identity due to their experience of racism and social exclusion, then this expectation demands a great deal of trust on their behalf. Their awareness of the gift of access to their lives that they are offering the supervisor may reasonably make them very sensitive to how this opening up is respected by the supervisor. Ignorance and clumsiness on the part of the supervisor may in these circumstances be perceived as not just regrettable, but also as fundamentally insulting.
Equally, for the majority ethnic supervisor the engagement with the supervisee's ethnicity reciprocally exposes the nature of their own ethnicity. Members of majority ethnic communities are not routinely comfortable with exploring their ethnicity. It has had a taken-for-granted normality. Thus, engaging with their own ethnicity may generate some uncomfortable insights. Importantly, given the politicised nature of ethnic relations in contemporary Britain, it is not inconceivable that the majority ethnic supervisor may feel unsure about making comparative judgements about the values and practices they take to be normal, even natural, and the contrasting values and practices found in other cultures. As has been discussed above, there is a genuine concern about being perceived to be ethnocentric or racist. There is often a confused sense that all cultural comparisons are illegitimate and this may easily engender hurt and anger in the supervisor.
Thus, all supervisors, majority and minority, should have a clear understanding of the implications of cultural relativism in nursing practice and in supervision. The ambiguity surrounding this question of how we demonstrate respect for other cultures has proved unnerving and distressing to many nurses. Not wishing to be accused of being racist or ethnocentric, and accepting the core values of individualised holistic care, they do wish to demonstrate respect, understanding and empathy with patients and colleagues from other cultures. There are, however, cultural practices which individual nurses and midwives find contrary to their own values, and, therefore, objectionable. But, believing that cultural relativism is the expected professional posture, they then find themselves unclear about what they may legitimately do with their own feelings. This scenario is almost certainly guaranteed to create anxiety, frustration and resentment. However, the problem was created by the professional ambiguity that allowed for the belief that absolute cultural relativism was a requirement of transcultural nursing care to exist in the first instance.
As Hyland Eriksen (1995, p. 11-12) demonstrates, cultural relativism is a valuable tool of anthropological research; not an essential underpinning of multicultural policy:
"Cultural relativism is sometimes posited as the opposite of ethnocentrism. This is the doctrine that societies or cultures are qualitatively different and have their own unique inner logic, and that it is therefore scientifically absurd to rank them on a scale. If one places a San group, say, at the bottom of a ladder where the variables are, say, literacy and annual income, this ladder is irrelevant to them if it turns out that the San do not place a high priority on money and books. It should also be evident that one cannot, within a cultural relativist framework, argue that a society with many cars is 'better' than one with fewer, or that the ratio of cinemas to population is a useful indicator of the quality of life.
Cultural relativism is an indispensable and unquestionable theoretical premise and methodological rule-of-thumb in our attempts to understand alien societies in an as unprejudiced way as possible. As an ethical principle, however, it is probably impossible in practice, since it seems to indicate that everything is as good as everything else, provided it makes sense in a particular society. It may ultimately lead to nihilism. For this reason, it may be timely to stress that many anthropologists are impeccable cultural relativists in their daily work, while they have definite, frequently dogmatic notions about right and wrong in their private lives.
Cultural relativism cannot, when all is said and done, be posited simply as the opposite of ethnocentrism, the simple reason being that it does not in itself contain a moral principle. The principal of cultural relativism in anthropology is a methodological one - it helps us investigate and compare societies without relating them to an intellectually irrelevant moral scale; but this does not logically imply that there is no difference between right and wrong".
Reflecting absolute cultural relativism as a necessary element in transcultural nursing practice helps to clarify matters, but it does not make life easy. Absolute cultural relativism invites a suspension of moral judgement - which may be consistent with a fascination with the variety of forms of human solutions to the act of living, but hardly sustains a viable social order.
In essence, there is no easy fix to the challenge of transcultural nursing. So much of nursing draws upon an engagement with one's own inner self. The compulsion to care, the capacity to empathise and an ability to engage with the emotional labour of nursing all require that nurses stay in touch with their inner self. Their personal authenticity is integral to their ability to be a nurse. Their moral sensibilities are fundamental to this personal authenticity.
The politics of difference invites us all to recognise difference, and to be prepared to treat each other equally through respecting that difference. The first task is to understand the difference. And ethnic diversity is always interactive: we are different because I differ from you and you differ from me. This is an appropriate relativism, for it rejects the distorting normative assumptions of ethnocentrism. From an understanding of the difference we can all then move to demonstrating respect between equals. No one who has isolated themselves from their own identity and values can do this. Holistic nursing requires holistic nurses: rounded, complex, whole persons. Thus, transcultural nursing challenges us to live and practice through respect for difference, and to learn how to negotiate difference appropriately. The core values of British nursing provide a positive platform for pursuing this goal.
Thus, transcultural supervision requires a necessary confidence on the part of the supervisor in addressing the realities of ethnic diversity. Being 'tolerant' of difference will not do. The supervisor must have a rounded understanding of racism and ethnicity, a competence in transcultural communication and a clear self-awareness of their position on cultural relativism. This is an ideal which will take some time to achieve within the context of contemporary British health care; but it is attainable. And, the expanding process of training in transcultural nursing is beginning to address this agenda. At the present time, an honest recognition of the challenge of transcultural supervision will enable supervisors to begin to equip themselves for effectively addressing their responsibilities.