section one

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

In the occupation of nurse one occupies many diverse roles being, for example, a carer to the patient, a colleague to one's peers and a manager within the context of a clinical team. In fulfilling these roles very different aspects of yourself may be appropriately employed in ensuring that you are efficient, professionally competent and caring. Being empathetic, stern, light-hearted and even detached may all, in the right circumstances, be an appropriate element of your professional role.

Roles are behavioural expectations that are attached to specific statuses that we may possess.

"A status is a socially defined aspect of a person which defines a social relationship and entails certain rights and duties in relation to others."

(Eriksen, 1995:39)

Outside of the work environment we all fulfil very many other roles. As parents, siblings, friends, club-members, citizens and customers in the queue at a check-out we are familiar with the very different expectations that are placed upon us. We are constantly engaged in 'role-switching' and are amazingly adept at negotiating this complex feature of our social world. Some roles, however, make contradictory demands upon us. Long working hours and family obligations are typical of the role conflict we may experience. Roles are part of the choreography of our social world.

Roles

Therefore, in order to be acceptable, or behave appropriately, in a series of different contexts and with different people, one changes roles. As you leave the hospital or clinic after your final shift, knowing that tonight you will see someone you love, your mood may change to optimistic enthusiasm, when only ten minutes earlier you were tired. It is all part of changing roles from, for example, 'helpful colleague' to 'romantic partner'; whilst at the same time perhaps being a parent to four children.

In everyday life no one lives in a vacuum. Most of what we think, say and do is defined by the impact that the world and people have upon us. The nurse, at one and the same time occupies both her/his professional role in any clinical setting, but is also a socialised human being with personal feelings, attitudes, and values. In the process of communication we are all negotiating the most relevant role for the situation. If someone goes bouncing into a room emanating gaiety and glee, but then suddenly discovers that someone present has just lost a relative, they change the way they act. We act in terms of the normative framework, which dictates that the role we 'should' play, be one of understanding, and sympathy.

A nurse might also 'put on a brave face' in many professional situations, even when tired, afraid, or supporting others in difficulty. The very idea of being 'professional' invokes expectations of self-control and an understanding of what is expected of 'a nurse'. In a different setting she/he may bump into an orthopaedic consultant in the supermarket. An initial sense of anxiety or uncertainty about whether to introduce her/his partner, or even whether to say hello, may be due to 'role conflict'. A senior member of the health service hierarchy and a fellow shopper with their arms in the frozen vegetable cabinet elicit quite different expectations.

We exist in a reciprocal relationship with the world around us.

All societies have developed mechanisms for enabling people to live together within the context of their surroundings. The climate, the manner in which materials are produced and distributed and the organisation of family units are only some of the factors which interact in shaping the social framework within which we live. The social structures which have developed in particular societies have about them a quite erroneous naturalness about them.

In Britain we give over our children for a large part of their youth to be educated by strangers in schools. And, we expect young people to negotiate an awkward and potentially rebellious period of adolescence. We also have beliefs about the class system. These are ways of thinking about the world that are the product of a particular history and current circumstances. Our beliefs about education, adolescence and class are also replicated in the structure of our world. In a stratified educational system, in a distinct youth leisure industry and in, for example, housing patterns. We all at birth enter a world that already has a distinct social structure and which has developed a shared language that gives meaning to this environment.

All our social roles exist within such a social framework. The roles we occupy bring meaning to our individual lives and help to make sense of the world. The roles we learn give a taken-for-granted naturalness to our social world. In learning these roles and in developing competence in performing them we come to share a particular culture.

We are socialised into these roles, and are acting in relation to them at all times.

Identity

Like a sponge we become saturated in the bath water of our culture, so another term for socialisation is 'enculturation'. Each of us may have a wide variety of human traits, but these are only acted out in terms of what we culturally feel ourselves to be - or what society will allow us to be. We are socialised, however, mainly into a knowledge of what is appropriate in our own culture.

The word 'culture' denotes a way of life (family life, patterns of behaviour and belief, language etc.) but it is more important to note that cultures are not static, especially in a community where there are several cultures living side by side. Culture refers to 'child rearing habits, family systems, and ethical values common to a group.

(Fernando 1991:10 quoted in Robinson 1998:54)

We are all socialised into some uniform 'national' culture; encountering broad cultural values and practices through the specifics of our own environment - region, gender, local community. At the same time, in the 21st Century we also soak up an array of other, alternative, cultural realities. Travel, immigration and the media constantly remind us of differences between ourselves and others. Some of us have become acculturated; were born and socialised into one culture, but adopted some of the codes and customs of British culture whilst at the same time maintaining some of the old.

The idea of a 'British' culture reminds us that we tend not to encounter our culture as merely a convenient set of rules for shared living. Our culture is acquired with a sense of its history and its importance as a core feature of our identity. As the module on 'The Politics of Diversity' has discussed, collective identities build upon a sense of shared history and shared culture. Whether it is a national or an ethnic identity, our socialisation into that identity leads us to value our culture. This is not a culture, it is our culture. Consequently, in multicultural societies there is frequently a tension involved in negotiating the cultural diversity found there. In contemporary Britain, and certainly in the NHS, there is an expectation that we all show respect for other cultures. And often as an abstract principle that is warmly embraced. However, when coming to communicate across a cultural boundary, the historical urge to think - 'my culture normal - your culture exotic' - all too often lurks in the background. Ethnocentrism - taking your own culture as an absolute norm for judging others - is a negative by-product of strong national and ethnic identifications.

A recognition of the cultural diversity within any nation or ethnic group, and an historical sense of how much our culture has changed over time, are useful routes into understanding how naïve and wrong is ethnocentrism. Multiculturalism does not require anyone to give up their culture, but it does require everyone not to make false and unsustainable claims for the primacy of their culture.

It is social propriety which dictates the roles we are inevitably called upon to occupy in defining which roles are appropriate to specific situations. To think of being alone is to think of the absence of others. And to be able to have this thought involves the use of a language that one has learned from others. To be understandable to others in terms of our 'role performances' or 'social representations', and thus to behave appropriately, we follow elaborate sets of rules, mainly unconsciously. These are 'codes of behaviour' to which we will return later.

When speaking of learning and rules it is useful to reflect on the two forms of learning we bring to our performance of roles. We may speak of learning how and of learning why. In our practical consciousness we acquire an ability to do things. We learn the actions, the posture, the emotions that constitute an appropriate act. Much of this is an unconscious embodied learning. It is an over learned habit of our muscles and physiology. On the other hand, in discoursive consciousness we have an ability to think of our actions and to reflect upon them. We can, in this case, explicitly examine the rules which guide our behaviour. (For an account of how these two forms of consciousness are expressed in nursing practice see Burkitt et al, 2001).

Given that socialisation involves an intricate fusion of practical and discoursive consciousness, it follows that it can be difficult to know how our culture is embodied within us. We may explicitly verbalise the rules and values of our culture whilst having little understanding of the innumerable ways in which our culture is encoded in our actions. Ironically, we may be all too alert to the many ways in which their culture is expressed in someone else's actions. All cross-cultural interactions are reciprocal, but our scanning for cultural markers is not equally balanced. We tend to be aware of the cultural differences of the other. This is a platform upon which ethnocentrism can easily build. All of our knowledge of the world in fact, has been imparted to us through experience of relationships between our selves and the world. Everything we 'know', communicate about ourselves to others, or act upon, takes place in the interpersonal space between ourselves and others. And that space is occupied with the giving and receiving of messages; from me to you, and from you to me. When we reflect on this space we use mental representations.

It is clear from the above that what we think of as natural - our own enculturated reality - is actually merely a version of reality that our own nation, family, or profession believed to be the correct one. It is in fact one of many possible useful ways of looking at the world - it works because we agree to use it. It is our normative framework, which is further defined below.

Interpersonal space is the arena between oneself and other people, within which we exchange meaning.

Exercise 1.1 Self reflection activity

Before moving on to the reading, reflect on and write down your answers the following questions.

How many different roles do you occupy? (In both your work setting and your personal life.) List them according to 'professional' and 'personal' roles
Can you identify instances of role-conflict - where there is a contradiction between the demands of two or more roles? List as many as you can
Think of a particular instance of role conflict and reflect on how you dealt with/deal with it.
What does this response tell you about yourself in terms of the value you place on different roles or the normative framework that you operate within?

Read the following text

Norms

The social sciences provide us with many ways of having insight into our world and the concepts that they provide often overlap. This is both useful and an irritation. The fact that there is some overlap assists us to see the links between concepts. This same overlap also means that there is often an element of ambiguity we must each come to terms with. The relationship between roles and norms is such a conceptual interaction.

Erikson (1995, p. 48) states that:

"Every social system requires the existence of rules stating what is permitted and what is not. Such rules, whether they are stated openly or are simply followed by tacit consent, are called norms.

All norms have in common that they are connected with sanctions. In principle, both positive and negative sanctions exist. A positive sanction involves a reward for following the norms, while a negative one entails punishment for breaching the rules."

We can easily see that the status of nurse has attached to it expectations about the role of the nurse in clinical practice. Indeed much of the education of nurses is directed toward socialising nursing students into their professional identities. However, the delivery of nursing care takes place in particular clinical settings and local norms can be seen to develop as over time fairly stable teams develop their shared way of fulfilling the role expectations. Thus, how the emotional labour of nursing is negotiated may differ from location to location. Or, how a clinical team respond to NHS guidelines on transcultural care may be resisted or embraced. Gerrish et al (1996), for example, report how Project 2000 students who had education in cultural sensitivity might find the prevailing norms in a clinical setting were contrary to those in the School of Nursing.

Here the role conflict between being a good student, a good nurse and a good colleague was stressful and harmful. Positive and negative sanctions are capable of being delivered in the most subtle, but unambiguous ways. As we will discus below, verbal explicitness is not at all necessary in order to transmit a powerful message.

We all have very many statuses; but not all are equally important to us. Some of our statuses have become the focus for our investing a great deal of our personal commitment and worth. Our personal identity is strongly attached to these statuses. Many people play a sport without it being central to their life. But, for athletes committed to the sport, their performance in it is of great personal significance.

Nursing and health care professionals are typically committed to their work. Their work is not so much a job as a vocation and, for example, being 'a good nurse' has personal relevance. The norms operating in nursing are, therefore, capable of strongly impacting on individual nurses. The positive and negative sanctions applied in relation to compliance with the norms in a clinical setting can consequently be very powerful. Thus, in looking at developing culturally safe practice it is important to keep in mind the responsibilities of both the individual nurse and the larger health care institution.

As human beings we all seek to bring meaning into our world. This assertion underlines the fact that we are all actively engaged in making sense of the world. We are not passive receivers of messages constructed elsewhere which enter directly into our consciousness. As we shall see in the next section our unique personal identity is always an active element of our negotiation of our social roles.

Exercise 1.2 Activity and discussion

In relation to a context you share with others (in a clinical setting, in an educational setting or a leisure context)

identify the prevailing norms; and
specify the mechanisms by which they are 'policed' by the group
Discuss your responses to these questions with one or two other people who share the 'setting' you describe above. How is their perspective similar and different from your own?

Interpersonal perception

In the following section useful supporting reading can be found in:

Peter Hartley (1993) Interpersonal Communication. London: Routledge.
This provides a good introduction to interpersonal communication expressed in a very accessible way.
Perry R. Hinton (1993) The Psychology of Interpersonal Perception. London: Routledge
A rather more demanding and extended account.

Read the following text

Hinton (1993) uses a series of day-to-day examples to illustrate the ways in which we are continually 'summing people up' and 'making snap judgements about them, what they are like, whether they are telling the truth.' Yet, as he observes 'the only information we have about these people is that gained from a brief encounter' (1993:6). The significance of this is twofold:

Firstly, it illustrates the power of non-verbal information and the inferences we make from it; and
Secondly, it highlights the ways in which snap judgements can influence how we behave.

Consequently we should be interested to understand what specific inferences people make on the basis of different sources of non-verbal information. In this respect, Hinton identifies four sources of non-verbal information.

physical characteristics - e.g. skin colour, height or shape of face;
physical appearance - e.g. hairstyle, choice of clothes, jewellery;
'dynamic aspects of the body' - the way a person moves, talks and other characteristic actions; and
'dynamic aspects of appearance' - e.g. a smile of a frown. (1993:7)

Inferences from external appearance

There is a long history of linking aspects of a person's physical make-up to perceptions of their underlying character. Peoples' physique has often been read as a strong clue to their temperament and character: the jovial fat person, and the highbrow (literally) 'egghead' are but two of the more obvious examples. The casting of actors for television and film would seem to indicate that the suggestive powers of facial features and body type are far from lost upon their contemporary audiences. The 'refined' features of the aristocrat and the lumpish vulgar proletarian are to be found in contemporary television in ways that would have been recognisable to our Victorian predecessors. The coding of body type and facial features into judgements of personal worth in relation to beauty, respectability or indeed criminality has a long, and continuing, history.

However, whilst research has shown that personality characteristics cannot be accurately assessed from facial features, there are, nonetheless, commonly held beliefs that particular facial features indicate or reflect certain personality traits. In relation to this, Secord (1958) has identified five kinds of inference processes generally used by individuals. These are:

Temporal extension - whereby a momentary expression is taken as indicative of an enduring characteristic.
Parataxis - in which we generalise personality characteristics from someone we know to someone we do not know.
Categorisation - we categorise someone as a member of a group (e.g. sex, age, race) and infer characteristics we believe are held by that group.
Functional quality - based on the functions of the various parts of the face (e.g. thin lips pressed together indicated someone who is 'tight-lipped'.
Metaphorical generalisation - where inference is based on a number of physical attributes taken together - e.g. a woman with thin lips and her hair in a tight bun is taken as having a severe personality. (Hinton 1993:10-11)

This listing of how we move from observation to inference provides us with an insight into just how far we can go in interpreting 'the evidence' we find in someone else's appearance or behaviour. One particular implication of these perceptual strategies is that on the basis of very limited current evidence we make assumptions that have lasting implications.

When we look at what may be the basis of this 'evidence' then we have further reason to be concerned about our willingness to make interpersonal judgements on the basis of very limited ones. In fact it is this willingness to make such inferences that gives us an insight into how strongly these messages are embedded in our culture.

We make inferences on the basis of hair colour and hairstyles. Are read heads really fiery? are blondes really more sexy? Why is it that spectacles are often taken as implying greater intelligence or seriousness? The fashion industry both exploits and creates a symbolism of body type and clothing. Certain body types are seen as beautiful whilst others are regarded as unattractive. And yet any understanding of the history of beauty will demonstrate how extensively these assumptions about the beautiful person may vary over time. And, how they may vary extensively from one culture to another. This reality underlines a significant truth about this process of inference from appearance to other human characteristics; namely that the relationship is culturally constructed and learned.

Since there are some aspects of our physical characteristics that we cannot easily change - such as our sex, age, 'race', or height, we are all confronted by having to live with the cultural implications of our appearance. The massive scale of the cosmetics industry, the growth of plastic surgery as an accessible and acceptable strategy, and the use of commodities and possessions to position ourselves in relation to others tells us that individuals are not quietly passive about how they may be perceived. We need to recognise that each individual may be actively engaged in seeking to control their appearance in order to control the inferences that others make about them. Whether it is about dressing to create a certain kind of image (for example, at a job interview), or simply the way we present ourselves in everyday life, people are capable of engaging in 'impression management'. However, even a moments reflection is sufficient to inform us that 'impression management' is only possible if we have a pretty sophisticated understanding of the appropriate cultural expectations; and a realistic appreciation of our ability to efficiently carry off a performance. Society can be cruel towards those whose attempts at impression management fail. Phrases such as 'she's mutton dressed as lamb', 'they're nouveaux riche' or 'he's a coconut' can be harsh responses to failed attempts at impression management.

Thus long before we start to deal with the complex multi-layered reality that is interpersonal communication, in Section Four below, we have already recognised how potentially dangerous is our willingness to make inferences about other people. We have also encountered a further significant factor, namely that people frequently engage in a variety of forms of impression management. In fact we expect it of each other, as it is part of our capacity for efficiently performing our many roles. Nurses uniforms with their capacity to signal one's place in a hierarchy, just like the consultant's suit and tie, are culturally defined ways of enabling the patient and other staff to draw appropriate inferences about their health carer.

Of course one of the questions that we ask of persons fulfilling a role is how much of themselves they allow to be visible through the role. The role of a shop assistant is essentially to facilitate the shopper with their purchasing the goods they need. But many people prefer the local shop to the supermarket because they are served by a recognisable person, not merely an efficient sales operative. For nurses and other health carers their aspiration to deliver individualised holistic care routinely means that they must be present in enacting their caring role. The whole issue of the emotional commitment of the nurse to their delivery of care (Bennet, 1984) requires the nurse to remain personally vulnerable, to some degree, in their act of caring. Thus as we proceed through this module we will give a considerable amount of attention to the social psychology of identity. For it is the mutual vulnerability of people in interaction that makes interpersonal communication so important.

Hinton's account of how we may make inferences from non-verbal communication acts as salutary warning about how we may enter into interaction with other people. Even before we begin to attempt to make sense of what they may have to say, we have already made a range of important decisions about them: which will in turn influence our interpretation of their conversation. The conceptual language of 'parataxis' or 'temporal extension' may seem strange, but the perceptual behaviour they refer to can be all too familiar to us.

Earlier we noted that as human beings we all seek to bring meaning into our world. It seems that we spontaneously interpret our surroundings and that we are impatient when faced with limited information. Not only are we capable of making inferences on the basis of limited information; we then proceed as though the judgement we have made is sound. Our embarrassment on these occasional instances when such hasty judgements are disconfirmed is precisely linked to the flimsy evidence we had for it.

Exercise 1.3 Self reflection activity

Name and explain the four sources of non-verbal information identified by Hinton (1993)
Name and explain the five kinds of inference processes identified by Secord (1958)
Hinton observes that employing inferences about the non-verbal aspects of a person can 'tell' us much more about them. But what are the underlying dangers and potential implications of making assumptions about a person's personality based on non-verbal information?
* Think of an instance where you made an erroneous judgement about someone on the basis of a brief contact. What went wrong?

Reading

For those who would like a clear and helpful account of the social psychology of social inference, Chapter 2 of M A Hogg and G M Vaughn's (1988) Social Psychology, London, Prentice Hall, called 'Social Cognition and Social Thinking' is very useful.