section six

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only.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

Our personal competence to operate effectively in a cross-cultural context is, as we have seen, a function of both individual interpersonal skills and our understanding of the context in which we are operating. Consequently, in relation to developing transcultural communicative competency within the context of British health care, we need to start from a broad understanding of this context. This is the institutional and social context within which interpersonal communication takes place.

There is a growing body of literature which provides detailed evidence of the variations in health, health care needs and access to health of different ethnic communities in Britain. This includes:

Ahmad, W. (1993) 'Race' and Health in Contemporary Britain, Buckingham: Open University Press.
Smaje, C. (1995) Health, Race, and Ethnicity, London: Kings Fund Institute.
Modood, T., Berthoud, R., Lakey, J., Nazroo, J., Smith, P., Virdee, S. and Beishon, S (1997) Ethnic Minorities in Britain: Diversity and Disadvantage, London: Policy Studies Institute.
Nazroo, J. (1997) The Health of Britain's Ethnic Minorities, London: Policy Studies Institute.
And see the module 'Towards an Epidemiology of Diversity' by Mark R D Johnson.

This literature reminds us that developing transcultural skills can never be reduced to simply becoming more sophisticated in using our channels of communication. We must employ these skills within a framework of understanding of contemporary ethnic relations in Britain. This will enable us to be sensitive to the possibly different routes into care of different patients; to their expectations of appropriate modes of treatment and to their own models of health and illness. The power of inter-group dynamics, and the ability to draw upon stereotypes in shaping our response to others, partially lies in our failure to remain consciously sensitive to this wider political context.

The Intercultural framework

The NHS now has a number of formal policy documents which encourage and require health care providers to be aware of the ethnic diversity of contemporary Britain and to ensure that service delivery is ethnically sensitive. In other countries the concept of culturally safe practice has proved to be a useful way of making these multiple demands simply understood.

In a British system of health care delivery, guided by the language and practice of clinical governance, a commitment to culturally safe practice can be given meaningful institutional support. We have already stressed the importance of the social context for determining interpersonal interaction, and nowhere is this more relevant than in relation to how individual nurses and health carers feel about the expectations placed upon them to deliver culturally safe care.

We have introduced above the concept of authenticity - of being true to oneself. Therefore, going through a superficial, literally a surface, demonstration of ethnic sensitivity is unlikely to fool anyone. In any case, as has become apparent, we have too many ways of 'leaking' our true feelings. After all, a representation of cultural awareness may all too easily be betrayed by the presentation of patronising resentment (see Danziger 1997).

In the nursing context, 'holistic individualised care' may be betrayed by feelings that this patient has lesser entitlement to care, or is being given an unreasonable amount of 'special care and attention'. Populist views about minority ethnic citizens and asylum seekers as being unfairly advantaged in relation to the national ethnic majorities are easy to find in the British press and other media. Thus, before moving on to examine how we might approach developing individual transcultural competencies it is necessary to first pause to reflect upon the contemporary context in which these skills may be developed and deployed.

All of us are familiar with the idea that we live in a multicultural society. However, there is also, often, a lack of clarity about what different people mean by multiculturalism. Concepts like 'political correctness' have made it possible to see a professional concern for being sensitive to someone else's culture and identity as some form of externally imposed fetish. Clearly, a significant proportion of colleagues feel comfortable in ignoring demands to develop transcultural competencies; and others express views and behave in ways that might best be described as racist. Therefore, it is clear to see that the social context in which transcultural interpersonal communication takes place is not necessarily one that is conducive to and easy or successful process.

In order to move forward we will reflect on a chapter from Gerrish et al's (1996) Nursing for a Multi-Ethnic Society. This reading exposes us to recent research based material which will help to structure our understanding of the context of transcultural communication, and our understanding of transcultural communication itself.

Implications for health care

At a personal level, nursing professionals need to be prepared to:

reflect honestly on their own ethnicity;
interrogate (both intellectually and emotionally) their response to the reality of ethnic diversity among their client population;
make explicit any implicit attitudes which might impact negatively on the professional care given to people of a different ethnic background.

For, as Gerrish et al comment:

An ability to adopt a, perhaps self-conscious, cultural relativity is a necessary starting point for responding to ethnic diversity. Without that, the acquisition of knowledge about other communities will be tainted at source, and minimal descriptive accuracy in bringing meaning and understanding to the behaviour of others will not be achievable. (1996:20)

Gerrish et al's suggestion is that nursing professionals need to acquire and develop transcultural communicative competence which requires cultural competence - learning to understand the cultural values, behavioural patterns and rules for interaction in specific cultures - the purpose of which would be to learn how to manage one's own behaviour so as to:

put those to whom you are speaking at ease, and create an environment in which you can then efficiently exchange the meanings, ideas, information and issues which are essential to professional care. (1996:27)

At the heart of this lies the capacity for 'adaptability' in the sense that you are able to 'suspend or modify your own cultural expectations' and 'accommodate to new cultural demands'.

It is an ability to respond flexibly and creatively to the challenges of cultural difference and intergroup posture, and to manage the stress generated by these in ways that do not distort your ability to respond to 'the stranger'. This really means that such an individual has learnt to transcend defensive responses to difference and had avoided rigid mental and behavioural strategies for handling the stress of cross-cultural interaction.

(Gerrish et al 1996:28)

In addition, an understanding of the structural dimension of ethnicity reminds us that interactions are not merely a matter of individual encounters. Institutional structures, policies, values and practices also exercise a powerful impact. This leads Gerrish et al to comment:

it is essential to examine those systematic structures of power over resources within institutions which determine both the type of resources made available, and their distribution across client populations. [Since] Any number of competent transcultural practitioners are not likely to impact upon the political process which allows inequalities of provision between health authorities to persist. (1996:32)

Exercise 6.1 Reflective activity

Reflect on your experience of cross-cultural contact; whether on holidays, at work or even in restaurants.
How do you rate your behavioural flexibility - do you find it easy/comfortable to take on new behaviour?
How easy do you find it to sustain a positive affective stance? Do negative inter-group postures easily come into play?
How open are you to new ideas?

Becoming transculturally competent - and the fear of failure

As discussed in the chapter 'Ethnicity, the minority ethnic community and health care delivery', communication across a cultural boundary is frequently accompanied by anxiety. This anxiety arises not only from the ambiguity inherent in such exchanges but also because of the fear of failure. After all it is no longer only personally awkward and embarrassing when communication breaks down, it may also be professionally threatening.

In addition, the 'expectation' that health care provision should be ethnically sensitive is made explicit by both Government and minority ethnic patients. Regrettably, the training and resources that have been required to ensure this state of affairs has not, to date, been put in place. Thus, individual nurses may feel exposed and vulnerable when faced by this mismatch of expectation and performance. Nor is this anticipation of failure stressful only in terms of professional sanctions; there is also an added possibility that their lack of competence may be explained as racism.

Certainly racism is to be found in the NHS and within nursing. But, incompetence in transcultural communication is not necessarily evidence of personal racist intent. A resistance to developing transcultural competence may be a racist refusal to recognise the identity, needs and rights of people from a different cultural background from oneself. But, the failure of institutions to develop staff competencies to enable them to meet the needs of minority ethnic clients, does not provide justification for labelling individual nurses as racist.

Nonetheless, a fear of being perceived to be discriminatory or racist is often found within the health care professions. Thus, anxiety about transcultural practice can be very high; and can seriously diminish the level of professional care being offered. Indeed, it can even inhibit the use of available knowledge and skills as nurses 'freeze' under the anxiety of 'getting it wrong'.

In interviewing nurses and midwives about their experience of transcultural practice a distressing implicit professional formula for practice frequently was revealed. It took the following form:

i) I deliver holistic individualised care.
ii) This patient has a minority ethnic identity : they are 'x'.
iii) I have learnt something of the culture and health beliefs of 'x'.
iv) It is wrong and dangerous to stereotype.
v) I dare not use what I think I know.
vi) I deliver holistic individualised care.
vii) I treat this patient as a unique human being.
viii) I am caring and sensitive; and empathise with them as a fellow human being.

This caring calculus produces a practice that is deeply humanistic; and universalistic in treating all people as equal. In their fear of stereotyping their patients some of the most caring and sensitive nurses deny themselves the possibility of recognising difference. Yet, being comfortable with difference is at the heart of transcultural care.

The model of transcultural communicative competence developed in Gerrish et al (1996) identifies two elements as present in its performance.

cultural communicative competence; and
inter-cultural communication.

Cultural communicative competence

This requires the nurse to learn to understand the cultural values, behavioural patterns and rules for interaction in specific cultures. This means developing specific knowledge and insights into a specific culture; and being prepared to draw upon that knowledge to guide your understanding of the patient or colleague.

In terms of Argyle's model it means having the necessary relevant information to enable you to translate your intentions into action; and to have a sensitive tuning to the appropriate stimuli in your environment to enable you to adequately tap the changes in the environment that will accurately inform your feedback. In interpersonal communication an understanding of the rules and values that shape expectations in particular cultures is necessary to an adequate understanding of roles and their definition. But, in a complementary manner, a knowledge of the micro-behavioural norms of interpersonal interaction is also essential to a reading of the responses to your communication. Of course, Argyle's model is based on the operation of a motor skill and consequently repetition and practice are essential. One definition of a skill is: an over-learned habit. Thus, we need to be careful to note that knowledge of rules is not the same as practice in the use of them. Whether it is driving a car, riding a bicycle or typing we all develop our own way of doing it. Our own way of sharing someone else's culture is something we need to become comfortable with. Thus, cultural communicative competence is no different to any other nursing skill. It has a knowledge base and is existentially acquired in practice.

Thus, cultural communicative competence requires us all to know about the identity and culture of the persons with whom we interact. This consequently means that we need to learn how to learn. How do we access relevant information, how do we know that it is reliable, how do we use it? And how do we learn from our use of it? Waqar Ahmad (1993) has provided strong and clear warnings about the dangers of simple minded experts and the naïve use of acquired knowledge.

Thus, we need to:

know how to acquire relevant information;
be reflexive about why we are seeking it; and
be sensitive in how we use it.

Intercultural communication

The analysis of transcultural communicative competence in Gerrish et al (1996) also identified a complementary dimension to cultural communicative competence - namely, intercultural communication. That is:

the generic ability to recognise the challenges of communication across cultural boundaries; and
the capacity to respond to such challenges in an open and reflexive manner

This represents, in essence, the essential perspective that is needed to enable us to enter into developing cultural communicative competence.

In addition, the reflexive awareness of our existing cultural schemes provides a necessary honesty about our repertoire for dealing flexibly with new encounters. Our willingness to encounter our 'normal' routines and expectations as problematic for other people is essential to our resisting ethnocentric responses to the challenges of communicating across cultures. Therefore, if we are to acquire knowledge and insight into another culture we can only use it if we are prepared to extend the usual cognitive, affective and behavioural capacities that we already possess.

We can expect to work on developing this level of open adaptability in relation to our thought processes, cognition; our feelings, affect; and our behaviour. The cognitive dimension of intercultural competence is defined by a willingness to resist being dogmatic and be open to new ways of seeing the world. It involves a rejection of the easy option of reducing new experiences to familiar and safe categories.

The affective dimension of intercultural communicative competence is defined by empathy and a willingness to be open to others. It is a natural complement to the nurse's aspiration to deliver individualised holistic care for it requires a rejection of the ethnocentric resentment of difference and an active emotional openness in our encounters with others.

The behavioural dimension relates directly to ability to express in action the openness and flexibility at the core of the other two dimensions. How willing are we to try new foods? How responsive can we be to other cultures different use of touch in conversation or the different social distance that is comfortable for them? The behavioural dimension is all about our ability to adapt and be flexible in new situations.

The importance of intercultural communicative competence is that it is not specific to relating to a specific culture. It is an invitation to build our generic confidence, and competence, in entering into any intercultural interaction. Unlike in cultural communicative competence, where the confidence is derived from already possessing knowledge about this culture, here the confidence is founded on knowing that we can rapidly learn what is required to ensure appropriate interaction in a new cross-cultural interaction. It is a personal style, a disposition toward difference, which builds competence in cross-cultural interaction through facilitating confidence and success in negotiating cultural difference.

Transcultural communicative competence is the creative synchronised fusion of cultural communicative competence and intercultural communicative competence. Intercultural communicative competence enables the nurse to work the ambiguity that is present in any cross-cultural interaction in an open and empathetic negotiation of the patient's identity and needs; whilst appropriate cultural communicative competence provides the knowledge and experience to enable the nurse to have confidence in responding to the ethnic identity of the patient. Clearly, one type of competence feeds off the other. An understanding of the nature and complementarily of these two forms of competence in shaping transcultural communicative competence will aid the health care practitioner to recognise the different forms of learning that are required in order to deliver culturally safe practice.

While completing the following task try to keep in mind the complementarity of cultural and intercultural competence.

Exercise 6.2 Activity: in pairs

What is the difference between cultural communicative competence and intercultural communication?

Reflect on the following questions and discuss your response with one other practitioner in your work setting:

in your professional community of practice what are the range of views about ethnic diversity in Britain?
what range of views are there about the requirement to develop culturally sensitive practice?
what implications does this have for your own ability to develop and deliver culturally safe practice?

The User's experience

Before moving into some more experientially based activities it is important to reflect on users' experience of nursing care specifically within the British context.

Gerrish et al (1996) carried out 75 interviews with Afro-Caribbean, Chinese, Gujarati, Irish, Jewish, Pakistani, Polish, Sikh and Somali users of nursing and midwifery care. In so doing, they identified four key aspects of care.

Language as a key issue in service delivery.
The attitudinal dimension - respect and the recognition of difference.
Recognising and meeting cultural needs.
The role of the minority ethnic professional.

Language as a key issue in service delivery

Too often users speak of using children, relatives or friends to act as translators...This introduces a whole range of limitations into the interaction between service provider and service user. There is no reason to believe that the ad hoc 'translator' has adequate linguistic competence to achieve the task efficiently. Specifically, they may be ill informed or ignorant of the medical jargon employed by the health professional and hence resort to guessing or merely having to declare that they have no idea what is being said. Additionally, there is the very real problem of confidentiality where both symptoms and treatment may be painfully awkward to share with a friend of family member. Thus the absence of an adequate interpretation service may lead to distressing or inefficient health care experiences...

(Gerrish et al 1996:38)

The attitudinal dimension - respect and the recognition of difference

linguistic competence alone is not a sufficient criterion for evaluating the quality of cross-cultural communication...[since]...Intonation and body posture may say very much more than a health care service provider may wish to acknowledge. [After-all]...Explicit verbal insults and racial epithets are not necessary to convey to a client a practitioner's sense of hostility and resentments: 'intergroup posture' may be more than adequately declared through non-verbal communication. [Therefore] ... An ability to demonstrate respect for the client and a degree of understanding of his or her world view are equally essential.

(Gerrish et al 1996:40)

Recognising and meeting cultural needs

While certain aspects of cultural beliefs and practices may be difficult to identify, and even more elusive to comprehend, from the outsider's perspective there are basic needs which are accessible and, while different in his or her particular case, part of a common experience of living.

(Gerrish et al 1996:43)

For example, food, notions of decency and privacy and access to particular provisions (e.g. skin and hair creams specifically developed for Black people)

The role of the minority ethnic professional

Clearly where user and carer share a common cultural background, even though there may be significant gender, caste, class and age differences, many of the difficulties of cross-cultural communication will be significantly minimised. ...However, ...there are dangers in allowing the ethnic matching of carer and user to be prescribed as the panacea to all the troubles facing the provision of nursing care in a multicultural society...

(Gerrish et al 1996:45-46)

For, while the nursing professions rightly require individual practitioners to take responsibility for the quality of their caring, it remains an inescapable truth that health care provision is highly responsive to government policy priorities and the allocation of scarce resources. We have seen in the literature the identification of 'blaming the victim' as a feature of some analysts' accounts of the health status of minority ethnic communities. Scapegoating health care professionals as the sole responsible cause of failures in health care delivery is equally inaccurate and unacceptable.

(Gerrish et al 1996:46)