Crossing borders, intraculturally and transculturally
Daily, we encounter some form of cultural clashing. This is a broad statement, but consider the following examples.
- You are driving on the interstate, and the driver of the car next to you attempts to enter your lane. You begin to reduce your speed to allow entrance. You say nothing and think nothing more of the event. The passenger riding in the front seat of your car begins to scream: "Speed up, speed up, don’t let them in front of you! The dummy driving that car is just a road hog!" You are shocked by your friend’s comments.
- At a restaurant, the server taking your order is not only chewing gum, but also making smacking sounds, blowing bubbles, and popping them. You believe it is OK to chew gum, but it is extremely rude and disrespectful to chew gum while working in a public setting.
- While traveling, you decide to visit a place of worship. In your hometown, dress attire for worship is "come as you are," even if it’s jeans and a T-shirt, so you don nice jeans, clean shirt, and a jacket. When you arrive at the out-of-town location, the men are dressed in suits with ties, and women are wearing dresses and high heels. The congregation immediately begins to stare and whisper, and several teenagers say, "Why is that person in jeans?"
What do these somewhat hypothetical situations have in common? Values and beliefs (cultures) are in direct conflict, resulting in cultural clashes.
Not if but when
Humans are wonderfully unique, with values, beliefs, and different ways of living and doing. Cultural clashing, therefore, is inevitable. It is not a question of if but when we will be called to navigate the choppy waters of cultures in conflict, and these clashes occur with varying degrees of intensity. As healthcare workers, we have cultural clashes with patients, as well as their families and support members. In healthcare settings, these clashes may be peer-to-peer, supervisor to subordinate, between and among units, and between and among departments and external agencies. In acute care settings, all of the above may occur multiple times every hour.
When you consider the number of cultural clashes that may occur in an eight- or 12-hour work period, it’s clear they can exhaust and drain even the most seasoned healthcare worker. These cultural collisions happen when values and ways of doing within a healthcare setting clash with those entering the system. When personal biases, prejudices, and stereotypes of healthcare workers are directed toward those using a system’s services, healthcare disparities may result
and may lead to cultural clashes between healthcare workers. What’s a healthcare worker to do?
Airlines give passengers these instructions: In the event of decompression, an oxygen mask will automatically appear in front of you. If you are traveling with a child or someone who requires assistance, put your mask on first, and then assist the other person. Similarly, before attempting to broker understanding and conciliation when cultural differences and clashes occur—this involves bridge building—healthcare workers must first be equipped to handle personal cultural clashes (Ellis Fletcher, 2015).
Self-care training needed
Yet where in our professional education, onboarding, or mandatory reviews are we educated on caring for self when cultural clashes occur? It seems logical enough. If the majority of a healthcare worker’s day is spent confronting cultural clashes, we as nurse leaders should provide support, guidance, and leadership in caring for self when clashes occur. Ideally, learning to handle cultural clashing should take place prior to cultural confrontation, when powerful clashing may happen, and refresher training should occur at regular intervals. Unfortunately, such self-care is not on the radar for most agencies and educators.
To engage in cultural clashing self-care, one should first have a working definition of biases, prejudices, and stereotypes. According to the unabridged version of dictionary.com, "bias
" involves a preconceived opinion whereas "prejudice
" is an opinion, either positive or negative, not based in knowledge. "Stereotyping
" conjures up a mental picture associated with a bias or prejudice toward a group or individuals with similarities.
A plausible next step is to apply cultural sensibility, a proactive behavioral process designed to help healthcare workers navigate cultural clashes they may experience on a daily basis. Rather than focusing on racial or ethnic differences, cultural sensibility provides a proactive guide for dealing with differences, starting with acknowledgment that, as healthcare workers, we all have biases, prejudices, and stereotypes (BPS). By proactively identifying one’s personal BPS (self-awareness), cultural sensibility enables healthcare workers to bracket—identify and suspend—their personal BPS, thus better preparing them for potential cultural-clash encounters. With their biases, prejudices, and stereotypes bracketed, healthcare workers can enter into situations that hold potential for conflict—whether between a healthcare provider and a patient or between two healthcare workers—and be confident that the participants will engage in a more culturally appropriate healthcare experience (Ellis Fletcher, 2015).
Five steps to cultural sensibility
There are five steps in the cultural sensibility process: 1) All humans have biases, prejudices, and stereotypes that are both conscious and unconscious. It follows that, because healthcare workers are human, they also have BPS. 2) Identify your personal BPS. 3) Learn to bracket—suspend—your BPS during healthcare worker interactions. 4) Active critical thinking and reflection will help healthcare workers to be present—in the moment—during healthcare worker interaction. 5) Workers facing potentially negative interaction who apply the cultural sensibility process are better able to hear, see, and grasp the meaning of the message—whether verbal or nonverbal—that another person seeks to convey. The journey of developing cultural sensibility is ongoing, but it begins with taking small steps to recognize one’s personal BPS. It is important to be mindful that cultural sensibility creates change in personal behavior.
Recently, a nurse colleague shared with me her frustration with a diabetic patient who kept scheduled provider visits at sporadic intervals, continued to poorly manage blood sugars, and rejoiced that he no longer eats carryout, fast-food fried chicken but now eats home-fried chicken sandwiches. The patient was rapidly approaching irreversible vision, kidney, and vascular damage.
During a verbally charged visit, both nurse and patient were frustrated with each other. The patient felt the nurse was not pleased with his progress and changes he had made. The nurse felt the patient was not listening and not following provider instructions. As their frustration mounted and voice levels escalated, the nurse internally paused. Recognizing her belief—assumption—that patients seek healthcare to receive instructions from the healthcare provider, the nurse realized that this assumption was her perspective, her bias—that it was all about what the healthcare provider told the patient to do.
At that point, the nurse who was sharing this story with me said she mentally removed—bracketed—her bias from the interaction. As the patient continued to angrily express his frustration, the nurse realized she did not know what the patient really wanted or why he did not follow her instructions. Upon coming to that conclusion, the nurse went from standing to sitting and said to the patient: "You’re right. I’m not listening to you. I apologize. Please tell me what is important to you in continuing to manage your diabetes."
In this example, the nurse rapidly moved through the cultural sensibility process. Her bias, she realized, was not racial, ethnic, or gender-based. Rather, it was a belief that patients want healthcare workers to tell them what to do and that they will follow those instructions in detail. Some patients may have that perspective, but to broadly assume that it is true of all patients is inaccurate.
Cultural clashing is a large topic. As nurse leaders, we can begin small by 1) providing basic definitions for attitudes and beliefs—BPS—that contribute to cultural clashing, 2) viewing appropriate situations from a cultural clashing perspective, and 3) inviting experts to explore cultural clashing and cultural sensibility in greater depth from a provider’s perspective.
Sally N. Ellis Fletcher, PhD, RN, FANP,
formerly a professor at the University of Rochester, is author of Cultural Sensibility in Healthcare: A Personal & Professional Guidebook,
published by the Honor Society of Nursing, Sigma Theta Tau International.
Ellis Fletcher, S. N. (2015). Cultural sensibility in healthcare: A personal & professional guidebook.
Indianapolis, IN: Sigma Theta Tau International.
To read about crossing borders intraculturally, see "A matter of gender
," by Sarmad Muhammad Soomar.