The Provider Culture

Providers of health care and patients often begin their relationship separated by a huge cultural gap. As providers of health care we are socialized into the culture of our profession. This professional socialization teaches us a set of beliefs, practices, habits, likes, dislikes, norms and rituals, factors that comprise a given culture. We speak a different language (medical terminology) and our understanding and beliefs regarding health and illness differ greatly from the population at large. Patients and staff also differ in social class. Doctors are often wealthy and nurses are fairly well off, in contrast, patients are disproportionately poor and suffer misfortunes which compound each other.

The Health Care Provider Culture (Spector, 1979)

Beliefs

a) Standardize definitions of health and illness. b) The omnipotence of technology. a) The maintenance of health and the prevention of disease via such mechanisms as the avoidance of stress and the use of immunizations. b) Annual physical examinations and diagnostic procedures such as Pap smears. a) Charting b) The constant use of jargon c) Use of a systematic approach and problem solving methodology. a) Promptness b) Neatness and organization. c) Compliance. a) Tardiness b) Disorderliness and disorganization. a) Professional deference and adherence to the "pecking order" found in autocratic and bureaucratic systems. b) Hand washing c) Employment of certain procedures attending birth and death. a) The physical examination. b) The surgical procedure. c) Limiting visitors and visiting hours.

Practices

Habits

Likes Dislikes

Customs

Rituals

Western medicine by its nature treats patients as medical objects, a biomechanical entity. Patients are detached from their own lives and life stories and physically taken from their home settings into the unfamiliar setting of a hospital, to be treated by different specialists. But patients often resist this treatment in a number of ways and the resulting conflicts express themselves as "ethical problems." Given the cultural and economic gaps between health care providers and patients, it is not surprising we often make moral judgments on the behavior of patients. Even if we deny the reality of the situation, as health care providers we must understand that we are ethnocentric. Health care providers adhere rigidly to the western system of health care delivery and with few exceptions, do not sanction any other methods of prevention or healing. We fail to recognize or use any source of medication that has not been proven to be effective by scientific means. So how can we as providers of health care, meet the perceived needs of the patient as defined by the patient, when we do not recognize nor sanction others beliefs regarding health and illness, prevention or treatment ? Care means that the patient should be treated as a human being, with a life beyond the hospital and a meaning beyond the medical world. Nursing care is hands on, a face - to - face encounter with the patient. It is entirely appropriate to explore alternative ideas regarding health and illness and adjust our approach to coincide with the needs of the specific patient Galanti (1991) makes two important points regarding disease etiology. First, the treatment must be appropriate to the cause. If the germs cause disease, kill the germs. If the body is out of balance, restore balance. If the soul is gone, retrieve it. If a spirit has taken over the body, exorcise it. If a rule has been broken, do penance. If an object has entered the body, remove it. All these remedies are perfectly logical. Whether these etiologies are the true causes of the disease is irrelevant. A patient who believes he or she is ill because of soul loss will not be cured by any amount of antibiotics. The mind is very powerful, as the placebo effect demonstrates. The patient's beliefs, as well as body, must be treated. Second, we must not let our ethnocentrism blind us to the merits in the beliefs of other cultures. They may be right. It is easy to look down on other systems, citing science to support Western medical beliefs. But all medical systems are based on observed cause - and - effect relationships. The major difference with the scientific approach is that science is falsifiable. A scientific hypothesis can be proven wrong. The beliefs of other systems cannot.

References:
Galanti G.A.: Caring for Patients from Different Cultures. University of Pennsylvania Press, Philadelphia, 1991 Spector, R.E.:Cultural Diversity in Health and Illness. Appleton - Century - Crofts, New York, 1979

Caring for Patients from Different Cultures

Geri-Ann Galanti Fourth Edition 312 pages | 6 x 9 Paper 2008 | ISBN 978-0-8122-2031-5 | $19.95s | 13.00 | Add to cart View table of contents "An excellent book for those interested in providing culturally responsive and effective care to our nation's increasingly diverse population"Dr. Robert Like, Robert Wood Johnson Medical School "A must-read book for any healthcare professional. . . . It should be in every hospital library."Caregiver Journal What happens when a Cherokee patient summons a medicine man to the hospital, or when an Anglo nurse refuses to take orders from a Japanese doctor? Why do Asian patients rarely ask for pain medication, while Mediterranean patients seem to seek relief for even the slightest discomfort? If the goal of the American medical system is to provide optimal care for all patients, healthcare providers must understand cultural differences that create conflicts and misunderstandings and can result in inferior medical care. Geri-Ann Galanti's updated classic, Caring for Patients from Different Cultures, is even more comprehensive than the first three editions, containing new appendices for quick reference, an expanded and updated bibliography with Internet resources, and a detailed index. Caring for Patients from Different Cultures contains more than 200 case studies illustrating crosscultural misunderstanding and culturally competent health care. The chapters cover a wide range of topics, including birth, end of life, traditional medicine, mental health, pain, religion, and multicultural staff issues. The case studies illustrate important concepts from the fields of cultural diversity and medical anthropology. This volume is an important resource for nurses and physicians in achieving cultural competency. Geri-Ann Galanti is on the faculty of the Department of Anthropology at California State University, Los Angeles, the School of Nursing at California State University,

Dominguez Hills, and the Doctoring Curriculum at the David Geffen School of Medicine at UCLA. ShareThis | View your shopping cart | Browse Penn Press titles in Health, Medicine, Caregiving | Join our mailing list
ur families are like unique cultures. Each culture has its own way of communicating, arguing, eating, sharing, and showing affection. Most cultures remain intact by passing along their nuances, habits, and sayings for hundreds of years, with only slight variations occurring within each generation. The same is true for families. When two people get married, it can be like a clash of cultures. Each person brings to the relationship their own unique way of communicating and dealing with conflict. As the infatuation stage wears off in most relationships, awareness of those differences become more apparent. This is around the time when couples start asking questions like:

Why won't you talk to me? Why do you treat me that way? Why do you shut down like that? Why won't you do the things I asked you to do? What's wrong with us?

No matter how hard we try to be different from our families (mainly our parents), we will repeat many of their behaviors throughout our marriage. It is important for couples to discuss with each other how their families behave in different circumstances, and explore reasons why. Couples then need to talk about how they would like to handle things in their own relationship. This will most likely involve a lot of compromise and will be something that couples will work on throughout their marriage. Part of having a meaningful and enjoyable marriage is having an awareness of each other's family culture. From there, couples can develop their very own unique way of communicating that incorporates positive aspects from both families, and hopefully

Nursing Responses to Transcultural Encounters: What Nurses Draw on When Faced with a Patient from Another Culture | pdf>>
Celeste Cang-Wong, RN, MS Candidate; Susan O Murphy, RN, DNS; Toby Adelman, RN, PhD

Abstract
Objective: We explored nurses experiences when they encounter patients from cultures other than their own and their perception of what helps them deliver culturally competent care. Methods: Registered nurses from all shifts and units at Kaiser Permanente Santa Clara Medical Center were invited to complete a questionnaire. Within the time frame allowed, 111 nurses participated by returning completed questionnaires. A descriptive survey was conducted using a questionnaire that contained multiple-choice, fill-in-the-blank, and open-ended items. Results: A large majority of respondents reported that they drew on prior experience, including experience with friends and family, and through their education and training, and more than half also included travel experience and information obtained through the Internet and news media. They also expressed a desire for more training and continuing education, exposure to more diverse cultures, and availability of more interpreters. When respondents were asked to enumerate the cultures from which their patients have come, their answers were very specific, revealing that these nurses understood culture as going beyond ethnicity to include religious groups, sexual orientation, and social class (eg, homeless). Discussion: Our research confirmed our hypothesis that nurses are drawing heavily on prior experience, including family experiences and experiences with friends and coworkers from different cultures. Our findings also suggest that schools of nursing are providing valuable preparation for working with diverse populations. Our

research was limited to one geographic area and by our purposeful exclusion of a demographic questionnaire. We recommend that this study be extended into other geographic areas. Our study also shows that nurses are drawing on their experiences in caring for patients from other cultures; therefore, we recommend that health care institutions consider exposing not only nurses but also other health care professionals to different cultures by creating activities that involve community projects in diverse communities, offering classes or seminars on different cultures and having an active cultural education program that would reach out to nurses. The experiences provided by such activities and programs would help nurses become more sensitive to the differences between cultures and not immediately judge patients or make assumptions about them.

Introduction The Changing Face of the Patient Population

The cultural face of the Americas population is changing. According to the US Census Bureau,1 one of every three persons in the US comes from an ethnicity other than non-Hispanic white. In Kaiser Permanente (KP), Santa Clara County, CA, we care for an especially diverse population. The most recent census,2 which was in 2006, showed that of the 1.7 million people in Santa Clara County, CA, 63% are white, 30.5% are Asian, 2.8% are black, 0.8% are American Indian or Alaska Native, 0.4% are native Hawaiian or other Pacific Islander, and 2.5% are persons who identified with two or more races. In 2004, the Kaiser Family Foundation published the Sullivan Commission Report,3 recommending the following three goals related to racial and ethnic diversity: First, all racial and ethnic groups in a community should be represented among health care professionals. Second, talents, skills, and ideas from ethnically different groups should be incorporated systemwide. Third, health care institutions should change the health care culture by promoting diversity through creating professional development opportunities. Overall, the commission3 emphasized the importance of increasing the representation of minorities in the workforce. Despite this growing diversity in the US and in our service area, diversity among nurses has not kept up with that of the population. In many health care settings, nursing does not reflect the demographics of the general population. Even when nurses are well educated and culturally sensitive, the lack of ethnic diversity among them creates a challenge for those who are attempting to provide holistic care to an increasingly diverse group of patients. Holistic care is a term often used in nursing that means to care for patients in their entirety: body, emotions, mind, and social and cultural, environmental, and spiritual aspects. To develop an effective and therapeutic relationship with a patient, a nurse must establish trust and respect with the patient. Acknowledging a patients individual cultural perspective is an important part in establishing this trust.4,5 Misunderstanding cultural differences can be a barrier to effective health care intervention and can even cause harm. This is especially true when a health care professional misinterprets or overlooks a patients perspectives that are different from those of the health care professional.

Cultural Encounter as Workplace Stressor Workplace stress has been defined as the physical and emotional outcomes that occur when there is disparity between the demands of the job and the amount of control the individual has in meeting those demands.6 Stress may occur when nurses are unable to provide the kind of care that is expected of them. If nurses are unprepared to deal with cultural differences in the workplace, a stressful situation can result. The presence of workplace stressors not only affects the delivery and quality of care but also creates unnecessary costs for the institution. When nurses are constantly exposed to stress, absenteeism increases and employee turnover may result, both of which can have a significant financial impact on the organization. Family and Cultural Sensitivity Family support during illness has unique meanings across cultures that help maintain integrity within the extended family, especially in an unfamiliar environment with norms and values that differ from those of the family. In caring for patients and interacting with families, nurses must demonstrate cultural sensitivity, respect diverse practices and beliefs, and understand how cultural differences might alter the way care is provided. In some cultures, it is considered a moral responsibility for a family member to be by a patients side and to provide care.711 Family members may find it difficult to arrange transportation to and from distant medical facilities, to locate someone to stay with the patient, or to take care of children during a parents hospitalization; in such a situation, they often rely on other members of their widely extended family. In some cultures, the

family stays with the patient to ensure that if the patient dies, a family member is there to hear the patients last words. Communication Across Cultures Sensitivity to cultural needs, beliefs, and values, including in communication, is essential for nursing interventions to be effective.12 Communication is the central factor in providing transcultural care.13 One of the most obvious challenges occurs when a nurse and a patient do not speak the same language. Non-native English-speaking patients or nurses may have to process English conversation in their native tongue-interpreting word for word, thinking in their native tongue, and then trying to make sense of their thoughts before expressing them.14 In the meantime, there may be an uncomfortable silence and a delay in response, which the patient may misinterpret. It is difficult to give timely care when the nurse has to look for a certified interpreter at the hospital. Nailon15 studied the experiences of Emergency Department (ED) nurses when dealing with non-English-speaking Latino patients. She found that there was often a delay in care because nurses had to interrupt their nursing assessment to look for a translator who was not always available. Sometimes the nurses checked vital signs and reviewed the test results, choosing to secure a translator later when a physician would be ready to assess the patient. The nurses expressed their concern that care was delayed because of a lack of interpreters, especially in a setting with a great many patients requiring acute care. It was also a concern that nurses were using family members as interpreters, because patients might have withheld some information because they knew that it could affect their relationship to the family. Other times, nurses did not use telephone translators, even when such aid was readily available; instead, they tried to communicate using their limited Spanish vocabulary. Sometimes nurses would ask a staff member who was not formally trained to interpret. Using an interpreter who is not formally trained may result in inaccurately interpreted messages; if nurses cannot verify patient responses, there is no assurance that the message was accurate. Another way of communicating cultural needs among staff is through a patients medical record (charting). Such documentation can help promote cultural sensitivity and foster continuity of care.16 Theoretic Perspective Generally, the providers attitudes and personal biases are the primary barrier to culturally competent care. Several conceptual frameworks have been proposed to support the development of greater cultural sensitivity in delivery of health care.12,1719 The common denominators among these models and frameworks include gaining self awareness, checking for personal biases, avoiding the tendency to stereotype, and refraining from discrimination. An introspective examination of this kind is, of course, challenging, especially for health care professionals who have limited transcultural experience or have not been trained in dealing with cultures different from their own. In developing the ACCESS (assessment, communication, cultural negotiations and compromise, establishing respect, sensitivity, and safety) model for providing health care, Narayanasamy20 explored nurses responses to the cultural needs of their patients. Nurses were asked to give an example of a nursing situation in which cultural care was given. On the basis of the data, Narayanasamy reported that the nurses tended to associate cultural needs with food or religion. Even though the study suggested that nurses recognize cultural needs and that they actively practiced culturally sensitive care, such care was interpreted within a more narrow understanding.20 Research Question Our study built on the work of Narayanasamy20 in 2003, in that we wanted to gain a greater understanding of nurses cultural awareness by asking nurses to describe their own experiences with diverse patients and families. Specifically, the aim of our study was to explore how nurses know how to care for patients from cultures different from their own. Given the growing diversity of our patient population, we sought to clarify what nurses draw on in taking care of patents from multiple cultures. We hypothesized that many of the ways they do so are drawn from personal or professional experience and exposure to other cultures, as well as from formal education.

Methods We developed a questionnaire to inquire how nurses responded to transcultural encounters. It included multiple-choice, fill-in-the-blank, and open-ended questions (Figure 1). This format invited nurses to speak for themselves about what they saw as culturally important and unique experiences. (The responses to the multiple-choice and fill-in-the-blank questions are reported here; the open-ended responses will be reported in a subsequent article.) Approval for the study was obtained from both the KP Northern California institutional review board (IRB) and the IRB of the university in our service area. Questionnaires were distributed to 250 registered nurses from KP Santa Clara Medical Center. Nurses were recruited from all shifts and units (including the ED, critical care, pediatrics, maternal and child, medical surgical, telemetry and step-down units, and the perioperative department). A letter of information was attached to the questionnaire, outlining the purpose of the study, explaining that respondents would remain anonymous, and inviting participants to return their completed surveys to a designated box on each unit.

Results One hundred eleven nurses completed the survey--a response rate of 44.4%. Four of the items on the questionnaire (items 1, 2, 5 and 6) were multiple-choice and fill-in-the-blank questions. Item 1 invited participants to reflect on what they draw on when they are caring for someone from a different culture (Figure 2). The questionnaire provided multiple possible answers; participants were asked to circle all answers that applied and to add other answers of their own. A large majority of the respondents reported that they drew on prior experience, including experience with friends and family, and on their education and training; more than half also included travel experience and information gained from the Internet or the news media. Participants were also asked to enumerate the different cultures, communities, or ethnicities represented by the patients they had cared for (Table 1). Although some respondents identified broad ethnic categories (Caucasian, Asian, African American, and Hispanic), the specificity and breadth of the responses given were unexpected and remarkable. Participants identified unique, highly specific groups or ethnicities, including Croatian, Russian, East Indian, Korean, Tibetan, Yapese, Hmong, Nigerian, Ethiopian, Brazilian, Nicaraguan, Cuban, and Colombian. Furthermore, their responses revealed that these nurses understood culture as going beyond ethnicity to religious groups, sexual orientation, and social class (eg, homeless). In this article, we have chosen to fully report the wide range of responses that participants listed. We suspect that this breadth and specificity reflects a population of nurses who are particularly socially and culturally sensitive, who recognize the unique attributes of patients beyond broad categories of ethnicity or race. We do not know if a similar specificity and breadth of responses would be obtained if our questionnaire were given to different health care professionals or administered in more rural or more socially conservative communities and agencies. However, this might be an interesting area to investigate in a future study. In item 5, participants were asked to identify (without any prompts) what resources had proved helpful in caring for patients from other cultures. Respondents reported that interpreters, ethnically diverse coworkers, patients and their families, have been especially helpful to them. The range of resources cited by the respondents indicate that they appreciate the variety of resources that have influenced their care, including verbal and nonverbal communication mechanisms, charting, and other coworkers, such as clergy and social workers (Table 2). Finally, the nurses were asked what else they felt they needed to be able to provide more culturally competent care. Limited choices were provided for this item, and respondents were asked to circle as many as were relevant and to add other needs. Seventy-seven percent (86 respondents) reported that they wanted more training and continuing education on culture; 63% (71) said that there should be more interpreters. Respondents also perceived more exposure to more diverse cultures, as well as reading materials, as potentially helpful. When nurses were asked what would help them provide culturally competent care, a significant number of respondents agreed that training and continuing education would be helpful (Figure 3).

Additionally, >50% of the respondents replied that interpreters, exposure to more diverse cultures, and reading materials would help them give culturally competent care.

Discussion In this study, we were inspired to address some of the concerns raised in the Sullivan Commission Report3 concerning potential health disparities resulting from the lack of a diverse and culturally competent workforce. Our patient population, especially in Santa Clara, is unusually diverse, and our nursing workforce, although also ethnically varied, does not yet reflect the extent of the diversity of our patient population. In our study, we invited nurses from all inpatient units at the Santa Clara inpatient facility to share their experiences in working with diverse populations. Specifically, we addressed the questions What do nurses draw on when caring for patients and families who are from a culture different from their own? How do nurses know what to do when caring for a diverse patient population? What resources have been helpful to them in these kinds of situations? What other resources do nurses believe would be helpful in increasing their cultural competence? These are critical questions to answer if we are to meet the goals of the Sullivan

Commission. We have reported here our findings from the descriptive portion (multiple-choice and fill-in-theblank items) of the study. Study participants reported working with an unusually broad and detailed range of cultures, and their responses revealed that many of the nurses understand culture as extending far beyond broad ethnic categories (white, black, Hispanic, Asian), to include individuals from specific, less common cultures, social groups, religions, and social class. We suspect that this reflects a unique level of cultural sensitivity and awareness. We do not know if a similar response would come from other health care professionals, from nonurban centers, or from more conservative states. Sampling from only one facility in one geographic setting is clearly a drawback, and we would recommend that this investigation be extended into other geographic and political regions. In this study, we asked nurses to identify the resources that they find themselves drawing on when caring for a patient of a culture different from their own. Their responses confirmed our hypothesis that nurses are drawing heavily on prior experience, including family experiences and experiences with friends and coworkers from different cultures; a large majority also reported that they drew on their training and education, which suggests that schools of nursing are providing valuable preparation for working with diverse populations. A controlled, statistical study measuring the impact of such training on their graduates would be a worthy area of inquiry for schools of nursing. The participants in this study found certain resources very helpful, including coworkers, translators, clergy, and communication by documentation in medical records. However, what stands out when one looks at the question of necessary resources is the very clear message that nurses want more continuing education and more translators. These are areas where health care agencies can follow up immediately. We can expand translation services. We recommend that efforts be directed toward identifying the educational interventions and continuing-education approaches that are most effective in fostering cultural sensitivity. The participants in this study specifically indicated that more experience with diverse cultures would be especially helpful. A significant limitation of our research is our purposeful decision to not include a demographic questionnaire because we wanted to make our study anonymous, thereby encouraging participants to be completely honest in their responses. Later, as we were analyzing the data, we found that it would have been especially helpful to know whether the cultural, linguistic, and educational characteristics, age, or religious ties of respondents were related to their perceptions and experiences. Study respondents also brought rich, open-ended descriptions of their transcultural experiences with patients, their insights, and their challenges. The qualitative responses reveal an amazing breadth and depth of cultural sensitivity and creativity as well as the frustrations and challenges in addressing language, behavioral, and familial differences. These findings will be reported in a future article.
Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgment Katharine OMoore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Grieco EM, Cassidy RC. Overview of race and Hispanic Origin: 2000: Census 2000 Brief [monograph on the Internet]. Washington, DC: US Census Bureau; 2001 March [cited 2009 Jun 3]. Available from: www.census.gov/prod/2001pubs/c2kbr01-1.pdf. 2. State and county QuickFacts: Santa Clara County, California [Web page on the Internet]. Washington DC: US Census Bureau; 2006, updated 2009 May 5 [cited 2009 Jun 3]. Available from: http://quickfacts.census.gov/gfd/states/06/06085.html. 3. Briefing: missing persons: minorities in the health professions [monograph on the Internet]. Menlo Park, CA: Kaiser Family Foundation; 2004 Sep 20 [cited 2009 Jun 3]. Available from: www.kaisernetwork.org/health_cast/uploaded_files/092004_sullivan_diversity.pdf. 4. Clegg A. Older South Asian patient and carer perceptions of culturally sensitive care in a community hospital setting. J Clin Nurs 2003 Mar;12(2):28390. 5. De D, Richardson J. Cultural safety: an introduction. Paediatr Nurs 2008 Mar;20(2):3944. 6. Lambert VA, Lambert CE. Nurses workplace stressors and coping strategies. Indian J Palliative Care 2008 June;14(1):3844. 7. Harle MT, Dela RF, Veloso G, Rock J, Faulkner J, Cohen MZ. The experiences of Filipino American patients with cancer. Oncol Nurs Forum 2007 Nov;34(6):11705.

8. Juntunen A, Nikkonen M. Family support as a care resource among the Bena in the Tanzanian village of Ilembula. Vard I Norden 2008 Sep 22;Publ No. 89;28(3):248. 9. Liao MN, Chen MF, Chen SC, Chen PL. Healthcare and support needs of women with suspected breast cancer. J Adv Nurs 2007 Nov;60(3):28998. Erratum in: J Adv Nurs 2007 Dec;60(5):575. 10. Gerdner LA, Cha D, Yang D, Tripp-Reimer T. The circle of life: end-of-life care and death rituals for HmongAmerican elders. J Gerontol Nurs 2007 May;33(5):209; quiz 30-1. 11. Searle C, McInerney F. Nurses decision-making in pressure area management in the last 48 hours of life. Int J Palliat Nurs 2008 Sep;14(9):4328. 12. Narayanasamy A. The ACCESS model: a transcultural nursing practice framework. Br J Nurs 2002 May 9 22;11(9):643650. 13. Sherer JL. Crossing cultures: hospitals begin breaking down the barriers to care. Hospitals 1993 May 20;67(10):2931. 14. Parrone J, Sedrl D, Donaubauer C, Phillips M, Miller M. Charting the 7 cs of cultural change affecting foreign nurses: competency, communication, consistency, cooperation, customs, conformity and courage. J Cult Divers 2008 Spring;15(1):36. 15. Nailon RE. Nurses concerns and practices with using interpreters in the care of Latino patients in the emergency department. J Transcult Nurs 2006 Apr;17(2):11928. 16. Gebru K, Ahsberg E, Willman A. Nursing and medical documentation on patients cultural background. J Clin Nurs 2007 Nov;16(11):205665. 17. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a culturally competent model of care. Cincinnati, OH: Transcultural C. A. R. E. Associates; 2003. 18. Giger JN, Davidhizar RE, editors. Transcultural nursing: assessment and intervention. St Louis, MO: Mosby; 1999. 19. Leininger M, McFarland MR. Transcultural nursing: concepts, theories, research, and practice. 3rd ed. New York: McGraw-Hill; 2002. 20. Narayanasamy A. Transcultural nursing: how do nurses respond to cultural needs? Br J Nurs 2003 Feb 13 26;12(3):18594.

Chapter 229Dealing with Patients from Other Cultures

Robert W. Putsch, III and Marlie Joyce.

Methodology in Cross-Cultural Care

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The DiseaseIllness Dichotomy

"Sickness" is what is happening to the patient. Listen to him. Disease is what is happening to science and to populations. (Weed, 1978, p 205)1 The biomedical model has become a cultural imperative, its limitations easily overlooked. In brief, it has now acquired the status of a dogma Biomedical dogma requires that all disease be conceptualized in terms of derangement of underlying physical mechanisms. (Engel, 1977, p 130)
1

Weed's use of the term sickness encompasses issues raised by others discussing the "illness vs. disease" dichotomy as it applies to biomedical practice (see Engel, 1977; Fabrega, 1975; Mechanic, 1968; Kleinman, 1978). In addition, he uses the term to describe the sequelae of complex interactions between multiple, interactive physiologic, psychologic, and social problems.

Health care is a complex issue. Cultural and language barriers complicate the situation. Western medicine has developed into a subculture with its own history, language, codes of conduct, expectations, methods, technologies, and concerns about the science which supports it. Science teaches us that human populations are governed by biologic universals that transcend cultural boundaries. The methods and language of biologically based and somatically focused health care have created an extraordinary gulf between practitioners and the public they serve.

There is a disparity between the biomedical categorization of human disruptions as disease and the patient's personal and social experience of illness. The dichotomy between disease and the illness experience has provoked extensive commentary. It has been proposed that the inability to deal with illness is a major failing of biomedicine. Cross-cultural circumstances often magnify the discrepancy between the views held by patients and health care providers. The inability to recognize and deal with perspectives of illness that deviate from those of the biomedically trained practitioner can paralyze attempts at identifying problems and developing plans for solving them. Biomedicine must use approaches that recognize and account for the views and values of the individual and of cultures, not only in determining the nature of a patient's problems but also in describing solutions. To undertake this task, the practitioner must be prepared to accommodate to the dictates of biology as well as the experience of illness as it is perceived by the patient, his family, and his group.

Issues of Provider Dominance in Communicating with Patients

Providerpatient communication involves socialization, diagnostic inquiry, planning, negotiation, goal setting, therapy, and education. As a verbal interchange progresses, each communicant has an evolving sense of his or her contribution to the information being shared, its basic meaning and content. Cultural boundaries are a major source of discrepant views of reality. In patient care, factors that distort the development of commonly shared information will necessarily alter the perceptions of clinical reality. Clinical realities are formulated in a setting heavily influenced by a provider-dominant relationship with recipients of health care. Consider that (1) the provider has been asked to help, diagnose, counsel, treat, and often to certify the patient as "sick" in a socially approved fashion; (2) the provider organizes the discussion, directing it in a fashion that will be optimally relevant to the patient's complaints and situation; (3) the provider molds patient responses and findings into recognizable, manageable patterns (this allows for problem description via paradigms about illness that have been developed and accepted within the context of biomedical practice); (4) the provider determines which portions of the material will be regarded as significant, and this decision is often made unilaterally, independent of the patient's views; and (5) the provider then describes both the diagnostic and therapeutic actions to be taken. Provider dominance may introduce an extraordinary bias, which can lead to a unilateral and ethnocentric view of "what's wrong." Provider views may be further biased by his or her personal background, values, and social class. In addition, formal training, instruction and certification in medical methodology creates a sense of correctness, authority, and superiority in which "the doctor knows best." These circumstances can lead to a situation in which patient views are overlooked or excluded as invalid concerns. Faced with the potential for discrepant views of what constitutes illness in cross-cultural interchanges, the provider must first recognize what it means for him or her to be in a dominant role. Provider dominance can serve to impede rather than improve communications. Failure to recognize this issue can block the practitioner's ability to consider the patient's views and role in the illness process.

Accommodating to a Broader Universe of Patient Needs and Views

Symptoms and disruptive life events are often a stimulus for problem-solving activities. Patients often use more than one system for problem solution. For example, it is not unusual to discover that a "modern" Westerner has called upon biomedicine, religion, and a popular therapy like chiropractic to solve a problem. This circumstance can be diagrammed as follows:

In patient care settings, biomedical and popular systems of care must be viewed as parallel, often simultaneous activities. It is often necessary to reach an accommodation between them. The patient's views must be taken into account and dealt with. It is clear that popular or folk therapies often work, although at other times they may have a negative effect. When patients have special knowledge or views (e.g., a cultural construct of cause and necessary therapy), a language or communication problem, or

familycommunity problems, these issues may need to be elevated to a level of concern on a par with a problem such as congestive heart failure. Cross-cultural accommodation in the care process allows biomedical, psychosocial, and popular definitions to coexist within the framework of both cultural systems. It requires that patient and provider consider plans and therapy directed at problems arising from both points of view. Failure to establish this accommodation may lead to failure in the health care process.

Ethnocentricity in Differing Diagnostic and Therapeutic Traditions

Diagnostic and therapeutic processes in different cultures have evolved from both ancient and borrowed traditions. Each healing tradition, including biomedicine, is inherently ethnocentric. In cross-cultural settings, it is necessary for both patients and providers to accommodate to the circumstances of an illness described in the context of more than one system. In general, these systems involve the discovery and evolution of an illness, a description of what is wrong, the actions taken, and attempts at resolution. Patients may connect life process and symptomatology in a way that does not fit with biologic definitions.2 In addition, special knowledge and popular health beliefs may play a prominent role in patient concerns. Individual experience with traditional practices and beliefs as well as the ability to articulate them may vary. Many cultures discourage the revelation and exposure of personal and family issues. Unfortunately, biomedical focus often precludes these revelations, and they remain unrevealed and unspoken. Each step of the problem-solving process is ethnocentric. In cross-cultural care, patientprovider interactions are complicated by the existence of parallel, usually discrepant, explanatory systems that may include disparate descriptions of natural phenomena. When an event occurs, entirely discrepant problem-solving methods and views may be called upon to describe and explain "What's wrong?" "Why?" "What should we do about it?" Hidden behind explanatory systems we find variations in communication and language use, different expectations regarding interpersonal interactions and interpersonal responsibilities, as well as different approaches to problem solving. The very complexity of cross-cultural circumstances magnifies the serious problem biomedicine currently has in dealing with nonbiomedical issues.

The Application of Problem Orientation in Cross-Cultural Care

The problem-oriented method, described by Weed (1969), shifted medicine away from narrow biomedical focus and conclusions. It was his view that: doctors prefer to see only physical problems on a problem list; they"re neater. A patient may resent a doctor's suggestion that problems can be blamed on his or her spirit, attitude, mind, home or job; and some doctors don"t like patients who want to discuss their spirit, mind, home or job. Most of medicine should be understanding and grappling with interactions between social and mental and physical problems. (Weed, 1978, p 19) This approach facilitated a methodologic shift. Weed encouraged practitioners to state problems in language that best described the patient's circumstance. This prompted the use of a broader descriptive process. Biomedical and mental health diagnostic endpoints became part of an expanded universe of descriptions of patient's problems. If the problem-oriented methodology is used appropriately, one has to account for the patient's view and devise a care plan that accounts for the complex interactions between medical, social, psychiatric, and demographic 3 issues. Weed developed a basic description of problem solving around illness episodes (Fig. 229.1). This four-step model can be applied to problem solving in general, and may be used to compare the work of health care providers and healers universally. A formal outline of problemoriented problem solving is described in Figure 229.2.

Figure 229.1 Problem solving around illness episodes.

Figure 229.2 The problem-oriented method in biomedical practice. We will examine each aspect of medical interactionsdata gathering, problem description, plans for care, and followup activitiesfrom the perspective of cross-cultural circumstances. The purpose of this process is (1) to point out the differences in expectations regarding varying modes of health care and "healing"4 interventions; (2) to suggest steps that allow for and encourage cross-cultural exchange that incorporates and accounts for both the provider's and the patient's view of "what's wrong"; and (3) to describe an adaptation of biomedical methodology that allows for a broader study of illness process from both intracultural and intercultural perspectives.

Data Gathering
The patient's sense of what's wrong is based on prior life experience, the course of recent events, and the lessons taught by cultural process. Fears, as well as hopes and expectations, are based on this prior experience. There may be a basic disparity in expectations regarding how a problem is uncovered or solved. Consider the dichotomy between biomedical and traditional Native American diagnostic techniques: Biomedicine Assumes People learn things by detailed inquiry and examination. People learn things by means of prayer, visions, dreams or divination. Native American Medicine

Thorough inquiry depends upon Extensive or brief questioning, physical or lab examination. Extensive or brief divination, prayers or supplication, entering into a trance state.

Diagnostic practices worldwide are based on a broad spectrum of folk beliefs and historical traditions, and often on magical or religious practices. Whether the parallel diagnostic technique is pulse reading by a traditional Chinese doctor, the Nooksak sgwdli instrument, or a Hmong shaman's trance, the message is similar. 5 The expectations generated by these practices may lead to puzzlement with biomedical diagnostic practices and/or the attribution of magical qualities to both diagnostic and therapeutic procedures. Extensive questioning at the onset and during the course of an illness may puzzle those whose culture does not prepare them for biomedical methods of problem solving. Uncertainty in Cross-Cultural Inquiry Faced with uncertainty about what to expect in diagnostic or therapeutic encounters, the patient may withhold personal views of what's wrong or histories of nonbiomedical diagnostic and therapeutic actions already undertaken. Patients may be reluctant to discuss beliefs, herbal therapies, home remedies and practices, and religious efforts at healing. They often fear the practitioner's disdain for these activities. Information may be withheld or altered to avoid labeling, to cope with anxiety about the illness, and at times to comply with provider's wishes. Although scant systematic evidence regarding patient behaviors in different crosscultural settings is available, the literature suggests that patients will report their illnesses differently depending on the behavior, language skills, ethnic identity, and degree of specialization of the biomedically trained practitioners they encounter.

Biomedical diagnostic technique includes history, physical examination, and laboratory investigation. By contrast, in some diagnostic traditions questioning and touching the patient is not a routine. For example, Navajo crystal gazers use quartz crystals to "see" objects shot into a patient, and in Vietnam: traditional practitioners of Indochinese medicine were not allowed to touch the body of their female patients, except to take their pulse. A female figurine was provided by the physician, and the wise physician could diagnose physical complaints of female patients based on the patient pointing to the area on the figurine corresponding to her own symptoms. (Hoang and Erickson, 1985) Alternative Inquiry Techniques Since the expectations set by traditions vary, the question arises: how does a non-Western traditional patient react to biomedical diagnostic techniques and settings? As the personal experiences and background of provider and patient are increasingly disparate, each participant has diminished ability to relate to the other's perception of the illness experience. As a result, it is useful for the provider to shift the interview focus as follows. Broaden Inquiries About the Family History The family history is a traditional part of medical inquiry and is crucial in cross-cultural settings. It is a major source of information and simultaneously allows the provider to show interest and become familiar with a patient's background. An expanded family history often reveals information and concerns that are not offered spontaneously. Many traditional cultures are tied to an extended family process in ways that surprise Westerners. For this reason, the inquiry needs to go beyond the "did anyone ever have ?" stage. It is useful to discuss the whereabouts and current activities of family members. Look for similar symptoms or illness in the family, and establish the dates and possible causes of these events. For example, in Native American and refugee families it is quite common to discover multiple incidents of loss, injury, and illness. Look for problems and events within family and community that the patient ties to the illness experience. Explore life events, day-to-day activities, and interpersonal relationships. Irrespective of the character and source of the current illness episode, narratives regarding prior life experiences help uncover the focus of patient views and explanations. Seek Alternative Explanations for the Illness The explanations used by patients are dynamic and change over time. They represent an amalgamation of the patient's life experiences, knowledge, training, and experience with the illness as well as with therapeutic efforts and advice. Some patient explanations and beliefs are based on highly focused cultural constructs of illness. Kleinman et al. (1978) have used direct questioning to elicit these patient "explanatory models."6 Direct questioning is often revealing and prompts a clear description of how patients view their illnesses. These revelations are often key to problem solving, as illustrated by the case in Figure 229.3.

Figure 229.3 A patient's explanatory model for his illness. At times, however, direct inquiry is unsatisfactory. Many groups and individuals will not discuss personal or ethnocentric views until the interview technique is altered. Furthermore, some individuals feel that the direct questions about what they think has caused their problem are a sign that the provider is uncertain ("If you don"t know what's caused my problem, I"m in the wrong place."). This issue was pointed out by Harwood (1981), who noted that some ethnic groups "expect the physician to be the ultimate experts on diagnosis and treatment."

The following techniques help to obtain information in circumstances in which the patient seems reluctant to provide explanations or historical data: 1. Use an indirect approach, externalize questions by referencing problems in others. Traditional patients who are unwilling to answer questions regarding feelings and fears directly often provide illustrations of their own concerns by discussing illness in others. Acknowledge traditional beliefs, and illustrate them. Reference folk terms in conversation, or discuss what others have said in similar circumstances. For example: as ill as you have been Patients who are} ill the way you are they can"t sleep they have had trouble with dreams (or reference an actual dream) tell me} friends say they were (use a relevant folk term, eg, embruhado)

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Change direct "questions" into narrative statements (as in the examples given in 2). Information exchanged in this fashion gives patients and families a broadened sense of the practitioner's focus, permits discussion of issues often left undisclosed, and avoids direct inquiry. Inquire about special terminology that may apply to the problem ("What is this called in your own language?"). If the patient doesn"t know, ask what a grandmother or an elder would say about the difficulty. This indirect approach sidesteps the unwillingness of some traditional patients to discuss their problems openly and directly appeals to family knowledge and beliefs. Inquire about dreams and difficulties with sleep. Discussion of sleep and dreaming patterns often leads to the revelation of key information regarding the illness's impact and the nature of the patient's concerns. Dreams have increased significance in settings where magicalreligious beliefs have played a role in healing and problem solving. They are often critical markers in the assessment of mental status.

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Take Language and Communication Style into Account If a patient's personal vocabulary does not include terms like depression, allergy, cholecystitis, or even gallbladder disease, these words should be avoided. Response times in speech patterns vary. Native Americans often report that "Anglos go too fast," and do not take sufficient time in conversation. Some individuals are perplexed by a provider's insistence on reporting certain details while seeming to ignore others (which may be important to the patient). Building trust is a major issue. Individuals from small groups or rural backgrounds are accustomed to dealing through family and kinship networks. Help is sought through personal contacts and generally comes from individuals known to the family or community. Health care institutions often represent loss of personal choice in the sense that the patient does not "know" the providers, and vice versa. Breaking this barrier is an essential component of providerpatient interactions and often involves breaking the pattern of neutrality, distance, and noninvolvement that physicians are encouraged to use. Summary The altered interviewing methods presented here are aimed at encouraging the patient to discuss special life events, issues, or beliefs. These modes of inquiry establish familiarity and acceptance on the examiner's part and simultaneously broaden the database via wider-ranging discussion of the views held by the patient. The establishment of rapport with patients extends the purpose of interviews and the health care process. Elevating patient concerns and views to a level of significance and respect is not only important but requires additional time and a certain level of personal commitment.

Problem Description
Descriptions of "what's wrong" are heavily tied to culture. Differing perspectives on problems and causality require reconciliation and accommodation Decisions about "what's wrong" in cross-cultural settings call for a broadening of the scope of possible problem descriptions. The practitioner must reset the goals of problem description from a classic diagnostic and therapeutic end point toward the balanced management of biological and psychosocial issues, including those issues based on non-biomedical traditions. Remember, disparities in communication style and discrepant expectations may be as critical in the care process as establishing a correct diagnosis. Dealing with Parallel Explanations of Illness Dealing with discrepancies in problem description is a necessity. One can begin by describing problems in parallel with each other. This is illustrated by the case in Figure 229.4 in which two ethnocentric views of "what's wrong" are recognized and accounted for. The case illustrates a situation in which a biomedical disease has a parallel and totally discrepant explanation within an alternative ethnomedical system. Having determined that discrepant views exist in a clinical setting, problems must be dealt with in context with one another. One is faced with a dilemma: In what ways are both descriptions valid? How can a biomedically trained practitioner deal with constructs about illness and disease that fall outside of the realm of biomedical "culture"? A number of points are raised by this example:

Figure 229.4 Discrepant explanations by patient and physician of a patient's problem, its cause, and appropriate therapy. 1. Although a biomedical problem may have a parallel, discrepant description in a traditional or popular system, traditional diagnoses and therapies often do not match biomedical diagnoses on a one-to-one basis. The tendency of biomedically trained practitioners to look for biologic equivalents in folk theories is confounded by the fact that folk definitions do not match biologic definitions. Popular systems may describe problems that are culture specific. Remember, biomedical problems are not only culture specific when viewed from an outsider's perspective, but biomedical practice itself is culture specific and loaded with the values of Western society. Many traditional systems do not separate religion and healing. This results in etiologic conclusions that have interpersonal, spiritual, and moral overtones and lack the relatively amoral quality of biologic etiologies. An example exists in Asian systems where religion and healing are based on ancestral process. In ancestral systems, illness, causation, and family members (living and dead) are intricately interwoven. Family problems, dreams, and specific events may be viewed as etiologic. Some constructs patients present about illness are descriptive and combine a variety of actions and social relationships with feelings and symptoms. These constructs are often viewed as significant by patients, but may be relatively acausal from a biologic perspective. In addition, they are often difficult to integrate as coherent explanations of "what's wrong," and should be dealt with as valid individual experience and concerns attached to illness and disease.

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Many feel that acknowledgment of a nonbiomedical traditional view perpetuates the notions supporting "folk traditions." In the experience of the authors, alternative views are a clinical reality and may be acted upon concurrently irrespective of whether the practitioner recognizes, acknowledges, supports, or denounces them. In situations where practitioners deal with patients who hold traditional, nonbiomedical beliefs, it is necessary to evaluate the impact of these beliefs on the problem-solving process and, when appropriate, to encourage the concurrent use of these nonbiomedical traditions.

Parallel Explanations in Public Health Disparate problem description plays a role in public health as well as individual health care process throughout the world. Zola addressed this problem in public health when he pointed out that: many public health programs flounder when transported in toto into a foreign culture. In such a situation, when an outside authority comes in and labels a particularly prevalent condition a disease, and, as such, both abnormal and preventable, he is postulating an external standard of evaluation which, for the most part, is incomprehensible to the receiving culture. To them it simply has no cognitive reality. (Zola, 1966, p 618) For example, Chinese mothers in Hong Kong have refused to accept measles vaccination because the measles rash was felt to be essential in the life process, representing "the release of a hot maternal poison" during childhood or adolescence (Topley, 1976). Similarly, in spite of multiple public health campaigns and efforts at education, one of the authors (MJ) had great difficulty getting rural fishing villagers in India to accept the smallpox vaccination. Lack of acceptance of the vaccination program was based on a widespread belief that smallpox was caused by the Goddess Kali and not by a virus. Out of desperation, the author promoted the vaccination in a different light: "This vaccination can be considered a mark of respect to the Goddess Kali. You will notice that those who have this mark do not need to be taken by the Goddess as a sacrifice." Within weeks, villagers attended clinic to acquire "marks of the Goddess" and village acceptance of immunization was no longer a problem. This accommodation allowed villagers to see things in a cultural context and allowed biomedical intervention in a culturally acceptable mode. It was a pragmatic approach, and did not deal with the longer-term issues of religious beliefs and their relationship to education, science, and societal structure. In the United States, major groups of "true believers" describe problems in the context of fundamentalist religious beliefs that may restrict certain biomedical interventions. "Thou shall not heal by the arm of the flesh" is a phrase used by a fundamentalist group in southwestern Colorado to explain its rationale for disallowing immunization. Deaths from diphtheria in nonimmunized children in these communities were perceived as "acts of God" (Clausen, 1977). The state's ability to cope with these deaths and with the nonimmunized schoolchildren was limited to screening, quarantine, and antibiotics for carriers. "These events have led to much soul searching throughout the state. Issues of the inviolability of religious belief are in conflict with beliefs in preventive health care for children. We cannot but expect other tragedies to occur; if not diphtheria, then tetanus, polio or measles deaths" (Colorado, 1976). Examples of similar problems in Western peoples arise in the care of Jehovah's Witnesses and Christian Scientists. The latter groups use religious traditions to explain and focus their views regarding acceptable health care interventions around illness and "healing." Summary A number of observations are useful here. First, cross-cultural negotiation is not always successful. Either the patient or the provider has failed to communicate or has taken a "true believer" role, and has refused to accommodate to an alternative view. Second, when accommodation is reached, either or both sides may have to bend important "givens" and "truths" about what is right in order to cope with "what's wrong." Third, there are times when alternative therapies and theories seem dangerous, and in these circumstances, the provider's skill at education, negotiation, and manipulation across cultural boundaries is tested. Fourth, acknowledging the use of coexisting explanations and therapies for an illness is necessary to establish a basis for cross-cultural understanding and negotiation.

Plans for Care

In planning for care in cross-cultural settings, disparate views of risk and the perceived responsibilities of the individuals surrounding an ill friend or family member must be taken into account. Individuals surrounding an ill patient are all potential survivors of the illness and traditional, nonbiomedical systems often seem to meet essential needs of this group. The problem-oriented method describes nine separate steps for establishing and carrying out patient care plans. These begin with goals, or "aims" for problem management.7 Special attention should be focused on setting goals for therapy, how a problem contributes to the patient's "sickness,"1 the effects/disabilities produced by a given problem, and the use of education in the therapeutic process. All of these issues relate to the process of negotiation and accommodation that is necessary in cross-cultural care. The basic goals and implications of therapy may be widely divergent. Consider the following dichotomy:

Biomedicine assumes that most disease is an individual issue. What's wrong, from a biomedical perspective, invokes a therapeutic response aimed at the individual. Only in circumstances that involve genetic or infectious disease, environmental problems, or threatening mental health behavior will biomedicine intervene on behalf of the group. This is an extraordinarily different perspective from that seen in traditional therapies, which are often aimed at the group as well as the individual. By involving multiple individuals in the therapeutic process, traditional therapies often neutralize perceived threats to the group posed by an individual's illness. For example, in Thai treatment of soul loss, community and family actively participate in therapy by praying for restitution of the patient. Strings representing the lost soul are attached to the patient's arm, symbolically attaching a blessing and reattaching the soul. Similarly, Nooksak spirit dancers may burn gifts for ancestors either to ward off trouble or to treat an illness in a family or community member. "Burning" is carried out in a group setting in which dancers and members of the family and community participate. There is a common Nooksak perception that the group as well as the individual are treated, cleansed, and protected by this process. There is a remarkable parallel between the Nooksak system and similar attempts to placate the dead via ancestral meals and gifts in Asia. When healing is tied to an ancestral religious process, an individual's illness (or disease) is woven into the family fabric in ways that make the Western focus on the individual extraordinarily difficult for some patients and families to understand. Negotiation over Illness and Disease It is important to negotiate a balance between the management of biomedical problems and traditional illnesses. Margolin (1975) presented a 58-year-old Spanish American man whose complaints of nocturnal episodes of nausea, vomitting, abdominal pain, and inability to sleep led to extended emergency room and clinic visits. He had a remarkably complicated health history (Figure 229.5). The patient believed that his illness was the result of being embruhado ("bewitched"), and his explanation was based on folk beliefs that date to the fifteenth century and the system of curanderismo. His illness had begun after a dispute with an older neighbor, a woman felt to be a bruha ("witch"). Some members of his family concurred with his beliefs.

Figure 229.5 Medical history of a patient seeking repeated treatment. The patient was a 58-year-old Spanish-American man who made numerous visits to the emergency room during the fall of 1974. The negotiation regarding therapy involved a number of issues. First, the patient was offered a referral to a curandero ("folk healer"). He declined, acting on the advice of family members and being aware that Margolin had successfully treated one of his relatives for a similar illness. Second, it was essential to separate his active biomedical problems (diabetes and coronary disease) and his culture-bound explanation of his problems with sleep, pain, nausea, and vomiting. It was agreed that the therapy was aimed solely at thebrujeria ("witchcraft") problem and that he would continue to use his insulin and cardiac medications on a regular basis. The patient was treated with a combination of hypnosis and suggestion, and was instructed in the use of a prayer directed to St. Cipriano (a saint occasionally used by folk healers). He responded immediately. Over a 4-year follow-up period he continued to use his prayer and had not had a recurrence. It was felt likely that he would use the same system to explain serious disruptions in his life or health in the future. The goals for management in this case involved careful attention to the patient's medical problems and incorporation of his beliefs into a therapeutic plan. A number of issues are raised by this case. 1. 2. Patients with complex medical problems may use traditional explanations to deal with them. Traditional explanations of illness may remain hidden from the view of practitioners, even after extensive evaluations of illness episodes. The inability of biomedically trained practitioners to resolve an illness may support the family's belief that the patient is "sick in some other way." In this way, biomedicine is often used as a testing ground for folk diagnoses. There is often an option to treat the patient in either or both systems, and judgments must be made about needs. (Margolin's patient was using excessive Excedrin to cope with his nocturnal symptoms. The Excedrin may have

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contributed to his nausea, vomiting, and abdominal pain. The physicians involved in the therapeutic decisions thought that stopping the drug might help resolve his gastrointestinal symptoms, but would not deal with the considerable fear and anxiety provoked by his beliefs.) 5. Explanation and negotiation between systems is essential. In this instance, the fundamentalist view of "healing" after treatment, which included the use of a prayer, might have led the patient to discontinue essential medications on a trial basis. Referrals for issues related to traditional beliefs are often made through an extended family network. At times, therapy for culture-bound syndromes can be provided on a cross-cultural basis.

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Summary and Guidelines There is no simple formula for establishing plans in cross-cultural health care settings. However, assuming that the data collection methods and problem description have allowed for the recognition of psychosocial problems, the following general guidelines for the planning process should allow the provider to deal with the complexities of cross-cultural care settings: 1. Planning involves negotiation with the patient and family over issues related to both the biomedical disease processes and the patient's views and experience of illness. Family involvement in therapy should be encouraged at all levels of care, both popular and biomedicaltechnical. In the latter instance, health care providers can support and empower families and patients in the care process. This can be accomplished by means ranging from simple instruction to monitor and adjust therapy for hypertension or diabetes at home, to keeping records of weights, dietary intake medications, and playing therapeutic roles in complexly ill patients. Illness creates the risk of loss, and providers must take the needs of potential survivorship (following another's death or disability) into account. Encourage family actions that will meet people's need to participate, to help, and to neutralize fears related to traditional beliefs as well as to biomedical diagnoses. The survivors need to know that they have "done what they can." Having biomedically trained personnel shoulder this burden (as is often the case in ICU care) is an error and may deny family members a sense of participation. It also places practitioners at risk of becoming targets of anger in the face of loss. Compare explanations of illness with the patient. Mold your therapeutic plans to accommodate special beliefs and perceptions held by the family. When alternative therapies seem clearly to put the patient at risk, use education and justification of biomedical process as a counter. Look for unusual perceptions of "what's wrong," discrepancies between biomedical goals and patientfamily goals, and difficulties that relate directly to communication style or to miscommunication across cultural boundaries.

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Follow-up
Assessments of process and measurements of outcome vary across cultures. What is deemed a cure in one system may be viewed as a failure by another. The means of assessing success or failure may seem mutually exotic or bizarre. Viewed from a biomedical perspective, traditional systems often seem to lack models for chronic disorders. A Sioux medicine man commented that his therapy works because none of his patients had to come back. A physician commented that his therapy works because his patients always come back. What's going on here? These boasts of therapeutic efficacy reflect disparate expectations about illness and therapy. The physician sees the patient's return as evidence of success in the face of ongoing process. The medicine man's cure often appears to leave no need for further therapy. It should be clear that their methods are entirely discrepant, and are based on different expectations. The circumstance is further complicated by patient wishes and expectations that therapy will provide a permanent relief or cure. Patients often reject and struggle with chronic illness and do so in a manner that challenges healers in any tradition. Discrepant Models for Chronic Disease and Illness People with diseases such as diabetes mellitus, cardiac or renal failure, severe hypertension, or myxedema had little chance of survival under prebiomedical conditions. However, nonlethal, chronically bothersome, and disabling diseases have posed a major

problem for both biomedicine and traditional healing systems. The traditional therapies aimed at chronic diseases are frequently useful in that they provide recognition of the illness and a social context for care, hope, and ongoing support. In addition, there is evidence that when these illnesses are primarily self-limiting or represent mild psychosocial disruptions, traditional therapies are often successful. On the other hand, it is difficult to demonstrate curative success when traditional therapy is used for disruptions that are biologically based. The models that do exist for long-term "maintenance" in traditional systems are generally social, herbal, physiologic, and magical or religious orientations. Traditional systems may insist that treatments be undertaken over prolonged periods of time. It is said that failure to do so may cause new trouble, a recurrence of the illness, or have serious implications for the family. For example, in the Hmong system, soul loss is an etiologic explanation for a variety of illness problems. Recurrent soul loss is prevented by a Keeglaw ceremony: The souls of some people do not like to stay with them, but want to go out from their bodies all the time. If this happens the owner of the souls will be in continuous ill health and a shaman may advise the holding of a healing Keeglaw ceremony for him. If the ceremony is successful, the shaman will recommend him to hold the Keeglaw ceremony each year for the rest of his life, otherwise his souls will keep going out from his body and then he will be sick and may even die. (Chindarsi, 1978, p 104) The Hmong concepts parallel a widespread belief system tied to Buddhism and spirit cults in Southeast Asia. In Thailand, for instance, "the Khawn ["one of the body's souls"] takes fright and leaves its owner's body when he is frightened, sick or in trouble, or caj bau dee ["mind not good"]. The very act of its fleeing exposes the owner to suffering illness and misfortune" (Tambiah, 1970, p. 58). The notion that chronicity is associated with recurrent soul loss provides an explanation of a chronic illness state. Therapy in this circumstance is aimed "not so much to cure the patient as to reconstitute the morale of a very sick person. When the elders call the Khwan and restore it to the body, it is they who are charging the patient with the vital social force of morale" (Tambiah, 1970, pp 227, 243). The portions of the Hmong and Thai traditional care systems we have referenced react to ongoing dysfunction by therapies based on sacred traditions. These approaches have a socializing effect and incorporate the family in treatment activity. Patients are often pragmatic and will seek help from multiple sources when confronted with ongoing illness or failure to recover satisfactorily. This is illustrated by the patients in Figures 229.3 and 229.4. The Navajo grandfather (Figure 229A.4) left the hospital against medical advice in order to complete a ceremonial. He later surprised his physician by returning after the ceremonial, completing his antistaphlococcal therapy, and continuing his antituberculous medication. At the same time, he used daily herbal therapy prescribed by a Navajo medicine man. Traditional therapy may consist of advice, prayer, herbal therapy, or even physiologic treatments (such as sweats or a massage therapy). Even herbal therapies deal with the notion of chronicity. "Chinese medicine is reputed to act slowly. Because it is believed to treat the "underlying cause" rather than symptoms, patients usually are willing to wait for considerable periods, even in the face of persistent symptoms, before deciding that a Chinese medicine has failed to work" (Kleinman, 1980, p. 194). Therapy that has either religious or social/moralistic overtones is often aimed at what one must do to improve, or to remain safe over time. Once the advice is given or correct procedure is followed in treatment, patients are often left to their own devices. Measures of outcome vary. For example, the Navajo occasionally use a Shock rite to determine patient response to therapy. Its use is based on mythologic teachings, and involves placing the patient (toward the end of a 5- to 9-day ceremonial) in a structure that represents the Home of Snake. The test is carried out by two men dressed as Bear and Holy Boy. If the patient fails to respond properly (by fright), the medicine man may decide to stop and establish another diagnosis, and/or seek a different, correct ceremonial therapy. Explanations based on religious dogma often make judgments regarding outcome that are heavily dependent on magicalreligious premises and process. Therapeutic Failures and Death The question remains with chronic or recurring conditions and failure to respond: What shall we do? Biomedically trained practitioners should be prepared for disparate views within the family about what to do. Families exposed to multiple healing traditions, or to the variety of choices within one system, may disagree among themselves. For example, the grandson of an Arapaho medicine man was torn between advice to use the Native American Church, or a Protestant church, or the grandfather's traditions in dealing with a chronic medical problem. Other family members thought the solution lay with biomedically trained physicians and that the traditional solutions were unwarranted. Family disputes over an illness often reflect preexisting or current family dynamics and struggles. When they come to the attention of health care providers, they are often garbed in the cloak of culture. It is often useful to sort these issues out, as they may be key to negotiating a solution. Death, loss, dysfunction, and disability often bring blame and guilt into the illness picture. Many systems do not accept natural death as defined by biomedical process. Individuals and families will seek a cause within their own social fabric and belief

structure. Individuals and/or events may be blamed. Practitioners need to take these issues into account in dealing with the potential survivors. People need to be reassured that they have "done what they can." Therapists can neutralize blame by discussing cause of death or disability with the family together so that everyone receives the same messages, including messages that defuse blame. This is especially important in settings where a monolingual family is using one of the family members to interpret. In these instances it is critical to deal with care issues through a trained interpreter who is not a family member. Failure to do this will result in a skewing of the information exchanged and places an extraordinary burden on the family member who has acted as interpreter. Summary The influence of the family on the decision-making process should not be underestimated. Illness is experienced and acted upon by those around the sick individual in a fashion that can alter the course of evaluation and therapy. Faced with a poor response to biomedical inquiry and therapy, it is useful to reexplore patient and family perceptions. Search for undisclosed or unresolved issues relating to "what's wrong." Misconceptions about symptoms and about what is likely to happen can lead to serious disruptions of the care process. These issues are generally related to the illness experience and are often key to problem resolution. When patients and families ascribe therapeutic success or improvement to nonbiomedical therapies, it is useful to listen nonjudgmentally. The message may reflect a variety of views, for example, mistrust of biomedicine, rejection or fear of a diagnosis, the existence of parallel explanations, a fundamentalist religious stance, or a focus on a broader scope of illness-related issues. It is important to take the lack of a model for chronic disease into account in cross-cultural therapy. Patients often hope for a quick response to Western therapy and may be unaware of the implications of chronic disease management. Explanation is essential in these instances. Failure to set expectations of therapeutic outcome may lead to a patient conclusion that the treatment did not work. Death and dysfunction call mechanisms of blame and guilt into play. Both biomedical explanations and traditional means should be used to help those around a sick patient to neutralize these issues.

Conclusion
Problem orientation offers a means of adapting clinical methods in biomedical practice to cross-cultural care and study. Each step of the problem-solving process has parallel activities in traditional and family systems of care. At each step, discrepant expectations, practices, family function, and communication style highlight areas of potential concern in clinical problemsolving. Problem-solving across cultural boundaries often involves seeking help from members of the community, from the sociologic, anthropologic, and ethnographic literature, and from anthropologists. In addition, patients become an invaluable source of information and, when sick, often reveal issues that might otherwise never be disclosed.

References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Ackerman A. et al. Lead poisoning from lead tetroxide used as a folk remedyColorado. MMWR. 1982;30:647 48.[PubMed] Amoss P. Coast Salish spirit dancing. The survival of an ancestral religion. Seattle: University of Washington Press, 1978. Bose A, Vashita K, O"Loughlin BJ. Azarcon por Empachoanother cause of lead toxicity. Pediatrics. 1983;72:106 8.[PubMed] Chindarsi N. The religion of the Hmong Njua. Bangkok: Siam Society, 1978. Clausen J. The natural experiment: a method for studying conflict resolution between health care professionals and clients. Ph.D. dissertation, University of Colorado, 1977. Colorado Communicable Disease Bulletin. Once again: diptheria in Cortez. 1976;4(7). Dixon JL, Smalley MG. Jehovah's Witness: the surgical/ethical challenge. JAMA. 1981;246:247172. [PubMed] Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:12936. [PubMed] Fabrega H. The need for an ethnomedical science. Science. 1975;189:96975. [PubMed] Freidson E. The sociology of medicine. Curr Sociol 1962;10/11:12340. Gould-Martin K, Ngin C. Chinese Americans. In: Harwood A, ed. Ethnicity and medical care. Cambridge: Harvard University Press, 1981. Harwood A. Introduction. In: Harwood A, ed. Ethnicity and medical care. Cambridge: Harvard University Press, 1981. Hoang GN, Erickson RV. Cultural barriers to effective medical care among Indochinese patients. Annu Rev Med.1985;36:22939. [PubMed]

14. Jehovah's Witnesses and the question of blood. Brooklyn, NY: Watchtower Bible and Tract Society, 1977. 15. Kiev A. Curanderismo: Mexican American folk psychiatry. New York: Free Press, 1968. 16. Kleinman A. Patients and healers in the context of culture. An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, Los Angeles, London: University of California Press, 1980. 17. Kleinman AK, Eisenberg L, Good B. Culture, illness and care. Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:25158. [PubMed] 18. Kleinman AK, Sung LH. Why do indigenous practitioners successfully heal? Soc Sci Med [Med Anthropol] 1979;133(1):726. [PubMed] 19. Lewis P, Lewis E. Peoples of the Golden Triangle. New York, London: Thames & Hudson, 1984. 20. Margolin SJ, Putsch RW. Cross-cultural therapy for Brujeria: discrepancies between patient and physician views of problems due to ethnocentricity. Paper presented at the Central Neuropsychiatric Association Meeting, Colorado Springs, Colorado, October 24, 1975. 21. Martin HW, Martinez C, Leon RL, Richardson C, Acosta VR. Folk illness reported to physicians in the lower Rio Grande valley: a binational comparison. Ethnology. 1985;24:22936. 22. Mechanic D. Medical sociology: a selective view. New York: Free Press, 1968. 23. Mechanic D. Health and illness in technologic societies. In: Mechanic D. The growth of bureaucratic medicine, New York: Wiley, 1976;822. 24. Reichard GA. Navaho religion. A study of symbolism. 2nd ed. New York: Bollingen Foundation, 1963. 25. Relman A. Editorial. Christian Science and the care of children. N Engl J Med. 1983;309:1639. [PubMed] 26. Rosenblatt D. Barriers to medical care for the urban poor. In: Shostak AB, Gomberg W, eds. New perspective on poverty. Englewood Cliffs, NJ: Prentice-Hall, 1965. 27. Swan R. Faith healing, Christian Science, and the medical care of children. N Engl J Med. 1983;309:1639 41. [PubMed] 28. Talbot N. The position of the Christian Science Church. N Engl J Med. 1983;309:164144. [PubMed] 29. Tambiah SJ. Buddhism and the spirit cults in North-east Thailand. Cambridge: Cambridge University Press, 1970. 30. Topley M. Chinese traditional etiology and methods of cure in Hong Kong. In: Leslie C, ed. Asian medical systems: a comparative study. Berkeley, Los Angeles, London: University of California Press, 1976;24365. 31. Trotter RL, Chavira JA. Curanderismo: Mexican American folk healing. Athens: University of Georgia Press, 1981. 32. Weed LL. Medical records, medical education, and patient care: the problem oriented record as a basic tool. Chicago: Year Book, 1969. 33. Weed LL. Your health care and how to manage it. Rev. ed. Essex Junction, VT: Essex Publishing, 1978. 34. Williams G. The genesis of chronic illness: narrative reconstruction. Soc Health Illness. 1984;6:175200. 35. Young A. When rational men fall sick: an inquiry into some assumptions made by medical anthropologists. Cult Med Psychiatry. 1981;5:31735. [PubMed] 36. Zola IK. Culture and symptomsan analysis of patients" presenting complaints. Am Sociol Rev. 1966;31:615 30. [PubMed]

Language in Cross-Cultural Care

Go to:

Top The physician speak a strange and often unintelligible dialect [which] creates a communication gap between physician and patient that is acknowledged by neither. (Kimball, 1971, pp. 1378) Patients and providers often speak different languages, even when both are using a common tongue. Both meaning and intent are problematic. Each message or complaint may stand for a spectrum of unspoken issues. The issues patients attach to illness episodes are far more diffuse than the confines of biologic dictates. These issues are experiential, arising from life process, family events, and circumstances as well as special perceptions of what causes illness. These attachments to illness episodes may go unrecognized or remain as the unspoken focus in verbal exchanges regarding illness. The health care provider's views are complicated by the use of special language and a focused methodology. Patient complaints are interpreted to match recognizable biomedical patterns and disease processes. Unfortunately, biomedical focus is such that it operates to exclude consideration of diverse interpersonal, psychologic, and social components that patients attach to illness.

Personal Vocabularies and Special Terminology

Biomedical training develops special knowledge about methodology and meaning. At the same time, it alters and narrows focus. Even when the same language is being used, special terms often require explanation. Individuals often have personal vocabularies that do not include the terminology used by health care providers. Personal vocabularies can vary based on language skills, ethnicity, intelligence, education, and socialization. Prior life experience may lead an individual to attach special meanings to a specific term or circumstance. "Terms such as "diabetes," "rheumatoid arthritis," or "multiple sclerosis" may seem deceptively simple. Careful analysis will disclose that they represent a complex set of physiologic, chemical and structural facts" (Fabrega, 1975). Terms that seem common to providers are often perceived and understood in a fashion that does not match the originally intended meaning. Each biomedical term has a complex meaning, a meaning that continues to evolve from its historic origins or that may be replaced as biomedical research refines our perception and understanding. When health care personnel discuss illness with patients, they use biomedical terms. At the same time, they often fail to use explanation and justification as part of their therapeutic armamentarium. As a result, patients often remain uninformed about the meaning (either the biomedical view or the practitioner's) of what is wrong. Medicine, like any other subculture, not only has a complex lexicon, but also has its own jargon and folk speech. Institutional processes and places are often reduced to initialsER, ADL's, ASAP, PRNor brief terms such as chemotherapy or work-up. Some terminology deals with the stresses of health care settings. Dying patients are said to be going down the tubes, and irritating patients may be described as dumps, gomers, or crocks. These latter descriptions of patients by health care personnel represent a "rich albeit esoteric folklore" that "flourishes providing a much needed outlet for doctors and nurses who are under almost continual round-the-clock pressure" (George and Dundes, 1978). It should be noted that the folklore and its attendant language is no less esoteric than the language of biomedicine itself.

Folk Terminology
People's health beliefs and activities interact with secular or sacred healing traditions to produce a rich terminology about human disruptions. Communication problems in medicine are a two-way street. For example, a Chinese American patient referring to cold or hot features of an illness may have special notions about the meaning of the message. Alternatively, the message of hot or cold may be hidden in a comment or question about a food that is thought to play a role in illness. Hot and cold theories about illness are widespread, vary from group to group, and may change with time and across geographic boundaries. The interaction between folk notions and biomedicine is demonstrated by the term hypertension. Hypertensive patients may view their illness as related to being hyper and/or tense, and to stress. All three terms are related in American idiom. The juxtaposition of common idioms and a common diagnostic term have thus provided a folk definition of etiology. Another term for hypertension, high blood pressure, often leads in concerns over life's pressures and their relationship to the diagnosis. "High blood pressure" becomes, "I"m under too much pressure." At first glance, high blood pressure appears to have been foreshortened by both urban and rural blacks to the term high blood. The term actually reflects a notion that certain foods can cause the blood to rise up in the body, or cause the blood volume to "go up." The close parallel between the biomedical term and the folk term results in an interesting interaction between biomedicine and a subculture. When patients use the term, they may be referencing either notionthat they have "too much blood" or that they have high blood pressure. However, they may simultaneously reference a special idea about etiology and treatment, for example, that certain foods such as "lemon juice, vinegar, pickles, olives cut the blood and bring it down" (Snow, 1976). The terminology can cause confusion. For example, problems may arise: when the individual is advised that his or her blood count is low and the blood pressure is high: since in folk nosology, high blood and low blood are obviously mutually exclusive the physician making this diagnosis will be thought a fool and the patient may not return for treatment. (Snow, 1976). The rich and special terminology used within the black community offers an interesting example of folk terminology in a subculture (Table 229.1).

Table 229.1 Influence of Traditional or Folk Terminology and Beliefs on the Understanding of Physical Problems: American Black Terms for Some Medical Conditions. Providers who are familiar with folk terminology may inappropriately assume that they are attaching the meanings that patients intend. Thus a patient's statement that "I fell out," like the statement "I"ve taken cold," has a meaning that requires exploration. Totake cold alludes to a commonly held belief that cold is causative of health problems. It references a widespread etiologic notion that may be used to explain any number of illnesses. Like the report of a prior episode of "double pneumonia" or prior "nervous breakdown," these terms may stand for a variety of human experiences. Beware! Patients and practitioners alike attach special meanings to their language, meanings that are often unspoken. To attach simple or brief translations to these terms is only a start. Full elucidation of meaning often requires a broad-based explanation of the patient's intent, beliefs, or circumstance. Folk terminology is special in regard to both origin and usage. Usage varies with the circumstance, and some usage is idiosyncratic. Elucidation allows the practitioner to understand an "individual in his own idiom before attempting to treat his complaints" (Kimball, 1971).

Complex Terms and Special Usage

Specialization fosters a complex lexicon. Biomedicine and traditional health systems are specialized, each in its own right. Terminology and purposes may seem hard to understand across cultural barriers. As the gulf across cultures increases, terms may appear more exotic. In part, this is an artifact created by lack of familiarity. New terms in one's own language generally appear in a context of readily available associations, whereas first exposure to a term in another language lacks the easy attachments of familiar language. Terms are always somewhat out of context across language barriers. In addition, cultural theories regarding illness produce a complex set of behaviors and an entire supporting lexicon. These constructs about illness produce special terms and meanings that are often hard to understand without a broad defining process. For example, the Hmong, a refugee hill tribe from Southeast Asia, have a rich terminology that appears to tie the "liver" to psychosocial disruptions (Table 229.2).

Table 229.2 Illustration of Cultural Differences in the Understanding of Physical Problems: Hmong Terminology for Liver Problems and What They Signify a. These Hmong terms imply a special set of definitions for human disruptions. Like folk terms in any language (e.g., susto orembruhado for Mexican-Americans), they reflect a portion of an entire historic tradition. Hmong terminology richly illustrates the problem for patients and providers in cross-cultural medicine. How does someone from a Hmong background relate to a Western health care provider's reference to liver trouble of any sort? How does a Westerner deal with Hmong views of psychosocial disruptions? What special meanings do the terms imply? How does an interpreter handle the situation? This circumstance is illustrated by a parallel problem in Vietnamese, where the word hepatitis: is very often loosely translated into "liver disease." There is a widely accepted notion that "liver disease causes itching." A reported history of hepatitis may mean that the patient has had a symptom of "itching" which may, in fact, be secondary to a superficial dermatitis. (Hoang and Erickson, 1985) Western-trained providers need to be made aware of these differences in language and explanatory systems and must learn to deal with the difficulties they present. Complexity of meaning varies with usage. For example, the Lakota (a Sioux dialect) term iyumi, which translates "distorted/twisted face," appears on the surface to describe individuals with a stroke or Bell's palsy. Its use as a phrase of warning in Lakota idiom broadens its meaning: "Don"t do that, you"ll get iyumi." However, its use in special situations like death and dying has more complex implications.

An 18-year-old Sioux woman was confronted with the impending death of her 34-year-old step-mother, L. For months prior to her death, L. had been angry and difficult. The daughter approached her father about her concern: "What will happen when L. dies? I wonder if she"ll iyumi us." Her father brought this comment to the attention of the physician and nurse caring for his wife. When asked what it meant, he indicated that the twisted face was caused by a ghost, or "spirit of the dead," and that some ghosts were known to be dangerous. He stated that L. intended to "watch over me" after her death. L.'s comment and his daughter's observation had caused deep concern on his part. The Lakota term, explained in this context, provided insight into special meanings L.'s eventual death might have for the survivors. Her ongoing care and eventual death had to be discussed in terms that took into account difficult interpersonal relationships and Sioux beliefs. It was necessary to defuse the sense of blame and guilt felt by family members who, while providing L.'s day-to-day care, had been the target of her anger. A direct discussion of Sioux beliefs regarding interactions with the dead was undertaken. To interpret iyumi as an abstraction for impending loss, stress, grief, frustration, and anger misses the concrete Sioux concern about interference from the dead and the Sioux experience with ghosts or spirits. There was clear evidence that the family's views were not idiosyncratic. According to Buechel (1970), iyumi is also used in the longer phrase wana i iyumi, which literally translates "ghost distorted/twisted face." L.'s husband had also referenced this term, further clarifying the nature of his concern. For these reasons, the discussions held with the father included reference to the prayers and practices differing Plains Indian peoples have used to protect the living from the potentially malevolent influence of the dead. 1

Lack of Linguistic Equivalency

Many concepts about "what's wrong" are sufficiently ethnocentric that they lack equivalents in other languages. Cross-cultural care is replete with terms and ideas that may seem close in that they describe a similar behavior or physiologic state, but they are often different by definition or common usage. For example, the Navajo term iich aa (moth sickness) describes a form of mental illness. It is seldom referenced by interpreters, however, because it implies an etiology that relates to incest. It is not a generic term for mental illness, and in common Navajo usage it may relate to epilepsy or epileptiform attacks. It is an example of the difficulty going from a common English term to its parallel in a language that lacks a clear equivalent. Lack of linguistic equivalency is complicated by the fact that biomedicine has not been a model in many societies, and the major segments of biomedical lexicon may be missing from the language or target populations. This problem is illustrated by an attempt to produce a term for allergy in a VietnameseEnglish medical guide. There is no equivalent term in Vietnamese. In the 1980 Vietnamese edition of Wagner's Medical Guide and Glossary, we find "allergydi u"ng." Back-translation of the Vietnamese phrase reads "unusual reaction." Di u"ng replaced a phrase from an earlier edition that back-translated to mean "a kind of symptom that is easy to get." The translators were clearly having difficulty creating a Vietnamese equivalent to a biomedical term. Attempting to coin a new Vietnamese term is not a solution; the phrases developed as Vietnamese "equivalents" clearly miss the special meaning and intent of the term allergy. Clinically, di u"ng is useful only in the context of a broader, more descriptive defining process. Health care providers often cope with language issues by the use of written instructions, questionnaires, and educational materials. This became a major effort in clinics and health care systems that had to deal with the influx of refugees from Southeast Asia in the 1970s. A number of issues are operative here. First, a significant subset of the group (e.g., the Hmong and Mien hill tribes) came from nonwritten language backgrounds. Second, a subset of those from rural backgrounds may have used languages that are written (e.g., Lao or Khmer) but are themselves functionally illiterate. Third, references to special terminology, terms such as anxiety, allergy, contagious, and pap test, involved a complicated process of translating these ethnocentric concepts into languages that have no conceptual models for comparison. 1. A Cree prayer illustrates some of the historical tradition associated with rites at the time of death in Plains and Woodland Indians (Dusenberry, 1962):

Go. Go straight ahead. Do not take anyone with you. Do not look back. When you reach your destination, talk for us.

Tell them not to trouble us. Or not to come here and take anyone else away. In an interesting and informative example, Werner and Campbell (1973) describe preparation of an interview schedule to be used as a guide to assist bilingual interpreters in performing a Navajo health survey. The survey included the question: "Did you ever have measles?" The nearest literal translation into Navajo follows: Navajo lich" 'aah haajeehsh English "red" "on something unspecified" "comes up and out in pleural form" "at one time" "it caught you?" Lah nidooln?

Werner points out that the three terms lich', 'aah, and haajeehsh are translated together as measles in most Navajo dictionaries. In common use, however, they indicate any kind of rash!

Special Use of Language, Dreams, and Hallucinations

Lack of familiarity with communication style robs communicants of the ability to interpret meaning and to be predictive about what someone will say or do. Nonliterate societies use language in ways that surprise outsiders. Verbal interchanges become the basis for agreements. People who use written languages, in contrast, frequently view verbal exchanges as casual and often will not commit to or believe something until they "see it in writing." since religious and healing practices are based on oral traditions in nonliterate societies, the spoken word is often imbued with power. A Cree couple explained that words have power: It's not just words. It is meaning. For example, a person wants to get a job. He goes out and looks for work. Someone else is saying he won"t get it. That is witch talk, for then he won"t. There is no special language a person uses. It can be done regardless of race, creed or color. That is why one must be careful what he says. (Dusenberry, 1962) Thoughts, intuition, dreams, and hallucinations are also regarded in a different light. Dreams may be predictive, hallucinations the source of great interest, and intuition may be attributed to an external source. This use of language leads to a certain level of caution in inquiry, agreements, and interpersonal interactions. Many traditional patients are uncertain about the intense interest shown by practitioners. Positive interest may be mistaken for the willingness or ability to do or to act on something. For example, the comment "We might do something about that" means "we might, if" to the practitioner. It is often misinterpreted by traditionals to mean that "they said they were going to do something about it, they"ll take care of it." This miscommunication of intent is common enough between English speakers. It is magnified in cross-cultural settings and in any circumstances that are unfamiliar. Assessment of mental status becomes difficult. For example, in "some non-literate societies there is anxiety-free acceptance of and willingness to describe hallucinatory experiences hallucination per se is seldom disturbing; its content is the focus of interest" (Zola, 1966, p. 618). Hallucinations, like dreams, may take on concrete meanings. Since neither is likely to have played a major role in the training and life experience of biomedically trained practitioners, they are often missed as the keys to an illness pattern: A 52-year-old Inupiat Eskimo hunter/trapper and minister had unrelenting flank pain. Extensive inpatient evaluation in three different institutions, including a university referral center, had failed to reveal a diagnosis. After two and a half months of inpatient care, he was being managed as a chronic pain problem. The inability of physicians to resolve his problem led to a period of marked anger and panic. He threatened to leave the hospital and discontinue evaluation, and demanded increased medications. He became disruptive on the ward. An interview undertaken at this juncture revealed that he had dreamed about his deceased relatives (parents and a brother):

"My mother and father were sitting on the ice with wet clothing they asked me to help change their clothes I sat down and changed my own socks." "My brother was setting a seal net, he asked me to help I sat down on the shore and told him what to do but I didn"t touch the net." His concern over the dreams had led to a long distance radio phone call to his wife. She shared his fears; "You didn"t touch their clothes did you?" When asked what would have happened if he had touched the net or his parents" clothes, he quickly stated: "Then I would have been like them." He had clearly become convinced that his own death was imminent. (Putsch, unpublished, 1980) The dreams were telling the patient what's wrong, what's going to happenthings the doctor didn"t know about. He was using his dreams, language, and thoughts in a concrete, predictive fashion. Thus the formula, to think/wish/dream something = to cause it = to do it, a formula for magical thinking, seemed to be playing a role in his illness. His revelation of the dreams was induced after multiple prior attempts to assess his mental state had been unsuccessful. The key was a shift in interviewing that took his disparate language use into account. He was told that the interviewer knew a man who could hunt caribou by dreaming. This comment prompted dreaming stories from the patient and eventually the story of his own dreams. He subsequently reported a long history of events that led to his illness and that involved a traditional explanation of the entire process. The discussions led to the loss of need for pain medication. Previous assessments were based on direct inquiry about feelings, something Eskimo individuals are socialized to keep to themselves. Native American patients are reluctant to tell health care providers about a hallucination or dream experience. The risk of labeling is too great, and there is concern that the dominant society would take such talk as evidence of psychosis. This is no surprise; Westerners also avoid discussing hallucinatory experience. Rees (1971), in a study of the "hallucinations of widowhood," found that, with one exception in 137 cases, Welsh widowers and widows never discussed their hallucinatory experiences with either health care providers or ministers. Those who had talked about it did so only with friends. The Welsh experiences of hallucinatory phenomena remain within the framework of acceptable "folk" expression and interchange. They are simultaneously excluded from formal interchange with authority figures. In clinical settings, dreams often play a role in patient concerns, and this is true of patients from a wide variety of backgrounds, written language or no. However, in rural patients and nonliterate groups, dreams may be viewed as predictive. Individuals and groups have used dreams to hunt, to diagnose, and to predict the future. It is clear that dreams are often key to the assessment of mental status of Native Americans. This may also hold for evaluating mental status and health concerns of otherwise somaticizing Asian patients.

Monolingualism and Interpreter-Dependent Health Care

"Cross cultural interpretation requires special training and highly developed skills. Just any bilingual person, chosen at random, is not sufficient."(Young, 1968, p. 17) Interpretation in health care is a difficult task and requires exceptional skill. Monolingual providers who work in settings where other languages are in use should use trained interpreters whenever possible and simultaneously should attempt to upgrade their own skills in both language and interpreter-dependent transactions. The presence of an interpreter adds a whole new aspect to providerpatient exchanges. Two diagrams of the patientinterpreterprovider communication triad are presented in Figure 229.6. The diagram on the left presents a hypothetical situation in which all three parties are contributing to the same database, considering the same events, and discussing the same questions and answers. "Same" in this context implies a relatively high degree of equivalence in each participant's view of the content of the exchange. This hoped-for situation is not borne out in actual practice. The diagram on the right more closely approximates interpreter-dependent information exchange. One database is shared by the patient and the interpreter, and a second by the interpreter and the provider. But note that each participant also has an independent view of the transaction (represented by the nonoverlapping areas marked A, B1, B2, and C). At issue is the degree to which A + B1 and B2 + C are equivalent.

Figure 229.6 Cross-cultural communication is strongly influenced by the extent to which the patient, the provider, and the interpreter share the same understanding and beliefs about the medical problem under discussion. The ideal model shown on the left is seldom (more...) Studies of recorded back-translated materials reveal a number of common problems that interfere with the generation of equivalent messages. Many information transfer problems are linguistic: bad paraphrasing, lack of linguistic equivalency, substitution or addition of terms, incorrect numbers and names, and garbling of the message. Other issues include interpreter beliefs, biases, emotions, disparate views of meanings (of events, terms, and transactions), and the personal image of the interpreter. Messages and meaning can be distorted for a wide variety of reasons.

Summary
Miscommunication is often a source of providerpatient difficulties. Discrepant meanings and intent are often at the root of the trouble. These discrepancies often go unrecognized. The special character of cross-cultural communications makes it imperative that providers address these issues with care and work to develop their own communication skills.

References
1. Bliatout B. Understanding the differences between Asian and Western concepts of mental health and illness: Hmong and Lao. Proceedings of Region VII Conference, Refugee Mental Health: Paths to Understanding and Helping. Kansas City, Missouri, May 2021, 1982. DHHS, Office of Refugee Resettlement. Blumhagen D. Hyper-tension: a folk illness with a medical name. Cult Med Psychiatry. 1980;4:197224. [PubMed] Buechel E. A dictionary of the Teton Dakota Sioux language. Pine Ridge: Red Cloud Indian School. 1970;262:536. Dusenberry V. The Montana Cree. A study in religious persistence. Uppsala: Almqvist and Wiksell, 1962. Fabrega II. The need for an ethnomedical science. Science. 1975;189:96975. [PubMed] George V, Dundes A. The Gomer. A figure of American hospital folk speech. J Am Folklore. 1978;91:56881. Gould-Martin K. Hot cold clean poison and dirt: Chinese folk medical categories. Soc Sci Med. 1978;12:39 46. [PubMed] Harwood A. The hot-cold theory of disease: implications for treatment of Puerto Rican patients. JAMA. 1971;216:115358.[PubMed] Hoang GN, Erickson RV. Cultural barriers to effective medical care among Indochinese patients. Annu Rev Med.1985;36:22939. [PubMed] Kaplan B, Johnson D. The social meaning of Navaho psychopathology and psychotherapy. In: Kiev A, ed.: Magic, faith, and healing: studies in primitive psychiatry today. New York: Free Press, 1964;20329. Kiev A. Curanderismo: Mexican American folk psychiatry. New York: Free Press, 1968. Kimball CP. Medicine and dialects. Ann Intern Med. 1971;74:13739. Launer J. Taking medical histories through interpreters: practice in a Nigerian outpatient department. Br Med J. 1978;2:93435. [PubMed] Levy J, Neutra R, Parker D. Hand trembling, frenzy witchcraft and moth madness. A study of Navajo seizure disorders. Tucson: University of Arizona Press, 1987;3960. Madsen W. Hot and cold in the universe of San Francisco Tecopsa, Valley of Mexico. J Am Folklore. 1955;68:123 39. Marcos LR. Effects of interpreters on the evaluation of psychopathology in non-English-speaking patients. Am J Psychiatry.1979;136:17174. [PubMed] Putsch R. Cross-cultural communications: the special case of interpreters in health care. JAMA. 1985;254:3344 48.[PubMed] Rees WD. The hallucinations of widowhood. Br Med J 1971;4:3741. Snow LF. Folk medical beliefs and their implications for the care of patients. A review based on studies among Black Americans. Ann Intern Med. 1974;81:8296. [PubMed] Snow LF. High blood" is not high blood pressure. Urban Health. 1976;5(3):5455. [PubMed] Svarstad BL. Physicianpatient communication and patient conformity with medical advice. In: Mechanic D, ed. The growth of bureaucratic medicine. New York: Wiley, 1976;22038. Trotter RL, Chavira JA. Curanderismo: Mexican American folk healing. Athens: University of Georgia Press, 1981. Wagner C, Rullo J, Thach-Nguyen, Loc-Vu. Medical guide and glossary, Vietnamese edition. Portland, OR: Indochinese Language Resource Center, 1978; revision, 1980.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

24. Weidman HH. Falling-out: a diagnostic and treatment problem viewed from a transcultural perspective. Soc Sci Med.1979;138:95112. [PubMed] 25. Werner O, Campbell DT. Translating, working through interpreters and the problem of decentering. In: Naroll, Raoul, Cohen, eds. A handbook of method in cultural anthropology. New York, London: Columbia University Press, 1973;398420. 26. Young RW. English as a second language for Navajos. An overview of certain cultural and linguistic factors. Rev. ed. Bureau of Indian Affairs, Albuquerque Area Office, 1968. 27. Zola IK. Culture and symptomsan analysis of patients" presenting complaints. Am Sociol Rev. 1966;31:615 30. [PubMed]

Footnotes
2

Patients often have explanations that connect diverse personal, family, community, religious or even economic issues to illness. These patient views have been described via narrative reconstructions (Williams, 1984) or explanatory models (Kleinman, 1978). In addition, biomedical activities have many of the qualities of folk systems. At times it appears that practitioners and patients, acting in the guise of science, use biomedicine to the exclusion of any other approach and in an almost magical context. Fabrega (1975, p. 969) has pointed out that "biomedicine. constitutes our own culturally specific perspective about what disease is, and how medical treatment should be pursued; like other medical systems, biomedicine is an interpretation which "makes sense" in light of cultural traditions about reality." 3

Statistical methods and demography are examples of recent changes in health care theory and practice. Their evolution and application have helped define a new mode of problem description and planning in health care. Weed's methods allow for the incorporation of "demography" as an illnesswellness issue. He suggested that demographic problems be added to problem lists and added to health maintenance flow sheets and plans. These plans for problem description and health care interventions account for known risk factors based on age, sex, and ethnicity (Weed, 1969). 4

The term healing has been used to remind the reader that healing interventions, including biomedical practices, are often dissimilar.

The traditional diagnostic techniques and tools referenced are all still in use. The Nooksak are a Northwest Coastal tribe. Their language is related to the Salish language group (Coastal and Plateau) which extends around the Puget Sound, north into British Columbia, and as far east as northwest Montana. Patients euphemistically refer to the sgdli instrument as the "Nooksak x-ray." It is used to hunt for lost objects, find a dead body, or locate spirits (Amoss, 1978). The Hmong are a hill tribe from Southeast Asia. Refugees following the Vietnam war, they represent a small minority group in southern China, and occupied (at one time) the hills and ridges of northern Laos and Thailand (Lewis, 1984). Historically, neither the Nooksak nor the Hmong had written language, and both have relied extensively on shamanistic practices. 6

"The wording of questions will vary with characteristics of the patient, the problem, and the setting, but we suggest the following set of questions to elicit the patient explanatory model. Patients often hesitate to disclose their models to doctors. Clinicians need to be persistent in order to show patients that their ideas are of genuine interest and importance for clinical management. (1) What do you think has caused your problem? (2) Why do you think it started when it did? (3) What do you think your sickness does to you? How does it work? (4) How severe is your sickness? Will it have a short or long course? (5) What kind of treatment do you think you should receive? (6) What are the most important results you hope to receive from this treatment? (7) What are the chief problems your sickness has caused for you? (8) What do you fear most about your sickness?" (Kleinman, 1978, p. 256).

Weed's description of the planning process is paraphrased below. Each step in planning includes a subset detailing its implications for planning and care.

1.

State aims (goals) for problem management.

2.

Check how the problem may be related to the patient's "sickness."

3.

Check for effects/disabilities produced by the problem.

4.

Check for function/status of systems involved with the problem.

5.

Assess and follow course.

6.

Investigate the problem and its etiology.

7.

Watch for/prevent complications of the problem.

8.

If indicated, institute and monitor treatment.

9.

Use patient education wherever appropriate. (Weed, 1978, pp. 5, 202)

Copyright 1990, Butterworth Publishers, a division of Reed Publishing. Contents

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Print View MAJOR CONCEPTS AND DEFINITIONS

Care refers to abstract and concrete phenomena related to assisting, supporting or enabling experiences or behaviours toward or for others with evident or anticipated to ameliorate or improve a human condition or lifeway. Caring refers to actions and activities directed toward assisting, supporting, or enabling another individual or group with evident or anticipated needs to ameliorate or improve a human condition or lifeway, or to face death

Culture refers to the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways Cultural care refers to the subjectively and objectively learned and transmitted values, beliefs and patterned lifeways that assist, support, facilitate, or enable another individual or group to maintain their well-being, health, to improve their human condition and lifeway, or to deal with illness, handicaps, or death Cultural care diversityrefers to the variabilities and/ or differences in meanings, patterns, values, lifeways, or symbols of care within or between collectivities that are related to assistive, supportive or enabling human care expressions Nursing refers to a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well-being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death Worldview refers to the way people tend to look out on the world or their universe to form a picture or a value stance about their life or world around them Cultural and social structure dimensionsrefers to the dynamic patterns and features of interrelated structural and organizational factors of a particular culture (subculture or society) which includes religious, kinship (social), political (and legal), economic, educational, technologic and cultural values and ethnohistorical factors, and how these factors may be interrelated and function to influence human behavior in different environmental contexts Environmental contextrefers to the totality of an event, situation or particular experiences that give meaning to human expressions, interpretations, and social interactions in particular physical, ecological, socio-political and/ or cultural settings. Ethnohistory refers to those past facts, events, instances and experiences of individual, groups, cultures and institutions that are primarily people-centered (ethno) and that describe, explain, and interpret human lifeways within particular cultural contexts and over short or long periods of time Generic (folk or lay) care system refer to culturally learned and transmitted, indigenous (or traditional ), folk (home based) knowledge and skills used to provide assistive, supportive, enabling or facilitative acts toward or for another individual, group or institution with evident or anticipated needs to ameliorate or improve a human lifeway or health condition (or well-being) or to deal with handicaps and death situations Professional care system(s) refers to formally taught, learned and transmitted professional care, health, illness, wellness and related knowledge and practice skills that prevail in professional institutions usually with multidisciplinary personnel to serve consumers Health refers to a state of well-being that is culturally defined, valued and practiced, and that reflects the ability of individuals (or groups) to perform their daily role activities in culturally expressed, beneficial, and patterned lifeways Cultural care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death Cultural care accommodation or negotiation refers to those assistive, supporting, facilitative or enabling creative professional actions and decisions that help people of a designated culture to adapt to, or to negotiate with, others for a beneficial or satisfying health outcome with professional care providers Cultural care repatterning or restructuring refers to those assistive, supportive, facilitative or enabling professional actions and decisions that help clients reorder, change or greatly modify their lifeways for new, different and beneficial health acre pattern while respecting the clients cultural values and beliefs and still providing a beneficial, healthier lifeway than before the changes were coestablished with the client Cultural congruent (nursing) care refers to those cognitively based assistive, supportive, facilitative, or

enabling acts or decisions that are tailor made to fit the individual, group or institutional cultural values, beliefs and lifeways in order to provide or support meaningful beneficial and satisfying health care or well-being services.

urses are in constant inte raction with different clients from all walks of life. Regardless of their age, status or condition, we are bound to provide them with the utmost care they deserve. It is a pledge that we made, and one that we have lived by. However, sustaining the care we provide in ensuring that they maintain their well-being is an issue. Health education and maintenance plays a major role in healthcare and one that is highly participated by nurses. Taking into account our clients differences in their beliefs, values and practices is tantamount to the success of health promotion. It is with this premise that a sensitivity and knowledge on cultural differences takes the stage. Madeleine Leininger was the first to identify the impact of culture in relation to nursing. She spent years understanding and developing their connection and how one can influence the other. In this regard, she studied anthropology and utilized it in nursing. The combination of the two brought about her Theory of Cultural Diversity and Universality. In here, she defined Transcultural Nursing as a subjective area of study and practice focused on comparative cultural care (caring) values, beliefs and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people face unfavourable human conditions, illness or death in culturally meaningful ways (Barnum, 1998). Moreover, it goes beyond an awareness state to that of culture care nursing knowledge to practice culturally congruent and responsible care (Tomey, 1998). Cultural Diversity and Universality is therefore the highlight of Leiningers theory. Cultural Diversity is defined as variations in each culture. In acknowledging these differences, the nurse is able to avoid stereotyping and assume that all clients will respond to nursing care in the same manner. Culture Universality on the other hand, pertains to the similarities. Both these concepts lead to the goal of the theory and that is, to discover similarities and differences about care and its impact on the health and well-being of groups (Leininger, 1995) Internalizing the concepts on culture diversity and universality gives rise to culture-specific and culturally congruent care. The former refers to the identification the clients care practices brought about by their culture and utilizing them to plan and apply nursing care. This in turn would bring about nursing care that fit the specific care needs and life ways of the client (Leininger, 1995). The latter, speaks about cognitively based assistive, supportive, facilitative, or enabling acts or decisions in order for the nurse to provide meaningful, beneficial, satisfying care that leads to health and well-being (Leininger, 1995). This, according to Leininger, is the central idea and goal of the Theory of Cultural Care.

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The Sunrise-Enabler Model

Effective care is the ultimate task of nurses. We are the members of the health team who have direct patient/client interaction and therefore it is through our knowledge & understanding of the values, customs, beliefs & practices our patients culture that we can provide effective care. A better way of understanding the factors that influence a persons perception of well-being is the sunrise enabler of Madeleine Leininger. Leiningers model of cultural care can be viewed as a rising sun. When using this model, the nurse can begin anywhere depending on the focus of nursing assessment. The model reflects influences of ones worldview on cultural and structure dimensions. The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors. Each of these identified systems affects health. These cultural and social structure dimensions in turn influences environment and language, wherein emphasis should be placed since this is where the patient/client find themselves such as home conditions, access to particular types of food and family access to transport. Environment and language influence the involved health systems the folk, professional and nursing systems. The folk health system includes the traditional beliefs and practices on health care while the professional health systems are those practices we learned cognitively through formal professional schools of learning. The combination of the folk health system and the professional health system meets the biological, psychosocial, and cultural health needs of the patient/client. These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. To be able to make sound nursing care decisions and actions, these factors should be assessed properly and always be taken into consideration. To achieve culture congruent care, nursing actions are to be planned in one of three modes: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring. A research project on health and social practices regarding dengue in 2008 on three countries in Southeast Asia could be used as an example on how Leiningers sunrise enabler can be applied on the community level. Some of the cultural and social factors that were assessed are as follows:

Cultural and Dimensions Technological

Social

Structure lack of awareness of first aid remedies and safety procedures on dengue prevention at

home Religious Kinship and Social community people view dengue as a bad omen women are always the caregivers, thus more women are prone to psychological burden of caring for the sick member of the family health is of lesser priority; more priority is given to basic needs such as food lack of policy programs by the local government regarding dengue prevention practices more males acquire dengue since most of them are night shift and farms/plantation workers low level of education is noted. Most are secondary level graduates, knowledge and comprehension on proper health practices on dengue prevention is low

Cultural Values Political and legal

Economic Educational

Incorporating cultural diversity in nursing care: an action plan

by Betty Pierce Dennis, Ernestine B. Small Comments

Abstract: This article examines the context of culture from the perspective of the increase in immigration and concomitant growth of diversity within the United States. It proposes that nurses who deliver culturally competent care are brokers of three cultures: their own; the health care system; and the client. The mechanism for creating approaches to care that utilize this concept is the nursing process. A culture-specific assessment can be achieved using the explanatory model of illness. The inadequacies of some frequently used strategies such as nursing diagnosis are also discussed with suggested changes. Key Words: Culture, Diversity, Nursing Process, Competence

MoreArticles of Interest

Cultural Awareness of Nurses in Practice Culturally competent care: a strategic imperative "The ethics of diversity" ALLOWing for cultural diversity Strategic management: A process for increasing cultural diversity in nursing...

********** It is essential to know man, it would seem before attempting to do him good. --Nathaniel Hawthorne-Nurses function in a health care environment that mirrors the diversity and cultural complexities of the larger society. The diversity of clients is varied and related to gender, age, socioeconomic status, education, physical and mental disabilities, regional

locations, sexual life-style, and racial and ethnic backgrounds. It is beyond the scope of this paper to explore the range of issues and their implications for nursing care. This paper does, however, present an overview of the genesis of the evolving cultural diversity in the United States. It describes the essential role of the nurse in cultural transactions within health care, and proposes an approach to cultural inclusiveness crafted from the nursing process. The wave of new immigrants and the different existing groups underscores the need to do more than we have done in the past. In addition to a fundamental approach to care, nurses must bring the will and commitment to change. Increasingly, we learn and practice in a global society. The United States is, and always has been, a nation of people representing multiple ethnic and cultural backgrounds who share a common subculture or "American experience. English settlers began the colonization of this country as an immigrant group. Today, the United States is perhaps the most diverse nation in the world and it has served her well. People throughout the world, with many talents and abilities, are attracted to her shores. Until the decade of the 1960's America was viewed as a melting pot society. It was assumed that individual and group differences were replaced with a generic American identity. By the late 1970's the melting pot concept was clearly not supported. The early wave of immigrants to America was primarily of European descent from countries like England, Germany, Russia, Poland, Scandinavia, France, China, Italy, and the Netherlands. In large urban areas, distinct ethnic enclaves such as the Polish, Irish, Jewish, and Italian communities persisted. For example, many Germans settled in the Pennsylvania area. Individuals of English heritage populated the New England states. Some persons of Scottish-Irish descent were imported as indentured servants. Italians and Polish migrated in large numbers to New York and Chicago, respectively. Asian and Hispanic communities grew in California and New York. These enclaves were havens for the new immigrants. Although planted on new soil, they were able to maintain some of their traditional customs and practices while adopting new ones. It is fair to say that the differences in social structures, customs and beliefs of the various groups contributed to inter-group conflict, tension and discriminatory practices. Two groups are notable exceptions to this immigration pattern: African Americans, who were captured and brought to America and forcibly enslaved; and native Americans, whose lands were appropriated, some tribes decimated to extinction and nearextinction, and way of life permanently changed. Today, native Americans may be the least dispersed with the vast majority living on reservations. African Americans originally lived in the southern states but many migrated to large cities in the northeast USA during the first half of the 20th century. Eventually, the original English settlers and their offspring became the normative group whose values and customs were imposed as the standard of American culture. Over time, skin color replaced country of origin as a reference label. Europeans were combined into the category of white race as a reference label. Others were included based on "white" skin such as non-black Hispanics. Americans of African, Asian or other heritage were accordingly assigned. Thus, in the 21st century, American pluralism has emerged with a definite emphasis on ethnic identity and cultural diversity, in part, because of growing recognition that we are who we are because of our cultural heritage. As health care providers in a pluralistic society, nurses must incorporate cultural differences in the creation of nursing care approaches. CULTURE AS A COMPONENT OF NURSING CARE In our world with its many and mobile populations, the cultural mix can be expected to intensify. This is especially challenging to nurses because they will be expected to deliver care that encompasses these differences. Over the last several decades, nursing literature has examined culture as a concept and determinant of health behaviors and beliefs. Several nursing theories have emerged to address culturally derived meanings and perspectives of health and illness behavior. In these theories, culture is presented as a distinctly important aspect of nursing care. However, there are few guidelines as to their pragmatic implementation in practice and education. Characteristics of Culture Culture is dynamic. Its changes are usually gradual, but always constant. Culture is one of the few attributes important enough that no one was left out. We all have at least one; many of us have more than one. Culture is defined as the lifeways of a group (Dennis, 2000). It includes values, beliefs, attitudes, customs, rituals, and behaviors. It will vary within the group by age, gender, religion, and social class. The lifeways of a group are their transmitted memories and changes in those lifeways that occur over time. Changes within a culture are continuous and are effected by social environment and the extent to which the group members adapt to change. For example, when members of other cultures immigrate to the United States, they often maintain their cultural distinctiveness, but to varying degrees they take on the attributes of the new culture. A Japanese American may enjoy

hamburgers and baseball games and faithfully practice the Shinto religion. Invariably, change accelerates in the offspring of immigrants who either arrive here very early in their lives or are born here. Several terms are used to describe cultural change. In acculturation or the mosaic concept, the contact between groups brings changes in one or both groups with or without actual intermingling. The relationship between whites and African Americans or whites and Native Americans in the United States are examples of acculturation. Assimilation or the melting pot concept is a process by which different groups fuse separate cultures into one common culture. Usually, one of the groups is dominant and the features of the less dominant group gradually fade through intermarriage and structural breakdown. The ancient Egyptians are an example. After invasions by the Persians, Greeks, Romans, and finally the Arabs, the art, architecture, language, religion, rituals, people, and dress of the ancient Egyptian culture is no longer distinct. Today, the culture and language of people of Arabic descent dominate Egypt. Nurses must recognize the process of continually cultural change through acculturation or assimilation. Once the dynamism of cultures is accepted, a static description of behaviors or the naming of specific cultural attributes has limited utility. A Filipino, Korean, Romanian, or African client may have been born, educated and lived their entire life in this country. The degree of acculturation will likely differ among them. It will also differ between members of the same group who have had dissimilar experiences such as economic status, level of education, or length of time in the United States. The `laundry list' of various cultural attributes will acquaint the nurse with broad outlines of a cultural group, but will not provide the information that nurses must have for the individualized care that we give. Because members of a group are continually adapting and changing, one set of behaviors is never applicable to every member of that group. In fact, depending on static descriptions raises the risk of stereotyping client behaviors. Stereotypical behaviors are defined as fixed, unchanging, characteristics that are ascribed to all members of a particular culture. Recent trends propose a generic view of culture that begins with the individual and expands to include components of the context in which that individual exists such as family and community. For instance, some Native Americans avoid eye contact as a way of showing respect; however, this behavior may not be true of all tribes. Also, depending on the degree of acculturation, it may not be true of all members of the same tribe or tribes that do practice this behavior. Attempting to learn cultures through composites of rituals, behaviors, and beliefs, is impractical and probably impossible. Instead, both the person and the group must be the focus of care.
1 Transcultural Nursing: Providing Cultural Care for the Elderly
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Print Page Send to a Friend Share By Christina Orlovsky, senior staff writer Throughout history, America has been called a melting pot-a place that draws people from all cultures to live and thrive together. What most cultures hope, however, is that in that pot, they are able to maintain the flavors that make them so unique. For elderly ethnic Americans, cultural identity is one characteristic too precious to lose to the aging process-especially when a nursing home is their melting pot. "Elderly people of all cultures really want to maintain their life ways-whatever routines or traditions they had in place before they went into the nursing home," said Marilyn McFarland, RN, Ph.D., co-author of Culture Care Diversity and Universality: A Worldwide Nursing Theory. For this reason, McFarland has long been a proponent of transcultural nursing, a practice that supports health care providers' learning of cultural mores and beliefs in order to provide "culture specific or culturally congruent nursing care" to all people. Transcultural nursing is a method that was introduced to the health care field by Madeleine Leininger, RN, Ph.D., FAAN, in the 1950s. Since then, Leininger has paved the way for the education of nurses interested in addressing the cultural needs of their patients as a way of providing them with comprehensive health care. McFarland, who co-wrote her book with Leininger, feels that cultural care should be a concern of all nurses.

"It's very important for nurses to really find out about people's traditions, life ways and beliefs about health care, so they can honor them and combine them with professional care," she said. Through an abundance of nursing school courses, continuing education classes and books and journals on transcultural nursing, nurses have the ability to educate themselves on successful methods of cultural assessment. "There's a framework that guides nurses into asking questions about a patient's beliefs about health care, technology, religion, politics and the micro-political arena in the nursing home," McFarland said. "These are all important things for us to know." Culture Clusters What makes these issues so important is the growing number of ethnically diverse U.S. residents-and the elderly population that will continue to increase as Baby Boomers age. According to the 2000 Census, there were more than 31 million foreign-born citizens living in the United States. Nearly 11 percent were 65 years and older. More than one-third were between the ages of 40 and 65. The growing cultural diversity is most strongly felt in traditional "gateway" areas, such as New York City, the Miami metropolitan area and the southwestern border region from Southern California to Texas. However, in recent years, urban areas across the country are also seeing growth in foreign-born populations. One of these regions is Chicago, which now ranks third among U.S. cities in its number of foreign-born residents. In an effort to address the cultural needs of its growing population of ethnically diverse elderly residents, several nursing homes in the Chicago area have begun grouping residents according to ethnicity. In doing so, these facilities are able to provide traditional foods, language and activities for a variety of different cultures. Kevin Kavanaugh, spokesperson for the Illinois Council on Long-term Care, acknowledged that this method is a growing trend among Chicago facilities, fulfilling a need that many patients and their families are supporting. "There are many different ways that culture impacts the care that is provided," Kavanaugh said. "Groupings are based on meeting cultural needs in a variety of areas." Kavanaugh provided the example of a Korean unit in one facility, where traditionally medicinal foods, such as seaweed soup, are served to residents; beds are lower to the ground for the comfort of a population used to sleeping closer to the floor; and religious activities and language are geared toward Korean residents. What's most important, according to Kavanaugh, is to get the residents and their families involved, in order to learn exactly how a resident's cultural needs affect his health care needs. "Whether a facility has separate units for different ethnic groups or there are different programs for people from different cultures, it's best if the facility talks to the family to see what they would like-especially if there's a language barrier," he said. Another important factor, Kavanaugh said, is to avoid stereotypes that can lead to inaccurate assumptions about a patient's needs. "You can't put people into boxes," he said. "Within every culture, there are subcultures-you can't make stereotypes and assumptions. Instead, you have to follow the concept of person-centered care, looking at the individual and making a thorough assessment to find out if what's important to the culture is really important to the person." While not all experts agree that grouping residents is the best way to address their cultural needs, all share a common concern about treating each patient's needs on an individual level. "If you can put people with similar values and traditions together, that might be helpful," McFarland said. "But first you have to think about assessing them as individuals and finding out what they're like and what they want. "Sometimes, as nurses, we tend to think we have a good idea about a patient's needs just by looking at them," she added. "Really, all nurses need to do a cultural assessment and see how people want their care to be." Making Quality Care Universal In addition to cultural care provided in nursing homes, initiatives have been created to address cultural differences in all health care arenas.

The term "cultural competence" is used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to describe the strategies used by health care providers to accommodate cultural differences while also providing quality health care to an increasingly diverse population. While many JCAHO policies have been made to encourage cultural competency in all health care institutions, some culture care experts feel efforts still aren't strong enough. "Culturally diverse care is a new fad now. Everyone is jumping on the bandwagon, even though it's been around for decades," said Victor Fernandez, RN, BSN, co-founder of CultureDiversity.org, a non-profit organization dedicated to increasing awareness of transcultural nursing. "Today, medical and nursing schools have had an increase in cultural care curricula, and there's indoctrination in JCAHO," he added, "but the sad thing is that in the trenches, culture is not being addressed." Like Kavanaugh and McFarland, Fernandez believes that in order to provide culturally diverse care, providers need to overlook the stereotypes that force assumptions about a patient and their needs. "The duty for us as health care providers is to educate ourselves," Fernandez said. "We can't just learn the stereotypes and think we know everything about a culture. That's just the overall picture," he added. "Nurses need to keep that picture in the background, but then take the time to learn about each patient: who he is, what he feels and, most importantly, what he needs."

Culture and Conflict

By Michelle LeBaron July 2003

Culture is an essential part of conflict and conflict resolution. Cultures are like underground rivers that run through our lives and relationships, giving us messages that shape our perceptions, attributions, judgments, and ideas of self and other. Though cultures are powerful, they are often unconscious, influencing conflict and attempts to resolve conflict in imperceptible ways.

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Cultures are more than language, dress, and food customs. Cultural groups may share race, ethnicity, or nationality, but they also arise from cleavages of generation, socioeconomic class, sexual orientation, ability and disability, political and religious affiliation, language, and gender -- to name only a few. Two things are essential to remember about cultures: they are always changing, and they relate to the symbolic dimension of life. The symbolic dimension is the place where we are constantly making meaning and enacting our identities. Cultural messages from the groups we belong to give us information about what is meaningful or important, and who we are in the world and in relation to others -- our identities. Cultural messages, simply, are what everyone in a group knows that outsiders do not know. They are the water fish swim in, unaware of its effect on their vision. They are a series of lenses that shape what we see and don't see, how we perceive and interpret, and where we draw boundaries. In shaping our values, cultures contain starting points and currencies[1]. Starting points are those places it is natural to begin, whether with individual or group concerns, with the big picture or particularities. Currencies are those things we care about that influence and shape our interactions with others.

How Cultures Work

Though largely below the surface, cultures are a shifting, dynamic set of starting points that orient us in particular ways and away from other directions. Each of us belongs to multiple cultures that give us messages about what is normal, appropriate, and expected. When others do not meet our expectations, it is often a cue that our cultural expectations are Additional insights into culture different. We may mistake differences between others and us for evidence of bad faith or lack of common sense on the part of others, not realizing that common sense is also cultural. and conflict are offered by Beyond What is common to one group may seem strange, counterintuitive, or wrong to another.

Intractability project participants.

Cultural messages shape our understandings of relationships, and of how to deal with the conflict and harmony that are always present whenever two or more people come together. Writing about or working across cultures is complicated, but not impossible. Here are some complications in working with cultural dimensions of conflict, and the implications that flow from them: Culture is multi-layered -- what you see on the surface may mask differences below the surface. Therefore, cultural generalizations are not the whole story, and there is no substitute for building relationships and sharing experiences, coming to know others more deeply over time. Culture is constantly in flux -- as conditions change, cultural groups adapt in dynamic and sometimes unpredictable ways. Therefore, no comprehensive description can ever be formulated about a particular group. Any attempt to understand a group must take the dimensions of time, context, and individual differences into account. Culture is elastic -- knowing the cultural norms of a given group does not predict the behavior of a member of that group, who may not conform to norms for individual or contextual reasons. Therefore, taxonomies (e.g. "Italians think this way," or "Buddhists prefer that") have limited use, and can lead to error if not checked with experience. Culture is largely below the surface, influencing identities and meaning-making, or who we believe ourselves to be and what we care about -- it is not easy to access these symbolic levels since they are largely outside our awareness. Therefore, it is important to use many ways of learning about the cultural dimensions of those involved in a conflict, especially indirect ways, including stories, metaphors, and rituals. Cultural influences and identities become important depending on context. When an aspect of cultural identity is threatened or misunderstood, it may become relatively more important than other cultural identities and this fixed, narrow identity may become the focus of stereotyping, negative projection, and conflict. This is a very common situation in intractable conflicts. Therefore, it is useful for people in conflict to have interactive experiences that help them see each other as broadly as possible, experiences that foster the recognition of shared identities as well as those that are different. Since culture is so closely related to our identities (who we think we are), and the ways we make meaning (what is important to us and how), it is always a factor in conflict. Cultural awareness leads us to apply the Platinum Rule in place of the Golden Rule. Rather than the maxim "Do unto others as you would have them do unto you," the Platinum Rule advises: "Do unto others as they would have you do unto them."

Culture and Conflict: Connections

Cultures are embedded in every conflict because conflicts arise in human relationships. Cultures affect the ways we name, frame, blame, and attempt to tame conflicts. Whether a conflict exists at all is a cultural question. In an interview conducted in Canada, an elderly Chinese man indicated he had experienced no conflict at all for the previous 40 years.[2] Among the possible reasons for his denial was a cultural preference to see the world through lenses of harmony rather than conflict, as encouraged by his Confucian upbringing. Labeling some of our interactions as conflicts and analyzing them into smaller component parts is a distinctly Western approach that may obscure other aspects of relationships.

Culture is always a factor in conflict, whether it plays a central role or influences it subtly and gently. For any conflict that touches us where it matters, where we make meaning and hold our identities, there is always a cultural component. Intractable conflicts like the Israeli-Palestinian conflict or the India-Pakistan conflict over Kashmir are not just about territorial, boundary, and sovereignty issues -they are also about acknowledgement, representation, and legitimization of different identities and ways of living, being, and making meaning. Conflicts between teenagers and parents are shaped by generational culture, and conflicts between spouses or partners are influenced by gender culture. In organizations, conflicts arising from different disciplinary cultures escalate tensions between co-workers, creating strained or inaccurate communication and stressed relationships. Culture permeates conflict no matter what -- sometimes pushing forth with intensity, other times quietly snaking along, hardly announcing its presence until surprised people nearly stumble on it. Culture is inextricable from conflict, though it does not cause it. When differences surface in families, organizations, or communities, culture is always present, shaping perceptions, attitudes, behaviors, and outcomes. When the cultural groups we belong to are a large majority in our community or nation, we are less likely to be aware of the content of the messages they send us. Cultures shared by dominant groups often seem to be "natural," "normal" -- "the way things are done." We only notice the effect of cultures that are different from our own, attending to behaviors that we label exotic or strange. Though culture is intertwined with conflict, some approaches to conflict resolution minimize cultural issues and influences. Since culture is like an iceberg -- largely submerged -- it is important to include it in our analyses and interventions. Icebergs unacknowledged can be dangerous, and it is impossible to make choices about them if we don't know their size or place. Acknowledging culture and bringing cultural fluency to conflicts can help all kinds of people make more intentional, adaptive choices.

Culture and Conflict: How to Respond

Given culture's important role in conflicts, what should be done to keep it in mind and include it in response plans? Cultures may act like temperamental children: complicated, elusive, and difficult to predict. Unless we develop comfort with culture as an integral part of conflict, we may find ourselves tangled in its net of complexity, limited by our own cultural lenses. Cultural fluency is a key tool for disentangling and managing multilayered, cultural conflicts. Cultural fluency means familiarity with cultures: their natures, how they work, and ways they intertwine with our relationships in times of conflict and harmony. Cultural fluency means awareness of several dimensions of culture, including

Communication, Ways of naming, framing, and taming conflict, Approaches to meaning making, Identities and roles.

Each of these is described in more detail below. Communication refers to different starting points about how to relate to and with others. There are many variations on these starting points, and they are outlined in detail in the topic Communication, Culture, and Conflict. Some of the major variations relate to the division between high- and low-context communications, a classification devised by Edward T. Hall.[3] In high-context communication, most of a message is conveyed by the context surrounding it, rather than being named explicitly in words. The physical setting, the way things are said, and shared understandings are relied upon to give communication meaning. Interactions feature formalized and stylized rituals, telegraphing ideas without spelling them out. Nonverbal cues and signals are essential to comprehension of the message. The context is trusted to communicate in the absence of verbal expressions, or sometimes in addition to them. High-context communication may help save face because it is less direct than low-context communication, but it may increase the possibilities of miscommunication because much of the intended message is unstated. Low-context communication emphasizes directness rather than relying on the context to communicate. From this starting point, verbal communication is specific and literal, and less is conveyed in implied, indirect signals. Low-context communicators tend to "say what they mean and mean what they say." Low-context communication may help prevent misunderstandings, but it can also escalate conflict because it is more confrontational than high-context communication. As people communicate, they move along a continuum between high- and low-context. Depending on the kind of relationship, the context, and the purpose of communication, they may be more or less explicit and direct. In close relationships, communication shorthand is often used, which makes communication opaque to outsiders but perfectly clear to the parties. With strangers, the same

people may choose low-context communication. Low- and high-context communication refers not only to individual communication strategies, but may be used to understand cultural groups. Generally, Western cultures tend to gravitate toward low-context starting points, while Eastern and Southern cultures tend to high-context communication. Within these huge categories, there are important differences and many variations. Where high-context communication tends to be featured, it is useful to pay specific attention to nonverbal cues and the behavior of others who may know more of the unstated rules governing the communication. Where low-context communication is the norm, directness is likely to be expected in return. There are many other ways that communication varies across cultures. High- and low-context communication and several other dimensions are explored in Communication, Culture, and Conflict. Ways of naming, framing, and taming conflict vary across cultural boundaries. As the example of the elderly Chinese interviewee illustrates, not everyone agrees on what constitutes a conflict. For those accustomed to subdued, calm discussion, an emotional exchange among family members may seem a threatening conflict. The family members themselves may look at their exchange as a normal and desirable airing of differing views. Intractable conflicts are also subject to different interpretations. Is an event a skirmish, a provocation, an escalation, or a mere trifle, hardly worth noticing? The answer depends on perspective, context, and how identity relates to the situation. Just as there is no consensus across cultures or situations on what constitutes a conflict or how events in the interaction should be framed, so there are many different ways of thinking about how to tame it. Should those involved meet face to face, sharing their perspectives and stories with or without the help of an outside mediator? Or should a trusted friend talk with each of those involved and try to help smooth the waters? Should a third party be known to the parties or a stranger to those involved? John Paul Lederach, in his book Preparing for Peace: Conflict Transformation Across Cultures,identifies two third-party roles that exist in U.S. and Somali settings, respectively -- the formal mediator and the traditional elder.[4] The formal mediator is generally not known to those involved, and he or she tries to act without favoritism or investment in any particular outcome. Traditional elders are revered for their local knowledge and relationships, and are relied upon for direction and advice, as well as for their skills in helping parties communicate with each other. The roles of insider partial (someone known to the parties who is familiar with the history of the situation and the webs of relationships) and outsider neutral (someone unknown to the parties who has no stake in the outcome or continuing relationship with the parties) appear in a range of cultural contexts. Generally, insider partials tend to be preferred in traditional, highcontext settings, while outside neutrals are more common in low-context settings. These are just some of the ways that taming conflict varies across cultures. Third parties may use different strategies with quite different goals, depending on their cultural sense of what is needed. In multicultural contexts, parties' expectations of how conflict should be addressed may vary, further escalating an existing conflict. Approaches to meaning-making also vary across cultures. Hampden-Turner and Trompenaars suggest that people have a range of starting points for making sense of their lives, including:

universalist (favoring rules, laws, and generalizations) and particularist (favoring exceptions, relations, and contextual evaluation) specificity (preferring explicit definitions, breaking down wholes into component parts, and measurable results) and diffuseness (focusing on patterns, the big picture, and process over outcome) inner direction (sees virtue in individuals who strive to realize their conscious purpose) and outer direction (where virtue is outside each of us in natural rhythms, nature, beauty, and relationships) synchronous time (cyclical and spiraling) and sequential time (linear and unidirectional).[5]

When we don't understand that others may have quite different starting points, conflict is more likely to occur and to escalate. Even though the starting points themselves are neutral, negative motives are easily attributed to someone who begins from a different end of the continuum.[6] For example, when First Nations people sit down with government representatives to negotiate land claims in Canada or Australia, different ideas of time may make it difficult to establish rapport and make progress. First Nations people tend to see time as stretching forward and back, binding them in relationship with seven generations in both directions. Their actions and choices in the present are thus relevant to history and to their progeny. Government negotiators acculturated to Western European ideas of time may find the telling of historical tales and the consideration of projections generations into the future tedious and irrelevant unless they understand the variations in the way time is understood by First Nations people. Of course, this example draws on generalizations that may or may not apply in a particular situation. There are many different Aboriginal

peoples in Canada, Australia, New Zealand, the United States, and elsewhere. Each has a distinct culture, and these cultures have different relationships to time, different ideas about negotiation, and unique identities. Government negotiators may also have a range of ethno cultural identities, and may not fit the stereotype of the woman or man in a hurry, with a measured, pressured orientation toward time. Examples can also be drawn from the other three dimensions identified by Hampden-Turner and Trompenaars. When an intractable conflict has been ongoing for years or even generations, should there be recourse to international standards and interveners, or local rules and practices? Those favoring a universalist starting point are more likely to prefer international intervention and the setting of international standards. Particularlists will be more comfortable with a tailor-made, home-grown approach than with the imposition of general rules that may or may not fit their needs and context. Specificity and diffuseness also lead to conflict and conflict escalation in many instances. People, who speak in specifics, looking for practical solutions to challenges that can be implemented and measured, may find those who focus on process, feelings, and the big picture obstructionist and frustrating. On the other hand, those whose starting points are diffuse are more apt to catch the flaw in the sum that is not easy to detect by looking at the component parts, and to see the context into which specific ideas must fit. Inner-directed people tend to feel confident that they can affect change, believing that they are "the masters of their fate, the captains of their souls."[7] They focus more on product than process. Imagine their frustration when faced with outer-directed people, whose attention goes to nurturing relationships, living in harmony with nature, going with the flow, and paying attention to processes rather than products. As with each of the above sets of starting points, neither is right or wrong; they are simply different. A focus on process is helpful, but not if it completely fails to ignore outcomes. A focus on outcomes is useful, but it is also important to monitor the tone and direction of the process. Cultural fluency means being aware of different sets of starting points, and having a way to speak in both dialects, helping translate between them when they are making conflict worse. These continua are not absolute, nor do they explain human relations broadly. They are clues to what might be happening when people are in conflict over long periods of time. We are meaning-making creatures, telling stories and creating understandings that preserve our sense of self and relate to our purpose. As we come to realize this, we can look into the process of meaning making for those in a conflict and find ways to help them make their meaning-making processes and conclusions more apparent to each other. This can be done by storytelling and by the creation of shared stories, stories that are co-constructed to make room for multiple points of view within them. Often, people in conflict tell stories that sound as though both cannot be true. Narrative conflict-resolution approaches help them leave their concern with truth and being right on the sideline for a time, turning their attention instead to stories in which they can both see themselves. Another way to explore meaning making is through metaphors. Metaphors are compact, tightly packaged word pictures that convey a great deal of information in shorthand form. For example, in exploring how a conflict began, one side may talk about its origins being buried in the mists of time before there were boundaries and roads and written laws. The other may see it as the offspring of a vexatious lawsuit begun in 1946. Neither is wrong -- the issue may well have deep roots, and the lawsuit was surely a part of the evolution of the conflict. As the two sides talk about their metaphors, the more diffuse starting point wrapped up in the mists of time meets the more specific one, attached to a particular legal action. As the two talk, they deepen their understanding of each other in context, and learn more about their respective roles and identities. Identities and roles refer to conceptions of the self. Am I an individual unit, autonomous, a free agent, ultimately responsible for myself? Or am I first and foremost a member of a group, weighing choices and actions by how the group will perceive them and be affected by them? Those who see themselves as separate individuals likely come from societies anthropologists call individualist. Those for whom group allegiance is primary usually come from settings anthropologists call collectivist, or communitarian. In collectivist settings, the following values tend to be privileged:

cooperation filial piety (respect for and deference toward elders) participation in shared progress reputation of the group interdependence

In individualist settings, the following values tend to be privileged:

competition independence

individual achievement personal growth and fulfillment self-reliance

When individualist and communitarian starting points influence those on either side of a conflict, escalation may result. Individualists may see no problem with "no holds barred" confrontation, while communitarian counterparts shrink from bringing dishonor or face-loss to their group by behaving in unseemly ways. Individualists may expect to make agreements with communitarians, and may feel betrayed when the latter indicate that they have to take their understandings back to a larger public or group before they can come to closure. In the end, one should remember that, as with other patterns described, most people are not purely individualist or communitarian. Rather, people tend to have individualist or communitarian starting points, depending on one's upbringing, experience, and the context of the situation.

Conclusion
There is no one-size-fits-all approach to conflict resolution, since culture is always a factor. Cultural fluency is therefore a core competency for those who intervene in conflicts or simply want to function more effectively in their own lives and situations. Cultural fluency involves recognizing and acting respectfully from the knowledge that communication, ways of naming, framing, and taming conflict, approaches to meaning-making, and identities and roles vary across cultures.

Cultural Competence

To be culturally competent the nurse needs to understand his/her own world views and those of the patient, while avoiding stereotyping and misapplication of scientific knowledge. Cultural competence is obtaining cultural information and then applying that knowledge. This cultural awareness allows you to see the entire picture and improves the quality of care and health outcomes. Adapting to different cultural beliefs and practices requires flexibility and a respect for others view points. Cultural competence means to really listen to the patient, to find out and learn about the patient's beliefs of health and illness. To provide culturally appropriate care we need to know and to understand culturally influenced health behaviors. In our society, nurses don't have to travel to faraway places to encounter all sorts of cultural differences, such as ethnic customs, traditions and taboos. The United States provides plenty of opportunities for challenges stemming from cultural diversity. To be culturally competent the nurse needs to learn how to mix a little cultural understanding with the nursing care they offer. In some parts of the United States culturally varied patient populations have long been the norm . But now, even in the homogeneous state of Maine where we reside, we are seeing a

dramatic increase in immigrants from all over the world. These cultural differences are affecting even the most remote settings. Since the perception of illness and disease and their causes varies by culture, these individual preferences affect the approaches to health care. Culture also influences how people seek health care and how they behave toward health care providers. How we care for patients and how patients respond to this care is greatly influenced by culture. Health care providers must possess the ability and knowledge to communicate and to understand health behaviors influenced by culture. Having this ability and knowledge can eliminate barriers to the delivery of health care. These issues show the need for health care organizations to develop policies, practices and procedures to deliver culturally competent care. Cross, T., Bazron, B., Dennis, K., and Isaacs, M. (1989) list five essential elements that contribute to an institutions or agencys ability to become more culturally competent. These include: 1. valuing diversity; 2. having the capacity for cultural self-assessment; 3. being conscious of the dynamics inherent when cultures interact; 4. having institutionalized cultural knowledge; and 5. having developed adaptations of service delivery reflecting an understanding of cultural diversity. These five elements should be manifested at every level of an organization, including policy making, administration, and practice. Further, these elements should be reflected in the attitudes, structures, policies, and services of the organization. Developing culturally competent programs is an ongoing process, There seems to be no one recipe for cultural competency. It's an ongoing evaluation, as we continually adapt and reevaluate the way things are done. For nurses, cultural diversity tests our ability to truly care for patients, to demonstrate that we are not only clinically proficient but also culturally competent, that we CARE.. Meyer CR.(1996) describes four major challenges for providers and cultural competency in healthcare. The first is the straightforward challenge of recognizing clinical differences among people of different ethnic and racial groups (eg, higher risk of hypertension in African Americans and of diabetes in certain Native American groups). The second, and far more complicated, challenge is communication. This deals with everything from the need for interpreters to nuances of words in various languages. Many patients, even in Western cultures,

are reluctant to talk about personal matters such as sexual activity or chemical use. How do we overcome this challenge among more restricted cultures (as compared to ours)? Some patients may not have or are reluctant to use telephones. We need to plan for these types of obstacles. The third challenge is ethics. While Western medicine is among the best in the world, we do not have all the answers. Respect for the belief systems of others and the effects of those beliefs on well-being are critically important to competent care. The final challenge involves trust. For some patients, authority figures are immediately mistrusted, sometimes for good reason. Having seen or been victims of atrocities at the hands of authorities in their homelands, many people are as wary of caregivers themselves as they are of the care. As individuals, nurses and health care providers, we need to learn to ask questions sensitively and to show respect for different cultural beliefs. Most important, we must listen to our patients carefully. The main source of problems in caring for patients from diverse cultural backgrounds is the lack of understanding and tolerance. Very often, neither the nurse nor the patient understands the other's perspective. References :
1. Cross, T., Bazron, B., Dennis, K., and Isaacs, M. Toward a Culturally Competent System of Care, Volume 1. Washington, D.C.: Georgetown University. (1989.) 2. Meyer CR. Medicine's melting pot. Minn Med 1996;79(5):5