Role of Communication in Building Cultural Competency · the diverse cultural beliefs, attitudes, ... own cultural beliefs, values, perceptions and convictions will ... OF COMMUNICATION

Running head: ROLE OF COMMUNICATION IN BUILDING CULTURAL COMPETENCY 1

Role of Communication in Building Cultural Competency

Guevara, Fredesminda

Stenberg College

ROLE OF COMMUNICATION IN BUILDING CULTURAL COMPETENCY 2

Role of Communication in Building Cultural Competency

An increasing trend in migration today is reshaping the demographic of western countries

such as the USA, Canada and the UK (Elsegood & Papadopoulos, 2011); Park, Chesla & Rehm,

2011) which translates to a growing demand for culturally-appropriate mental health care

(Campinha-Bacote, 2002). This increasing need calls for a strategic discipline that will address

the diverse cultural beliefs, attitudes, prejudices and norms of this escalating diversity. Cultural

competency can answer this need by empowering mental health care providers and psychiatric

nurses through building of skills, attitudes and knowledge (Maier-Lorentz, 2008).

Communication among mental health care providers and culturally diverse patients will increase

satisfaction, consistency with treatment goals and positive treatment results (Stewart, 1995).

Effective communication skills do build up cultural competency in psychiatric nurses by

enabling therapeutic interactions, enhancing cultural awareness and knowledge, and facilitating

cultural assessments.

Therapeutic interaction established through effective communication is an important tool

for nurses to achieve cultural competence. It connects culturally diverse individuals to their

mental health service providers and creates positive experiences for both and adherence of the

clients to follow-up instructions (Hulme, 2013). Creating and maintaining this therapeutic

relationship is a major factor for success in the delivery of optimum care for the client.

Therapeutic communication can be established through attending and effective listening

(Keashuk & Newton, 2009). Attending, according to Burnard (2005), is the process of giving

one’s full attention to the client and focusing on what he is trying to communicate across to the

nurse. It is reinforced by active listening to the client’s verbal and nonverbal cues. Verbal cues

such as value-laden words and phrases, and metaphors can be a wealth of information for the


nurse’s assessment of the client (Burnard, 2005). Contextual meanings and thoughts that are not

spoken but inferred may also be considered as verbal cues. Volume and tone of voice, pitch, and

other paralinguistic aspects of communication are gauges of a client’s feelings which can

mislead if not confirmed with the client. Nonverbal cues constitute but are not restricted to, body

language, touch, facial expressions, gestures, eye contact, proximity, positioning of the body, and

body movements (Burnard, 2005). Care must be taken with some of these nonverbal cues, such

as eye contact, space and distance, which can have negative implications when used in the

context of transcultural nursing. However, paying more attention to nonverbal cues are often

more productive than contemplating verbal cues (Sederstrom, 2013). Verbal communication,

especially in a transcultural setting, can cause confusion when language barriers are present.

Language barriers are identified as the most common obstacle for nurses in giving culturally

competent care in cross-cultural clinical settings (Berry-Cabán, & Cresp, 2008; Maier-Lorentz,

2008). Unresolved barriers can lead to inaccurate medication histories, not complying with

discharge instructions, or failure to give consent for procedures (Sederstrom, 2013). To avoid

adding to the barriers, nurses must use simple language without figures of speech and avoid

speaking fast. At initial meetings with a client, it is important to establish conditions for

therapeutic communication such as appropriately greeting the client and using his preferred

name, offering a firm handshake, putting the client at ease by using a positive tone of voice while

explaining in clear language the agenda of the meeting, and using professional and respectful

language. Actively listening, paraphrasing the client, and procuring the services of an interpreter

will ensure no misunderstanding or ambiguities in communication (Sederstrom, 2013). Active

listening is also validated by reflecting what the client just said, recapitulating, and inviting the

client to share more of himself and his experiences. Moreover, therapeutic interaction between


nurse and client is also facilitated by nonverbal communication. Facial expressions and body

language reveal emotions and feelings which may contradict spoken words and confuse the

client. Eye contact is regarded in western countries as essential to nursing, as it connotes honesty

and respect for the other person (Maier-Lorentz, 2008). However, some cultural groups , such as

the Arabs, Southeast Asians and Native North Americans perceive direct or prolonged eye

contact as lacking respect, hostile and rude (Maier-Lorentz, 2008). Touch is a good

communication tool to convey sympathy, comfort and therapeutic relief, as viewed through

Western glasses (Maier-Lorentz, 2008). But in Arabic and Hispanic communities, touching by a

male nurse on certain female anatomy is prohibited, and females are not allowed to touch males.

A good rule of thumb for necessary touching is to communicate to the patient the necessity of the

procedure before performing the act (Maier-Lorentz, 2008). Silence is another positive nonverbal

skill employed by Native North Americans, Chinese, Japanese, Arabs and surprisingly, by

English clients. It is seen as showing respect and is used like a pause to allow for contemplation

of what had just inspired. However, some may attribute (White North Americans) silence as

disrespectful and an indication of depression and lack of interest (Maier-Lorentz, 2008). On the

other hand, open body language, such as legs and arms not crossed, invites the client to share

more of himself and be more responsive to the nurse’s questions (Hulme, 2013).

Well-developed communication skills can also enhance cultural awareness and

knowledge which are prerequisites for attaining cultural competency through transcultural

nursing. Transcultural nursing is the discipline that deals with culture-specific health care for

ethnically diverse individuals or cultural groups in accordance with his cultural beliefs, practices

and values (Leininger, 1978). Cultural awareness is the process of self-assessment and self-

exploration to identify prejudices, biases and expectations against people who belong to


ethnically diverse groups (Campinha-Bacote, 2002). The nurse can be full of her own biases and

prejudices which she might not even know so a self-assessment will bring this out to light. An

excellent tool to aid self-assessment is reflective journaling (Lasater & Nielsen, 2009). Writing

about and challenging one’s own cultural beliefs, values, perceptions and convictions will not

only be therapeutic but will help expose bigotry and biases which can adversely affect how the

nurse provides culture-sensitive care to ethnic group members (Papadopoulos & Lees, 2002).

This personal prejudices and biases are red flags for possibilities of stereotyping, general

assumptions, and discrimination because of the glaring incongruity in both cultures (Maier-

Lorentz, 2008). An ethnocentric (Burnard, 2005) perspective may be used by the nurse on this

disparity and assign the lack to the client’s culture, and fail to provide the culture-specific need

of the client. It is this awareness that will help the nurse recognize the similarities and

differences between her culture and others which will increase her understanding and

appreciation of the diversity, and enable her to be sensitive to the special care needs of the client

(Papadopoulos & Lees, 2002). Without this awareness, the nurse may inadvertently inflict her

cultural beliefs, values and behavioral patterns on the client (Leininger, 1978). Cultural

awareness, then, is essential in building cultural knowledge which is acquired through effective

cross-cultural communication. A nurse with a sincere desire to be more culturally knowledgeable

will engage in therapeutic interactions with the client to know more about his cultural

perspectives and identify his culture-specific requirements for care (Narayanasamy, 1999a).

Culture-sensitive care is facilitated by considering relevant issues in transcultural nursing such as

health disparities and perception of mental illness among different cultures. The roles of

stereotyping, discrimination and assumptions adversely affect labeling of illnesses, psychiatric

interventions, and health care opportunities for Black and other ethnic communities


(Narayanasamy, 1999b). Identifying these cultural differences will allow for congruent responses

to diagnoses and treatment care plans of ethnically-diverse clients. And by modifying practices

to accommodate cultural contexts in transcultural care, culture-congruent care is demonstrated.

Park et al (2011) suggest that deficiencies in cultural competencies of health care providers have

contributed to inaccurate diagnoses, incongruent treatment care plans, miscommunication

between health care provider and clients, mistakes in clinical practice and early termination of

treatment. Transcultural communication is a key factor in addressing these disparities through

cultural awareness and knowledge. Validation of this concept is evident in the culturally-

congruent care plans of mental health providers in treating Asian-Americans in San Francisco,

USA. (USA). Family involvement is prevalent in this ethnic group and can have far-reaching

effects in diagnosis and treatment of the ill member. Service providers consult families and

groups of the same ethnic community to assess similarity of cultural norms to stock cultural

knowledge. These customs are considered and appropriately integrated into the patient care plans

(Park et al, 2011). One example is of a Laotian woman who was admitted for depression after an

emotional breakup, reported the presence of a ghost in her room watching her daily from a

corner. A nurse asked a colleague and was told that it was a Laotian superstition which prompted

the treatment team to deliberate on the best approach and agree on inviting a shaman to deal with

the ghost. The woman’s conditions improved which allowed the team to proceed with treatment

of her depression instead of the initial appearance of psychosis (Park et al, 2011). Indeed,

cultural awareness and knowledge are key indicators of cultural competence.

Cultural assessments of mental health clients with diverse ethnic backgrounds are

facilitated by nurses’ effective communication skills. Assessments involve questions about

important facets of their care such as medication history, food preferences/taboos, pain tolerance


and healthcare beliefs (Maier-Lorentz, 2008). For some cultures, there are certain notions about

food that relate to their religious practices and cultural beliefs. In Filipino culture, of which this

author is a member, food is a language by itself (Pasco, Morse, & Olson, 2004). It is central to

socialization and it is used as a communication tool to establish friendships and social

interactions. Family members, being integral parts of the treatment process, communicate their

approval of health care staff through gifts of food. A sick member will be brought home-cooked

food because the act communicates the love of the family for the sick member (Pasco, Morse, &

Olson, 2004). The nurse should check with the client about foods that are considered to be

healthy or not healthy in times of illness. During assessments, it is important that the nurse

consider both verbal and nonverbal cues on the topic of pain. Pain tolerance is sometimes subject

to cultural context and patients do not declare pain because it is expected, but nonverbal clues

such as facial expressions or body language may give the client away (Maier-Lorentz, 2008).

Different healthcare beliefs are important factors that should be considered during assessment. In

American culture, advance directives for severely ill patients are welcomed. For Asian-

Americans, families prefer to keep the truth from the patient to protect and afford him peace

(Turner, 2002). The process of assessment is a significant part of building cultural competence

and must be culture-sensitive. To facilitate the assessment, the interviewee or the nurse must

observe congruent behaviors and attitudes such as being open-minded, non-judgemental and

formal, taking all considerations such as cultural value systems, perceptions and tendencies. To

establish a therapeutic interaction, the nurse must use therapeutic strategies such as asking open

questions, reflecting or selectively reflecting the client’s words, building empathy and confirm

understanding (Burnard, 2005).


In summary, the ever-increasing diversity of most countries require cultural competency

to provide culture-sensitive mental health care. Cultural competency of psychiatric nurses can be

attained through effective communication skills which help create therapeutic relationships,

increase awareness and knowledge of cultural diversity, and ensure culture-specific client

assessments.


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Role of Communication in Building Cultural Competency · the diverse cultural beliefs, attitudes, ... own cultural beliefs, values, perceptions and convictions will ... OF COMMUNICATION