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Embracing Global Similarities: A Framework for Cross-Cultural Obstetric Care
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THOUGHTS & OPINIONS
Embracing Global Similarities: A Framework for Cross-Cultural Obstetric Care Patricia A. Ottani, CNM, PhD
In this era of consistent global migration, cultural competency is necessary in all aspects of the care nurses provide to families. Cultural competency is particularly significant in maternal-newborn nursing because childbirth, as one of life’s most significant events, is culturally shaped and socially constructed. In this article, a framework is provided to enable nurses to focus on several global phenomena and thus provide care that is more culturally sensitive, congruent with the client’s needs, and competent. Suggestions for integrating cultural issues into nursing curricula are offered. JOGNN, 31, 33–38; 2002. Keywords: Childbirth—Competence—Cross cultural—Culture Accepted: March 2001 In the United States each year, nurses, midwives, and other providers of obstetric care offer their services to families from increasingly diverse cultures. Women from places such as Southeast Asia, Central America, Russia, and Lebanon are seen in everyday clinical encounters (Downs, Bernstein, & Marchese, 1997). Although research is available for nurses and educators regarding the cultural practices of differing populations (Abdullah, 1995; Spector, 2000; Williamson, Stecchi, Allen, & Coppens, 1996), a broader look is needed at the factors that are consistently important in caring for women from all over the world. It is not possible to learn the specific rituals and beliefs of all the Earth’s populations. As well, such a narrowed perspective can lead to stereotyped assumptions. A broader perspective may actually allow nurses greater opportunities to cross culJanuary/February 2002
tures in their daily encounters. Culturally competent care is particularly important in maternal-newborn nursing because childbirth, as one of life’s most significant events, is influenced by cultural norms and expectations (Jordan, 1993). In nearly every society around the world, childbirth is a “socially marked life crisis event that is consensually shaped and socially patterned” (Jordan, 1993, p. xii). As a result, attitudes and values shape each woman’s childbearing behaviors and even the experience of pain during labor (Callister, 1995). Consequently, the care offered by the nurse must match the laboring woman’s needs so that she may have a satisfying childbirth experience here in the United States. The following excerpt highlights the necessity of such an approach: The thing is we have to follow their practices here. They treat you all the same way, whatever country you come from anyway. So if they say, “take a bath,” you take a bath. . . . Of course you are not satisfied (Small, Liamputtong Rice, Yelland, & Lumley, 1999, p. 92). How do nurses become culturally competent care providers when such diversity exists among and between societies? I use a perspective that is often not considered: that of global similarity. The ability to focus on the similarities between ourselves and our world neighbors may provide us with a userfriendly concept that will permit nurses, and other maternal-newborn care providers, to cross cultures in our daily encounters with clients. This approach is possible because, according to Giger and Davidhizar (1995), at least six worldwide phenomena con-
JOGNN 33
sistently appear. These are (a) communication, (b) social organization, (c) space/touch, (d) time, (e) environmental control, and (f) biologic variation. Awareness and understanding of at least the first four of these phenomena will help to increase the nurse’s ability to deal with cultural issues. Using the acronym COST to highlight four of these phenomena, a COST-efficient framework is offered for
C
hildbirth is a significant life event and is influenced by the social norms and expectations of the woman’s community.
increasing understanding of other’s values and beliefs. As well, an understanding of these global similarities can heighten the nurse’s awareness of the presence of an ethnocentric bias, particularly as it pertains to the medicalization of childbirth and the technocratic model pervasive in the United States (Davis-Floyd, 1994). This realization can help improve cross-cultural care (Carillo, Green, & Betancourt, 1999), especially in situations in which the model of childbirth in use may vary from the model of childbirth familiar to women from other cultures. This is particularly important for Western providers of obstetric care. Approximately 80% of the world’s newborns are born at home (Dunham, 1991). Yet, women who enter the U.S. health care system are expected to enter the hospital and give birth the way that we do, while being cared for by nurses, midwives, and others who may not understand their cultural values and beliefs surrounding pregnancy and childbirth. In addition, varying degrees of acculturation or assimilation, or both, may alter one’s perspective on even the most common cultural practices. An awareness and understanding of these core phenomena can provide students, nurses, and others with a tool to allow them to provide care that better matches maternal desires and needs and increases their competency in providing cross-cultural care. Examples of how one can use these phenomena follow.
Communication Communication may appear to be the largest barrier to providing culturally competent care. However, nurses interact and communicate daily with physicians, fellow nurses, children, clerks in the grocery store or fast-food restaurant, or any number of people from different places. How is it that one can effectively communicate within these subcultures, each with its own set of norms and expectations? How is it that nurses can care for patients who have lim-
34 JOGNN
ited or no ability to speak because of a stroke or surgery? It is the basic understanding that communication incorporates nonverbal as well as verbal communication techniques (Marshall & While, 1994) that makes it possible for people to understand and communicate on varying levels when a common spoken language is not an option. As nurses, we must use the knowledge and skills we already possess and rely on the subtleties of communication such as style, volume, silence, gestures, and eye behaviors. These forms of communication are familiar to intrapartum nurses. After all, how often have you assessed that your client is in discomfort or needs to push even before she has said a word? Apply these same skills to mothers who cannot speak English. Suspend reliance on the spoken word and reach deeper. Rely on the knowledge that you already have. Observe and listen. Watch the way your clients and their family members interact. Listen to their tone of voice. Notice communication cues. Does the woman make eye contact with you? In some cultures, it is disrespectful to look into the eyes of those with greater authority (or supposed authority). This observation also will provide you with information regarding who is the elder of your client’s community, if she or he is present. Loud vocalization may be considered disrespectful. Once you understand how this woman and her family communicate, realize that this is what is expected of you if you wish to provide care that is culturally sensitive and competent. You can resume nurse linguistics when you step outside of her domain. Generally, it takes only a few minutes to observe the tone, gestures, and techniques that are being used. Use every moment of interaction as an opportunity to learn what is acceptable. Trust your instincts. Value the knowledge you have and the knowledge that you will gain. When interpretation is necessary, some general guidelines have been offered by the experts. Khalaf and Callister (1997) called for two interpreters: one an insider to the culture in question and the other an outsider. The insider is necessary to discover the nuances or subtle meanings particular to the woman’s world. The outsider provides the local perspective or understanding of a particular situation, phrase, or gesture. This outsider can be the nurse. Use of both kinds of interpreters together can help clarify misunderstandings and strengthen the accuracy of the interpretation. For example, when some women are asked if it burns when they urinate, they may reply that it does because urine feels warm (Kemp, 1985). However, when asked if it hurts when they urinate, they may reply no. In addition, green may mean blue, and yes may be the appropriate response to anything one does not understand (Uba, 1992). These nuances can be discovered by someone who is familiar with the colloquialisms of the specific culture. An interpreter with training in medical terminology is essential. Sometimes, a hospital employee can fill this role, but first make sure the woman is com-
Volume 31, Number 1
fortable having a stranger interpret for her. Be sure that the interpreter is fluent in English and the language in need of translation. The interpreter should be female and approximately the same age as the client so that any real or potential power inequities are reduced (Khalaf & Callister, 1997). Women may feel especially vulnerable during childbirth. The use of children as interpreters, especially the woman’s own, is discouraged because in most societies, it is not acceptable for children to know more than their parents (Kemp, 1985). Learn from your clients. Value their diversity and embrace the similarities in the ways we communicate.
Organization, Space, and Touch How often have you walked into a birthing room to find half a dozen or more people of all ages surrounding the laboring woman? The extended family is integral in many cultures (Spector, 2000) and is evident during life events, such as childbirth. The presence of family members can provide the nurse with clues regarding the individual mother’s belief about the family unit, social organization, and valuing of space and touch. In most societies, space and touch are regulated by social orders and rules, just as in the United States. Observe the proximity of family members to one another and to the laboring woman. Note whether there is a lot of hugging or touching between family members or whether distance is kept between people. The distance that is permitted for close family members generally is closer than is acceptable for the nurse. Note whether the woman’s mother or another significant female family member is present. This information will provide you with clues as to how this woman values space and touch, as well as the social organization and role of women in her community. Some societies value patriarchal systems (Catolico, 1997). It will take only a few minutes to recognize the woman’s reliance on the male partner, often to the point that he may answer questions asked of her. Value his ability to answer the questions because this shows respect for your client’s social norms. A hands-off policy may be congruent with some women’s needs, although the use of technology in the United States often warrants otherwise. This can violate the woman’s values of space and touch, so be sensitive to this issue and explain why you must touch her. Be sure the touching is necessary. Thinking about the similarities in how we organize our worlds, socially and proximally, will provide clues as to how you can respect and learn from your clients.
Time Have you ever been in a birthing room that did not have at least one clock hanging almost surreally above or near the woman’s bed? This is representative of the WestJanuary/February 2002
ern value of and reliance on clock or calendar time, yet this is not consistent with other cultures, which may use the sun or moon to refer to the passage of time (Jambunathan & Stewart, 1995). Differences in perception of time may become apparent when the mother appears disinterested in the clock or has difficulty relating events in terms of calendar days. Creativity can help in determining such things as a probable due date by how many moons have passed since the last menses. A way to encourage a woman who tracks time differently may be to let her know that her newborn will come before sunrise or after dawn. When referring to the timing of medications, it may help to incorporate other aspects of time, such as “when your husband arrives” or “before the next meal.” Have fun with this concept, and see if it helps your clients as well as yourself to establish more meaningful and culturally competent relationships.
Control Environmental control, or one’s ability to control the setting that one is in, may or may not be a problem for women born in this country. Obstetric care providers in the United States often ask their clients to devise a birth plan. Women may bring such things as radios, pillows, or pictures to create the environment in which they choose to give birth. Similarly, women from other cultures learn
S
uspend reliance on the spoken word, and use the skills you already possess.
how to create their own comfortable birthing environments. This is a global phenomenon. Yet, because many of these women may be used to giving birth in their own home or a family member’s home, they have lost control over their environment when they come to our obstetric units. Compounded by other factors, such as language barriers, women from other countries may feel helpless on our birthing units. Nurses must be sensitive to women’s needs to have family members and friends present; assume “nontraditional” birth positions; refuse food or drinks, or even a shower after giving birth; or insist on bottle-feeding until their milk comes in (Mattson, 1995). Nurses and other care providers need to observe, listen, and ask. Value another’s values.
Biologic Variation Biologic variation, the last of the identified global phenomena, refers to differences in body structure that
JOGNN 35
appear to be related to ethnicity, gender, or race. The implication such variation has on the provision of quality, culturally competent care lies in the avoidance of stereotypical thinking, such as assuming that all smallframed women will have difficult labors. Instead, nurses must focus their care on helping their clients give birth in the manner most satisfying to them. Biologic variations within cultures warrant greater attention when addressing hereditary disorders, such as thalassemia and sickle cell anemia, as part of the core curriculum in most maternalnewborn courses. In summary, thinking about the way the woman communicates (C), organizes her life around her family or is able to control birth events (O), values space and/or touch (S), and understands or relates time (T) to other factors can provide information that allows nurses to interact with and provide care for women from other cultures in a
A
broader perspective of cultural issues may enable more individualized care.
way that meets their needs. Without consideration of these phenomena, it is not likely the nurse can provide care that is sensitive and congruent. Nurses need to value diversity and embrace global similarities rather than aiming to decrease those differences inherent in the cultural rite of giving birth.
Cross-Cultural Education The integration of cross-cultural knowledge must begin during the student nurse years. A basic understanding of cultural terminology and several frequently used definitions of culture should provide the groundwork. One commonly used definition of culture is “the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways” (Leininger, 1991, p. 47). Subcultures exist within any larger cultural framework, however. For example, within the medical culture, physician subcultures, nursing subcultures, and medical technician subcultures are found. Subcultures exist within subcultures. Cultural stereotyping, or presuming that individuals within any given community think and behave the same way, should be avoided. Culture is shaped by gender, age, sexual preference, and other factors (Giger & Davidhizar, 1995). Maternal-newborn nurse educators can help increase their students’ competency in cross-cultural nursing. It is not enough to have a single chapter or section of a chap36 JOGNN
ter in a text devoted to cultural issues. Rather, the educator needs to choose a text in which cultural issues are integrated throughout. One such text is Maternal Newborn Nursing Care: A Family and Community-Based Approach (Olds, London, & Ladewig, 2000). In this book, topics such as cultural beliefs about activity and pregnancy, conception and fetal development, the postpartum period, and menstruation are discussed. Other issues that educators should look for in a text include references to complementary alternative therapies, such as the use of herbal remedies for dysmenorrhea, for example. A discussion on the use or nonuse of contraception can spur conversation regarding accepted and discouraged behaviors in other cultures. Issues surrounding the need for modesty and female care providers or the presence of female family members highlight the importance of sensitivity to a woman’s valuing of space, touch, and social organization. The educator need not search far for descriptions of any of the above if the text chosen has clearly integrated cultural issues as described above. A lecture on childbirth would not be complete without mention of birthing positions. Two films by the Global Maternal/Child Health Association offer opportunities for students to view birthing techniques and positions used by women around the world. Gentle Birth Choices (1993) depicted women in many natural and physiologically productive positions. Birth Into Being (1999) demonstrated water-birthing techniques used in Russia. Both films can expand students’ perspectives on the ways women give birth. At the same time, students need to be taught that they can discover what is necessary to make each woman’s birth experience satisfying through observation, use of verbal and nonverbal communication techniques, and an awareness of the social organization of the particular family. The COST acronym can help remind students that an understanding of the woman’s communication techniques, organization of her family and environment, and valuing of space/touch and time can help the nurse provide culturally competent care. When discussing the use of analgesics and anesthetics during childbirth, it is important to stress that medication use during labor varies with culture. Although analgesics and oxytocin are commonly used in the United States, their use is considered a potential hazard to both mother and child in other countries (Jordan, 1993). This view may determine a woman’s willingness to take medications or continue their use. A discussion of other pain relief techniques, such as meditation, prayer, song, massage, or herbs, can expand students’ horizons concerning the diversity of health beliefs and practices. In some societies, women are expected to adhere to specific behaviors during the postpartum period. Some women are expected to rest during the postpartum period, stay warm, avoid drafts, consume only warm and/or hot fluids and foods, and abstain from showering. StuVolume 31, Number 1
dent nurses should be taught to adapt their practices to their clients’ needs. Optional sources for students who wish to gain a deeper understanding of cultural practices could include texts such as Fadiman’s (1997) The Spirit Catches You and You Fall Down, Hayslip’s (1989) When Heaven and Earth Changed Places, or Spector’s (2000) Cultural Diversity in Health & Illness. Gary, Sigsby, and Campbell (1998) identified the need to have culturally competent faculty members who provide an environment that “supports differing worldviews.” St. Clair and McKenry (1999) demonstrated the benefits of “cultural immersion” for groups of nursing students. Although this is not possible for all students, St. Clair and McKenry reinforced the need to use clinical sites that serve diverse populations. A key concept for students is an understanding that what one believes to be true is based on one’s own social and cultural influences and will influence one’s health promotion activities. To provide culturally competent care, one must strive to adapt one’s practice to the family’s needs rather than trying to adapt the client’s needs to our own. As outlined in Healthy People 2010 (U.S. Department of Health and Human Services, 2000), health promotion and risk reduction are components of care. Consequently, core concepts such as health and wellness offer an opportunity to address cultural issues. For example, the World Health Organization’s definition of health as being more than the absence of disease (Spector, 2000) has been accepted by the medical profession. Other cultures view illness as an imbalance of body fluids or yin and yang, a loss of heat, or even as a curse, punishment, soul loss, or spirit possession (Andrews & Boyle, 1999). The Western view of illness as pathologic thus is only one perspective. Students need to be aware of the presence of other perspectives. Health promotion activities are influenced by culture and are largely based on the beliefs stated above. If one believes that carcinogens cause cancer, one can choose (or not choose) to avoid them. Health promotion and diseaseprevention techniques also can include prayers, the wearing of amulets, or even the avoidance of drafts (Spector, 2000). A teacher can ask students to offer their home remedies for a cold to provide an example of how diverse people’s beliefs can be even within a small population. This discussion leads to the opportunity for the teacher to initiate a discussion of the cultural barriers to health promotion. Language, financial resources, social support, and beliefs are linked. Statistics demonstrating health disparities can spur a conversation regarding inequities in the health care system. By weaving in cultural factors without specifically addressing any particular one, the educator can function from a broader perspective, allowing students to focus on January/February 2002
any individual woman’s needs without assuming that she will have the same preferences as another woman from her culture. For instance, how many times can one recall thinking that a certain woman would be a definite “epidural” or “C-section”? Educators must discourage stereotypical generalizations and encourage students to value diversity while embracing people’s similarities. We have much to learn from societies in which women give birth unimpeded by technology and politics. Instead of focusing on differences, nurses must focus on the similarities in the way we communicate, touch, and organize our worlds. As the largest workforce in the health care delivery system (Meleis, Isenberg, Koerner, Lacey, & Stern, 1995), nursing has the responsibility to be the voice of action and to reduce care inequities. A COST-efficient framework can allow nurses and others to identify phenomena that can contribute to the provision of culturally competent care. A greater understanding may help bridge the gap between what we as nurses assume is best for our clients and what they actually desire or need. REFERENCES Abdullah, S. N. (1995). Towards an individualized client’s care: Implication for education: The transcultural approach. Journal of Advanced Nursing, 22, 715-720. Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care (3rd ed.). Philadelphia: Lippincott. Callister, L. C. (1995). Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24, 327-329. Carillo, J. E., Green, A. R., & Betancourt, J. R. (1999). Crosscultural primary care: A patient-based approach. Annals of Internal Medicine, 130(10), 829-834. Catolico, O. (1997). Psychological well-being of Cambodian women in resettlement. Advances in Nursing Science, 19(4), 75-84. Davis-Floyd, R. (1994). The technocratic body: American childbirth as cultural expression. Social Science & Medicine, 38(8), 1125-1140. Downs, K., Bernstein, J., & Marchese, T. (1997). Providing culturally competent primary care for immigrant and refugee women. Journal of Nurse-Midwifery, 42(6), 500-508. Dunham, C. (1991). Mamatoto: A celebration of birth. New York: Penguin. Fadiman, A. (1997). The spirit catches you and you fall down. New York: Noonday. Gary, F. A., Sigsby, L. M., & Campbell, D. (1998). Preparing for the 21st century: Diversity in nursing education, research, and practice. Journal of Professional Nursing, 14(5), 272279. Giger, J., & Davidhizar, R. (1995). Transcultural nursing: Assessment and intervention (2nd ed.). St. Louis, MO: Mosby Year Book. Global Maternal/Child Health Association. (1993). Gentle birth choices [Motion picture]. (Available from Global Maternal/ Child Health Association, P.O. Box 1400, Wilsonville, OR 97070).
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Global Maternal/Child Health Association. (1999). Birth into being: The Russian waterbirth experience [Motion picture]. (Available from Global Maternal/Child Health Association, P.O. Box 1400, Wilsonville, OR 97070). Hayslip, L. L. (1989). When heaven and earth changed places. New York: Penguin. Jambunathan, J., & Stewart, S. (1995). Hmong women in Wisconsin: What are their concerns in pregnancy and childbirth? Birth, 22(4), 204-210. Jordan, B. (1993). Birth in four cultures (4th ed.). Prospect Heights, IL: Waveland. Kemp, C. (1985). Cambodian refugee health care beliefs and practices. Journal of Community Health Nursing, 2(1), 41-52. Khalaf, I., & Callister, C. (1997). Cultural meanings of childbirth: Muslim women living in Jordan. Journal of Holistic Nursing, 15(4), 373-388. Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing. Marshall, S. L., & While, A. E. (1994). Interviewing respondents who have English as a second language: Challenges encountered and suggestions for other researchers. Journal of Advanced Nursing, 19, 566-571. Mattson, S. (1995). Culturally sensitive perinatal care for Southeast Asians. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 19, 566-571. Meleis, A. I., Isenberg, M., Koerner, J. E., Lacey, B., & Stern, P. (1995). Diversity, marginalization and culturally competent health care issues in knowledge development (monograph of the American Academy of Nursing, Serial No. 1557810-113-6).
38 JOGNN
Olds, S. B., London, M. L., & Ladewig, P. A. (2000). Maternalnewborn nursing care: A family and community-based approach (6th ed.). Englewood Cliffs, NJ: Prentice Hall. Small, R., Liamputtong Rice, P., Yelland, J., & Lumley, J. (1999). Mothers in a new country: The role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia. Women & Health, 28(3), 77-101. Spector, R. E. (2000). Cultural diversity in health & illness (5th ed.). Upper Saddle River, NJ: Prentice Hall. St. Clair, A., & McKenry, L. (1999). Preparing culturally competent practitioners. Journal of Nursing Education, 38(5), 228-234. Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public Health Reports, 107(5), 544-548. U.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: Author. Williamson, E., Stecchi, J. M., Allen, B. B., & Coppens, N. M. (1996). Multiethnic experiences enhance nursing students’ learning. Journal of Community Health Nursing, 13(2), 73-81. Patricia A. Ottani is an assistant professor in the College of Health Professions, Department of Nursing, at the University of Massachusetts, Lowell. Address for correspondence: Patricia Ottani, CNM, PhD, Assistant Professor, College of Health Professions, Department of Nursing, University of Massachusetts Lowell, 3 Solomont Way, Suite 2, Lowell, MA 01854. E-mail: [email protected].
Volume 31, Number 1
THOUGHTS & OPINIONS
Embracing Global Similarities: A Framework for Cross-Cultural Obstetric Care Patricia A. Ottani, CNM, PhD
In this era of consistent global migration, cultural competency is necessary in all aspects of the care nurses provide to families. Cultural competency is particularly significant in maternal-newborn nursing because childbirth, as one of life’s most significant events, is culturally shaped and socially constructed. In this article, a framework is provided to enable nurses to focus on several global phenomena and thus provide care that is more culturally sensitive, congruent with the client’s needs, and competent. Suggestions for integrating cultural issues into nursing curricula are offered. JOGNN, 31, 33–38; 2002. Keywords: Childbirth—Competence—Cross cultural—Culture Accepted: March 2001 In the United States each year, nurses, midwives, and other providers of obstetric care offer their services to families from increasingly diverse cultures. Women from places such as Southeast Asia, Central America, Russia, and Lebanon are seen in everyday clinical encounters (Downs, Bernstein, & Marchese, 1997). Although research is available for nurses and educators regarding the cultural practices of differing populations (Abdullah, 1995; Spector, 2000; Williamson, Stecchi, Allen, & Coppens, 1996), a broader look is needed at the factors that are consistently important in caring for women from all over the world. It is not possible to learn the specific rituals and beliefs of all the Earth’s populations. As well, such a narrowed perspective can lead to stereotyped assumptions. A broader perspective may actually allow nurses greater opportunities to cross culJanuary/February 2002
tures in their daily encounters. Culturally competent care is particularly important in maternal-newborn nursing because childbirth, as one of life’s most significant events, is influenced by cultural norms and expectations (Jordan, 1993). In nearly every society around the world, childbirth is a “socially marked life crisis event that is consensually shaped and socially patterned” (Jordan, 1993, p. xii). As a result, attitudes and values shape each woman’s childbearing behaviors and even the experience of pain during labor (Callister, 1995). Consequently, the care offered by the nurse must match the laboring woman’s needs so that she may have a satisfying childbirth experience here in the United States. The following excerpt highlights the necessity of such an approach: The thing is we have to follow their practices here. They treat you all the same way, whatever country you come from anyway. So if they say, “take a bath,” you take a bath. . . . Of course you are not satisfied (Small, Liamputtong Rice, Yelland, & Lumley, 1999, p. 92). How do nurses become culturally competent care providers when such diversity exists among and between societies? I use a perspective that is often not considered: that of global similarity. The ability to focus on the similarities between ourselves and our world neighbors may provide us with a userfriendly concept that will permit nurses, and other maternal-newborn care providers, to cross cultures in our daily encounters with clients. This approach is possible because, according to Giger and Davidhizar (1995), at least six worldwide phenomena con-
JOGNN 33
sistently appear. These are (a) communication, (b) social organization, (c) space/touch, (d) time, (e) environmental control, and (f) biologic variation. Awareness and understanding of at least the first four of these phenomena will help to increase the nurse’s ability to deal with cultural issues. Using the acronym COST to highlight four of these phenomena, a COST-efficient framework is offered for
C
hildbirth is a significant life event and is influenced by the social norms and expectations of the woman’s community.
increasing understanding of other’s values and beliefs. As well, an understanding of these global similarities can heighten the nurse’s awareness of the presence of an ethnocentric bias, particularly as it pertains to the medicalization of childbirth and the technocratic model pervasive in the United States (Davis-Floyd, 1994). This realization can help improve cross-cultural care (Carillo, Green, & Betancourt, 1999), especially in situations in which the model of childbirth in use may vary from the model of childbirth familiar to women from other cultures. This is particularly important for Western providers of obstetric care. Approximately 80% of the world’s newborns are born at home (Dunham, 1991). Yet, women who enter the U.S. health care system are expected to enter the hospital and give birth the way that we do, while being cared for by nurses, midwives, and others who may not understand their cultural values and beliefs surrounding pregnancy and childbirth. In addition, varying degrees of acculturation or assimilation, or both, may alter one’s perspective on even the most common cultural practices. An awareness and understanding of these core phenomena can provide students, nurses, and others with a tool to allow them to provide care that better matches maternal desires and needs and increases their competency in providing cross-cultural care. Examples of how one can use these phenomena follow.
Communication Communication may appear to be the largest barrier to providing culturally competent care. However, nurses interact and communicate daily with physicians, fellow nurses, children, clerks in the grocery store or fast-food restaurant, or any number of people from different places. How is it that one can effectively communicate within these subcultures, each with its own set of norms and expectations? How is it that nurses can care for patients who have lim-
34 JOGNN
ited or no ability to speak because of a stroke or surgery? It is the basic understanding that communication incorporates nonverbal as well as verbal communication techniques (Marshall & While, 1994) that makes it possible for people to understand and communicate on varying levels when a common spoken language is not an option. As nurses, we must use the knowledge and skills we already possess and rely on the subtleties of communication such as style, volume, silence, gestures, and eye behaviors. These forms of communication are familiar to intrapartum nurses. After all, how often have you assessed that your client is in discomfort or needs to push even before she has said a word? Apply these same skills to mothers who cannot speak English. Suspend reliance on the spoken word and reach deeper. Rely on the knowledge that you already have. Observe and listen. Watch the way your clients and their family members interact. Listen to their tone of voice. Notice communication cues. Does the woman make eye contact with you? In some cultures, it is disrespectful to look into the eyes of those with greater authority (or supposed authority). This observation also will provide you with information regarding who is the elder of your client’s community, if she or he is present. Loud vocalization may be considered disrespectful. Once you understand how this woman and her family communicate, realize that this is what is expected of you if you wish to provide care that is culturally sensitive and competent. You can resume nurse linguistics when you step outside of her domain. Generally, it takes only a few minutes to observe the tone, gestures, and techniques that are being used. Use every moment of interaction as an opportunity to learn what is acceptable. Trust your instincts. Value the knowledge you have and the knowledge that you will gain. When interpretation is necessary, some general guidelines have been offered by the experts. Khalaf and Callister (1997) called for two interpreters: one an insider to the culture in question and the other an outsider. The insider is necessary to discover the nuances or subtle meanings particular to the woman’s world. The outsider provides the local perspective or understanding of a particular situation, phrase, or gesture. This outsider can be the nurse. Use of both kinds of interpreters together can help clarify misunderstandings and strengthen the accuracy of the interpretation. For example, when some women are asked if it burns when they urinate, they may reply that it does because urine feels warm (Kemp, 1985). However, when asked if it hurts when they urinate, they may reply no. In addition, green may mean blue, and yes may be the appropriate response to anything one does not understand (Uba, 1992). These nuances can be discovered by someone who is familiar with the colloquialisms of the specific culture. An interpreter with training in medical terminology is essential. Sometimes, a hospital employee can fill this role, but first make sure the woman is com-
Volume 31, Number 1
fortable having a stranger interpret for her. Be sure that the interpreter is fluent in English and the language in need of translation. The interpreter should be female and approximately the same age as the client so that any real or potential power inequities are reduced (Khalaf & Callister, 1997). Women may feel especially vulnerable during childbirth. The use of children as interpreters, especially the woman’s own, is discouraged because in most societies, it is not acceptable for children to know more than their parents (Kemp, 1985). Learn from your clients. Value their diversity and embrace the similarities in the ways we communicate.
Organization, Space, and Touch How often have you walked into a birthing room to find half a dozen or more people of all ages surrounding the laboring woman? The extended family is integral in many cultures (Spector, 2000) and is evident during life events, such as childbirth. The presence of family members can provide the nurse with clues regarding the individual mother’s belief about the family unit, social organization, and valuing of space and touch. In most societies, space and touch are regulated by social orders and rules, just as in the United States. Observe the proximity of family members to one another and to the laboring woman. Note whether there is a lot of hugging or touching between family members or whether distance is kept between people. The distance that is permitted for close family members generally is closer than is acceptable for the nurse. Note whether the woman’s mother or another significant female family member is present. This information will provide you with clues as to how this woman values space and touch, as well as the social organization and role of women in her community. Some societies value patriarchal systems (Catolico, 1997). It will take only a few minutes to recognize the woman’s reliance on the male partner, often to the point that he may answer questions asked of her. Value his ability to answer the questions because this shows respect for your client’s social norms. A hands-off policy may be congruent with some women’s needs, although the use of technology in the United States often warrants otherwise. This can violate the woman’s values of space and touch, so be sensitive to this issue and explain why you must touch her. Be sure the touching is necessary. Thinking about the similarities in how we organize our worlds, socially and proximally, will provide clues as to how you can respect and learn from your clients.
Time Have you ever been in a birthing room that did not have at least one clock hanging almost surreally above or near the woman’s bed? This is representative of the WestJanuary/February 2002
ern value of and reliance on clock or calendar time, yet this is not consistent with other cultures, which may use the sun or moon to refer to the passage of time (Jambunathan & Stewart, 1995). Differences in perception of time may become apparent when the mother appears disinterested in the clock or has difficulty relating events in terms of calendar days. Creativity can help in determining such things as a probable due date by how many moons have passed since the last menses. A way to encourage a woman who tracks time differently may be to let her know that her newborn will come before sunrise or after dawn. When referring to the timing of medications, it may help to incorporate other aspects of time, such as “when your husband arrives” or “before the next meal.” Have fun with this concept, and see if it helps your clients as well as yourself to establish more meaningful and culturally competent relationships.
Control Environmental control, or one’s ability to control the setting that one is in, may or may not be a problem for women born in this country. Obstetric care providers in the United States often ask their clients to devise a birth plan. Women may bring such things as radios, pillows, or pictures to create the environment in which they choose to give birth. Similarly, women from other cultures learn
S
uspend reliance on the spoken word, and use the skills you already possess.
how to create their own comfortable birthing environments. This is a global phenomenon. Yet, because many of these women may be used to giving birth in their own home or a family member’s home, they have lost control over their environment when they come to our obstetric units. Compounded by other factors, such as language barriers, women from other countries may feel helpless on our birthing units. Nurses must be sensitive to women’s needs to have family members and friends present; assume “nontraditional” birth positions; refuse food or drinks, or even a shower after giving birth; or insist on bottle-feeding until their milk comes in (Mattson, 1995). Nurses and other care providers need to observe, listen, and ask. Value another’s values.
Biologic Variation Biologic variation, the last of the identified global phenomena, refers to differences in body structure that
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appear to be related to ethnicity, gender, or race. The implication such variation has on the provision of quality, culturally competent care lies in the avoidance of stereotypical thinking, such as assuming that all smallframed women will have difficult labors. Instead, nurses must focus their care on helping their clients give birth in the manner most satisfying to them. Biologic variations within cultures warrant greater attention when addressing hereditary disorders, such as thalassemia and sickle cell anemia, as part of the core curriculum in most maternalnewborn courses. In summary, thinking about the way the woman communicates (C), organizes her life around her family or is able to control birth events (O), values space and/or touch (S), and understands or relates time (T) to other factors can provide information that allows nurses to interact with and provide care for women from other cultures in a
A
broader perspective of cultural issues may enable more individualized care.
way that meets their needs. Without consideration of these phenomena, it is not likely the nurse can provide care that is sensitive and congruent. Nurses need to value diversity and embrace global similarities rather than aiming to decrease those differences inherent in the cultural rite of giving birth.
Cross-Cultural Education The integration of cross-cultural knowledge must begin during the student nurse years. A basic understanding of cultural terminology and several frequently used definitions of culture should provide the groundwork. One commonly used definition of culture is “the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways” (Leininger, 1991, p. 47). Subcultures exist within any larger cultural framework, however. For example, within the medical culture, physician subcultures, nursing subcultures, and medical technician subcultures are found. Subcultures exist within subcultures. Cultural stereotyping, or presuming that individuals within any given community think and behave the same way, should be avoided. Culture is shaped by gender, age, sexual preference, and other factors (Giger & Davidhizar, 1995). Maternal-newborn nurse educators can help increase their students’ competency in cross-cultural nursing. It is not enough to have a single chapter or section of a chap36 JOGNN
ter in a text devoted to cultural issues. Rather, the educator needs to choose a text in which cultural issues are integrated throughout. One such text is Maternal Newborn Nursing Care: A Family and Community-Based Approach (Olds, London, & Ladewig, 2000). In this book, topics such as cultural beliefs about activity and pregnancy, conception and fetal development, the postpartum period, and menstruation are discussed. Other issues that educators should look for in a text include references to complementary alternative therapies, such as the use of herbal remedies for dysmenorrhea, for example. A discussion on the use or nonuse of contraception can spur conversation regarding accepted and discouraged behaviors in other cultures. Issues surrounding the need for modesty and female care providers or the presence of female family members highlight the importance of sensitivity to a woman’s valuing of space, touch, and social organization. The educator need not search far for descriptions of any of the above if the text chosen has clearly integrated cultural issues as described above. A lecture on childbirth would not be complete without mention of birthing positions. Two films by the Global Maternal/Child Health Association offer opportunities for students to view birthing techniques and positions used by women around the world. Gentle Birth Choices (1993) depicted women in many natural and physiologically productive positions. Birth Into Being (1999) demonstrated water-birthing techniques used in Russia. Both films can expand students’ perspectives on the ways women give birth. At the same time, students need to be taught that they can discover what is necessary to make each woman’s birth experience satisfying through observation, use of verbal and nonverbal communication techniques, and an awareness of the social organization of the particular family. The COST acronym can help remind students that an understanding of the woman’s communication techniques, organization of her family and environment, and valuing of space/touch and time can help the nurse provide culturally competent care. When discussing the use of analgesics and anesthetics during childbirth, it is important to stress that medication use during labor varies with culture. Although analgesics and oxytocin are commonly used in the United States, their use is considered a potential hazard to both mother and child in other countries (Jordan, 1993). This view may determine a woman’s willingness to take medications or continue their use. A discussion of other pain relief techniques, such as meditation, prayer, song, massage, or herbs, can expand students’ horizons concerning the diversity of health beliefs and practices. In some societies, women are expected to adhere to specific behaviors during the postpartum period. Some women are expected to rest during the postpartum period, stay warm, avoid drafts, consume only warm and/or hot fluids and foods, and abstain from showering. StuVolume 31, Number 1
dent nurses should be taught to adapt their practices to their clients’ needs. Optional sources for students who wish to gain a deeper understanding of cultural practices could include texts such as Fadiman’s (1997) The Spirit Catches You and You Fall Down, Hayslip’s (1989) When Heaven and Earth Changed Places, or Spector’s (2000) Cultural Diversity in Health & Illness. Gary, Sigsby, and Campbell (1998) identified the need to have culturally competent faculty members who provide an environment that “supports differing worldviews.” St. Clair and McKenry (1999) demonstrated the benefits of “cultural immersion” for groups of nursing students. Although this is not possible for all students, St. Clair and McKenry reinforced the need to use clinical sites that serve diverse populations. A key concept for students is an understanding that what one believes to be true is based on one’s own social and cultural influences and will influence one’s health promotion activities. To provide culturally competent care, one must strive to adapt one’s practice to the family’s needs rather than trying to adapt the client’s needs to our own. As outlined in Healthy People 2010 (U.S. Department of Health and Human Services, 2000), health promotion and risk reduction are components of care. Consequently, core concepts such as health and wellness offer an opportunity to address cultural issues. For example, the World Health Organization’s definition of health as being more than the absence of disease (Spector, 2000) has been accepted by the medical profession. Other cultures view illness as an imbalance of body fluids or yin and yang, a loss of heat, or even as a curse, punishment, soul loss, or spirit possession (Andrews & Boyle, 1999). The Western view of illness as pathologic thus is only one perspective. Students need to be aware of the presence of other perspectives. Health promotion activities are influenced by culture and are largely based on the beliefs stated above. If one believes that carcinogens cause cancer, one can choose (or not choose) to avoid them. Health promotion and diseaseprevention techniques also can include prayers, the wearing of amulets, or even the avoidance of drafts (Spector, 2000). A teacher can ask students to offer their home remedies for a cold to provide an example of how diverse people’s beliefs can be even within a small population. This discussion leads to the opportunity for the teacher to initiate a discussion of the cultural barriers to health promotion. Language, financial resources, social support, and beliefs are linked. Statistics demonstrating health disparities can spur a conversation regarding inequities in the health care system. By weaving in cultural factors without specifically addressing any particular one, the educator can function from a broader perspective, allowing students to focus on January/February 2002
any individual woman’s needs without assuming that she will have the same preferences as another woman from her culture. For instance, how many times can one recall thinking that a certain woman would be a definite “epidural” or “C-section”? Educators must discourage stereotypical generalizations and encourage students to value diversity while embracing people’s similarities. We have much to learn from societies in which women give birth unimpeded by technology and politics. Instead of focusing on differences, nurses must focus on the similarities in the way we communicate, touch, and organize our worlds. As the largest workforce in the health care delivery system (Meleis, Isenberg, Koerner, Lacey, & Stern, 1995), nursing has the responsibility to be the voice of action and to reduce care inequities. A COST-efficient framework can allow nurses and others to identify phenomena that can contribute to the provision of culturally competent care. A greater understanding may help bridge the gap between what we as nurses assume is best for our clients and what they actually desire or need. REFERENCES Abdullah, S. N. (1995). Towards an individualized client’s care: Implication for education: The transcultural approach. Journal of Advanced Nursing, 22, 715-720. Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care (3rd ed.). Philadelphia: Lippincott. Callister, L. C. (1995). Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24, 327-329. Carillo, J. E., Green, A. R., & Betancourt, J. R. (1999). Crosscultural primary care: A patient-based approach. Annals of Internal Medicine, 130(10), 829-834. Catolico, O. (1997). Psychological well-being of Cambodian women in resettlement. Advances in Nursing Science, 19(4), 75-84. Davis-Floyd, R. (1994). The technocratic body: American childbirth as cultural expression. Social Science & Medicine, 38(8), 1125-1140. Downs, K., Bernstein, J., & Marchese, T. (1997). Providing culturally competent primary care for immigrant and refugee women. Journal of Nurse-Midwifery, 42(6), 500-508. Dunham, C. (1991). Mamatoto: A celebration of birth. New York: Penguin. Fadiman, A. (1997). The spirit catches you and you fall down. New York: Noonday. Gary, F. A., Sigsby, L. M., & Campbell, D. (1998). Preparing for the 21st century: Diversity in nursing education, research, and practice. Journal of Professional Nursing, 14(5), 272279. Giger, J., & Davidhizar, R. (1995). Transcultural nursing: Assessment and intervention (2nd ed.). St. Louis, MO: Mosby Year Book. Global Maternal/Child Health Association. (1993). Gentle birth choices [Motion picture]. (Available from Global Maternal/ Child Health Association, P.O. Box 1400, Wilsonville, OR 97070).
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Global Maternal/Child Health Association. (1999). Birth into being: The Russian waterbirth experience [Motion picture]. (Available from Global Maternal/Child Health Association, P.O. Box 1400, Wilsonville, OR 97070). Hayslip, L. L. (1989). When heaven and earth changed places. New York: Penguin. Jambunathan, J., & Stewart, S. (1995). Hmong women in Wisconsin: What are their concerns in pregnancy and childbirth? Birth, 22(4), 204-210. Jordan, B. (1993). Birth in four cultures (4th ed.). Prospect Heights, IL: Waveland. Kemp, C. (1985). Cambodian refugee health care beliefs and practices. Journal of Community Health Nursing, 2(1), 41-52. Khalaf, I., & Callister, C. (1997). Cultural meanings of childbirth: Muslim women living in Jordan. Journal of Holistic Nursing, 15(4), 373-388. Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing. Marshall, S. L., & While, A. E. (1994). Interviewing respondents who have English as a second language: Challenges encountered and suggestions for other researchers. Journal of Advanced Nursing, 19, 566-571. Mattson, S. (1995). Culturally sensitive perinatal care for Southeast Asians. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 19, 566-571. Meleis, A. I., Isenberg, M., Koerner, J. E., Lacey, B., & Stern, P. (1995). Diversity, marginalization and culturally competent health care issues in knowledge development (monograph of the American Academy of Nursing, Serial No. 1557810-113-6).
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Olds, S. B., London, M. L., & Ladewig, P. A. (2000). Maternalnewborn nursing care: A family and community-based approach (6th ed.). Englewood Cliffs, NJ: Prentice Hall. Small, R., Liamputtong Rice, P., Yelland, J., & Lumley, J. (1999). Mothers in a new country: The role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia. Women & Health, 28(3), 77-101. Spector, R. E. (2000). Cultural diversity in health & illness (5th ed.). Upper Saddle River, NJ: Prentice Hall. St. Clair, A., & McKenry, L. (1999). Preparing culturally competent practitioners. Journal of Nursing Education, 38(5), 228-234. Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public Health Reports, 107(5), 544-548. U.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: Author. Williamson, E., Stecchi, J. M., Allen, B. B., & Coppens, N. M. (1996). Multiethnic experiences enhance nursing students’ learning. Journal of Community Health Nursing, 13(2), 73-81. Patricia A. Ottani is an assistant professor in the College of Health Professions, Department of Nursing, at the University of Massachusetts, Lowell. Address for correspondence: Patricia Ottani, CNM, PhD, Assistant Professor, College of Health Professions, Department of Nursing, University of Massachusetts Lowell, 3 Solomont Way, Suite 2, Lowell, MA 01854. E-mail: [email protected].
Volume 31, Number 1