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Communication across the cultures—a learning unit
NURSE EDUCATION TODAY
Communication across the cultures learning unit
a
Peter Callery Staff Nurse, Department of Neonatal Medicine and Surgery, City Hospital, Nottingham
WITHIN OUR multiracial society, problems of crosscultural communications must inevitably arise. Different cultural frames of reference can inhibit effective communication even when people share a common language. Communication involves much more than simply the use of verbal' language, as Desmond Morris's Manzaatching (1977) illustrates very effectively. Our cultures and traditions enable us to communicate easily with people who share them but become barriers when we try to communicate with people of different culture and tradition. Communication problems are especially crucial when nurses and their clients* are involved: communication is essential to nursing; if we cannot communicate with a client by some means, we cannot nurse him. Despite this, cross-cultural communication is not generally taught in nurse training. It was my concern about this that led me to experiment with a learning unit to develop nurses' cross-cultural communication skills. It is a 'learning unit' because it is an attempt to guide learning in the clinical area rather than to teach. Cross-cultural communication is not an academic discipline-as, for instance, physiology isbut the result of interpersonal interactions. By examining our own interpersonal behaviour we may be able to modify it and so improve communication. The learning unit is a guide to examining one's interpersonal interactions with this aim in mind. The heart of the unit is an exercise in which the nurse is asked to consider questions about her communication behaviour during an interaction with her client. The first series of questions are for consideration before initiating the interaction: 1. Why have you chosen this particular client? 2. What do you already know about the client? 3. What specific items of information do you need to find out? (For instance, religion, diet.) 4. How do you think you will be able to find out this information and what communication aids will you use?
5. How do you plan to talk generally with your client and what communication aids will you use? 6. How do you plan to ernpathise with and reassure your client? 7. What specific items of information do you want to convey to your client and how do you intend to achieve this? The aim is to encourage the nurse to set herself objectives (for instance, getting the specific information mentioned in question 3), and plan ways of realising these objectives (for instance, in the response to question 4). It is essential to remember that the interaction is not merely for exchanging information but will be important in building the nurse-client relationship, as questions 5 and 6 imply. Having made this assessment, established objectives and then devised a plan, the next step is implementation. After the interaction the nurse is asked to examine it 10 order to evaluate the effectiveness of communication. This enables replanning, if necessary, so that adaptations can be made to meet the individual needs of the client. This examination is guided by a further series of questions: 8. What was your initial approach? 9. Did you keep to your plan? Give reasons for your answer. 10. Did you change your plan during the interaction? Give reasons for your decision. 11. Describe the part of the interaction where you felt communication was most effective. 12. Describe the part of the interaction where you felt communication was least effective. 13. Did you obtain the specific items of information that you needed? 14. What else did you talk about with your client? 15. Do you think your client felt comfortable and able to talk to you?
*1 use the term 'client' because not all our clients are patients, they may be relatives, friends, lovers of the 'patient'. In addition, nurses do not always deal with sick people, or 'patients'. 'Client' is a broad noun which covers all these posslbilities.
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NURSE EDUCATION TODAY 16. What have you discovered about your client in addition to the specific items of information which you expected to gain? 17. Did your plans work! (a) If they did-why? (b) If not-why not? 18. How will you alter your approach when you next go to your client? 19. How will you advise colleagues to communicate with this client? 20. Have you any further comments? The first group of learners to use the unit were second-year student nurses, some of whom linked their responses to patient-care studies. One of these was by Susan Daniel, who chose a six-year-old Moslem girl because she was 'the oldest foreign patient' to be admitted during her secondment to a paediatric medical ward. Susan identified several possible approaches to her client, including: -looking at pictures and books, drawing -playing with toys together -encouraging the girl to play with other children. ('Children seem to have a way of communicating with one another,' as Susan says) -talking with older siblings who may be more familiar with speaking English. Susan also identified her own need to inform herself about her client's dietary, clothing and religious needs; and set the objectives of allaying the child's fears and gaining trust and confidence. The exercise encourages the nurse to plan a system of communication: to set herself objectives and direct her communication behaviour to the individual needs of her client. This exercise also makes it possible for the nurse to share her experience with colleagues: because Susan has discussed her plan in writing, it is available for other nurses to consider. Her plan formulated, Susan discussed its implementation and evaluated her effectiveness. At first things went well. Then Susan came across a problem she had not envisaged in her plan: the need for uncomfortable and frightening clinical procedures, initially venepuncture. Susan was honest and objective in self-criticism: ' Sh e [the child] did not have much trust left for me and was quite upset.' Susan persevered with chest radiography and then set about regaining lost ground. With sensitivity, Susan
decided to let the child make the first move-which she did, bringing a book to Susan and asking, 'Please read'. Evaluating her plan, Susan decided that her use of drawing had not been successful but that talking with the child in the company of an older sibling had been useful. Susan Daniel demonstrated how the use of the exercise enables the nurse to assess her client, plan her communication behaviour and evaluate her interactions. The exercise provides a means of examining interpersonal behaviour, which is usually intuitive, so that an objective approach to improving communication can be made. Caring communication, a copy of which has been sent to all the health authorities, contains a section entitled 'Cross-cultural communication'. The overall aims described are similar to my own but our approaches to the problem are different. Joanna Gray's unit is based in the classroom, focusses on communication problems in a theoretical way and uses role play techniques. In contrast, my unit is a framework for learning in the clinical environment. The two approaches could be complementary, and it might be a useful exercise to combine the two units. However, I feel that learning centred on actual clinical problems has particular advantages over learning based on postulated problems: confidence and practical skills develop as the learning takes place and practising nurses are more likely to accept the usefulness and relevance of a 'practical' approach than what to them may seem to be an artificial exercise. I would be pleased to hear from anyone interested in the problems of cross-cultural communication and techniques for improvement.
REFERENCES D Morris 1977 Manwatching. Cape, London. Gray J 1982 Caring communication DHSS/National Centre for Industrial Language Training.
ACKNOWLEDGEMENTS I am greatly indebted to my former senio r tutor, Mrs J North of Rotherham School of Nursing, and to Mr B Liddle of th e Trent Nurse Education Development Project. I also thank Susan D aniel for permission to use her work, and her colleagues for their interest. The work for this article was done while a student nurse in Rotherham.
We welcome articles submitted for publication in Nurse Education Today. Instructions to authors are printed in the inside back cover, and manuscripts should be addressed to The Editors, Nurse Education Today, Churchill Livingstone, Robert Stevenson House, 1-3 Baxter's Place, Leith Walk, Edinhurgh EH1 3AF.
~,
195 I Longman Group Ltd.
119
Communication across the cultures learning unit
a
Peter Callery Staff Nurse, Department of Neonatal Medicine and Surgery, City Hospital, Nottingham
WITHIN OUR multiracial society, problems of crosscultural communications must inevitably arise. Different cultural frames of reference can inhibit effective communication even when people share a common language. Communication involves much more than simply the use of verbal' language, as Desmond Morris's Manzaatching (1977) illustrates very effectively. Our cultures and traditions enable us to communicate easily with people who share them but become barriers when we try to communicate with people of different culture and tradition. Communication problems are especially crucial when nurses and their clients* are involved: communication is essential to nursing; if we cannot communicate with a client by some means, we cannot nurse him. Despite this, cross-cultural communication is not generally taught in nurse training. It was my concern about this that led me to experiment with a learning unit to develop nurses' cross-cultural communication skills. It is a 'learning unit' because it is an attempt to guide learning in the clinical area rather than to teach. Cross-cultural communication is not an academic discipline-as, for instance, physiology isbut the result of interpersonal interactions. By examining our own interpersonal behaviour we may be able to modify it and so improve communication. The learning unit is a guide to examining one's interpersonal interactions with this aim in mind. The heart of the unit is an exercise in which the nurse is asked to consider questions about her communication behaviour during an interaction with her client. The first series of questions are for consideration before initiating the interaction: 1. Why have you chosen this particular client? 2. What do you already know about the client? 3. What specific items of information do you need to find out? (For instance, religion, diet.) 4. How do you think you will be able to find out this information and what communication aids will you use?
5. How do you plan to talk generally with your client and what communication aids will you use? 6. How do you plan to ernpathise with and reassure your client? 7. What specific items of information do you want to convey to your client and how do you intend to achieve this? The aim is to encourage the nurse to set herself objectives (for instance, getting the specific information mentioned in question 3), and plan ways of realising these objectives (for instance, in the response to question 4). It is essential to remember that the interaction is not merely for exchanging information but will be important in building the nurse-client relationship, as questions 5 and 6 imply. Having made this assessment, established objectives and then devised a plan, the next step is implementation. After the interaction the nurse is asked to examine it 10 order to evaluate the effectiveness of communication. This enables replanning, if necessary, so that adaptations can be made to meet the individual needs of the client. This examination is guided by a further series of questions: 8. What was your initial approach? 9. Did you keep to your plan? Give reasons for your answer. 10. Did you change your plan during the interaction? Give reasons for your decision. 11. Describe the part of the interaction where you felt communication was most effective. 12. Describe the part of the interaction where you felt communication was least effective. 13. Did you obtain the specific items of information that you needed? 14. What else did you talk about with your client? 15. Do you think your client felt comfortable and able to talk to you?
*1 use the term 'client' because not all our clients are patients, they may be relatives, friends, lovers of the 'patient'. In addition, nurses do not always deal with sick people, or 'patients'. 'Client' is a broad noun which covers all these posslbilities.
. 118
©
198~
Longm:m Group Lrd.
NURSE EDUCATION TODAY 16. What have you discovered about your client in addition to the specific items of information which you expected to gain? 17. Did your plans work! (a) If they did-why? (b) If not-why not? 18. How will you alter your approach when you next go to your client? 19. How will you advise colleagues to communicate with this client? 20. Have you any further comments? The first group of learners to use the unit were second-year student nurses, some of whom linked their responses to patient-care studies. One of these was by Susan Daniel, who chose a six-year-old Moslem girl because she was 'the oldest foreign patient' to be admitted during her secondment to a paediatric medical ward. Susan identified several possible approaches to her client, including: -looking at pictures and books, drawing -playing with toys together -encouraging the girl to play with other children. ('Children seem to have a way of communicating with one another,' as Susan says) -talking with older siblings who may be more familiar with speaking English. Susan also identified her own need to inform herself about her client's dietary, clothing and religious needs; and set the objectives of allaying the child's fears and gaining trust and confidence. The exercise encourages the nurse to plan a system of communication: to set herself objectives and direct her communication behaviour to the individual needs of her client. This exercise also makes it possible for the nurse to share her experience with colleagues: because Susan has discussed her plan in writing, it is available for other nurses to consider. Her plan formulated, Susan discussed its implementation and evaluated her effectiveness. At first things went well. Then Susan came across a problem she had not envisaged in her plan: the need for uncomfortable and frightening clinical procedures, initially venepuncture. Susan was honest and objective in self-criticism: ' Sh e [the child] did not have much trust left for me and was quite upset.' Susan persevered with chest radiography and then set about regaining lost ground. With sensitivity, Susan
decided to let the child make the first move-which she did, bringing a book to Susan and asking, 'Please read'. Evaluating her plan, Susan decided that her use of drawing had not been successful but that talking with the child in the company of an older sibling had been useful. Susan Daniel demonstrated how the use of the exercise enables the nurse to assess her client, plan her communication behaviour and evaluate her interactions. The exercise provides a means of examining interpersonal behaviour, which is usually intuitive, so that an objective approach to improving communication can be made. Caring communication, a copy of which has been sent to all the health authorities, contains a section entitled 'Cross-cultural communication'. The overall aims described are similar to my own but our approaches to the problem are different. Joanna Gray's unit is based in the classroom, focusses on communication problems in a theoretical way and uses role play techniques. In contrast, my unit is a framework for learning in the clinical environment. The two approaches could be complementary, and it might be a useful exercise to combine the two units. However, I feel that learning centred on actual clinical problems has particular advantages over learning based on postulated problems: confidence and practical skills develop as the learning takes place and practising nurses are more likely to accept the usefulness and relevance of a 'practical' approach than what to them may seem to be an artificial exercise. I would be pleased to hear from anyone interested in the problems of cross-cultural communication and techniques for improvement.
REFERENCES D Morris 1977 Manwatching. Cape, London. Gray J 1982 Caring communication DHSS/National Centre for Industrial Language Training.
ACKNOWLEDGEMENTS I am greatly indebted to my former senio r tutor, Mrs J North of Rotherham School of Nursing, and to Mr B Liddle of th e Trent Nurse Education Development Project. I also thank Susan D aniel for permission to use her work, and her colleagues for their interest. The work for this article was done while a student nurse in Rotherham.
We welcome articles submitted for publication in Nurse Education Today. Instructions to authors are printed in the inside back cover, and manuscripts should be addressed to The Editors, Nurse Education Today, Churchill Livingstone, Robert Stevenson House, 1-3 Baxter's Place, Leith Walk, Edinhurgh EH1 3AF.
~,
195 I Longman Group Ltd.
119