Reflecting on intercultural dialogue in nursing

Una reflexión sobre el diálogo intercultural en la enfermería

Uma reflexão sobre o diálogo intercultural na enfermagem

ARTIGO ORIGINAL

REFLEXÃO TEÓRICA

Reflecting on intercultural dialogue in nursing

Uma reflexão sobre o diálogo intercultural na enfermagem

Una reflexión sobre el diálogo intercultural en la enfermería

Julie Gilbert

Registered Nurse. Master's of Nursing. International Coordinator & Sessional Faculty. Faculty of Nursing. University of Alberta. Edmonton/Canada

^Endereço

ABSTRACT

Nurses must provide culturally competent care in increasingly multicultural health care settings. This article is a reflection on a research study about intercultural dialogue as a means to increasing knowledge and awareness of other cultures. Hermeneutic methodology provides us a way to explore intercultural dialogue as it requires a commitment to a process of emerging understanding and self-transformation through dialogue. Concepts of intercultural dialogue, such as respect, power, willingness to stay in the process, responsibility, vulnerability and the expanding of one's horizons and self-discovery are included in this reflection.

Keywords: Nursing. Culture. Health.

RESUMO

As enfermeiras devem prover um cuidado culturalmente competente em cenários de saúde cada vez mais multiculturais. Este artigo é uma reflexão de uma pesquisa sobre o diálogo intercultural como um meio para aumentar o conhecimento e a consciência de outras culturas. A metodologia hermenêutica nos fornece um caminho para explorar o diálogo intercultural por requerer um compromisso com um processo de compreensão emergente e de autotransformação por meio do diálogo. Conceitos de diálogo intercultural, tais como, respeito, poder, disposição para permanecer no processo, responsabilidade, vulnerabilidade, expansão do próprio horizonte e autodescoberta estão incluídos nesta reflexão.

Palavras-chave: Enfermagem. Cultura. Saúde.

RESUMEN

Las enfermeras deben brindar un cuidado culturalmente competente en los diferentes escenarios de la salud cada vez más multiculturales. Este artículo trata acerca de la reflexión de una investigación sobre el diálogo intercultural como un medio para incrementar el conocimiento y la conciencia de otras culturas. La metodología hermenéutica nos proporciona un camino para la exploración de ese diálogo intercultural por el compromiso de éste como un proceso de comprensión emergente y de auto-transformación mediante el diálogo. Conceptos de diálogo intercultural tales como: respeto, poder, disposición para permanecer en el proceso, responsabilidad, vulnerabilidad, expansión del propio horizonte y la auto-descubierta son incluidos en esta reflexión.

Palabras clave: Enfermería. Cultura. Salud.

INTRODUCTION

Nurses are mandated to provide culturally competent care in a changing and increasingly intercultural world. Operationalizing this mandate, however, is far from an easy task.¹ Nurses continually develop an awareness of how conversation and dialogue enhance their understanding of particular individuals and families in nursing situations. Culturally competent care however requires nurses to engage in an intercultural dialogue which enables them to form meaningful and respectful relations with cultures quite different from their own. They must gather experiences that will support them in working toward understanding the culture and becoming more tolerant of cultural diversity and difference in their practice.

Historically nursing has operated within multicultural work through developing cultural assessment tools, designed to gather information about a client from another culture. While these tools are very helpful to nurses, they must be used as a guide only and not as replacement for dialogue and relation building with our multicultural clients. The nurse must activate the tools not let the tools activate her which may or may not result in a prescription for care that is not applicable to her nursing situation. Nurses are in a privileged position, providing care to all people regardless of their cultural heritage and circumstances. Nurses must seek out experiences in their own country or in another country to interact with other cultures, to be present with the experience, to develop trust in their ability to be attentive and to learn about self and other in the process. A multitude of multicultural experiences will gradually increase understanding and acceptance at a broader level within our profession.

BACKGROUND

Throughout my nursing career I have encountered patients from diverse ethnic and religious backgrounds. Always in these situations I questioned my ability to give comprehensive care for those people culturally different from myself. I questioned how could I truly care for them if I had no understanding of their experiences in the world and what those experiences meant to them? No doubt I provided care according to what I knew to be good, competent care and no doubt they obligingly accepted my care. After all, they were in my world. However, through my lack of cultural awareness and knowledge I worried that I would objectify these people. I wondered about the social, political and economic issues embedded in our interactions. Did they influence the direction of not only what the person revealed to me but also how I responded to these issues?

I also wondered about the power imbalances I knew about and those hidden ones I could not even imagine, being in a different culture. Through my career I felt a need to traverse the gap among differing worldviews and I wondered too about my own worldview. Did it embrace diversity and was my nursing care respectful of that diversity? I knew I had to learn about and appreciate our differences and similarities. I was drawn to understand these individual's worlds and to understand how they viewed my world. Nursing literature guided my knowledge development, however, there remained within me a strong sense that no amount of literature could answer the kinds of questions that surrounded me. I knew I had to have experiential learning, where the experience of immersing myself in another culture guided and taught me more than literature which seemed at the time, lacking insight and meaningful approaches.

The reflections discussed in this paper are an experiential account of a research study that examined intercultural dialogue from an engaged, situated stance, using a hermeneutic methodology. The account involved numerous conversations between a Canadian nurse, a Ghanaian clinic nurse in Africa and an African multicultural broker living and working in Canada.

INTERCULTURAL DIALOGUE

Intercultural communication on a global level involves interactions steeped in power and dominance. As power is an integral part of human interaction, intercultural communication as a form of social interaction between humans necessarily involves power. In such communication, people respond to each other and act upon their worlds in the way they know.² And perhaps as I experienced in this study, a shared world between us emerges.

Diversity is a relational and context- embedded reality.³ Cultural diversity should be seen as a positive entity where positive or negative consequences are related to individual or institutional responses to that diversity. Through dialogue we have the opportunity to explore the meanings we attribute to diversity without concentrating on the diversity itself.³ In dialogue we must own our own identity in difference. When we are responsible for our own identity, the threat of difference of another becomes an opportunity for growth, enrichment and mutuality and less of a threat to our own identity.⁴

The key to cultural competence lies in our ability to involve ourselves in reciprocal, responsive and respectful interactions across diverse cultural parameters.³ In culturally diverse situations we are challenged to recognize that a person is always more than and sometimes radically different from our preconceived ideas about whom they are. We must be mindful in dialogue not to reduce reality to a limited space.³

Respectful interactions require that we understand how another's behavior makes sense from their cultural and personal perspectives. In dialogue we work towards entering the third space, where differences are understood to be complimentary.³ This space is also referred to as the relational space where we commit to learning to understand each other.⁵ One must be willing and able to stay with the tension of contradiction or difference, holding divergent views in one's mind without having to force a choice between them. Existing in the relational or third space is learned best through practice, not theory alone.³

One must be able to assimilate their own cultural traditions, without using them as a means to an end. One must desire the unfamiliar and be comfortable with such contexts, have a cosmopolitan view of the world, and have engaged in a process of self-examination which is situated in the universality of the human condition and rich in diversity. Finally, one must be sensitive, tactful and open to expanding their own horizons.⁶

NURSING LITERATURE

Several nursing leaders beginning with Madeleine Leininger more than 40 years ago have attempted to conquer this task of how to best work with those of another culture. This author defines transcultural nursing as a sub-field of nursing which focuses on the comparative study of cultures with the goal of identifying differences and similarities in the dominant beliefs, values and practices of designated groups of people.⁷ More recently, prescriptive models and frameworks designed to organize our cultural knowledge and apply it to health care delivery, have been formulated by Giger, Davidhizar, Campinha-Bacote, and Purnell.¹ One has to question here whether nursing's focus on the development of a professional body of knowledge has objectified its work, including intercultural work? The hidden question that comes to mind here is also, do we expect people to embrace the dominant culture, how the dominant culture positions them?⁸ Due to the prescriptive nature of transcultural models and frameworks, has nursing successfully objectified clients of other cultures, by grouping and labeling them? Is the assumption, then, that all East Indian clients hold the same beliefs, values and practices related to healthcare? We know that differences between people within a culture can be as diverse as people of different cultures, with each member embracing differing numbers of traditions and practices of their culture.⁹ The uniqueness of the individual is surely lost when they are labeled according to their culture.

In reviewing the available nursing models, there is little mention of dialogue as a method to learn about one's culture, or perhaps it is taken for granted or embedded in the nursing history. Engaging in dialogue requires relation with another; discovering and learning can be mutual and equal. The focus in nursing models seems to be learning "about" another culture as opposed to learning "with" another culture and applying the knowledge found rather than through conversation and dialogue allowing oneself to come to a new understanding based on the content of the dialogue.

In Meleis'& Im's work on marginalization, they remind us that as nurses, we have asserted that nursing is about dialogue, and in-depth interactions. Through interactions and dialogue we influence each other's world. Without more knowledge about how dialogue enhances understanding, we are less tolerant of what we do not understand, become less familiar with diversity and difference, and settle into a more dehumanizing environment.¹⁰ In regard to learning about other cultures, gathering knowledge without attention to structural, political, economic and positional constraints itself is dehumanizing. Cultures cannot be examined or understood outside their politics and history, including the power structures within and outside of them.¹¹

Meleis and her work on culturally competent scholarship also inform me. She presents eight criteria to be used by researchers in order to ensure cultural competence in the development of knowledge. Contextuality involves sensitivity to all the conditions that contribute to participant's responses and to the interpretation of situations informed by the participant's experiences.¹¹ Relevance refers to the extent to which the research questions are considered meaningful and significant to the population being studied, as seen from their perspective. Relating to communication styles, for research to be culturally competent it must include evidence of understanding the variations in language, symbols and communication styles of the population being studied.¹¹ The researcher must be aware of and acknowledge power differentials. An attempt should be made to establish more horizontal relationships and shared ownership of data. The goal of any culturally competent researcher is to uncover the experiences of the participants in ways that are authentic to them and understandable to the audience. This represents the criteria of disclosure.¹¹ Reciprocation is achieved when the goals of both the researcher and the participants are identified and attempts are made to address these goals. Empowerment refers to the consciousness-raising of the researcher and the participants through the research process. Finally, time must be used in a flexible manner, to develop a trusting relationship, and to demonstrate respect for the potential differences in the cultural meaning of time.¹¹

In the discipline of nursing we are often educated to know ahead how to deal with many practice situations. Through the application of a known nursing model of practice or an assessment tool, the nurse provides competent care. While this is realistic and helpful in many nursing situations, it is difficult to follow this pattern in intercultural work. Much of the nursing literature related to cultural work fits comfortably into dominant western thought processes, which I have found serves to stifle interaction and potential understanding when working with another culture.

METHODOLOGY

I was drawn to the tenets of hermeneutics as a way to explore intercultural dialogue as it calls us to understand something from all sides. Knowledge is not acquired and applied, but a shared understanding emerges through the commitment of staying with one another in the process. The answer to any question is not found in expertise, but in dialogue, where the other half of the understanding is found.¹²

Phenomenological and hermeneutic research explores the humanness of being in the world. It strives to interpret and understand rather than to observe and explain. Where phenomenology is the description of an experience, hermeneutics is the interpretation of the experience.¹³ With questions that search for understanding, there can be no separation of the knowledge of the experience from the meaning of the experience.¹⁴ The success of hermeneutics as an interpretive methodology is in its ability to gain greater understanding of an experience while maintaining the context of the lived experience where meaning lives.¹⁵ The knowledge resulting from hermeneutic inquiry being very useful to nursing. This knowledge reforms understanding, leading us to more thoughtful action with others.¹⁶ The more that is known about human experience the more sensitivity can exist in relation to patients, families and other nurses. However, the nurse must be a participant, sharing in the patient's journey.⁵

Hermeneutics is helpful in mediating meaning in the context of cultural differences.¹⁷ Hermeneutics shows us the way the meaning of anything is arrived at referentially and relationally. Coming to understand something requires a commitment to a process of emerging understanding as well as the occurrence of perpetual self-transformation. In conversation, the same occurs with the other, and together trust is developed to gain understanding of one another. We must search for a language of understanding where difference invites us to consider the boundaries and limitations of our own understanding. Identity means nothing without a set of relations as our shared future is contained in the other.¹⁸ That identity is only something "we are" not "I am", meaning we develop our identities together. Engagement with new realities creates the potential for development of new shared realities.¹⁸

REFLECTIONS ON INTERCULTURAL DIALOGUE

Several of the concepts which became evident in the research study warrant full research on their own, illustrating the complexity and breadth of intercultural dialogue. They are briefly discussed below, supported by literature. The complexity of intercultural work and dialogue are immense, but this immensity should not deter us from working toward a greater understanding.

Intercultural communication requires openness and a willingness to stay present in the process, through differences, similarities and unknowns. If a person is willing to become someone who can temporarily transcend his or her own culture, beliefs and frameworks in order to understand another person of another culture, then dialogue can at least start on an equal plane and proceed as mutual sharing and reciprocal transaction.¹⁹ A script worked out a priori cannot guide us through the process without threatening objectification and generalization.

Respect and acceptance are paramount to the development of responsive and reciprocal intercultural relationships. On cultural competency in education, have authors that suggest that the willingness to develop respectful, reciprocal and responsive relationships through dialogue is the true measure of cultural competency.³ Respect involves suspending the need to impose one experience of reality over another. Reciprocity seeks to balance power between people in dialogue, while responsiveness is an openness to allow others to reveal who they are.³ It is important to understand that while respect is a universal concept, it is also situated and enacted in different cultures in different ways at different times. Dillon reminds us that we each have our own perspective from which we try to make sense of the world and ourselves. Respecting persons involves coming to understand them in light of their own self-conceptions and trying to see the world from their point of view. In relation we must account for our connectedness, our distinctness and our interdependence.²⁰

Another authors tell us that as our world becomes more interdependent, we will experience more face to face interaction with people of diverse ethnic, religious, cultural and social backgrounds. We will need to develop a more global mindset where we see things through the eyes of others, adding their knowledge to our existing knowledge. Only through competence in intercultural communication will this be possible.²¹ Dialogue which involves face to face interactions with people of different cultures helps to promote a sense of responsibility for each other. Responsibility in intercultural dialogue is required on many levels. One must have full responsibility to being present and engaged in so many aspects of reality, one must a responsible, global citizen and there must be responsibility for each other in dialogue.

Intercultural communication also requires commitment; commitment to enter the relational space, to remain in the space in the process of discovery until shared understandings develop and new horizons of understanding emerge. Commitment in intercultural dialogue is multifaceted. One must be committed to learning about another culture; their beliefs and experiences in the world. We must also be committed to self learning, about one's own culture, beliefs and experiences in the world. Finally we must commit to staying with each other in the process of emerging understanding as well as the occurrence of perpetual self-transformation; a finding of oneself in relation to others.¹⁷ This involves being committed to resist judgement of others. To cast judgement closes the door to our potential learning. It makes a statement saying we have nothing to learn from another person.

When we are willing to enter and dwell in the relational space, encourage and accommodate diversity, through dialogue we can see the potential for shared understanding to develop in this space. Staying in the relational space encourages learning about each other's "living I" and through the "living I" we acknowledge that each other has inherent knowledge.⁵ Through this acknowledgement we are less likely to impose our own realities on each other.

Understanding that power is relational is fundamental to intercultural work.²² It encompasses the ability to both produce and experience an effect and is necessary to sustain a relationship. In its ideal form power is synonymous with life. The amount of power we each have is determined in relation to others. Healthy relationships are those in which self and other are continually transformed. As each participates in the experiences of the other, the relationship is enlarged and the subjective reality of each individual is enriched²². While the existence of power in relationships is a fact of life, it may also be the single biggest factor affecting intercultural dialogue.

Finally, keeping a sense of vulnerability in our presence and communication encourages us not to theorize about or objectify the other. Recognizing and allowing vulnerability in oneself and others is also important in intercultural dialogue. A sense of vulnerability is created when leaving the comfort of what one knows and understands, to go to what one does not know or understand. Staying with the vulnerability in the present moment helps us not to be tempted to apply theory as much. Perhaps in this vulnerable state willingness for self-transformation occurs. Clearly in dialogue and interactions with other cultures we expand our cultural understanding, however, more importantly, we have the opportunity to increase our knowledge about ourselves and our own culture.

CONCLUSION

Intercultural dialogue is difficult to live authentically, truly and consistently. This work has provided me with some insight into why it is so difficult and alternately why we can so easily, though not consciously, objectify the other in intercultural situations.

The heart of nursing work is the formation of meaningful and respectful relationships with our clients. Therefore, nurses must strive to increase their knowledge of other cultures through engaging in nursing and intercultural literature, but also through intercultural dialogue and face to face experience with other cultures. It is through this that we learn situated understandings, understandings we can then take with us into our next nursing situation.

A hermeneutic methodology provides us a way to explore intercultural dialogue as it calls us to understand something from all sides. It requires a commitment to a process of emerging understanding through dialogue but also a sustained perpetual self-transformation.

Many of the concepts evident in intercultural dialogue documented here warrant full research on their own and include respect, power, willingness to stay in the process, vulnerability, responsibility, the expanding of horizons and self-discovery. Intercultural dialogue is a multidimensional project with elements that cannot be put into discrete categories but must maintain openness to what comes, to new learning and new possibilities to engage more fully in the process.

Acknowledgment

I would like to acknowledge my thesis supervisor Dr. Brenda L. Cameron for her support with this article.

Recebido em: 17 de setembro de 2005

Aprovação final: 15 de fevereiro de 2006

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Publication Dates

• Publication in this collection
  03 Apr 2008
• Date of issue
  Mar 2006

History

• Received
  17 Sept 2005
• Accepted
  15 Feb 2006