The supervisor is surprised when he hears this complaint. “I am in charge, and my job is to direct the staff,” he says. “My decisions are made to get the work done and keep things running smoothly.” When he discusses this problem with the nursing director, she suggests that the problem has arisen because of cultural differences in working styles.

Situations, in which miscommunication and differences in work styles create problems, such as the one described above, will become increasingly more common in the future. Communication and work styles are learned within a cultural context. Every nurse, regardless of specialty, whether working in a large medical facility or in a local clinic, will be working with colleagues and support staff from different cultural backgrounds. Learning about cultural differences in work patterns and communication styles, and specific strategies for working effectively within a diverse environment will benefit every nurse.

What is cultural diversity?

Culture is a shared system of values, beliefs, traditions, behavior, and verbal and nonverbal patterns of communication that hold a group of people together and distinguish them from other groups.¹ The concept of culture transcends ethnic identity. For example, Latinos from Mexico may have a common language —Spanish — with those who come from Ecuador or Cuba, Peru or Puerto Rico, but each country has its own cultural identity. Even a common language, while it is generally viewed as the same, has many subtle and not so subtle differences among groups that may cause communication gaps. Diversity refers simply to differences in race, ethnicity, culture, and language; as well as age, gender, and sexual orientation. These factors influence the way a person interprets the world and such aspects of life as work ethic and communication. Interestingly enough, diversity, when applied specifically to the workforce, usually refers to the presence of workers who are not white men. The U.S. healthcare system is unique in that nearly 80% of the workforce is composed of women, with women making up more than 91% of the RN population. While the vast majority of registered nurses are still white (77.4%, non-Hispanics),² the current nursing shortage has encouraged active recruitment of trained nursing professionals from abroad as well as recruitment of American-born minorities, and this “white majority” is rapidly decreasing.

Why is the growing diversity of the nursing workforce important? As more nursing colleagues enter the workforce from different cultures and varied language backgrounds, communication is bound to become more difficult. Unless nurses learn to overcome these language barriers, mistakes could occur, putting both nurses and patients at serious risk. An added complexity to this situation is that our values and goals are defined and molded by the culture to which we belong. You can’t assume that coworkers from various cultures mean the same thing when they say they have a strong work ethic or loyalty to an institution or supervisor. And differences among nurses of diverse cultures can and do cause misunderstandings and problems.³ The Joint Commission acknowledges the significance of this problem by requiring accredited hospitals to orient each staff member, student, and volunteer to cultural diversity and sensitivity issues.⁴

Madeleine Leininger, nurse educator, anthropologist, and founder of Transcultural Nursing, recognizes the importance of both the shared similarities and the distinct differences among people from different ethnic backgrounds. She says, “Similarities help to contribute to feelings of familiarity, while the differences stimulate new discoveries and approaches.”⁵ It is the responsibility of nurses and managers to be particularly aware of differences in the work setting that may affect the way staff works together.

We need to learn to use staff diversity so it becomes a positive force and a distinct asset in working together on behalf of the increasing number of patients who come from other cultures. Once nurses better understand each other, they can make more informed choices about their responses and actions, learn to communicate more effectively with one another, and provide better care to their patients.^3,5 An understanding and appreciation of diverse communication and work styles can lead to constructive strategies for working together.

The changing ethnicity of the workplace

The diversity in the U.S. population is increasing. In a population of just under 300 million, 51% are women. According to the U.S. Census Bureau, while almost 74% of the population are white, only 66% of those in that category are non-Hispanic; 12% are black, 14% are Hispanic (of any race), and 4% are Asian or Pacific Islander. About 0.8% are American Indian, Eskimo, or Aleut (some people are counted in more than one category). Future projections indicate that people of color will comprise just under half of the U.S. population by 2020.⁶

On March 18, 2004, new estimates of the U.S. Census Bureau showed that the Hispanic population rose almost 5% between April 2000 and July 2001, from 35.3 million to 37 million, while the non-Hispanic, black population rose less than 2%, from 35.5 million to 36.1 million.⁷ In certain parts of the country, including California, Texas, Florida, New York, and Illinois, Hispanic populations are rapidly growing, and in some, they already comprise more than 50% of the population. Hispanics have surged past blacks and now constitute the largest minority group in the U.S.

Ideally, a nursing staff in a particular facility should reflect the diversity of the community it serves, but this is often not the case. Within a estimated workforce of registered nurses of more than 2.5 million, 92% are women. About 11% of registered nurses are black, almost 8% are Asian, but, in spite of the enormous Hispanic patient population, only 4% of registered nurses are Hispanic; these figures differ drastically for senior management.² Within the U.S. healthcare system, for example, more men are at higher levels of management, and as D.O. Weber, a contributing editor for Health Forum Journal, puts it, less than 2% in management positions are people from “cultural complexion types that qualify in this country for the label minority.”^3,8

Differences among staff can create problems in communication and lead to conflicts that affect how the team works together. However, for nurses to be able to work effectively with staff from other cultures, they need to become aware of their own cultural values, beliefs, and behaviors, and understand how these factors influence their communication with other staff members and patients, as well as their decision making and clinical practice. The same principles nurses use to give culturally competent care to patients also apply to the work group. According to the National Standards for Culturally and Linguistically Competent Services (commonly referred to as the CLAS Standards), to be culturally competent means to function effectively as an individual and as an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.⁹

Differences in work styles

The values, beliefs, and practices that bind a society together are evident in the workplace. Expectations about work styles, role relationships, taking initiative, and concepts of time are examples of these cultural influences.

Hierarchic versus egalitarian work styles: All societies have a system of social structure. The structure of some societies is hierarchic, while the structure of others is egalitarian. In hierarchic societies, status is based on such characteristics as age, sex, occupation, and wealth. Status differences are considered very important, and those who have high status positions, such as a boss, supervisor, or an officer of the law, are given great respect.¹⁰ In most hierarchic societies, men hold a lot of power. For example, most Muslim societies are hierarchic in which men have a great deal of power over women and children. Men make the political, financial, and healthcare decisions for the family, and in general, their authority is often not challenged. In Latino societies, although men dominate decision-making outside the home, women have authority to make decisions about family purchases and finances. However, health decisions are frequently joint family decisions that may involve not only husband and wife, but also the extended family.

In egalitarian societies, everyone is supposed to be equal. Although not always achieved, equality is the ideal.¹⁰ Status and power depend on personal qualities, such as competence, leadership ability, and expertise. A person may have status in one area, such as a job, but not in the home. American culture is organized around egalitarian principles. For example, both women and men participate in childcare, have careers, and are able to hold public sector jobs and political office. It is acceptable to challenge people in authority. It’s OK to disagree with a supervisor or a teacher.

In the healthcare workplace, people from hierarchic societies may find it difficult to question any authority figure, such as the physician or nursing supervisor. Their concept of nursing may be rooted in the old fashioned “hand-maiden” tradition seen in the U.S. in the 1940s and 1950s, still present in many countries worldwide. Physicians from this cultural tradition may object to assertive nurses who question their orders. Nurses from a hierarchic tradition may expect to work under the direction of a supervisor or physician, rather than practice in an autonomous role. They might hesitate to question decisions made by those “over” them or take initiative to perform work on their own. On the other hand, staff members from more egalitarian societies will find it easier to question or challenge authority figures and to work more collaboratively with them because their cultural experience has prepared them to feel equal to others.

In the clinical example mentioned earlier, the Latino supervisor probably believed he had the best interest of his staff in mind when he made unilateral decisions for the unit. His experiences contributed to that belief. For example, if the Latino supervisor came to this country as an adult, his cultural experience most likely taught him that someone in authority, especially a man, needs to take responsibility for those he supervises. The nurses who were primarily young, Anglo, and white, on the other hand, expected a more egalitarian work style. They wanted equal input into the decision-making process. These differences are culturally based. To work more effectively together, the Latino supervisor needs to understand and appreciate the expectations and previous experiences of the staff. At the same time, the nurses have to consider that the supervisor has based his decisions on his perceived role in the hierarchy, not because he lacks respect for their knowledge and ability. To effectively work with this supervisor, they may have to find more subtle ways of expressing their ideas, feelings, or suggestions.

Role relationships and “Face”: Hierarchic order is closely connected to role relationships. In some societies, roles are strictly defined. For example, in Asian cultures, the status connected to a particular role is greatly respected. People do not directly question or disagree with someone of higher status, such as a physician or teacher. To do so is considered disrespectful, because it makes the person in authority lose face. Similarly, in many societies, people strictly adhere to gender roles. In some African societies, for example, men are considered superior to women, and it is considered inappropriate for women to tell men what to do. Problems can occur when women supervise men from male-dominated societies, as is often the case in healthcare settings.

Face has been defined as a projected image of one’s self in a relational situation.¹¹ While a universal concept, the definition of face varies greatly according to culture. Face involves the favorable sense of social self-worth and the estimated worth of others in a social situation.¹² Included in this concept is self-face, or the concern for one’s own image or reputation. Also included is the concept of other-face, which is the concern for the image of another, and mutual-face, or the concern for both parties’ images and/or relationship. In collectivist cultures (African, Arab, Asian, Latin, and southern European),¹³ the concept of face encompasses not only concern for the individual, but also for his or her family, work unit, and community. The concept of face for members of these cultures is strongly related to honor. In individualist cultures (Australian, Canadian, and American),¹³ on the other hand, the concept of face rarely goes beyond the social self-worth of the individual.¹⁴ Below is an example of how the collectivist concepts of role relationships and face may influence the behavior and the decisions of Asians and others from collectivist cultures.    

The administrators in a nursing department decide to reorganize by removing the layer of head nurses from the supervisory structure. When this new structure is implemented, Hyang-In, a Korean-born head nurse, resigns from her position. The supervisor tries to talk her out of leaving, explaining that she is a valued employee and will not receive a pay cut. Hyang-In explains that losing her head nurse position is a loss of face in the eyes of her friends and family. She feels ashamed and views the change as a serious demotion. In light of this response, the supervisor attempts to negotiate with upper management to retain the head nurse titles of those currently holding these, thus phasing out the role by attrition. But her suggestion is to no avail. As a consequence, in a time of serious nursing shortage, the organization loses a valuable employee.

The importance of understanding cultural aspects of role status and face can be seen in the above example. Taking away Hyang-In’s head nurse title was not intended by an Anglo administration to reflect her performance nor did it make any difference in her salary. But role status and face were so important to the Korean nurse who incurred such feelings of shame at the loss of her position that she chose to leave rather than live with the loss of role status. The resignation may not have occurred if those in upper management had a better understanding of and greater sensitivity to cultural diversity in the workplace.

Communication styles

Diverse communication styles also affect the workplace. Formal versus informal and direct versus indirect communication styles are examples of these differences.

Formal versus informal: U.S. culture is becoming more informal. North Americans tend to refer to and address others by their first names because they consider this a demonstration of openness, friendship, and acceptance.¹⁵ This practice occurs in business as well as in healthcare settings. In many cultures, however, this level of informality is seen as presumptuous and rude. In situations dealing with coworkers and patients of other cultures, it’s always a good idea to either address people by their family name or ask, “How would you prefer to be addressed?”

Informality also pervades nonverbal communication. For example, in North American society, we feel comfortable and at ease when visiting with a healthcare provider who is dressed casually. Casual dress gives us a feeling of openness and accessibility. In contrast, Latino, Asian, and many other cultural groups may view a casual appearance as lacking in professionalism and respect, resulting in a lack of confidence and trust.

In cultures where hierarchic structure is important, communication tends to be more formal in the work situation. For example, people in Latino cultures show respect by not only addressing those in positions of seniority or those they don’t know well by their family name, but also by shaking their hands each time they meet. Personalismo, a highly valued trait, also dictates that one politely asks people something about the well being of their family before getting to the business at hand. Although many Asians are not comfortable with shaking hands, they may also expect that one “establish a relationship” before getting down to the business of working together. To Anglos, who tend to be task-oriented and value “getting right down to business,” this kind of social “chit chat” may seem like a waste of time. But these signs of courtesy, common in other societies, are important to developing a comfortable working relationship with culturally diverse coworkers.

After a staff meeting, Amanda, an outgoing, well-liked African-American nurse, becomes annoyed at June, a reserved European-born nurse. “You never speak your mind at meetings,” she says. “I have to come up with all the ideas.”

June is shocked at this comment. She considers Amanda too informal and talkative to the point of rudeness with colleagues. “I’m here to get a job done, not to discuss ideas,” June responds.

“What? Don’t you like me?” says Amanda, who is hurt by what she perceives as rejection by June. Both Amanda and June are highly skilled nurses who receive excellent evaluations on their work.

Differences in levels of formality and in perceptions of work styles are illustrated in the above situation. For some cultures, while task accomplishment is important, relationships among workers are highly valued and a priority. Tasks are achieved within a context in which rapport and relationships are emphasized.¹⁰ In other cultures, tasks predominate, and personal relationships are not fostered in the work setting. Amanda enjoys friendly, informal relationships with her working peers. She is talkative, offering up ideas freely and generally speaking her mind. When June disregards her comments, Amanda feels hurt and rejected. June, on the other hand, is quiet, focusing on tasks. She considers informal banter between colleagues rude and a waste of time. She has no interest in developing friendships with people from the workplace. These differences in styles can also occur within cultures due to individual differences in people’s personalities. In either case, these differences can lead to misunderstandings and conflicts. In the above situation, a supervisor could help the nurses understand and appreciate their culturally based differences.

Direct vs. Indirect: Communication in mainstream U.S. culture tends to be direct. For example, if a nurse disagrees with a supervisor about a work schedule, he or she might approach the supervisor and ask to speak about the schedule. When sitting with the supervisor in the office, the nurse might say, “I worked on the last holiday, so I think it’s unfair that you’ve now scheduled me for the next holiday. Could you change my schedule?” This communication is clear and direct. A direct communication style occurs in what has been called low-context cultures. In low-context cultures, it’s necessary to spell things out because explicit verbal communication, rather than the context of the situation, is the way meaning is transferred.³ Direct eye contact is important, as well as getting directly to the business at hand.

In many other cultures, including Asian, Latino, and Native American, communication tends to be more indirect. These are considered high-context cultures, where the situation in which an utterance is made carries great meaning. Nonverbal communication, such as gestures, body language, voice tone and register, and the nature of the interpersonal relationship, are just as or even more important than the content of a verbal communication.³ In a high-context culture, the nurse in the example above might use an entirely different approach to communicate with the supervisor. First, the nurse might talk about the unfair scheduling among coworkers. He or she might enlist a couple of colleagues to eat lunch with a trusted intermediary, such as the charge nurse or a person who has informal leadership power, rather than going directly to the supervisor to complain about holiday scheduling. After pointing out the need for a better system for holiday scheduling, they would encourage the intermediary person to take action. For lower-level workers to confront a supervisor directly would seem inappropriate in a high-context culture. Direct, sustained eye contact may be considered disrespectful. Although many individual differences coexist within low- and high-context cultures, communication style is learned within a cultural context. Healthcare providers must know their own and coworkers’ styles of communication and to communicate effectively in the work setting.

Conflict management styles: The concept of face, discussed earlier, also has a strong influence on how people manage conflict. Afzalur Rahim, a professor at West Kentucky University, identified five different types of conflict management styles as: integrating, compromising, dominating, obliging, and avoiding. In general, members of individualist, U.S. mainstream culture, tend toward a dominating conflict management style, which emphasizes strategies that push for one’s own position or goal rather than those of the other person or group. This style is direct and linear and, because members of an individualist culture are usually able to separate the issue of the conflict from the party or parties involved, they normally get over the conflict relatively easily and can assume friendship or at least a friendly manner as soon as the conflict is resolved.¹⁴ Members of collectivist cultures (for example, Asians, who make up a large proportion of the non-mainstream culture nursing population) tend to use strategies, such as avoiding, obliging, and integrating to maintain interpersonal harmony.¹² They often try to maintain public face by using collaborating and/or passive strategies during conflict, avoiding open and direct conflict at all costs in order to display group harmony. The communicative style used by most Asians is indirect and circular or spiral. Because the conflict issue cannot be separated from the person or persons involved, it is more difficult for members of these cultures to get over the conflict.¹⁴ Even after the conflict is resolved, the individuals involved may be kept at a considerable distance.

Language: Although foreign-born nurses are required to speak English and successfully pass the U.S. licensure exam in English to practice in the U.S., bilingual staff still commonly use their native languages with others in the workplace. This practice can make those who don’t speak that language feel uncomfortable because they may feel excluded or even feel that those speaking the foreign language are gossiping about them. But picture yourself working in another country and speaking the language of that country. You would probably be thrilled to speak your native tongue with a person from your country of origin. Speaking with others in a common, native tongue is a way to stay connected with your language and culture. If you were in another country and met an American, wouldn’t you just naturally want to speak English?

On the other hand, if you were the nurse whose native language was not English and you were chatting, perhaps while at lunch, with a coworker in another language in front of other nursing staff, it would be polite to explain the gist of the conversation to the English-only colleagues. Needless to say, you would not want to speak your native language in front of patients unless it was their language also and you were facilitating communication on their behalf.

When working with people who are not native English speakers, it’s a good idea to simplify language by using shorter sentences and avoiding idioms until they are truly fluent in English. Idioms such as, “stop on a dime” or “let sleeping dogs lie,” can be difficult to understand or to translate because they are culturally based. When discussing a patient’s care or giving directions to colleagues who are nonnative English-speaking, it’s also a good idea to check their understanding. Rather than asking a yes-or-no question like, “Do you understand?” it is better to ask for informational feedback with a question such as, “Now, how will you do this?” or “Could you explain to me what you will do next?”

Time orientation: Language and time orientation are closely allied. The English language tends to be direct and linear. For example, a nurse giving instructions in English to another staff member is apt to use linear time markers, such as “First do such-and-such, and then do this.” In the same way, people in the U.S. culture view time in exact increments. If a staff meeting is scheduled from 9:15 AM to 10 AM, everyone is expected to arrive exactly at 9:15 AM and to terminate the meeting at 10 AM, precisely as planned.

Other societies see time as being more fluid and approximate, rather than exact. A 9:15 AM meeting simply means that participants should arrive somewhere around that time. The meeting may or may not start at that time, and it may start gradually in what seems to be a disorganized fashion. Staff members who have difficulty adhering to schedules can cause serious problems in staff relations because time is such an important norm in U.S. healthcare settings. One person’s casual orientation towards time can create disruption for both staff and patients. While a loose orientation toward time is culturally based and not necessarily a sign of laziness or irresponsibility, staff members who are not used to running their lives according to the clock need to do so if working in the U.S. All staff members need to learn the rules of punctuality, although some may need a careful private explanation of the value given to punctuality in U.S. workplaces and the expectation that the people who work in them need to be on time.

Strategies for working together

Working effectively in a diverse environment can be viewed from two broad perspectives. The person-centered approach holds that people should take responsibility for accommodating to and/or changing the work environment. Working together effectively depends on everyone involved, and each person has some responsibility for making this happen. On the other hand, an organization-centered approach holds that working effectively in a diverse environment is largely the responsibility of the organization’s management team. Organizational leaders set the policies, decision-making process, and the emotional tone that affect the working environment. However, working effectively in a diverse environment is colored by the degree to which management promotes diversity. The organization’s commitment can be evaluated by its policies and procedures, and its mission, vision, and values. Look at staff demographics and human resources hiring practices. These are the responsibility of management.

Both person- and organization-centered approaches are vital when formulating strategies for working together in a diverse environment. On one hand, nurses as individuals need to take responsibility for how staff interacts in the work environment. On the other hand, supervisors and managers can help cultural diversity through active leadership.^17,18

Person-centered strategies that can help include —

1. Understanding differences in role relations. Relations, interpersonal distance, and formality between supervisors and staff differ among cultural groups. When entering a unit in a healthcare system as a nurse employee, observe staff members to determine the dominant norms. Is the supervisor addressed on a first or last-name basis? Are people treated differently on the basis of gender? These are just some questions to consider.
2. Understanding differences in the concept of face and taking care not to injure the face or the strong sense of honor, which is an important concern of many who belong to collectivist cultures.  
3. Learning to accept differences in the way people manage conflict. Members of mainstream culture need to understand and try to avoid dominating strategies when dealing with Asian or other nurses from collectivist cultures. Those from collectivist cultures need to understand that the dominant behaviors of direct conflict and pressing for one’s own point of view are not intended as insults, but are simply other ways of dealing with conflict. They need to try to disassociate the person from the conflict incident and redevelop the relationship.
4. Being aware of people’s conception of what constitutes a “good employee.” If staff members from a hierarchic society do not seem to take initiative on the job, they may be demonstrating respect, whereas nurses from an egalitarian society expect to challenge authority and work more independently. Nurses from diverse cultures may want to observe and emulate the norms of the unit to meet the prevailing expectations of role independence.
5. Being aware of personal space and touching. All cultures have different customs and rules about interpersonal space and touching. Personal space can hinder communication and professional relationships if the staff members have different cultural bias about what is appropriate. For example, many cultures from South America, the Mediterranean, the Middle East, India, and Pakistan have a comfort zone of space closer in distance than is practiced in the U.S. A colleague from a culture where closeness and touching are normal may seem intrusive to someone from a culture where touching is taboo. The person from a culture where more distance is appropriate may back up in response to unexpected closeness, appearing to be acting negatively. U.S. culture gives mixed messages about touching. Touching and coming close to someone is often interpreted as a sexual or aggressive act, whereas in other cultures this is normal. To avoid misunderstandings, it is important to recognize and talk about these differences.
6. Understanding that communication styles in cultures differ in their level of formality. Some staff members interpret a more formal communication style as “snobbish,” whereas others may view informal styles as “rude.” It is best to be more formal, such as calling people by their last name, until trust is established. It may be helpful to discuss communication styles when attempting to clarify misunderstandings with others.
7. Not being hurt if staff members speak their own language when they are together. Remember that this is a way for them to stay connected to their cultural heritage. If you are part of the native language group, take the time to explain what you’re talking about to colleagues who only speak English, for instance, “We were talking about the movie we saw last night.” If you are the English-only speaking person, you might say something like, “You seem to be having a good conversation. Can you share it with me?”
8. Speaking clearly and facing staff members who have difficulty comprehending directions in English. Check understanding by getting them to describe what you have told them to do. Remember that language skills build slowly over time. Your patience will help colleagues improve their English language abilities.

Organization-centered strategies from managers that can help include —

1. Closely defining the job duties and expectations. Job descriptions are often taken more literally in other cultures than they are in the U.S. Culturally diverse staff may be afraid to step outside the boundaries of their position by taking on tasks not included in this description. Explain expectations regarding job performance carefully. If job expectations include making suggestions in meetings, giving opinions about improving the work environment, and taking initiative, state this outright. Give examples of some ways nurses and other staff might do this.
2. Facilitating the development of open communication between staff of diverse cultures. The supervisory team needs to watch and listen for signs of misunderstanding and conflict. Offer to serve as a nonjudgmental mediator to help clarify meanings. Avoid taking sides. Simply help staff clarify what was said or done. Where more than two staff members are involved, initiate staff meetings that provide an open forum for discussion of problems, such as the manner in which requests or instructions are given, or the way assignments are made.
3. Using diverse staff as resources for each other. For example, rather than asking culturally diverse staff to assume responsibility for the care of all the patients from their culture, ask them to serve as a resource and guide to other staff who come into contact with those patients. Ask them to explain any important rules of etiquette in treating patients from their culture or to explain any beliefs that may influence their response to treatment. This practice helps staff members appreciate and gain knowledge of each other’s differences.
4. Helping culturally diverse staff learn the appropriate ways to behave and interact in the mainstream culture. Explain accepted ways to address each other and the patients. Review with them some of the norms about work styles, communication, formality or informality, and time orientation on the particular unit where they will work. Help orient them to the norms of nursing practice by giving them inservice programs and professional articles to read. Developing and rehearsing scripts or role-playing simulated situations may also be helpful.
5. Finding and using any resources available at the healthcare facility. Federal regulations now require that healthcare systems provide cultural competency training to staff in dealing with the population served. Training and information should be provided in user-friendly ways so that staff will readily take advantage of these offerings. healthcare providers are now required to use interpreter services as needed. These interpreters can be a valuable resource for cultural information.

Cultural differences in work patterns and communication styles influence the nursing environment in many ways. In a society as diverse as ours, we need to develop sensitivity, awareness, and tolerance of cultural differences. Differences enrich the work environment by bringing a variety of perspectives to patient care. While the burden of conforming to unit norms falls on individual nurses, there are many things we can do, both at a personal and an organizational level, to foster the highest clinical skills and work productivity in each other. Staff members and managers, along with culturally diverse colleagues, can interact as a team to devise further ways to work together effectively in a multi-cultural workplace.