About 2.9 million nurses are in the U.S. workforce today. About 3.5% of these nurses were trained in another country.¹ If you are one of this growing corps of healthcare professionals, these modules have been written just for you. If you want to better understand the American healthcare system, you’re in luck. Part 1 will give you a glimpse into the values, world view, and communication styles of Americans in general. You’ll get a clear illustration of American patients’ health and illness beliefs, along with the expectations of the nurses who care for them.

Part 2 (on www.nurse.com/ce) offers invaluable information you’ll need to feel more comfortable working within the American healthcare organization and assist you in working with supervisors and fellow nurses. After completion, you’ll be well on your way to successfully fulfilling the role of nursing professional in the U.S. If you are American-educated, but working with nurses trained outside the U.S., this information is particularly important to your understanding of issues that may emerge in a culturally diverse workgroup related to divergent beliefs about healthcare, patients, and healthcare workers.

A culture snapshot

As you have likely already seen, Americans come in many sizes and colors. The diversity can be striking — especially to those who come from countries where the majority of the population “look similar” to one another. America has always been a nation of immigrants. The majority of the early settlers in the U.S. came from Great Britain and Northern Europe. So, not only did most early immigrants look fairly similar, they also shared a similar world view, work ethic, behavior, language, communication style, and attitudes about healthcare because these were heavily influenced by their early origins. Now, however, the immigration landscape has changed. While the majority of new immigrants are from Latino cultures that have been strongly influenced by Southern (rather than Northern) European traditions, the fastest growing group of legal immigrants to the U.S. is not from Europe, but from Asia. Here is where an influence from Eastern rather than Western cultural traditions has made the current immigrant population much different from that of earlier groups. Not only do they come from different cultural traditions from earlier immigrant groups, but they look noticeably different from the general population. No longer can the United States be referred to as “The Melting Pot” where new immigrants just “melt into” and become indistinguishable from the general population.

While just 4.3% of the total immigrant population is from Asia, their impact on the nursing profession has been great. Some 59.5% of all foreign-educated nurses are of an ethnic or racial minority background. Fifty percent of the foreign nurse population comes from the Philippines with a large percent of the other foreign nurse population coming from India, Korea, Japan, and China.¹

Culture is most often defined as the shared values, world view, beliefs, and traditions of a group of people. Culture has the tendency to hold people within that group together, but also to separate them from others who are outside that group. Culture impacts more than behavior and communication. It also influences one’s ideas about the cause and cure of disease and even the role of the caregiver and the health system.

If you received your nursing training outside the U.S., the information you received about the role of the nurse and how to be a sensitive and effective caregiver was no doubt influenced by that culture. If you were raised elsewhere, but trained in the U.S., your cultural background surely impacted your comprehension and interpretation of what was taught. In either case, the application of your training will be somewhat different from that of your American-born colleagues.

One nurse born and trained in Japan makes the following comparison: “I worked as a nurse in Japan for seven years before coming to the U.S. In spite of the fact that Japanese nursing education was imported from the U.S. after World War II, the scope of nursing practice in Japan is narrower. Here, nurses have more autonomy. Although I came to this country with nursing know-how, I had little experience with nursing expectations or the culture of this country.”

One’s culture comes by way of unconscious, ingrained learning through common daily experiences starting at almost the moment of birth. Though it is possible to consciously learn and adapt some aspects of another culture, it’s not really possible (or even desirable) to ignore one’s cultural heritage for that of another. However, to work well within the U.S. healthcare system, it is important to understand and respond effectively to American patients and colleagues while remaining comfortable with your own cultural background. This understanding and ability to respond effectively can be called cultural competence.

But I learned to …

If you come from any one of the many countries in Asia that have been helping to alleviate the shortage of nurses in the U.S., you have probably been brought up to consider the needs and benefits of family and society above your own needs as an individual. You have probably learned to avoid open conflicts, to respect those older and/or more senior than yourself, and to make sure you don’t make your elders or superiors lose face by pointing out errors, omissions, or showing that you are more knowledgeable in any subject. Because Asian cultures emphasize the consequences of the group, decision-making is usually a group process rather than an individual decision. This type of society is often referred to as a collectivist society. It is not limited to Asia, though societies from that continent are oftentimes used as examples of collectivism. Most African and some South American, Mediterranean, and Middle Eastern societies are also regarded as collectivist, and some (mostly Southern) European societies share aspects of collectivism.³

Unlike collectivist societies, America was founded on a belief in the “fundamental rights of the individual.” This concept comes from a seventeenth century philosophical tradition promoted by John Locke, an English philosopher who viewed the biological individual as the basic unit of nature. The term individualist society as it refers to American social structure was coined by Alexis de Tocqueville in the study Democracy in America, published in 1835. The great American scholar and statesman, Benjamin Franklin, epitomized that world view with his often quoted statement, “God helps those who help themselves.”³ That view of the individual’s ability to control his destiny has important implications for the American attitude toward healthcare.

Americans learn, at an early age, to view the world from the point of view of the self. Early in childhood, they are encouraged to make decisions for themselves, develop their own opinions, and solve their own problems. In fact, Americans are not expected to bow without question to the wishes of authority, whether it involves family, traditions, or some organization.⁴ These basic tenets help us better understand the American insistence on patient autonomy and informed consent.

American patients are usually culturally programmed to want to know exactly what’s going on. For example, most will ask specific questions such as: what is the illness, what is the prognosis, and what are the treatment options? Americans typically do not want to be protected from the truth or given false hope. These patients want to research the medical data on the disease and take control by participating actively in the choice of treatment options. Americans can’t truly fathom that a person from another culture might want to be protected from a negative prognosis or that medical decisions could be made by either the patient’s family or a physician authority figure.⁵

Common American expressions include, “If you want something done right, you’ve got to do it yourself,” and, “The only person you can count on is yourself.”⁶ American individualism is also at the root of many social customs. Consider, for example, the American preference for addressing people by their first names rather than family names. This “given name” establishes one’s personal identity and therefore takes precedence over the name of the family to whom one belongs. When American patients instruct the nurse to address them by their first name or ask for the nurse’s first name, it stems from a desire to interact individual-to-individual.

There’s us and them

In spite of America’s current role as a world power, it has a history that includes isolationism. Those who founded this nation crossed the ocean to be free to govern and worship without the influence of others. Even though America was founded by immigrants and has an extremely diverse population, a tendency has evolved for Americans to divide the world into us (Americans) and them (everyone living or from somewhere other than the U.S.). America is a large country and shares borders only with Canada and Mexico. As a result, many Americans have not had the opportunity (and often not even the desire) to travel outside its borders.⁷ Most have not learned to speak a foreign language; therefore, they do not have any concept of how difficult it is for a foreigner to learn to speak English.

One Japanese nurse lamented about Americans who refer to nonnative English-speaking people with Asian features as “your people,” as if all Asians formed one group. It is true that some Americans make no distinction between Asians of different nationalities and refer to them generically as “Orientals.” Similarly, they fail to distinguish among diverse Spanish-speaking groups. This single grouping of “us” versus “everyone else” may also be the root of strongly voiced patriotic feelings and the desire to display the American flag, which also confuses many immigrants.

Just say what you mean

Basically, words can have different meanings depending on the context in which they occur.⁸ Cultures, such as that of U.S. culture, that rely on low-context communication, depend on the words themselves to impart almost the entire meaning of any utterance. In other words, the context in which the words are said is very often ignored by the listener. In high-context cultures, communication relies not only on words, but on facial expressions, gestures, and assumed previous knowledge. Here’s where a communication gap can occur between the American patient and the foreign-born nurse.

Let’s use Japan as an example. Until very recently, Japan had a homogeneous population where most people shared similar history and culture. Because of this, the Japanese have a high-context style of communication: They assume that people are able to understand the main point of conversation without depending solely on words. They also rely on assumed previous knowledge or common history that may be reflected in nonverbal cues. Therefore, the words of a communication are often either indirect or even omitted completely. The U.S., on the other hand, is historically more diverse. Its people don’t share the same backgrounds or traditions. Americans don’t assume everyone knows the history or that they can interpret nonverbal cues. Furthermore, the American culture, with roots in classical Greek logic, bases its communication style on the belief that all facts and details must be spelled out clearly so the listener is able to apply deductive reasoning. Even the court system is structured so only what is said and recorded can be considered.

In Japanese and in most other Asian cultures, context is provided by innuendoes, by references to what Americans would interpret as unnecessary information, and body language. Much of the meaning is left unsaid. Americans, in their low-context style of communication, rely on direct, concise words, both in speaking and in understanding what others say. Therefore, in determining the meaning of any message, the American listener will tend to ignore or discount anything that isn’t stated outright “in plain English.”

Since words are so important to American patients, some become very impatient when communicating with persons who speak English with an accent. If an American patient experiences any trouble in understanding your words because of your accent, he or she may fear miscommunication and thus feel insecure about your ability to provide care. In addition, an accent may even be interpreted as lack of competence. In the words of a Japanese nurse, “Sometimes I am asked, ‘Are you a nurse?’ It’s a simple question and doesn’t sound strange, but the tone of their voice sometimes makes me feel they are doubting my competence. Maybe this is because of how I look, my name, and also my accent. Also, the phrases and words I use are not natural to them, so they want to confirm that they are speaking to the right person.”

Avoiding communication pitfalls

English communication is linear and precise. A good English communicator is one who simply states the main point, then gives relevant details in order of importance starting with the most important, and then summarizes by restating the main point. If, however, you come from a culture that relies heavily on context, or one in which information is ordered differently (perhaps the details are presented first and the main idea last), your patients may be unable to pick up on your contextual cues or follow your instructions.

Tone, pitch, volume, and speed are also cues that Americans use in communication. Unlike Chinese and other Asian languages, where pitch may change radically within words but not systematically at the end of sentences, Americans use pitch at the end of sentences as a means of communicating. For example, “What can I do for you?” said with a medium falling tone indicates normal interaction. If that same question is posed by a speaker, who does not use the rise and fall of pitch the American patient expects, it may be interpreted as brisk or angry.

People often raise their voices when speaking to someone who is from a language background other than their own in an effort to enhance understanding. However, it usually has the negative result of making the listener feel the speaker is angry and impatient. It’s important to remember that if your patient is having trouble understanding, it does not necessarily mean he or she is having trouble hearing.

Because you probably feel that Americans speak very quickly, you may try to increase your own speed to sound more American. However, if you use imperfect grammar or speak with an accent, faster speech will only make you harder to understand. In general, if you do speak English with an accent, it is best to slow down and even repeat what you say, if necessary. It may be a good idea to ask questions that require the patient to repeat information, such as, “Can you tell me, in your own words, how you will be taking this medicine at home?” By doing so, you will avoid the pitfalls involved in asking a question, such as, “Do you understand?” where the patient may just say, “yes,” so as not to offend or embarrass you.

The nonverbals

Although words are primary in American communication and nonverbal behavior is viewed as ancillary, cues, such as gestures and eye contact, do color the messages people convey. It is important that you make eye contact with your American patients, even if it doesn’t come naturally. Americans strongly believe that eye contact is a sign of openness and truthfulness. This is illustrated by such expressions as, “he wasn’t able to look me in the eye and say that.” Americans feel lack of eye contact indicates that a person is shifty and dishonest ,as opposed to other cultures that teach that indirect eye contact is a sign of respect and modesty.

Edward Hall, a leading American anthropologist who studied nonverbal communication, believed time and space were so important to human communication that he devoted a book to each. According to Hall, “Time talks. It speaks more plainly than words.”⁹ American and European languages “treat time as a continuum divided into past, present, and future.”⁸ Time is objectified and externalized, and Americans believe they can manage it, control it, spend it, save it, and waste it. Time is expressed in nouns, such as summer, winter, last week, next week, and tomorrow. Americans tend to think of time as fixed in nature and unavoidable. It’s seen as a road stretching into the future. However, unlike the “future” in most of Asia, which can stretch into many thousands of years, Americans think of the future as a time that is foreseeable. Long-term planning to an American can be one, five, or 10 years.

Time and promptness are highly valued, and lateness is taken either as an insult or an indication of lack of responsibility.⁹ In contrast, people from Iran and Afghanistan, who are primarily Muslim, handle time quite differently. For members of these cultures, the past and present are very important, while the future seems to have little reality or certainty. Therefore, suggesting that everyone make changes in the present to reap future benefits is not a successful approach.

Members of each cultural group have undoubtedly learned a “comfort distance,” which is maintained when speaking with others. For Americans, this distance is about three feet — the approximate distance assumed when shaking hands. In contrast, most Middle Eastern cultures have a comfort distance of only a few inches. Therefore, when members from these two groups converse, the Middle Easterner tends to stand close, which can make the American feel uncomfortable.

Touching is also culturally based. Most Latino and Mediterranean groups are “touch-oriented.” People tend to touch one another when talking. They touch to show sincerity, to show caring and sympathy, to show friendship, and even to show anger. This touching nature may make members of both Asian and American cultures uncomfortable. Both of these groups have been culturally programmed to believe that touching represents an invasion of personal space. Additionally, in America, uninvited touching can be construed as sexual harassment.

I’m not sick

When someone of the American culture is sick, he or she has a sense that they no longer play a useful role in society. Americans tend to praise sick people who “remain on their feet” because they have not let their illness interfere with their work. If people become so ill that they are hospitalized, they become, in a way, dehumanized. They are deprived of having a useful social role since their disease is defined as a physical breakdown that demands objective, and thus impersonal, treatment. As Edward Stewart and Milton Bennett, noted experts on intercultural communication, put it: “… it is the fittest individual who can command a place in society. Sick individuals are, by definition, not fit, and so they lose their functional roles.”⁴

The American’s need to control disease is one factor in the desire for patient autonomy in addition to the desire to master the environment. Americans also have a profound faith in science and technology. When the American patient is diagnosed with an illness, it is common for him or her to go to the library or to the Internet to research the disease. The patient will ask the physician many questions and may even request a specific kind of treatment.

This need to control treatment often enters into the nursing environment. The patient may ask the nurse what medications are being administered, how much is being given, or ask the nurse to increase or decrease the dose. As a nurse, you may be carrying out the physician’s orders, but it is likely that the patient will ask just what those orders are. Will you be ready to communicate this information effectively and in a culturally sensitive manner? And if your manager or another nurse has questions about your care, will you be able to respond in a culturally effective manner? Just as Part One of this CE offering has helped to hone your intercultural skills, Part Two will sharpen your skills with coworkers and supervisors.