A Shock to the System

Understandably, newcomers often have an uneasy feeling when they are unfamiliar with the language. Perhaps a sense of apprehension or isolation can occur as a result of not knowing how to interpret certain gestures or even facial expressions. This is culture shock — the sense of dislocation that arises from unfamiliarity with the new country and its customs.

Many of those suffering from culture shock begin to doubt their abilities because they don’t understand all the new things at once. As a result, they may experience homesickness, boredom, lethargy, withdrawal, irritability, hostility toward local people, irrational anger, or excessive sleeping.¹ According to Geert Hofstede, one of the foremost pioneers in cross-cultural research, apart from its effect on the individuals suffering from it, lack of adaptation when operating in alien cultural environments leads to communication breakdowns and loss of effectiveness.²

Typically, culture shock comes up during discussions about getting used to the life and culture of a new country. But how about the workplace? The American healthcare system represents a unique subculture of the workplace that has a language of its own as well as very distinct expectations and rules for interaction.

Settling In

If you experience shifting feelings about your decision to work in the U.S., you are not alone. Although not true of every person, generally speaking, four stages of adjustment to a new culture have been described: enthusiasm and excitement, culture shock, reemergence, and adaptation. Everyone does not necessarily go through all stages of adjustment. Additionally, the length of time needed to pass from one stage to another will vary, and the stages may overlap.

Stage 1: Enthusiasm and Excitement

This early stage of living abroad is often referred to as the honeymoon period because, like the life of newly wedded couples, it is usually filled with positive feelings. Both excitement and a feeling of being overwhelmed with fascination occur. You find the people friendly and helpful, and you look toward a promising future.

Stage 2: Culture Shock

You’ve begun to interact within the culture, and the novelty of living in the United States has worn off. The focus becomes the differences between what you knew and where you are now. You find yourself trying to overcome language barriers.

Perhaps you now find the American people unpredictable. You may begin to criticize aspects of the lifestyle, the politics, the culture, and the people, while, at the same time, you seek to make American friends. Now is when you start feeling the impact of stereotypes and prejudices about you, your country, and your culture. Because you feel anxious, you may tend to withdraw and start to feel homesick for family and friends. Work time seems to be spent on trying to understand how nursing is practiced in the U.S. Trying to relieve the psychological stress may seem impossible. Many of those who decide to return to their country of origin do so during this stage.

Stage 3: Re-Emergence/Adjustment

Familiarity unfolds. Facial expressions, gestures, and English phrases start to make sense. You experience periodic highs and lows. Your sense of humor returns, and things that you found annoying can now be viewed as amusing. Questioning your former assumptions about the world is common during this stage. You start to feel more comfortable with American culture and with your decision to stay.

Stage 4: Adaptation and Biculturalism

Your new environment no longer feels foreign but is beginning to feel like another home. The differences you see no longer affect you negatively, and you are able to live and work to your full potential. You are able to examine and critique other cultures you encounter without making value judgments. The ability to “culture switch” is becoming easier. You have the flexibility to move comfortably back and forth between U.S. culture, and your own based on need. Your new-found biculturalism in today’s multicultural nursing environment is a valuable asset. It not only helps you to better understand and accept differences in the behaviors, beliefs, work styles, and communication styles of others in the workplace and with patients but is seen as an asset by your managers and colleagues.

No consensus exists about how long it takes to pass through the stages of adjustment. Estimates range from as little as one year to as many as 10 years to get fully acclimated to working in the U.S. healthcare system. Some believe that it takes less time to adjust when coming from a country with a high degree of similarity to the U.S. Keep in mind, though, that the similarities in culture and language may not be as similar as they seem on the surface. The same phrases, gestures, and facial expressions used in your country of origin may mean very different things in the U.S. Furthermore, problem solving strategies and expectations for personal and professional interaction differ greatly — even among English-speaking countries.

Things you need to know

The United States is a highly litigious society. Individual nurses are more likely to be sued for malpractice in America than in any other country.³ Because of the legal threats to the institution, practice, or the individual nurse, documentation and accountability are all extremely important. This may require more paperwork than you are used to in your home country. You may feel frustrated with the lengthy notes you are required to keep as well as the fact that physicians cannot issue verbal orders, but must give them to you in written form.

To those of you from the Philippines and many other parts of Asia, the American concept of patients’ rights and patient education may seem incomprehensible.³ Remember, though, that patients’ rights, informed consent, and patient responsibility for choice of treatment are highly valued in the U.S. You have probably also found that treatments in the U.S. for the elderly and terminally ill are far more aggressive than those used in your home country.³

Nurses in the U.S. are expected to act more independently than they are in the health systems of many other countries. If you came from Asia, taking initiative, American style, may make you feel uncomfortable. You may be accustomed to demonstrating respect for supervisors by awaiting orders rather than taking initiative. Your sense of respect may keep you from suggesting alternative ways of doing things or disagreeing openly with the decisions of anyone in a higher position.

Learning to express disagreement, using the word no, questioning the decisions of those in authority by using personal judgment, and taking an independent course of action may present some of the hardest challenges to foreign nurses. Willingness to challenge authority and using one’s own judgment are often considered by Americans to be traits most sought after by employers. These qualities are almost required of any nurse wishing to advance professionally in the U.S.

One of the central tenets of nursing practice in the U.S. and in much of the Western Hemisphere is the nurse’s role as patient advocate.⁴ In fact, one cause for malpractice litigation against individual nurses is failure of the nurse to act as a patient advocate.⁵ You may have to consciously overcome any feelings that you have about avoiding confrontation to follow through, but here are two valuable tips to minimizing that risk.⁶

1. Question a medical order if you believe that it’s not in the best interest of the patient. Do this by speaking privately with the physician or nurse practitioner who wrote it — never in front of the patient or the patient’s family.
2. Do not carry out a medical order when you think it is dangerous or inappropriate. In such cases, contact your supervisor and clearly document the incident.

Getting the message

Lack of familiarity with the language as well as with the unwritten rules for personal and professional interaction within a new culture may present an obstacle to the adjustment process. Foreign-educated nurses often report communication difficulties in taking telephone orders, recording taped patient reports, understanding and participating in staff meetings, and exchanging information with other healthcare providers. These struggles may lead to a feeling of inadequacy, isolation, and alienation from the work environment and the people within it.¹

These issues are not limited to nurses who speak English as a second language. Nurses from other English-speaking countries may also find themselves at a loss to understand certain language expressions and/or behavior. In these situations, cultural and language differences are less easily recognized, and it is easy for both speaker and listener to falsely assume that clear communication has taken place.

Clear communication is vital, however. For Americans, language is considered a tool to get things done. Because of this, language functions as a tool rather than as a facilitator, Americans expect communication to be clear, precise, brief, and, in the workplace, based upon facts and logic.⁷

A high context-culture, such as is found in most of Asia, relies not only on words, but on facial expressions, gestures, and assumed previous knowledge. It allows one to be indirect in speech because what is being communicated does not necessarily have to be said. Those who come from a low-context culture, such as American culture, rely on the actual words that are being used. As a result, American colleagues may miss the indirect message of a team member from a high context culture. On the other hand, the message sent by an American may sound harsh or repetitious. This is where problems often arise. Orders given by Americans may sound rude to a foreign-born nurse unused to the American communicative style of directness, while an indirect request made by a foreign born nurse, often phrased as a suggestion to show politeness and respect, may be interpreted by American counterparts as something that they may or may not choose to follow.²

American-style communication

Verbal skill building is a central focus in the U.S. education system. Americans tend to fill silences with words in the form of questions and comments. They often measure a person’s ability, interest, and involvement in a discussion by the amount that he or she speaks. In American culture, it is common to ask a lot of questions. If the person to whom the question is posed needs time to think, he or she will answer with an expression such as, “Let me think about this” or “Just give me a minute.”

Disagreement is also part of the American communication process. Sometimes someone will seem to take an opposing stance — termed, playing the devil’s advocate — just to make sure that the issue is fully explored through discussion. Although showing too much emotion is frowned upon in the workplace environment, Americans can be seen to display impatience, annoyance, frustration, and anger through voice tone, gestures, and certain verbal expressions that may be difficult to interpret by someone from a foreign culture. Their general preference is for frank and open discussion, in spite if these indirect forms of expression.

When Americans hear “yes” in response to an order, request, or question about agreement or understanding, they are culturally programmed to believe that the request or order will be complied with. This is in contrast to some foreign cultures where “yes” can mean, “yes, I hear you,” “yes, because that is the answer I believe you want,” or, “yes, I will give it some thought.” If you have been culturally programmed to say “yes” while signaling disagreement in more subtle ways, learning to say “no” directly may present a major hurdle for you. In America, though, remember that it is possible to be polite and still say “no” clearly and directly.

It’s also important to make a verbal distinction between, “Yes, I am listening,” “Yes, I agree,” and, “Yes, I will do it.” Be sure to make the “yes” conditional if you are not sure that you will comply. For example, you might answer a request to complete some paperwork by, “Yes, I’ll try to do it if the unit quiets down a bit.”

This says that you will get to the paperwork only after the patient needs are seen to first.

Ask for clarification if you don’t understand a medical order to avoid making a costly or dangerous mistake.⁶ This is true while working with fellow nurses and other staff. Even if you speak and understand English quite well, the frequently used abbreviations and unfamiliar healthcare terms may make orders and general discussion about procedures difficult to understand. Asking for assistance minimizes the risk of doing the procedure incorrectly.

Feeling more a part of the team

While you may have been taught that it is rude to look a superior directly in the eye, failure to maintain eye contact with Americans — those in authority, peers, subordinates, or patients - may leave the wrong impression. Americans tend to believe that anyone who does not look directly at them when speaking is insincere, disrespectful, or dishonest.

As a member of the healthcare team, each nurse, whether American or foreign born, has obligations and responsibilities toward one another. If you finish your own work, you will be expected to offer assistance to other nurses. When others finish, they too are expected to offer their help to you. Accepting assistance from a colleague or supervisor does not indicate any lack of confidence; it only shows one’s willingness and ability to function as a team member.⁶

Nurses and other colleagues may address one another by their first names, even when one is older or in a position of authority. Generally, physicians are addressed by their title and family name while in front of patients and their families regardless of whether or not you are on a first name basis. And, it is not uncommon for physicians who are known fairly well to be addressed as “doctor” along with the first initial of their last name. “Dr. G” for example.

“Tooting one’s own horn,” is an American expression meaning that one should not only be proud of one’s accomplishments, but also acknowledge and even point them out to others. Americans let others know of their experience and ability and feel proud of praise and recognition for knowledge or good work. Because foreign-educated nurses may be hesitant to do this, their knowledge and ability can go unnoticed.

Foreign-educated nurses have a lot to offer. The fact that you bring another perspective is an important asset to today’s multicultural patient environment. Your own experiences can provide insights into the needs and expectations of culturally and linguistically diverse patients. Not only can you assist in caring for patients from your own language and cultural background, but you can offer valuable insights about communicating across cultures to colleagues. Here is just one of the areas in which you can openly toot your own horn. Job advancement in nursing in the U.S. is heavily dependent on demonstrating knowledge and experience and receiving recognition for these by both supervisors and colleagues.

American-style problem solving

A study of Korean nurses’ adjustment to working in U.S. hospitals analyzed the stages in the adjustment process of 12 Korean nurses who had been practicing in the U.S. for an average of 10 years.⁸ The study found that even after these nurses had begun to acquire self-confidence in their work, they felt deficient in American problem-solving strategies and interpersonal skills. These areas seem to be among the last barriers to overcome during the adjustment process.

An important factor in American problem-solving strategies and decision-making processes is an effort to anticipate the consequences of contemplated actions. Americans attempt to avoid failure in the future by taking action in the present. In Japanese, Chinese, and many other nonWestern cultures, things can be viewed as natural happenings or occurrences. This notion of things “just happening” is not acceptable to Americans, who tend to search for a cause that can be held responsible before they can concentrate on what to do about it. Americans have a need to ask and answer “why” questions, and they like information to be presented in cause and effect chains.⁸

Problem solving through critical thinking to discover the cause before trying to reach a conclusion about how to solve the problem is ingrained in the American thinking process. This process is often referred to as analytical thinking and can be contrasted to the more holistic or integrated thinking process that most European and nonWesterners were trained to use in solving problems.

Because of these cultural differences, you may find it difficult to follow the process of how Americans solve problems in your new work environment. It can be difficult for those who have been taught to view a problem from a holistic perspective to adjust to this way of thinking. In the process of adaptation to a new culture, listening to others in the process of problem solving and learning to identify elements in their approach can be very helpful.

Give this a try by focusing your attention on the manner in which American colleagues go about searching for a cause of a problem. Look for the structure of the arguments they use, and how they are strung together. You will begin to discover a linear pattern, such as “X caused Y, and Y caused Z.” Finally, you will notice that attention is paid to trying to foresee and avoid similar incidents in the future. During this search for insight, you will find that your own valuable knowledge and experience can contribute to the solution of problems as well.

The study of Korean nurses’ adjustment indicated that the Korean nurses found American nurses to be individualistic, self-oriented, and self-centered. However, as they became more comfortable with expressing their emotions and feelings and gained enough confidence to make requests, ask questions, and say “no” when appropriate, they began to feel more comfortable both in their personal and professional interactions with others.⁸

While limiting your social interaction to nurses from your homeland may be very comforting and offer valuable support when you first arrive in the U.S., it may help to form relationships with American nurses. Besides making you feel more at home in the workplace, these nurses can serve both as your language and culture teachers. When you express an interest in learning about the new culture and language, someone will help you.