Intercultural Competence and Patient-Centered Care _ _____________________________________________
Learning to communicate effectively also requires an under- standing of how different conversational traits influence the communication process, or how information is conveyed and interpreted. Again, the goal of this section is not to simply dichotomize individuals’ conversational styles into categories, but rather to understand the factors that play a role in how someone makes a decision on how to communicate [106]. As long as there are two parties involved in a conversation, nonverbal communication is inevitable, and it becomes salient particularly when it is processed from one culture to another. Nonverbal communication is any behavior (including gestures, posture, eye contact, facial expressions, and body positions) that transcends verbal or written forms of communication [113]. Nonverbal communication can enhance or reinforce what is said verbally, and conversely, it can completely contra- dict the message communicated verbally. It can also end up replacing what was verbally communicated if both parties do not share a native language [114]. In Western culture, communication is more direct and eye contact is highly valued. When eye contact is not maintained, many Westerners assume that the party is hiding pertinent information. However, in some cultures, reducing eye contact is a sign of respect [108]. Conversely, patients may interpret direct and indirect gazes differently. For example, in one study, Japa- nese individuals tended to rate faces with a direct gaze as angry and less pleasant compared with Finnish participants [115]. The amount of social space or distance between two com- municating parties is culturally charged as well. Depending upon the social context, Westerners tend to maintain a dis- tance of about three feet, or an arm’s length, in conversations [107]. In a public setting, where both parties are engaged in a neutral, nonpersonal topic, Westerners will feel encroached upon and uncomfortable if an individual maintains a closer conversational distance. However, in other cultures, such as Latino and Middle Eastern, a closer distance would be the norm [107]. Chung recommends that in a clinical setting the practitioner allow patients to set the tone and social distance [116]. The practitioner can sit first and permit the patient to select where they want to sit. Cross-cultural communication is by no means simple, and there is no set of rules to merely abide by. Instead, promot- ing culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [106].
CULTURALLY SENSITIVE ASSESSMENT GUIDELINES Practitioners may be categorized as either disease-centric or patient-centric [117]. Disease-centered practitioners are concerned with sign/symptom observation and, ultimately, diagnosis. On the other hand, patient-centered practitioners focus more on the patient’s experience of the illness, subjec- tive descriptions, and personal beliefs [117]. Patient-centered practice involves culturally sensitive assessment. It allows practitioners to move assessment and practice away from a pathology-oriented model and instead acknowledge the com- plex transactions of the individual’s movement within, among, and between various systems [118]. Practitioners who engage in culturally sensitive assessment nonjudgementally obtain information related to the patient’s cultural beliefs, overall perspective, and specific health beliefs [119]. They also allow the patient to control the timing [120]. The goal is to avoid the tendency to misinterpret health concerns of ethnic minority patients. Panos and Panos have developed a qualitative culturally sensitive assessment process that focuses on several domains [119]. Each domain includes several questions a practitioner may address in order to ensure that he or she is providing culturally responsive care. Alternatively, Kleinman suggests that the practitioner ask the patient what he or she thinks is the nature of the problem [121]. He highlights the following types of questions that may be posed to the patient [121]: • Why has the illness/problem affected you? • Why has the illness had its onset now? • What course do you think the illness will follow? • How does the illness affect you? • What do you think is the best or appropriate treatment? What treatment do you want? • What do you fear most about the illness and its treat- ment? Similar to Kleinman’s culturally sensitive assessment questions, Galanti has proposed the 4 Cs of Culture [122]: • What do you call the problem? • What do you think caused it? • How do you cope with the problem? • What questions or concerns do you have about the problem or treatment? Pachter proposed a dynamic model that involves several tiers and transactions, similar to Panos and Panos’ model [123]. The first component of Pachter’s model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional must be willing to acknowledge that they do not
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