_____________________________________________________________ Cultural Competence: An Overview
• Assumed recollection of shared experiences • Reliance on nonverbal cues such as gestures, tone of voice, posture, voice level, rhythm of speaking, emotions, and pace and timing of speech • Assimilation of the “whole” picture, including visual and auditory cues • Emotional speech • Use of silence • Use of more formal language, emphasizing hierarchy between parties On the other hand, low-context communicators can typically be described as [84; 85; 88]: • Employing direct patterns of communication • Using explicit descriptions and terms • Assuming meanings are described explicitly • Utilizing and relying minimally on nonverbal cues • Speaking more and often raising their voices (more animated, dramatic) • Often being impatient to get to the point of the discussion • Using more informal language; less emphasis on hierarchy, more equality between parties (more friendly) • Being more comfortable with fluidness and change • Uncomfortable using long pauses and storytelling as a means of communicating Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communi- cating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. A Chinese American man may not necessarily be a high-context communicator because he is Asian. A host of factors, such as level of acculturation, upbringing and social- ization, education, and family immigration history, will all play a role in how one learns to communicate. Third, a major criticism of the discussion of low-/high-context cultures is that they reinforce dualism and ultimately oversimplify the complexities and nuances of communication [89]. 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 [84].
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 [90]. Nonverbal communication can enhance or reinforce what is said verbally, and conversely, it can completely contradict the message communicated verbally. It can also end up replacing what was verbally communicated if both parties do not share a native language [91]. In Western culture, communication is more direct and eye con- tact is highly valued. When eye contact is not maintained, many Westerners assume that the party is hiding pertinent informa- tion. However, in some cultures, reducing eye contact is a sign of respect [86]. Conversely, patients may interpret direct and indirect gazes differently. For example, in one study, Japanese individuals tended to rate faces with a direct gaze as angry and less pleasant compared with Finnish participants [92]. 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 [85]. 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 [85]. Chung recommends that in a clinical setting the practitioner allow patients to set the tone and social distance [93]. 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 [84]. CULTURALLY SENSITIVE ASSESSMENT GUIDELINES Practitioners may be categorized as either disease-centric or patient-centric [94]. 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 [94]. Patient-centered practice involves culturally sensitive assessment. It allows
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