CHAPTER 5 Culture shock
Introduction
Earlier chapters have discussed the devastating impact of culture contact, culture clash and culture conflict between the original inhabitants of this country and the colonisers. The massive culture shock Aboriginal people experienced during and after invasion, the violation of human rights and the ramifications and living realities of colonisation (including structural issues such as poverty, low education, marginalisation and institutional racism) are clearly all major determinants of Aboriginal health today. Indeed, all facets of the cycles of dispossession, discrimination and disadvantage examined in Chapters 1, 2 and 3 contribute to the fact that when Aboriginal people use the dominant health care system they do not receive the same level of care as other Australians (House of Representatives Standing Committee on Aboriginal Affairs 1979; NAHS 1989; RCIADIC 1991; Cunningham 2002; Coory & Walsh 2005; Anderson et al 2007; Pink & Allbon 2008). Over the past 20 years, these reports and many others (such as Edward Russell’s story, Death by Neglect, ABC 2002) have highlighted the fact that dangerous, often life-threatening, situations may result from cross-cultural misunderstandings, culture conflict and culture shock.
This chapter explores the phenomenon of culture shock and some of the major stressors associated with it. It proceeds to analyse the impact of culture shock on Aboriginal/non-Aboriginal interactions and specifically on Aboriginal help-seeking behaviour. It particularly explores the impact of culture shock on Aboriginal hospitalisation, and it discusses how culture shock can influence non-Aboriginal people’s ability to provide services across cultures. It touches on some of the experiences of Aboriginal and non-Aboriginal health workers when their values conflict with those of the organisation or professional subcultures. Finally, it provides some insights into how to manage culture shock.
Culture shock
Kalervo Oberg (1954) was the first to apply the term culture shock to the tension and anxiety combined with feelings of isolation, sensations of loss, confusion and powerlessness, associated with entering a new culture (Neuliep 2003, p 353). Oberg (1960) used a medical metaphor—incubation, crisis, recovery and full recovery—to describe the emotional reactions of Americans working in Brazil.
Oberg (2006, p 1) maintains that:
Culture shock is precipitated by the anxiety that results from losing all familiar signs and symbols of social intercourse. These signs are the thousand and one ways in which we orient ourselves to the situations of daily life: when to shake hands and what to say when we meet people, when and how to give tips, how to give orders to servants, how to make purchases, when to accept and when to refuse invitations, when to take statements seriously and when not.
These cues, which may be words, gestures, facial expressions, customs, or norms are acquired by all of us in the course of growing up and are as much a part of our culture as the language we speak or the beliefs we accept. All of us depend for our peace of mind and our efficiency on hundreds of these cues, most of which are unconsciously learned.
When an individual enters a strange culture, all or most of these familiar cues are removed. He or she is like a fish out of water. No matter how broad-minded or full of good will he may be, a series of props have been knocked from under him. This is followed by a feeling of frustration and anxiety.
All definitions of culture shock assume that culture contact by its very nature is stressful, and ‘the interpretation of the word “shock” [is seen] as something, if not absolutely unpleasant, at least threatening’ (Fraga 1998, p 1). Most discussions about culture shock today acknowledge that it is a normal reaction, ‘a process of initial adjustment to an unfamiliar culture’ (Hofstede et al 2002, p 22) and/or adaptation to differences and, if managed appropriately, can have positive spin offs. Thus Ward et al (2001, pp 270–1), for example, while acknowledging that interactions with someone from another culture ‘can be, and usually are difficult, awkward and stressful’, agree that people’s responses to an unfamiliar environment should be viewed as an active process of dealing with change. The degree of ‘discomfort’, frustration, anxiety or stress underlying cultural adaptation, however, may be denied or simply not recognised by those experiencing it.
When we move to a new culture, we carry with us the core values and beliefs, customs and behaviours of our old culture. Depending on the degree of similarity between the old and the new culture, our values, beliefs, customs and behaviours may clash with those encountered in the new environment. A loss of familiar signs and symbols including words, gestures, facial expressions, customs or norms (Oberg 2006) can result in confusion, disorientation, misunderstandings, conflict, stress and anxiety—that is, culture shock.
Thus Lewenson and Truglio-Londrigan (2008, p 73) defined culture shock as:
The turmoil or a disturbance of mental equilibrium that includes feelings of helplessness, powerlessness, frustration, and dissatisfaction when a new culture or sub-culture is encountered.
Culture shock is often marked by physical and psychological changes that occur as a result of the adaptation required to function in the new environment for a prolonged period of time. Lynette Nixon outlines some of the changes she and her grandmother experienced within their lifetimes in the case study below.
Case study
What Granny must have thought
I often think about the old people you know, how they must have felt when the pastoral stations started here in the 1840s. How their lives changed so fast. Granny was born in 1883—she spoke the Gunggari language and told us kids endless stories about the old days and the old people. It was always about what we should and shouldn’t do. For instance, what we should do when someone dies. How you had to behave at certain ceremonies, you could only attend some not all. Tell us about the respect laws, for instance a man should not look at his mother-in-law; he had to speak to her with his back to her. Many stories, too many to mention at the moment. She would speak in lingo to the old people who passed if they were tormenting the young children. She was a true old knowledgeable lady, who was respected by everyone. She used to deliver a lot of the babies for many of the women of the day.
Granny used to talk about how, when she was young, she caught possums in the trees and how she cooked them. Also the many other uses she had for the possum. Then, as she became a woman, it was damper and corn beef, and living in tents and then two bedroom huts down the Yumba. Working at the hospital to put bread on the table. Walking four miles a day to and from work. She said her mother went in the head from too many deaths in the family, and mourning for lost loved ones. They had to change their whole way of life to the new way to survive. Their own language was no longer relevant to most of the day’s events. They no longer had the safety and security of bringing up their children the way they used to. Gran had three sons who went off to war, and had to move to Brisbane to wait for their return, how scary was that. As soon as they came back she moved back to her hometown. She lived a big part of her life on a Government reserve on the outskirts of Mitchell, known as the Yumba.
She passed away in Roma in 1984 at the age of 101. Can you imagine the changes in her life she had to make to adapt to this new way? She had brothers and sisters removed from their home country to missions and reserves, some she never seen again. But she remained strong and proud of who she was and how she had adapted to all those changes in her life. It was only when she would reminisce about the old days she would get a sad look and shed a little tear.
I remember the changes even we had to cope with. We used to live in tents in the bush wherever dad was working. We would come to town once a month; if it wasn’t raining. The river would flood and sometimes we would be stuck out there for weeks or months. Going to school was something of a drama, we were that used to living in the bush. Coming to town to live and attend school was very frightening. We didn’t know anyone and they were cruel, calling us names and teasing. So we didn’t stay at school long, we went out to work as soon as we could. I started work at fourteen, working on stations. We lived on the Yumba for a while, no water, no electricity, and moved to town in 1975. We were actually living in a house with running water and electricity then. So I suppose we went through some rapid changes too, from the bush to cities and back again. I never thought I would be attending national meetings all over Australia, after rearing my children by myself after my husband passed away. You move out of this very safe environment of your own home and family and into this big wide world … I still can’t believe how many of my values and beliefs don’t mean the same to some of my grandchildren. It is just like they are speaking another language and living another life; it is very dangerous. So we are trying to play catch up to our younger people. I worry that they don’t have the same strong foundation we had as children.
Activity
Consider how, in the space of only 100 years, language, traditions, everyday activities and lifestyles changed—note how cruel/racist comments confined this family’s life chances.
Contact between non-Aboriginal people and an Aboriginal community can also result in a stressful period of adjustment. Trudgen (2000, p 178), for example, points out that such ‘culture shock is very destructive, undermining the ability of dominant culture personnel to satisfactorily perform their professional tasks’. The Aboriginal community is left to cope with the repercussions as well as the effects of what Trudgen (2000, p 179) describes as ‘the “fall out” from the culture shock suffered by dominant culture personnel’.
Phases of culture shock
Over time different labels appeared to describe the various stages of culture shock (see Smalley 1963; Richardson 1974; Brink & Saunders 1976; Furnham & Bochner 1986; Oberg 2006). Most, however, continued to draw to some extent on Oberg’s original work to portray how culture shock progresses in psychosocial and emotional phases. Brink and Saunders (1976), whose early research informed our understanding of culture shock, identified similar phases to those outlined more recently by Ward et al (2001). These include:
We have found that the above phases (also depicted in Figure 5.1) provide a useful framework to explore the psychological and emotional adjustments that can occur when living or working in a different culture to our own. However, as Hofstede et al (2002, p 22) point out, ‘culture shock is a profoundly personal experience and is not the same for two people or for the same person during two different occasions’. Consequently, not everyone experiences a ‘honeymoon’ phase or euphoria during the process of initial adjustment to an unfamiliar culture.
A graduate student, who was also a Remote Area Nurse (RAN), for example, told Eckermann in the early 1990s that she never experienced a ‘honeymoon’ phase—when she neared the settlement she thought the plane was going to land on the rubbish tip—‘and it all went downhill from then on. I never got out of the disenchantment phase’! Nevertheless, most people develop some strategies, which work in the new environment, and begin to ‘recover’, to learn about the new culture and to function relatively effectively. The ‘effective functioning stage’ is marked by being as comfortable in the new environment as in the old, and by ‘feeling at home’ (Brink & Saunders 1976). We agree with Brink and Saunders that once people have reached the effective functioning phase, they are likely to experience a fifth phase of culture shock—that of reverse culture shock. This occurs when individuals return to their home culture only to find that it, and they, have changed during their absence:
Why? Because, when we adapt to new cultural experiences we develop changed perceptions towards our own traditions and beliefs … we may ‘forget’ some of the intricacies of expected behaviour, customs and interactions. Our own cultural traditions may consequently seem strange, uncouth, ‘not how it used to be’. Because we are members of the group we are expected ‘to know’; consequently far too little attention is paid to the process of debriefing necessary when ‘re-entry stress’ becomes dysfunctional.
Signs and symptoms of culture shock
The following case study records the levels of dis-ease that can be experienced during culture shock. It alerts us to many of the signs and symptoms of culture shock.
During the many workshops conducted by the Binaŋ Goonj Team from 1993 to 2006, Aboriginal and non-Aboriginal participants reflected on the phases of culture shock depicted in Figure 5.1 and identified the possible signs and symptoms of culture shock they had experienced and/or identified in others while working in one another’s cultures. These are listed in Table 5.1.
Table 5.1 Signs and symptoms of culture shock
| SYMPTOMS | SIGNS |
|---|---|
Case study
Reflections on culture shock
I worked with a nurse who had been charge nurse in an operating theatre before coming out to work as an RAN. She wanted to do 12 months Remote Area Nursing. She had no previous history of community work and had not done any extra preparation, i.e. reading etc, to prepare herself. It had been the dream of her life to be an RAN. She was a very caring nurse, probably much more caring than me. She literally made herself ill; worrying about the care people gave their children and the burden of disease. She lost weight and had chronic diarrhoea. She had also not considered what she would do for entertainment when not working. Her boyfriend was interstate and she worried about her relationship. My husband and I tried to include her with us in walks etc, but as I said to her (when she finally made up her mind to leave after 8 months), we were not the sort of people that she would normally socialise with. If we had worked together in a hospital we would have been perfectly friendly but she wouldn’t have asked me to the pub for a drink after work. We liked different sorts of TV shows and books. So she had multiple stressors, which she didn’t really have strategies for addressing. We got on well as work colleagues and were able to socialise but we couldn’t fill the gaps for her and she didn’t find anyone any more compatible in the other people in the community. I also think it was due to her stress and culture shock that she did silly things. She was upset one day when she came to work, telling me a man had come to her house at 10.00 o’clock at night wanting her to cook a birthday cake for his daughter. She didn’t know this man but had let him in and she cooked this cake and she was upset because he was in her house until midnight while the cake cooked, watching TV and eating food. I asked would she have done that in her home town if a strange man came to the door, but she really couldn’t understand the dangers in letting a stranger in her house, but she was upset that he had been there.
Activity
Identify some of the signs and symptoms of culture shock experienced by the nurse—in what ways did they affect her health and judgement?
When we are in a state of physical shock it is not unusual to be unaware of what is happening to us. The same can be true of culture shock. It is easy not to recognise the signs and symptoms, or to attribute them to something else. Winkelman (1994), however, suggests that when we do experience ‘atypical’ problems in a new environment, they are likely to be caused or exacerbated by culture shock.
Each person’s experience of culture shock will be different. But the more aware we are of the signs and symptoms of culture shock and its stressors, the more likely we are to recognise its degree of severity in others and ourselves. This puts us in a much better position to manage it successfully and/or to seek support.
Culture shock: stressors
As we have pointed out, most people experience some degree of stress and strain when they enter a culture different from their own, related to basic changes in diet, climate, housing, accommodation, communication, and personal and professional roles. Further, the shock of being separated from important people in our lives, such as family, friends and colleagues that we would normally talk to at times of uncertainty, can affect our physical, social, emotional and mental health. It is therefore not surprising then that any and all who come in contact with the health care system can experience culture shock.
Brink and Saunders (1976) identified major stressors indicative of culture shock, that is communication, attitudes and beliefs, customs and behaviours, isolation and mechanical differences. In addition to such general stressors, many Aboriginal people are, or have been, exposed to the aftermath of colonisation, culture clash, culture conflict, stress and rapid culture change as outlined in Chapters 1, 2 and 3. These form additional stressors for Aboriginal people interacting with non-Aboriginal society and its institutions. Karen Atkinson, an Aboriginal Nurse, recalls her early experience of culture shock.
Once I turned fifteen, and not long after the trauma of losing a parent, I was forced out of the home. It was policy that, once children turned fifteen, they had to get out and get a job. The thought of being on my own was frightening. I was in shock and had no idea what I would do for a job.
The thought of leaving familiar routines and safety of the home was daunting. In the institution, so much was done for me. In the homes there would be a siren telling me when to get up, when to go to bed, when to eat, when to go to school, and people telling me when I could see and speak to my brother (girls were not allowed to play or speak to the boys). At the same time, the idea of new experiences was exciting. The reality though, was that I was really terrified.
Of all the stressors, communication, commonly described as the essence of interaction, is likely to have the greatest repercussions in cross-cultural encounters. So we need to examine this primary stressor (which is often compounded by the other major stressors) in some detail.
Communication
In any cross-cultural environment we need to be able to obtain and give cues, and provide and receive feedback that enables us to modify our behaviour if it is not appropriate to the situation. Ward et al (2001) identify three aspects of interpersonal communication that are particularly relevant when considering communication as a major stressor: non-verbal communication, rules and conventions, and acceptable behaviour/etiquette. Table 5.2 summarises some of the patterns which characterise non-verbal communication, the rules and conventions that shape patterns of communications, as well as aspects related to acceptable behaviour that is etiquette in interactions with Aboriginal people.
The items listed in Table 5.2 are not exhaustive, and the emphasis placed on each will vary from community to community. A range of factors influences communication and include, in some parts of Aboriginal Australia, lore—that is, traditional knowledge, skin name and rules that govern all aspects of behaviour as well as world views and language, which, of course, underpin all cross-cultural communication.
Language
Even when we share a common language with others, marked or subtle verbal and/or non-verbal differences can make it hard to understand those different from ourselves. People may speak quickly, more slowly, more quietly or louder, and we may feel embarrassed or unsure about whether to ask them to repeat what they have said. So a different system of communication, both verbal and non-verbal, can be a primary stressor (Brink & Saunders 1976). It frequently blocks interaction when people from different cultures meet and interact, whether it is as neighbours, in the schools, at sports or in professional situations.
Although the majority of Aboriginal people speak English, it may not be Standard English. At times Aboriginal people are judged as speaking ‘poor English’ when in fact they may be speaking Kriol, which is a discrete language in its own right. The Kimberley Interpreter Service (KIS) stress that Kriol:
… should never be thought of as simply ‘bad English’. Kriol has an English base and may sound like English, but treating it as English will lead to serious miscommunication.
(www.kimberleyinterpreting.org.au accessed 14 July 2009)
When we encounter difficult communication situations we sometimes try to simplify our language and speak more slowly to help people understand. KIS, however, again warns that:
Simple English is not a good way to communicate essential information. Important information is often left out because it is too hard to explain in simple terms. In any case ‘simple English’ still uses all the grammar and confuses non-English speakers. If you don’t understand Japanese, it won’t matter whether someone speaks to you in that language very quickly or very slowly, you still won’t know what they are talking about.
(www.kimberleyinterpreting.org.au accessed 14 July 2009)
It can also be perceived as very patronising. In contrast, one of the KIS interpreters, Irene Bent, from Fitzroy explains:
Now I’m living in Perth, I can help all the old people when they come down for hospital. They feel happy when they hear their language and when I can tell them in their language what the doctors and nurses say. It makes the job easier for the doctor when I interpret for the old people too …
Even the Halls Creek mob get happy to see me. I tell them who my family is and where I’m from and explain that I’m an interpreter to help make the communication right between them and the doctor … to say exactly what they say in language to the doctor in English, and put into language what the doctor says for them to understand properly. I interpret in Kriol for Halls Creek mob. It’s really important …
(www.kimberleyinterpreting.org.au accessed 14 July 2009)
What about situations in which the client’s first language is English?
Brink and Saunders (1976, p 128) point out, ‘even when the language is known, tonal differences, colloquialisms, and other factors serve to obscure meaning’ and can block our access to important cues for responding appropriately. This is particularly so because patterns of non-verbal communication, rules and conventions and acceptable behaviours and etiquette differ between cultures.
Non-verbal communication
Non-verbal signals play an important role in communicating attitudes and affect, in expressing emotions, in supporting speech by elaborating on what is said. They also provide feedback from listener to sender and assist in synchronising verbal interactions by indicating to the participants when it is their turn to speak, when it is their turn to listen, and when it is appropriate to interrupt (Argyle 1975, 1980).
The unspoken messages given and received in Aboriginal cultures probably have the greatest impact on communication and, hence, potential rapport between members of the minority and the majority. Ena Chong explains that:
We take our cues from the other person, if someone, like we have a medical student here at the moment, who is keen to learn so he can deal better with the Murrie people he meets. He was a bit concerned because he’s never met an Aboriginal person before. That doesn’t matter, he’ll have no worries ‘cos he’s responsive and very caring …
So, lots of times it’s themselves … we get the cue from them which allows us to respond appropriately. If someone is unfriendly, brisk or abrupt, we pick that up pretty quickly and just step back. If that happens they either leave or if the contact is to be ongoing, you hope it improves! Just depends on the person but we get the cue from them. It’s hard sometimes waiting to see how people are going to be … but it can be really hard for us when we have to go out and initiate contact or conversation …
Activity
What aspects of non-verbal communication (cues) have you found to be important in your interactions with Aboriginal/non-Aboriginal people? How did you become aware of them?
These hidden cues are not difficult to learn, especially if you are guided by a mentor, an ‘insider’ from the other culture. Nevertheless, time needs to be taken to establish empathy and trust. It would be tempting for non-Aboriginal people to reach for simple solutions—a formula—for quick introduction to and interpretation of such cues. Instead, Ena Chong points out that:
It takes time for people to trust white people, particularly when they come in and out of our communities rapidly. We had a doctor come to us [at our Health Service] a half day a week for 6 weeks, it’s not a lot of time. You can meet people, show respect and start to get to know them in that sort of time. That’s good but you’ve got to allow time to develop trust …
Trusting
Trust is about relationships and trusting another is important to our social and emotional wellbeing. Johns (1996, p 80) defined trust as a ‘willingness to assume vulnerability and reply upon someone or something to perform as expected’. Hupcey et al (2001, p 290) suggest that in health situations trust emerges when a need has been identified that:
cannot be met without the assistance of another and some assessment of the risk involved in relying on the other to meet this need. Trust is willing dependency on another’s action, but it is limited to the area of need and is subject to overt and covert testing. The outcome of trust is an evaluation of the congruence between expectations of the trusted person and actions.
Many Aboriginal people find it difficult to trust white people, particularly those in authority, because past experiences have been demeaning and traumatic. Some will distance themselves keeping interactions to a minimum. Others may feel vulnerable or ‘fear being let down’ when they (or someone close to them) needs help. Ena Chong explains:
… because of our history and experiences we’ve learnt to be critical and cautious in taking a step forward … trusting a white person can be scary … but when there is a mutual give and take … built on honesty … harmony can result rather than conflict. If people are respectful, listen attentively that will start to pave the way for building trust.
Trusting can be ‘scary’, as Ena put it, because, as de Raeve (2002, p 161) points out, it:
Silence
Silences too form an important part of Aboriginal communication patterns. People will be quite happy to sit; there may be an occasional comment, but there is no obligation to ‘keep the conversation flowing’. For those used to interactions that have a particular focus, whether this be social or professional, tolerance of silence, acceptance of and relaxation in non-communication, can at times prove difficult and stressful. Toni Dowd (pers. comm.), for example, recalls:
I remember in one of our Binaŋ Goonj workshops with Executive Managers, a participant wanted to know how to work with Aboriginal organisations in a particular community. The Aboriginal facilitator was speaking about communication and protocols in her community. The participant interrupted and said ‘Yes, but I want to know what to do in … Community. What do I have to do to get them to collaborate with us?’ The facilitator paused and sat quietly thinking. Before she had time to respond, she was asked at least six more questions by other participants.
Lynette Nixon, who was the Aboriginal facilitator in this situation, reflects:
When someone asks you a question like that you have to have time to think about it … you don’t have the right to answer … they should really be talkin’ to someone in that community. When you talk you really can only talk on your own experiences, your own community.
The silence thing is probably hard for them but that’s how it is. My feeling was that they wanted something that you couldn’t really give them. They wanted something tangible. They wanted something that they could grab hold of and it’s not like that, it’s a process … there are things you don’t answer just off the top of your head.
When you see them just sitting there, lookin’ at their watches and that, you just feel ‘Well, I’m not goin’ tell ‘em nothing ‘cos they haven’t got the time’. It just takes time and they’ve got to take the time to listen … that’s what it’s all about. Probably if they listen the silence is a 1000 words.
Listening
Burton (2002, p 164) agrees that ‘when people are not heard, when others do not listen to them or pay attention to their being, they are diminished’. Groopman (2000, pp 230–1) advocates that ‘careful listening … is the starting point for careful thinking’. As Lynette explained we all sense when someone is listening carefully to us, and when someone is not.
Although ‘listening’ is valued in Western nursing and medical education, we may inadvertently internalise a culture of ‘saying without listening’ (Fiumara 1990, p 2) or what Levin (1989) calls a ‘forgetful’ way of hearing. The professional focus to reason, to be accountable, to explain and to be in control can easily devalue the importance of careful listening (Fiumara 1990). It is the key element missing from many health care interactions (Groopman 2000).
Kagan (2009), citing the work of Cocksedge and May (2005), notes that in doctor–patient encounters listening:
… is often not initiated and cues are frequently missed or not given proper attention. They found that the pressure of work, physician mood, and feelings toward a patient, among other factors, fostered the ‘limiting, blocking or resisting [of] listening [by] reassuring, changing the subject, interrupting, being directive or making a plan, reducing sympathy, and using body language’ (p 999).
Careful listening or what Burton (2002) prefers to call ‘compassionate listening’ requires work, especially in cross-cultural situations. We have to prepare ourselves to listen before we can engage in a process that demonstrates real listening.
Our discussion about ‘silence’ and ‘listening’ as well as our emphasis on preparation, seems to imply that there are clear, structured rules of interaction. This is not always the case. Aboriginal people will at times be sitting around talking and participating in four or five discussions at the same time—switching from one to the other with confusing rapidity and ease. Frequently such discussions appear to be conducted in a ‘shorthand language’, a combination of non-verbal cues mixed with ‘cryptic’ English that can leave the outsider bewildered. The only way to deal with both situations is to sit back and to listen—to relax with silences and to learn to tune in to local speech patterns and idioms.
Cultures also vary in the extent to which they allow bodily contact … in non-contact societies, touching is only allowed under very restricted conditions, such as within family, in brief handshakes with strangers, or in specialised role relationships (e.g. doctors, dentists, and tailors). Contact outside of these approved settings can be a source of considerable anxiety.
Non-verbal communication such as touching, eye contact, gestures and so on varies not only between Aboriginal and non-Aboriginal cultures but also within cultures. Caution is needed, therefore, to not assume that patterns of non-verbal communication encountered in one Aboriginal community will be common in other communities. Even if they appear to be similar, they may in fact mean something quite different.
Rules and conventions
Every culture has unspoken rules and conventions that influence how its members communicate and treat each other. These vary between cultures as well as between subcultures—and they are not easily explained to outsiders, because:
The communication patterns and social conventions of a particular society are usually taken for granted by its members. Consequently, people tend to be unaware of the operation, or even the very existence of these rules which often only come into prominence after they have been broken either inadvertently or by someone not familiar with them.
Consequently, when moving into an unfamiliar culture, everyday encounters can be a major source of stress simply because we don’t know what rules and conventions apply (Bochner 1982, p 159). Ena Chong explains that, in an Aboriginal community and/or health service:
Information given [about our rules] in good faith by an Aboriginal Health Worker and/or others in the group is given to benefit the visitor … listening attentively is a protection against making foolish mistakes. It makes it easier for the person to ‘fit in’ at the right time and in the right place.
The use of names and titles (what is appropriate, when and where) and the importance of people’s standing/status in the community are best learnt from members of the particular culture with whom you have established some rapport. It is easy for an outsider to miss vital cues and be disrespectful (sometimes without knowing it). If someone uses our name or title inappropriately, we are sure to notice it and, depending on the context and the relationship, we may even be offended. The same is true in our interactions with Aboriginal people; they ‘may interpret it as an insult, or at best, an indication of ignorance on our part’ (Ward et al 2001, p 60).
Activity
Remember our earlier discussion of culture—think about the different ways in which people decide what is important, how activities are allocated, how decisions are made, how respect is shown and how time is observed. In any culture, most aspects of everyday interactions are guided not only by rules and conventions but also by acceptable behaviour and etiquette, which we will explore next.
Acceptable behaviour: etiquette
Cultures differ in the extent to which people are direct or indirect, how requests are made, and more importantly, how requests are denied or refused (Dillard et al 1997; Kim 1995).
Basic to acceptable behaviour are issues of respect.
Respect
Over 15 years of discussions about appropriate behaviours in Aboriginal communities, the issue of respect has been highlighted by participants who have pointed out that:
respect should be exercised to everybody. If you disrespect—like being snappy at an older person or the children … they are two of the people we have tender respect for—if you make the mistake of treating ‘em in a disrespectful way … that’s really dangerous … could be violence … family conflict over it …
… talkin’ harsh to someone that’s drunk in a way that you wouldn’t talk to a sober person, that’s not on …
People look for that recognition … the nurse or the doctor got to make the first move … if they don’t we say they’re stuck up …
It’s a sign of respect in Aboriginal and Torres Strait society to wait rather than rush about.
At times it may seem to an outsider that ‘nothing is going to get done unless I get in and do it’. They may busy themselves with many tasks, totally unaware that they are encroaching on someone else’s area of responsibility.
If you don’t pay attention in any community setting when someone is giving you advice it could be troublesome. They may even consider you to be ‘shameful’ or ‘hard headed’.
It is a mark of respect when we’re in another person’s country or place, to remember that we are visitors. Whether we are familiar with or have little knowledge of those we visit, it is important to have a waiting attitude.
Although the need to be acknowledged and respected is important, the reality is that many Aboriginal people do not believe that they are respected members of this nation, and have many examples of disrespect to support that belief.
Case study
Just passing by …
We received a phone call to say that a representative from a government agency was dropping by in about five minutes. There was neither prior appointment nor notification of the visit other than the phone call. Immediately, a search for an appropriate staff person got underway as management was unavailable and the one in charge was uncomfortable with meeting the person at such short notice. Four staff members were directly contacted and three agreed to attend the meeting with the one in charge, after some persuasion.
When the visitor arrived, she was ushered into a small room and made welcome. After the introductions were completed, the woman told us how things would be better/different than before. When asked what that actually meant, she stated that since they (she and the agency) had arrived that everything was now going to be fine! This style of conversation continued for some time.
Well, we were all getting more and more edgy and many glances passed between staff members. She seemed unaware that her statements were causing discomfort or that her comments were disrespectful because they failed to recognise the status of the health service. It was clear that she knew nothing of our struggles and/or achievements over the years. We tried to let her know kindly, but she was so engrossed in her own images of ‘the future for Aboriginal people’ she didn’t listen and kept telling us how much better ‘things’ were going to be now she was here.
The Service did not know the woman nor was she known to anyone present. She was younger than any of us and it was finally too much for one staff person who confronted her, and with the other three staff tried to ‘set her straight’ about the service and our vision for it. I think she got a bit scared, because she decided she had to go as her superiors were expecting her. We never seen nor heard of her again. No feedback was ever received by the Service. Hopefully, she went away better informed than when she came. Somehow we didn’t really believe that to be the case!
Gender relationships
Part of paying respect is to acknowledge the conventions that regulate proper conduct between the sexes. Among many non-Aboriginal groups it is acceptable for men and women to mix freely, socially and professionally. Such mixing is not always acceptable in an Aboriginal context, where women tend to mix with women and men tend to mix with men. While it may be acceptable for a female non-Aboriginal health professional to treat male Aboriginal patients, it may not be proper for her to interact socially with such men unless accompanied by a chaperone. Further, in many communities throughout Australia it is unacceptable for a male doctor or a male nurse to treat Aboriginal women, particularly in relation to what is perceived to be women’s business (Dowd 1996; King et al 1998; Kildea 1999). In these circumstances, it is useful for non-Aboriginal health professionals to have access to a cultural broker who can advise and mentor them.
Cultural brokers
Aboriginal health professionals play a vital role in overcoming client mistrust of other health professionals by providing emotional support as well as advocacy for clients at their appointments (Genat et al 2006). One experienced Aboriginal Health Worker (AHW) explains how their role can help avoid misunderstandings:
A health worker is a person who has medical skills and is a link between the professional people like doctors and nurses, and all those sorts of professional people, to the Aboriginal community. Like, if we’re talking about Aboriginal health workers, I think we’re sort of like the middleman—‘cause I mean, they’re our people. We know how to deal with our own people. It’s easier for our clients to talk to us rather than professionals like doctors and nurses … we have a lot of medical sort of background—not only medical but there’s a lot of welfare stuff.
Although Aboriginal Health Workers continue to fulfil a crucial role at times, as one remote area nurse points out:
There is … a lot of lip service paid to ‘cultural brokers’ and ‘liaison’ people but not much respect and value given to their actual input (which is not always obvious and quantifiable like clinical tasks are). Often the only reason some of the women would come and see me was because … (AHW) had ‘approved’ or ‘sanctioned’ it. She had spoken to them and made them feel comfortable about seeing me. (RAN, pers. comm. 2009)
While Aboriginal Health Workers play a crucial role as cultural brokers, it would be wrong to assume that they will also, invariably, be the most appropriate people to act as interpreters. Thus Trudgen (2000, p 76), for example, was asked by one doctor, ‘How can you say we can’t communicate properly with the people when we use the health workers to interpret for us?’ He discovered in conversation with a health worker, whose first language was not English, that she found some of the language that the doctors used ‘very hard’ to understand. In this situation, the danger is ‘that patients do not hear in any clear way what their condition really is’ (Trudgen 2000, p 76), and health workers can too easily become ‘the excuse’ for poor communication with patients.
Cultural context
Apart from language, an awareness of the cultural context in which the interaction takes place is an essential element needed to communicate successfully in bilingual, cross-cultural situations (Trudgen 2000). Similarly, a remote area nurse highlights the importance of adapting communication patterns to suit the cultural context of the client/community.
I soon learned when gathering information in a clinic consultation in the remote Aboriginal community setting that it was different to mainstream consults. It was often more appropriate to enquire where a person fitted into the family structure before asking about the reason for their presentation to the health service. In other situations it was more appropriate to give or seek information from accompanying family members rather than the ill person. This established a framework for reference about the individual’s place in the community … someone presenting to the clinic with a physical need was still first and foremost part of the community … having some knowledge of how and where they fitted into the community helped me communicate more effectively.
Activity
Reflect on your own communication style. Recall a particular cross-cultural situation where you were clearly understood or misunderstood. What factors contributed to the outcome?
Reflect on how your status and power may have affected your ability to communicate.
Potential cross-cultural barriers
We have discussed previously how easy it is to take our own culture for granted, including our preferred ways of communicating. We may not realise, unless we make a conscious effort, how some aspects of how we ‘normally’ communicate may not be appropriate in other cultures. Many of the factors that influence communication are ‘hidden’ in the background. As a result, it is not uncommon when living in another culture to encounter what Fish and Spitzer (2005) refer to as ‘culture bumps’—points at which two cultures differ or ‘bump into’ one another. Unless the specific points of difference are carefully analysed, they can interfere with the development of successful cross-cultural relationships.
Socio-economic factors, cultural issues, language, gender, health beliefs, experience of authority figures and anticipation of approval/disapproval can all be barriers to communication. Cass et al (2002) address some of these issues in their research on the impact of negative communication on Aboriginal health. They conclude:
Sources of miscommunication included lack of patient control over the language, timing, content and circumstances of interactions; differing modes of discourse; dominance of biomedical knowledge and marginalisation of Yolngu knowledge, absence of opportunities and resources to construct a body of shared understanding; cultural and linguistic distance …
Cass et al’s (2002) comments highlight the possibly destructive influence of power in cross-cultural communication. Obviously these authors are referring to interactions in the ‘Top End’—however unequal power relationships also underlie Aboriginal/non-Aboriginal communications in rural/urban locations.
Consider how power relationships in an urban Aboriginal Health Service may have impacted on the following situation related by Ruby, a Family Care Health Worker.
… My story relates to a lady who was on the Family Care programme for about four weeks. I actually went to visit the lady in her home. When I got there, there was no family at home and she told me that she was dying and she wanted to die at home. I asked her whether she wanted me to call an ambulance or something like that. She said no, she just wanted to be left at home; so, I said I would go and call an AHS doctor—just to make sure she was comfortable and that there was nothing else we could do. Because she had no phone at her house, I had to go down the road to use the public phone.
The AHS doctor rang for an ambulance and the lady was taken to hospital before I got back to the house. She later died in hospital. The family was informed by the police.
When I got back to the AHS, they told me not to worry about it because I had done all that a health worker could do. I was left very frustrated that they didn’t respect my health worker role with the client—and that they thought that my decision wasn’t good enough—and that the doctor had the right, and the nurse had the right, to over-rule my decision.
Ruby’s actions were clearly intended to do ‘what the client wanted’ but her professional competence and cultural knowledge, respect and regard for the client were ignored. Why do you think this happened?
Although the onus is on health professionals to be competent in their communication, Engebretson et al (2008) reminds us that communication is interactive and the consumer also has a part to play. As an outsider in a community, the reason for our visit, duration of stay and, importantly, our actual or perceived ‘relatedness’ in the community will determine what is expected of us as well as what support is given.
Martin (2008) highlights that Aboriginal communities have ‘always exerted agency in the regulation of Outsiders’. She explains, for example, that to the Burungu, KuKu-Yalanji of Far North Queensland there are:
… three forms of relatedness: ngarrbal meaning ‘stranger’ is an Outsider who is unknown; waybal meaning ‘whiteman’ is an Outsider who is known about, and jarwon meaning ‘friend’ is an Outsider who is known. Each form of relatedness is regulated according to the types and levels of physical, social, emotional, cultural and economic relatedness between Burungu, Kuku-Yalanji and the Outsiders. These are either direct or indirect regulations that occur in limited interactions, limited engagements or sustained engagements. Accordingly, ngarrbal, or ‘stranger’ is regarded as a temporary state of relatedness by the Burungu, Kuku-Yalanji who regulate and mediate the interactions through a series of enfoldments and evolvements. These are established as processes of ‘coming amongst’ and ‘coming alongside’ the Burungu, Kuku-Yalanji in relatedness as ‘another’. Outsiders achieve this in fulfilling conditions of honesty, co-operation and respect and at the same time, maintain their own identity and autonomy so that relatedness is expanded and not diminished or replaced. Thereby, the agency of Burungu, Kuku-Yalanji, in the regulation of Outsiders of past, present and future, is as madja, meaning boss, in that they have never excluded anyone who fulfils these conditions but have equally protected their own relatedness.
Schott and Henley (2003) suggest that as health professionals become more skilled in fulfilling their responsibilities they also become more knowledgeable about channels of communication and power structures within the community, which can be used to achieve a therapeutic outcome. Nevertheless, as they point out, it is not always necessary to learn the local language. Similarly Byers (2009) observes that:
… inability on the part of the health professional to understand the local language allows the community a degree of control through privacy. New information can be discussed and reflected on by community members despite the presence of health professionals. Family decisions can be reached and then relayed to the health professional by the community member delegated to take responsibility. For this interaction to occur in a positive way, the health professional needs an understanding of their role in the community, and what power the community confers on that role. With this understanding, the health professional allows the community control in taking action and in using available resources to achieve outcomes. This process strengthens communities, enhances cohesiveness and allows new information to be incorporated appropriately into existing knowledge.
Beyond communication, another major stressor, mechanical differences, presents particular challenges in an unfamiliar environment.
Mechanical differences
Daily routines often have to be adapted to adjust to the reality of different geographical, cultural and living environments. We all become accustomed to our physical surroundings and how best to navigate them. When we travel or relocate from a rural area to the city, we encounter mechanical differences such as traffic lights, roundabouts and pedestrian crossings, and/or for the first time we may find ourselves caught in the midst of a crowd, in a lift or on an escalator.
Dowd recalls that in her time as a Remote Area Nurse, it was not unusual for older Aboriginal women to hide when they thought they had to travel by plane to a major regional base. At times, younger women were apprehensive about travelling on coaches. It is easy to observe how others cope when they come into our own environment without realising that these ‘taken for granted’ aspects of daily living can be very stressful. We may not relate mechanical differences to culture shock unless we have experienced them ourselves.
In remote areas, these may occur, for example, as a result of limited or no access to essential services such as fuel, gas, electricity, telephone, media, water supply and transport. Simple activities like going to the shop, along with more involved ones such as starting up a generator for power, changing gas cylinders or troubleshooting the air conditioning and mastering four-wheel driving can require time and effort, and sometimes cause frustration for the newcomer. It can be embarrassing and sometimes a source of ‘amusement’ for the locals. A lack of access to ‘luxury items’ including coffee shops, favourite pastimes, food or relaxation activities can also take their toll until new routines are well established. Undoubtedly loss of such familiar cues, can lead to stress, which people handle in different ways as outlined below.
Lynette Nixon’s experience in relocating from a small south-western Queensland town to metropolitan Brisbane clearly illustrates the fact that mechanical stressors are not just encountered in remote geographic locations. She reflects:
I guess the most culture shock that I ever had was when I had to come down here (Brisbane) to work from Mitchell. Gee that was terrible, ‘cos, you know, for somebody that’s lived in Mitchell all their life and hardly crossed the Maranoa River, let alone come all the way down to a big city, to live down here … it was scary.
I was working out at Herston then, doctor’s school, with Toni. But the actual getting to work, you know, catching buses, there were two buses I had to catch and I was really frightened. I was getting taxis ‘cos I was so scared of catching the wrong bus. And trains, I didn’t even know where the train station was, and that was worse. I thought it would be worse to miss a train than miss a bus. I’d get a taxi … and then if you got no money, you just ring up and say ‘I’m not coming!’
Toni Dowd, listening to Lynette’s reflections about their early days of working together, comments that:
You know it’s true, I can’t recall you ever getting a train or I must say, even a bus. I’ve only ever travelled by bus once or twice myself in Brisbane, so I would have been of no help! I remember we travelled mostly by car when we were working together. You were staying at your Auntie’s place and I guess I just assumed when I didn’t pick you up, that you had family there who looked after you. Didn’t think about you being by yourself and the anxiety of getting on and off a bus or train.
Remember when you first walked into Head Office, you said, ‘Where are all the Black faces, I can’t see any!’
Today, even when there are more ‘Black faces’ present in some of our mainstream systems, many Aboriginal people experience similar distress when interacting with the majority and its institutions because, as Lynette discovered, ‘things are done differently’.
The language, the expected routine, the emphasis on foreign protocol, the pattern of the day, and the speed of interactions—all of these create feelings of insecurity and uneasiness. This is particularly so when the person is all by him or herself. Physical, cultural and social isolation, the focus of our next section, may result.
Isolation
Isolation from family and community is generally a feature of living or working in another culture. Such isolation can be a most destructive element of culture shock for Aboriginal as well as non-Aboriginal people. Lyn Byers’ case study, Reflections on Culture Shock, highlights the need for companionship and reassurance, as well as the fact that isolation may throw together people who would normally not seek each other’s company.
Aboriginal people, who have to leave their communities and travel long distances to regional centres in order to access health services for specialist appointments, treatment and/or admission to hospital frequently encounter geographical, cultural and social isolation as a major stressor. As a consequence of isolation, according to Tanner et al (2005), people’s health and wellbeing is jeopardised.
Geographic isolation and dislocation
Non-Aboriginal service providers, including health care providers, frequently experience the stress caused by geographic isolation. They may be visiting rural areas and have to drive long and unfamiliar distances, they may be transferred to a regional or remote Aboriginal settlement and only be able to access ‘home’ by plane or boat. Soon such service providers believe that they ‘live on the job’ and, as Cramer (2006, p 197) records, ‘[i]n the remote area where work, home, and social life overlap together in one place, nurses feel they are “always on duty” ’. Geographic isolation exerts quite a different stress on Aboriginal people.
It is generally difficult for Aboriginal people to leave their communities, particularly at times of crisis. Kinship pressures and obligations, accessing transport and finance, accommodation and communication to keep in contact with family can be particularly problematic in regional centres. Personal security, especially for pregnant women, is one of the main reasons that Aboriginal women do not like leaving their community and families for extended periods of time. They may find that there is not enough money, and the little money that they do have they may feel obliged to share with kin. Accessing money, in circumstances where they don’t have a bank account or credit card, can be very stressful (Kildea 1999; King et al 1998). Yu et al (2008) maintain that the NTER’s income management policies and associated control of funds, and where they might be spent, intensifies stress due to geographic dislocation. Some premises also do not allow husbands, partners or family to stay with the women (King et al 1998). In these estranged situations, those who are ill understandably get worried and miss the support of their families—indeed for them geographic isolation is akin to dislocation.
In Cairns, Mookai Rosie-Bi-Bayan, an Aboriginal organisation established in 1983, has long recognised the stressors associated with women and their children leaving their familiar home environment. It is renowned as a welcoming, friendly, supportive and safe home away from home. Meals, transport to appointments, shops and recreational as well as educational activities keep the women occupied. King et al (1998, p 11) report that ‘such support lowers stress levels, which impacts positively on the health and wellbeing of women and children’.
Supports such as the Patient Transport Scheme (PTS) are available but can be limited and, at times, particularly in emergencies, costly. They usually do not cater for the needs of family members to be close to ill relatives for long periods of time, a need that is intensified in Aboriginal communities because of strong extended kin responsibilities and cultural values. Communities become stressed when ‘someone is very sick and people have no way to go down and see them’ (Eckermann et al 1992, p 39).
Cultural isolation
The Royal Commission into Aboriginal Deaths in Custody (1991) and the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families (1997) have clearly shown the damage that cultural isolation has inflicted on the emotional wellbeing of thousands of Aboriginal individuals and families. People cannot be strong unless they know where they come from, to whom they belong, with whom they can identify. Perhaps one of the most pronounced findings of the Inquiry was the harm done by trying to make Aboriginal people ‘white’. Attempts were made to force them to deny, forget, ignore and belittle their families, their cultural roots and their identities. Add to this the pain associated with being told that they were not wanted by their families and the constant racism many experienced because they were identified by the majority as Aboriginal, and you have a cocktail of pain and pathology.
Even when cultural isolation is not so traumatic, both Aboriginal and non-Aboriginal people will experience stress when they are unable to participate in the rituals and ceremonies which characterise their respective cultures. For example, Eckermann worked with an inspired, dedicated, successful teacher of Aboriginal adolescents in the late 1970s. He finally resigned—simply because one of his other passions in life beside teaching was playing bridge, and the remote far western town in New South Wales was too distant from the bridge tournaments he wanted and needed to attend.
Cultural isolation for Aboriginal clients and their families can also be perpetuated, albeit inadvertently, by medical and nursing practices, which are not informed by patients’ values. Sackett et al (2000, p 1) define their values as:
The unique preferences, concerns and expectations each patient brings to a clinical encounter must be integrated into clinical decisions if they are to serve the patient.
Activity
Consider the following comments by Aboriginal women:
Birth is a very special event for the family and community. We are aware of the unforeseen things that may happen during birth. We want mothers to have their choice to have their babies here, so that [our community] is written on their birth certificate. In our culture the husband should be the first to know the sex of the baby. Here [at the hospital] he is the last to know.
It is very frustrating that so many people from … Health have asked us about Birthing for so long and nothing has happened. We don’t know any more if we can expect support from … Health for Birthing on Homelands. The government want to control us. A lot has been taken away from us (culture). I rang Human Rights and we might have to go internationally.
There are, of course, occasions in practice when there are legitimate reasons to ensure that certain medical procedures are carried out, however, failure by health professionals to communicate and negotiate with people about what is possible, and what is not, can intensify their experience of isolation.
Social isolation
Social isolation haunts all those who venture into a foreign cultural environment, where they are ‘new’ and have no real friends; where their social network is restricted by gender, ethnicity or language. For Aboriginal people such social isolation is intensified by their negative experiences of mainstream society.
Members of the Stolen Generations probably exemplify this type of isolation. Their institutionalisation meant that they were isolated not only from their cultural roots, but also from social interaction with other Aboriginal people.
Other Aboriginal people, though not separated from their families, experienced social isolation because they were excluded from interaction with mainstream society. More than a decade ago, McLennan and Madden (1997, p 49) reported that racism was perceived by over 79 per cent of Aboriginal people as a serious social problem. Thus Ross (2005) explains that:
Racism is still alive and well today. Very little has changed over the last 200 years and, unfortunately, in Indigenous and non-Indigenous organisations there are still many small minds that think the colour of your skin still dictates your level of education and ability.
Similarly Lowitja O’Donoghue (2005) shares her experience of racism and how she coped with it.
I remember racism coming from patients. Some would say they didn’t want a black nurse. When that happened I wouldn’t make a fuss, but would tell the ward sister who would just transfer my patient’s care to another nurse. I never made anything of it. Anyway, I didn’t want a patient that didn’t want me. I thought they were missing out on getting the very best nurse on the ward.
Professional isolation can also become a reality when health care providers move out of their comfortable, familiar work environment, especially if they lose the support and ready access to colleagues and friends.
Professional isolation
Professional isolation can occur in any urban, rural or remote practice setting. However, in remote locations, where professionals for the first time may find themselves part of the minority, it can be even more pronounced. Sabina Knight (pers. comm. 2005), an experienced Remote Area Nurse, explains:
Working in small remote teams gives rise to a sense of professional isolation often not experienced elsewhere in health care in Australia. All remote health professionals experience such isolation, some more intensely than others. In fact as RANs we have more in common across the professions in the remote context than we often do with our colleagues in a mainstream setting. All work as specialist generalists, all have expanded practice and all face professional dilemmas … frequently without the professional support to assist with the making of clinical or professional decisions, or more importantly, to reflect on the intended and unintended consequences of those decisions. This is so often the root of miscommunication that translates to a loss of trust and respect and added confusion between those involved. The intensity of the professional adaptation process can blind a practitioner to the team that exists and/or supports that can be accessed differently, in particular via the telephone and or by a mentor.
Professional isolation is, and always will be, part of the reality of practice in remote areas. Dealing with mismatches in expectations, ‘mindsets’ as well as conflict between the rhetoric and realities of practice on the ground is an integral part of role adjustment.
Aboriginal people can also suffer professional isolation when they become health professionals. Their professional credentials may be challenged; they may be treated like maids rather than health care providers and:
As Aboriginal nurses, we always had to do things 110 per cent, and you always had to cover your tracks so that no one had anything on you …
… but I had to also prove to the white community that as an Aboriginal nurse I could do the duties that were required. I could tell they were not sure of me and I found myself having to constantly prove that I had the ability … my own professional integrity and ability to care for all patients, be they black or white, had to be such that I could not allow any criticism of anything I did.
Several Black Australian Nurses (Goold & Liddle 2005) highlight that a good deal of their professional isolation was due to racism and the fact that they did not conform to the stereotype of how an Aboriginal person should behave.
Customs
The way we act, our preferred customs, are culturally determined. All communities including our own have a range of customs—specific practices—that have been observed, discovered or learned over a long period of time. In a new environment, unfamiliar customs related to social behaviours may confuse, surprise or even sometimes offend you. Everyday happenings may conflict and cause stress and anxiety. As Spradley and Phillips (1972, cited in Brink & Saunders 1976, p 129) point out:
Customary, expected and/or anticipated patterns of behaviour differ between [majority] and [minority] and must be learned. Although this stressor is directly related to the system of communication, the entire concept of reciprocal role relationships enters in. In particular, sex-linked roles and relationships must be established in the new setting. New roles and systems of etiquette are often implicit rules of behaviour rather than explicit. Class and status, … kinship networks, and indeed the entire social structure, need to be understood to determine where one fits within the framework.
Local protocols exist in most communities and organisations to particularly guide ‘outsider’ behaviour so as not to offend. Such protocols guide visitors about where they may go, with whom they may interact and what kind of information will be shared with them.
In discussions, the Aboriginal Binaŋ Goonj Team members pointed out that quite a number of customs in their communities are changing. They highlighted that, although in the past people would move away from a house in which someone had died, or, indeed, burned the house, today people prefer to die at home:
Our custom is when somebody is dying it’s important for as many of the members of the family to see that person before he or she dies … it doesn’t matter what the hospital rules are …
It’s a form of respect together. It’s not just enough to send flowers and cards …
It’s important that your family is represented, their presence is important.
Or you visit the family before the funeral so that the night before there is a lot of support for that family …
… it’s important for them to die at home, amongst their own people. If they don’t come back to die they want their remains brought back thereafter. People are making these choices now. They want to be there. I think they’ve always wanted to be there at home when they pass on, which is why I think a lot of them don’t really want to go out, you know, when they get sick and they want to send them to Brisbane or away somewhere. They’re frightened they’re goin’ die down there and they’re not goin’ be able to get back.
And there’s a lot of stress related to the person not being buried at home you know, that the spirit will come back or your spirit might not get home.
Activity
Reflect on the above dialogue.
Attitudes and beliefs
Remember, cultures are built on deeply embedded sets of values, norms, assumptions, attitudes and beliefs. It can be surprising and sometimes distressing to discover that people do not share some of our most deeply held ideals. It is dangerous to assume that they are universally held.
Attitudes and values about human life and human behaviour tend to distinguish one cultural group from another (Kluckhohn & Strodtbeck 1961). Since belief systems are not necessarily explicit statements, they are more difficult to isolate and therefore easier to infringe upon. More insidious still, the [health worker] is often unaware of his own attitudes and belief systems prior to entering the field and reacts according to this belief system rather than of the host [community].
This point applies not only to personal but also to professional belief systems, and it is therefore perhaps more critical because health workers frequently advise, or expect, people to change their behaviour ‘to improve their health’. The advice may be well intended but based on very different values and beliefs to those of the individual, family or community and therefore will not be heeded.
We have already discussed some of the issues related to this culture shock stressor in terms of people’s varying attitudes to change. At this stage let us concentrate on the attitude that people ought to change their behaviour ‘to improve their health’. Aboriginal groups have been exposed to this attitude, reinforced by legislation, rules and by-laws, since colonisation.
For example, in the early 1970s, mothers in Cherbourg Aboriginal community could be brought before the local court, presided over by the manager, if they failed to bring their babies and toddlers to the local baby clinic for regular blood counts, iron treatments and immunisation (Dowd 1996; Eckermann 1973). The motivation behind this decree was perfectly justifiable. Cherbourg had recorded an extremely high rate of infant mortality during the 1960s and clinic attendance was considered vital in order to ensure that fewer babies died. Implementation of rescue programs, however, was not based on health education, or consideration of parents as partners in child health improvement, but compulsion.
Similarly, throughout the 1970s, 1980s and 1990s, Aboriginal women in western Queensland were lectured that they should breastfeed their babies (Eckermann 1977; Dowd 1996). Again the motivation was fine, but the implementation neglected to take into account the fact that, for at least a generation, Aboriginal mothers had been encouraged to bottle feed—social conventions had changed and many women considered it ‘shameful’ to breastfeed their babies.
Changes in professional belief systems, then, occur much more rapidly than in the communities, and in the process people will, as Ena Chong maintains, ‘stick with what we were brought up with and still remember with great fondness’.
Another health worker describes how sometimes client attitudes and beliefs made it difficult for her to get them to comply with medication regimes.
… this client, if she wakes up in the morning, she thinks, ‘Oh well, I feel alright, my blood pressure’s alright, my sugar level’s alright’—then she won’t take her tablets … One old lady who has got a urine infection has read somewhere that antibiotics is bad for your body, so she refuses to take them. It’s hard for us, ‘cause the doctor tells us to make them take their tablets … It doesn’t matter how hard we try, if they don’t want to take them, they don’t want to take them … I persuaded her to take them and she had an adverse reaction—she got cold shivers, really severe aches—so now she is convinced and now I don’t stand a chance of convincing her to take another type … Even some things that aren’t related, they’ll say, ‘Oh, that’s the tablets’. They’ve just associated it with the tablets.
Consequently, health workers sometimes encounter, what Genat et al (2006, p 181) describe as, ‘dispirited client responses’ that may be an expression of passive client compliance. Both add particular complexities and challenges to the health worker role. Some are evident in the following encounters.
‘Because I feel good today, I don’t need the tablets any more.’
[The clients] think, because they have taken their tablets today and they feel well, that come tomorrow they don’t have to take it … They need to take their tablets every day. [They think] … ‘go off them’ … not realising the importance of them.
(Rose, Family Care Health Worker, Genat et al 2006, p 34)
‘I’ve talked with her [sic] until I’m blue in the face.’
Teddy’s into Diet Coke and I’m forever saying, ‘You’re not supposed to have Diet Coke!’ ‘But I get high on it … I can get charged up’ … I said, you gotta do this and you gotta do that … I was telling him before, but he wouldn’t listen. I said, ‘Before long, you’re going to have a foot, a thumb, a toes [sic] or a finger or something cut off’, and he wouldn’t listen. I went and seen him yesterday [in hospital, after an amputation].
Such responses are likely to influence health worker/client interactions and impact negatively on health workers’ ability to influence client behaviours.
Recognition of the ways in which the six stressors of culture shock—communication, compliance, attitudes and beliefs, customs, isolation and mechanical differences—influence processes of communication will enable us to be more productive in developing health intervention programs.
The next section considers the effect of culture shock on Aboriginal people who are hospitalised, in order to enhance their social and emotional wellbeing.
Culture shock: hospitalisation
In the 1990s Aboriginal people entered hospital two to five times more frequently than non-Aboriginal people (Australian Medical Association 2002; McLennan & Madden 1997). This pattern has not changed. Indeed, some would argue that it has become worse. The Closing the Gap on Indigenous Disadvantage Report (Commonwealth of Australia 2009) records that in 2006–07, for example, Aboriginal people were hospitalised more than six times as often as non-Aboriginal people for potentially preventable chronic conditions, such as asthma, diabetes, hypertension and heart problems; this was 21.2% higher than the 2004–05 rates. Hospitalisation for Type 2 diabetes among Aboriginal people was more than five times as frequent as among the non-Aboriginal population—while Aboriginal hospitalisation for kidney disease occurred more than eleven times as often as among non-Aboriginal people (see McLennan & Madden 1997; National Aboriginal and Torres Strait Islander Health Strategy 2001; National Aboriginal Health Strategy 1989; National Health and Medical Research Council 2002).
… the Indigenous hospitalisation rate for potentially preventable acute conditions was 2.3 times the rate for non-Indigenous people.
Indigenous people were 45.8 times as likely as non-Indigenous people to be hospitalised for injury and poisoning and other external causes in 2005–2007 in NSW, Victoria, Queensland, WA, SA and public hospitals in the NT …
In addition, the ABS (2008) reports that more than twice as many Aboriginal as non-Aboriginal people sought help from a hospital casualty department. Hospitalisation and its stressors, then, are more likely to be a part of Aboriginal people’s reality than that of other Australians. Aboriginal Health Workers verify that Aboriginal clients are often reluctant to seek care and many remain mistrustful of doctors and hospitals.
See, a lot of family too, they don’t feel comfortable in hospitals, and they don’t understand what the doctor is saying anyway, a lot of them. So they’d prefer that you went, and you could tell the patient what’s going on, and then you can come back to the family and tell them what’s happening … Otherwise the family takes them [to hospital], the family doesn’t say something—y’know what I mean—‘cause they’re scared of the hospital themselves. So they go in there, and they see the doctor, and they agree with everything, and then they come home.
(Ruby, Family Care Health Worker, Genat et al 2006, p 33)
They hate hospitals… you wouldn’t get many of them to a doctor … A lot of people when they’re sick they won’t tell you. A lot of the real old ones, they’d just rather lay down and die … it’s sad … I don’t think they like hospitals … they hate hospitals. You wouldn’t get many of them to a doctor. They have to be dragged there.
(Christine, Family Care Health Worker, Genat et al 2006, p 32)
Brink and Saunders (1976) argue that involuntary hospitalisation may constitute an experience of culture shock for many groups, particularly those unfamiliar with the language, culture, rules and regulations of this institution. They write:
The individual may be faced with no choice regarding hospitalisation in the case of emergency surgery, injury (burns, automobile accidents), strokes, or heart attack. This abrupt transition from a free, productive adult to an immobilised patient in a new setting can be seen as a stressor that requires not only adjustments in lifestyle, but also in self perception.
Figure 5.2 notes six major stressors of culture shock. We have revisited and expanded Brink and Saunders’ factors to include compliance as a major stressor in order to better understand many Aboriginal peoples’ experiences of hospitalisation.
Figure 5.2 The six major stressors of culture shock and their implication for Aboriginal hospitalisation
In Figure 5.2 we have summarised and boxed our analysis of factors characteristic of the six cross-cultural stressors within institutions such as hospitals, and have supplemented these with Aboriginal concerns and reactions, some of which have been mentioned already.
In the cycle of culture shock, which for many Aboriginal clients is marked by fear, isolation, withdrawal, dependency, depression and powerlessness, each stressor for the client is in fact a facilitator for institutional and professional effectiveness.
Thus communication, that is the language and jargon of health, which may exclude the patient and create anxieties based on ignorance, is in fact a convenient shorthand for the profession, leading to greater efficiency and clarity. Nevertheless, when individuals do not share the same knowledge, those ‘in the know’ have power over those who are not and may thereby consciously or unconsciously reinforce the status differential between themselves and their clients.
Similarly, institutional and professional customs designed to efficiently manage and deliver effective health care may reinforce clients’ powerlessness as well as loss of autonomy and identity. If these stressors are coupled with isolation, mechanical differences and unfamiliar attitudes and beliefs, clients are seriously disadvantaged. In the unique environment of a hospital they are confronted by many mechanical differences—corridors and spaces, foreign equipment, strange beds, unfamiliar faces, smells and so on. In Kildea’s study (1999, p 41), for example, several Aboriginal women mentioned a fear of lifts and one woman said it ‘felt unnatural having your baby so far above the ground’. Further, a lack of familiar faces in mainstream settings often increases the women’s experience of isolation. Some related that in hospital, for example:
You often get left in a room by yourself where it is too cold, all white and not at all homely.
They should have someone who can sit with you, a friendly face, and there should be paintings on the wall, T.V. going … make it look like it is not a hospital.
Some service providers are well aware of the stressors of isolation and are equally concerned. However, government departments have been slow to respond and in some situations have introduced punitive measures. For example, women who have been known to frequently ‘abscond’ from hospital back to their community have had their return travel tickets withheld until after confinement (King et al 1998, p 17).
Consider the following case study.
Case study
‘Please take me home’
My youngest daughter is a chronic asthmatic; she has suffered from asthma since she was six weeks old. She inherited this illness from her father. She is the youngest of seven, and was truly loved and spoilt by all.
When she was about five years old she was hospitalised with a severe asthmatic attack. At the time there was a tragic car accident and a young man had committed suicide. It was a very sad time for the whole town.
She got sick about a day before the tragedy. At this time you were not allowed to stay at the hospital with your child. You could visit in the morning and afternoon. I used to visit every day. I could see she was getting very ill, and not getting any better. She had been in hospital about a week. I went up to see her one morning, and she could hardly walk. She said, ‘Mum please take me home. I hate it here, the nurses are very mean and I don’t like them.’ She started to cling and not let me go each time I went. I began to get very worried about her. I made my mind up that I was going to talk to the doctor and ask to take her home. I thought she was fretting more than anything, and that was making her sick. She also knew that there was a big funeral for the people that had died. I could not attend it as it was on when I needed to be at the hospital with her. We were both feeling a bit sick.
The next morning I asked the doctor if I could take her home, because I was so worried abut her not recovering and getting worse from my point of view. The doctor didn’t want her to go, because he was worried about her health as well. I just insisted that she needed to be at home, and she would get better there a lot faster. He said no, and if I wanted to take her home I would have to sign a release consent form. If anything happened after she left, the hospital would not be liable. I said that is fine and signed the form.
I took her home and the next day she was as bright as a button. Got better almost at once.
Activity
Managing illness requires a level of compliance with the treatment and advice provided. The values and attitudes underlying ‘compliance’ are major forces contributing to miscommunication between non-Aboriginal health care providers and Aboriginal clients (see Humphery & Fitz 2000; Humphery & Weeramanthri 1999; Humphery et al 2001). Generally, clients are expected to behave ‘appropriately according to frequently unarticulated parameters set by the health professional’ (Coyne 2006–07, p 154). Compliance assumes that clients ‘should comply with medical advice and that they are somehow “misbehaving” when they do not’ (Humphery et al 2001, p ix). Coyne (2006–07) points out that clients who challenge health professionals or become over involved or too detached and overstep the boundaries of their expected role, are also often deemed to be ‘non-compliant’.
The assumptions underlying ‘compliance’ then rest on the power of the professional and, by implication, the disempowering of the client. Consider the irony in the following RAN’s observations of some health providers’ expectations of Aboriginal clients in a remote cultural context very different to their own.
It’s all very well telling people to keep antibiotics in the fridge but generally they didn’t have a fridge. Same with telling people they had to be evacuated. That’s all very well, but people had families and children and who was going to look after them if mother was evacuated?
If you don’t have a clock, how are you going to give medicines at 8.00 am and 8.00 pm to your child? Wouldn’t it be better to relate it to sunrise and sunset?
If you don’t have soap what is the use of telling you to wash your children and bedding for scabies. You need to find out if they have facilities and if they will do it. Families aren’t going to wash blankets if it is too cold to dry them and they will have nothing for that night. No one likes having showers in cold weather and mothers worry about children catching a cold, so are less likely to do it then.
Children have much greater autonomy to make their own decisions and choices so we need to include them in discussions about their health care and treatment if we want to encourage compliance.
Sometimes it’s just ignorance (on the part of the health professional), not understanding the limited literacy levels people have in English and their difficulty in translating foreign concepts from English into their first language.
Schott and Henley (2003) suggest that health professionals may feel less job satisfaction and powerless, when they are unable to use their skills due to language barriers. In such a situation, the non-verbal cues sensed by the client, especially if the health professional is (or appears to be) ‘busy’ and/or ‘pushed for time’, are likely to be negative. The client is likely to either passively comply with immediate requests, or resist care by not accepting treatment or ignoring advice. In either case, both the practitioner and the client are likely to conclude the engagement feeling disempowered and unable to achieve (Bain 2006). Similarly, Oudshoorn et al (2006) found that in their relationships with health professionals, clients often expressed power through either passiveness or resistance. Without a positive channel of communication, much of the interaction between health professionals and Aboriginal clients falls into one of these categories, and results in accusations of non-compliance.
Coyne (2006–07) asserts that many nurses would openly admit to classifying families into two groups, ‘the good family’ and ‘the problem family’. Generally the ‘good family’ is the one that behaves appropriately according to the health professional’s expectations. Conversely ‘the problem family’ is the one that fails to conform to social norms and desired behaviours. All too often Aboriginal families are labelled as ‘difficult’ or ‘problematic’ because of perceived ‘non-compliance’. However, such labelling is based on ‘deficit’ thinking, preconceived ideas and biased attitudes. It also encourages clients to circumvent ‘the system’ in order to keep some control over their lives.
Case study
Compliance or control
A young unmarried woman from a neighbouring community, which did not have a resident RAN, came to see our visiting doctor for preconception advice. As she didn’t live in the community I forgot about her until about three months later when she turned up pregnant and the local women said she was going to stay in the community. Her medical history was complicated; she had been a fetal alcohol baby, born with massive facial deformities, which had required surgery as a child. She had cardiac and respiratory complications and was a very small person. Socially she was at the bottom of the pecking order. I wondered if this pregnancy was an attempt to change her social status. She stayed in the community for her pregnancy, visiting myself, as midwife, for antenatal care, compliant with all recommendations for scans, cardiac echoes and visits to obstetricians in Alice Springs. She was booked to go to Alice Springs for ‘sit down’ two weeks prior to her estimated date for birth. We had no night airstrip in the community and night evacuations required an acute hospital. One night she came to the clinic in established labour. It was not safe to go driving off for a night evacuation. A healthy baby girl was born in the early hours of the morning followed by a post partum haemorrhage (PPH) that could only be contained with constant massage and a Syntocinon drip. On discussion she revealed that she had been in labour all day, but had wanted her baby born in the community so did not present until it was too late for evacuation. She had planned her pregnancy and birth how she wanted it and had a positive outcome. She still needed evacuation due to her PPH but she maintained control over her pregnancy and birth.
It is undoubtedly true that hospitalisation, trauma and fear of the unknown are potential stressors for all patients. Brink and Saunders (1976) suggest that even health care workers, those ‘in the know’, experience significant stress related to the role change and dependency when hospitalised.
For Aboriginal people this cycle of stress is compounded by the legacies of segregation, regimentation, institutional racism and systemic bias—in fact, the legacies of colonisation and over 200 years of frequently unsatisfactory interaction with the majority. Unfortunately these legacies, which influence Aboriginal people’s actual and/or potential recovery, are frequently unrecognised, considered ‘unimportant’ or believed to be exaggerated examples of Aboriginal sensitivity. Actual and/or perceived negative behaviour and attitudes are sometimes linked to general racism, prejudice and discrimination rather than perceived professional neglect.
Aboriginal people related some of these experiences:
They make small remarks but to us they mean a lot. They’re putting us down, they make it obvious they don’t want us to use the service. It’s racism.
We’d lived here all our lives. We know a lot of them well—but nothing. My daughter rang me, she wanted the doctor to see her baby. ‘Cos we were worried about her. You expect someone to answer and be kind—you don’t want someone abrupt saying ‘Bring it over!’ She’s not an ‘it’—we don’t want to be regarded in that way.
Doctors don’t talk to them about things like Hep B screening. They’re never told what their path[ology] results are. They don’t sit down and talk to them. They’re quick to rush them in and rush them out.
This nurse had the cheek to ask ‘What’s wrong with you, high blood pressure or something you drank?’ They think you only turn up when you’re drunk.
The past has certainly left a residue of suspicion that can influence interactions. Aboriginal women, for example, comment about the local outpatients department:
At the time you’re waiting and you’ve made an appointment but you see white people coming in. We don’t want pity—we just want our rights.
The ignorance between groups, whether in relation to the past or anything of importance to either group, gives rise to ‘pressure points’ in communication, which lead to frustration and conflict, and reinforce limited or negative patterns of interactions. Although today there is no excuse for mainstream health professionals not to be aware of the realities of the past and their continued impact on Aboriginal people, discrepancies, ignorance and racism still exist (see King et al 1998; Trudgen 2000; Cunningham 2002; Humphery et al 2001; Goold & Liddle 2005; Genat et al 2006). Social determinants and distance between minority and majority contribute to this situation, particularly as there continues to be an under-representation of Indigenous people in our mainstream systems.
Let’s get one thing straight: we are not accusing any health professionals of being consciously racist. We have met some, however, who have negative attitudes towards Aboriginal people. These negative attitudes are often compounded by the negative circumstances in which health staff and minority members meet.
During hundreds of Binaŋ Goonj workshops over the past 15 years, non-Aboriginal health professionals have made us aware of their frustrations when Aboriginal clients don’t heed their advice or comply with recommended treatment. Their sympathy frequently evaporated when they were called to see the same child for the same complaint over and over again and the mother didn’t seem to do anything. Some Aboriginal colleagues also at times reached a point of exasperation where, as one related in Genat et al (2006, p 30), ‘You feel, what’s the point’.
Further, Aboriginal and non-Aboriginal health care providers, have had to deal with quite horrific situations of client abuse. Genat et al (2006) report that in one urban environment where health workers go into people’s homes:
Incidents of alcohol-related violence, physical, financial and emotional abuse of clients discourage and frighten [Aboriginal] health workers. They have few professional guidelines and little organisational support.
Those who have an opportunity to work in partnership with Aboriginal people have begun to critique their professional practice. Sue Kildea (1999), an RAN and midwife, for example, coordinated and facilitated an extensive review of birthing services for Aboriginal women from remote Top End communities. Prior to this project, Aboriginal women in the Top End had had no input into the development of birthing policy, practices or protocols.
The Protocols state that all pregnant women are to be encouraged to deliver their babies in the hospital. Women are transferred to town at 38 weeks gestation, or earlier if their expected date of birth is uncertain, or if there are complications necessitating hospitalisation. If a woman is reluctant to have her baby in hospital, the Protocols recommend she be reviewed by the doctor for any complicating factors and fully informed about the possible risk of birthing in the remote setting. The Protocols suggest that if women choose not to travel to the regional centre for the birth, then they should be attended by a skilled and experienced midwife. Unfortunately not all community centres have skilled and experienced midwives available, in fact some do not have midwives at all.
Obviously, when there are no local midwives, women have to continue to leave their communities despite their desire to have their babies at home. They are caught in the dilemma of ‘The Policy Is’. Consider the following case study. Note that this situation is not confined to remote Australia. In 2005, in order to rationalise services, many country hospitals throughout Australia stopped employing midwives, while in other rural areas those nurses who were qualified midwives did not birth enough babies to retain currency of practice. As a consequence, ‘a Nyngan teenager gave birth in the car park of the Nevertire pub. The 17-year-old was being driven to Dubbo to give birth at the maternity ward’ (ABC Central West News, 3 May 2005 11:20 AEST).
Case study
The policy is…
In 1987, a 28-year-old woman, and her five children, sisters, nephews and nieces, came to one of the remote Aboriginal communities in northern Australia from a coastal town.
In the community she remarried and became pregnant with her sixth child. She saw the midwife and visiting doctor several times during the pregnancy, and, although she was not regular with her antenatal care, she received more than during previous pregnancies—there was complete compliance with her iron treatment and her weight gains were normal and regular.
About halfway into the pregnancy she informed health staff that she had decided she wanted one of the sisters to deliver her baby in the community because she did not want to leave her other children or her husband.
One visiting doctor told her that it would be impossible—a relieving doctor told her it would be okay. The flying doctor, however, informed her and the nursing staff that it would be absolutely unacceptable for her to have the baby in the community because, although the hospital was staffed by two trained midwives, there was no emergency equipment and a sixth birth presented a far greater risk to baby and mother than previous pregnancies. A number of confrontations occurred between mother and doctor and the situation remained unresolved.
Health staff at the hospital spent a good deal of time counselling the mother, who remained firm in her decision—she maintained that she understood and accepted the risks and that she still wanted to have the child in the community.
She was expecting opposition from the doctor because he had scared her sister into having her sixth baby away from the community by telling her it was a breach birth, which proved not to be the case.
The doctor argued equally strongly that she would have to leave the community at thirty-six weeks because, as no safe facilities were available, he would be accused of negligence should any problems arise. ‘And the policy is that all women go out at that time.’
Another confrontation arose between mother and doctor in the thirty-fifth week. The doctor finally persuaded her to compromise and be evacuated to the coastal town from which she had moved in 1987. A week after the evacuation she sent word to the community that, unless the baby came in the next few days, she would come home—‘no matter what they said’.
This situation clearly divided health care worker and patient. It also divided health care workers amongst themselves. As one nurse explained:
‘I believe that if the mother has the risks explained, talks to the doctor, talks to her family, is fully aware of what she is doing and the possible consequences, then she should make up her own mind about where she has her baby. The doctor reckons that that is “professionally unsound” and that we “might as well tell them to have their babies under a tree”. The mothers are really badgered, from every medical/nursing staff that visits the community, about the problems of having babies here. They should be told clearly and nicely, but then left to make their own decisions. Any pregnant woman is vulnerable and can be easily badgered and intimidated …’
Activity
Reflect on the case study and the following opposing points of view identified by Kildea (1999, p 53).
Is it ethical to allow women who have the worst morbidity and mortality in Australia to choose to deliver their babies in a bush setting that may be several hours from specialist help and intervention?
Is it ethical to refuse women the choice when we cannot say with absolute certainty that their outcomes will be better in a hospital environment?
Today, many Aboriginal women still manipulate the system in order to have their babies in their communities. As one Remote Area Nurse explains:
What about the babies born in the community, mothers coming for all the antenatal checks I requested, just not presenting in labour until it was too dark to call a plane, (no night strip) because they wanted their babies born in the community. They gave me a few anxious moments whilst they were happening, but thankfully we had positive outcomes and I still think the births were much better than the hospital ones. Family could be present and mother and baby could go home after 24 hours in the clinic with a daily check-up. Mothers were much more relaxed and my Aboriginal Health Worker much more involved.
Although culture shock, at some level, is probably inevitable, there are ways in which it can be managed.
Managing culture shock
How well we manage culture shock will depend on a range of factors such as our personality, our motivation for being where we are, how we got there, who invited us to be there, as well as how long we are staying. Sometimes factors beyond our control, including past experiences with visitors or ‘outsiders’, affect people’s attitudes and how receptive and supportive the community might be. Similarly, how clients manage culture shock will depend on their personality, resilience, past experiences, and support mechanisms.
There are numerous ‘survival skills’ guides and checklists available to help people cope with culture shock. Interestingly, many of these have been written by ‘outsiders’ with the intention of helping newcomers and visitors bridge any ‘culture gaps’ as well as alerting them to some of the ‘culture bumps’ and how to respond appropriately.
Hopefully, you have run out of paper listing the dangers of an outsider (in isolation from local people) orientating a newcomer to your culture. That is not to suggest that someone who has adjusted, is accepted and respected in your community cannot be invited to contribute their experience and understanding to guide and support others coming into the community. That, clearly, is something that needs to be negotiated by those involved.
We believe there is a shared responsibility to help each other combat and effectively manage culture shock. Prior to entering a new culture it is important to be grounded in our own identity and to have a strong support system. A good support system in the community will also help to ease culture shock. On arrival in an unfamiliar environment, regardless of the preparation or pre-departure (regional) orientation, there is really no substitute for local orientation.
Remember our earlier discussions about culture and the points we have reiterated throughout about reflecting on and better understanding our own culture. That, we believe, is the starting point and the key to successfully managing culture shock.
Cultural adaptation hinges on trust which, we reiterate, takes time to develop. Our earlier discussion highlighted that trust is something that enables us to build relationships. Equally important is to base new relationships on empathy.
Empathy
Empathy and sympathy are closely related, and one cannot be considered without the other because their meaning and usage in most cultures overlap (Introduction to American Multicultural Literature 2004).
Sympathy basically means sharing other people’s feelings (not necessarily their experiences and thoughts). It implies caring and showing concern, and supporting that person. Empathy, on the other hand, is often portrayed as ‘walking a mile in another person’s shoes’. It means that we can’t really understand someone else’s experience unless we place ourselves in their situation. It suggests that we can ‘feel with someone’, or, as Ena Chong says, have ‘your pain in my heart’, even though the experience is not our own. Bellous (2000) points out that this involves a deeper involvement and connection to the person. She clarifies that:
Questions about empathy hinge on whether and to what extent we can enter into or come alongside other people’s experience in a way that they would recognise [and acknowledge as accurate].
The plea for empathy is clearly reflected in Tania Con-Goo’s poem.
It takes time to develop empathy. Unfortunately, too many health care providers are unable to spend the time in Aboriginal communities/organisations. This makes it difficult, as Roy Gray explains:
It seems to me that the past and current system of employing doctors to work in Aboriginal Communities on a short-term basis is a problem for both doctors and Aboriginal patients. It takes time for trust to develop between people, and the reality is, that most doctors just don’t stay long enough for the trust to develop.
Professional socialisation and education often reinforce the notion of being non-judgemental, when in reality the best we can probably do is ‘suspend judgement’ until we are better informed and/or our opinion is invited.
Suspending judgement
Our images, stereotypes and preconceptions of ‘the other’ culture are perhaps the greatest hurdles to successfully managing culture shock. We rarely question the images—they become mindsets that influence behaviour.
When we step into a new cultural environment, our ‘security rug’ for learning is the one we carry with us. It is our culture and we are not discarding it. Roy Gray likens the experience to:
testing your ability to be yourself and not somebody else. The key is to be yourself at all times and don’t try to imitate to ‘fit in’. You should be who you are, be true to yourself.
We may, however, experience a clash in our core values—something may not be acceptable to us. We need to acknowledge that that is the case and basically, although it might be difficult (depending on the consequences), accept the clash—we need to suspend judgement until we understand or at least respect how parts of a culture fit together into a coherent whole. It is important, particularly as health professionals, to try to see what people say or do in the context of their own culture’s norms. This will help us understand how individuals, families and communities view our behaviour and intentions, as well as how to understand theirs, especially in stressful situations.
Young Yun Kim (Yan 2004, p 1) believes that such stressful situations are necessary (indispensable) to a successful adaptation. It ‘propels one to learn new things in order to adapt’.
Andriessen (2002) suggests that when you encounter an unfamiliar situation or event that bothers you, you have to assess it and search for an appropriate response. Try the following:
Remember, you are not alone. You are a guest in another country and there are reciprocal rights and obligations in place to support you and to foster harmony and meaningful relationships. Lynette Nixon suggests that, as a guest:
Just don’t push anything … take it as it comes, see what’s appropriate for each place, depends on the situations as well and what’s goin’ on at the time … just step back, look and listen.
It takes a good deal of tolerance of ambiguity to step back, look and listen.
Tolerance of ambiguity
Tolerance, within the context of our discussion, means the willingness to recognise and respect the beliefs and/or practices of others. The word ‘ambiguity’ implies that something is unclear because it has more than one meaning, which is often the case in cross-cultural communication. One of the challenges of communicating across differences is to discover the different meanings. The implications of the concept of ‘tolerance of ambiguity’ in cross-cultural situations can be very demanding, particularly if there are differences in core values that lead to conflict. Kathy Abbott, one of the longest-serving Aboriginal Health Workers in the Northern Territory, advocates that communication between Aboriginal and non-Aboriginal people depends on a great deal of perseverance and patience (K. Abbott, pers. comm. 1995). She explained that much reassurance is needed, as Aboriginal people are often afraid of the unknown, and that this uncertainty may lead them to avoid situations in which they could be helped (pers. comm. 1995).
Figure 5.3 records some varying interpretations of ‘tolerance’, which are linked to particular attitudes, behaviours and consequences.
Activity
Review Figure 5.3.
Often the generalisations and assumptions about ‘the other’—that is, people from the other culture—prove to be wrong. Generalisations are, however, in the first instance, part of the process of learning to understand another culture. We all tend to hold particular ‘mindsets’ about ‘others’, but if we are open to change, as we get to know people such generalisations will be challenged and, in the process, we will learn more about ourselves. In contrast, lack of awareness, preconceptions and misinformation about people from a different cultural background, as well as unwillingness to learn more about ourselves, form the foundations of cross-cultural conflicts. They can trigger a vicious cycle of prejudice and group friction (see Figure 5.4).
The evidence suggests that the likelihood of the serious consequences depicted in Figure 5.4 increases as power, and social and cultural distance increase between groups (Ward et al 2001).
Related to empathy, successful suspension of judgement and tolerance of ambiguity is conflict resolution.
Resolving conflict
Dealing with embarrassing situations, ‘face-saving’ strategies or how people handle disagreements, varies across and within cultures. This can be a major source of difficulty in intercultural communication. Cross-cultural differences and the rules and conventions that govern conflict resolution between Aboriginal and non-Aboriginal people may not become apparent until there is conflict. This is probably the least likely time for learning what appropriate behaviour is. Sometimes outsiders may be totally unaware that they have in some way contributed to conflict.
In cross-cultural situations conflict may or may not be explained, and it helps to realise that it is not always necessary to give, or appropriate to receive, a reason for something happening or not happening. It is important, however, to be aware of our own communication styles so we can at least recognise differences and learn how to respond appropriately when we are a guest in someone else’s community. Ena Chong advises that it is best ‘to show a respectful, waiting attitude, withhold judgement, and maintain appropriate boundaries’.
One of our friends who is no longer with us, an Aboriginal Elder from Cape York, offered the following reassurance:
A lot of times the nurses out there are left alone, or feel that they are alone, but it’s good that they understand that there are people, Aboriginal people, in the community who can help them.
Activity
Reflect on the following potential conflict situation in an Aboriginal Community-Controlled Medical Service and how the HR person resolved it.
An Aboriginal staff member, Helen, who was having difficulty with another staff member, Joy, who happened to be non-Aboriginal, approached me requesting advice. She explained that Joy seemed to be busy completing her work as well as the other duties set down for Helen.
I looked into this and I discovered that Joy was a person who went about her tasks with vigour and when she had a moment to spare, rather than do nothing, she picked up other duties to continue working because as she put it ‘they had to be done anyway’.
I reminded her that each of the duties that she had been given were to be performed daily. When she ‘took over’ Helen’s duties, she made Helen feel incompetent and unable to perform properly. I also noticed that Joy worked at a faster pace than Helen but I let them know that each should have respect for the other’s ‘place’ in this arrangement.
Culture shock is significantly reduced for health care providers as well as Aboriginal clients if health professionals form partnerships with Aboriginal colleagues.
Working in partnership
The presence of competent Aboriginal Health Workers (AHW) (including doctors and nurses), liaison officers and interpreters in hospitals, we believe, lessens the likelihood of culturally dangerous situations occurring. They often are able to negotiate some of the ‘cultural bumps’ that arise when Aboriginal clients find themselves in an unfamiliar hospital setting. At times they also quietly intervene on behalf of non-Aboriginal health professionals, who sometimes do not recognise how vital their role is to their own cultural safety. Our friend, an experienced AHW who is no longer with us, believed that positive outcomes for Aboriginal clients in health care could only be achieved by working in partnership.
What we are hoping for in the partnership is that us who are HWs are recognised for our role … it’s a bit of two-way learning, we get skills off the nurses and doctors and they get local knowledge off us. It’s a two-way teaching thing. It’s about working together in partnership.
It does take a lot of trust, something that you really need to work on, not just trust but that respect has to be there from the start, you know, you respect my views and I respect yours, and it just builds up from there, where you just get into exchanging skills and recognising what areas you are better at …
Working in partnership in this way with AHW in communities or hospitals increases the chances of successful cross-cultural relationships and culturally safe outcomes for the client as well as for the health care provider.
The AHWs in this situation fulfilled a unique role in enhancing the cultural safety of their clients, and in the process alleviated many of the cultural stressors we have discussed in relation to hospitalisation. Aboriginal health professionals are, as one medical student quickly discovered, equally important in community health. She commented:
I have to respect, and honour the rules of the people who live here, and because of that, I can’t just bowl in and start talking to whoever I want. There needs to be like a go-between, a bridge person. And I think that’s great that we’re working with [Aboriginal nurses and HWs] because they’re the bridge.
Activity
Reflect on our discussions to date and particularly your own experiences of culture shock. What have you learned that you didn’t know before?
In some ways culture shock reflects how we respond to cultural differences—we can ignore them and hope they will go away, fail to recognise them and risk the consequences, or we can learn to respond appropriately, appreciate differences and experience the benefits. Managing culture shock successfully requires a conscious effort to at least respect, if not understand, that there are different yet still legitimate ways of doing things, which may not be part of our reality. Culture shock, at whatever level it is experienced, is not only inevitable but, if managed appropriately, can be a catalyst for effective learning, personal growth and adaptation in a new cultural environment as well as our own.
Activity
Tip: You may find it useful to revisit Table 5.2 to prompt your thoughts on local communication and cultural differences.