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  1. 1. Home Health Care Management & Practice Communication in Health Care: Improving Understanding Between Provider and Patient Yu Xu Home Health Care Management Practice 2006 18: 158 DOI: 10.1177/1084822305281830 The online version of this article can be found at: Published by: Additional services and information for Home Health Care Management & Practice can be found at: Email Alerts: Subscriptions: Reprints: Permissions: Downloaded from at UNIVERSITY LIBRARY on February 12, 2011
  2. 2. HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2006Diversity DiscussionIntercultural Communication in HealthCare: Improving Understanding BetweenProvider and PatientYu Xu, PhD, RN, CTNR ecently, I learned the shocking news that one of tem. I heard anxiety and frustration as well as a plea for our family friends for years (to whom we feel understanding in our lengthy conversations. As a certi- closer than some distant relatives) in the Deep fied transcultural nurse, I made conscious efforts to dis-South was diagnosed with colon cancer. It was shock- sect their experiences in the context of the Chinese anding because she was in seemingly perfect health with U.S. health care cultures to shed light on why a particu-no previous history of any major conditions or hospital- lar incident or experience happened. I feel that the leastizations. Well educated, she lives with her husband, I can do to help them cope with the daunting reality iswho is a tenured full professor at a local university. The improve their understanding of those situations anddiagnosis of cancer is the greatest challenge in their 20- nuances. The following is based on the couple’s experi-plus years of married life. As typical Chinese, the cou- ences that have relevance to those on both sides of theple is very considerate and sensitive, especially the stethoscope.wife. With plenty of spare time as empty nesters and As any other cancer patient and caregiver, both thebeing very health conscious, the couple played table wife and husband went through the stages of denial,tennis at least three times a week for 2 hours each time anger, and acceptance of the diagnosis. For the initialto keep healthy. In my mind, she would be the last per- few months after the diagnosis, the husband exhaustedson on earth to get cancer. With this devastating diag- all sources of information on colon cancer and hasnosis, their peaceful, laid-back life was turned com- become an expert on the condition. Apart from teach-pletely upside down. Until the cancer diagnosis hit ing, he literally withdrew from all other activities andthem, neither of them had real, in-depth experience and planned everything around the treatment of and care forknowledge of the U.S. health care system beyond his wife. For months, he could not help but dwell on hisimmunization and routine physical checks, in spite of wife’s condition. Within a 3-month period, he lost 10the fact that they have lived in the United States since pounds.the mid-1980s. As a close family friend and a nurse, I was keenlyinterested in their not-all-positive experiences as a can- Key Words: communication; cancer; husband; wife;cer patient and a caregiver in the U.S. health care sys- oncologistAuthor’s Note: Address correspondence to Dr. Yu Xu, School of Nursing, University of Nevada at Las Vegas, 4505 Maryland Parkway, LasVegas, NV 89154-3018; phone: (702) 895-3175; e-mail: Health Care Management & Practice / February 2006 / Volume 18, Number 2, 158-160DOI: 10.1177/1084822305281830©2006 Sage Publications 158 Downloaded from at UNIVERSITY LIBRARY on February 12, 2011
  3. 3. Xu / DIVERSITY DISCUSSION 159EXPERIENCE AND PERCEPTION tion channel that leads to an effective provider-patient relationship. Each time during their initial visits both husband and Regarding the husband speaking on behalf of thewife had a lot of questions to ask the oncologist regard- wife, it is customary in the Chinese culture or even parting the labs, treatment, side effects of medication and of the cultural programming (i.e., cultural inertia pro-chemotherapy, prognosis, and so forth. As time passed, grammed into one’s psyche based on one’s socializa-the couple continued to ask a host of questions during tion within a given culture that functions largely uncon-each follow-up visit. Additionally, the husband opted sciously) for the husband to reply to questions directedto answer many of the questions posed to the patient at the wife. Partly, this could be attributed to the hierar-(the wife) during the initial visits. However, they chical family structure not uncommon in the Chinesesensed something abnormal about their behavior when culture. In this case, the husband was more educatedthe doctor suggested that both should seek help from a and might have assumed that he could communicatepsychiatrist to manage their anxiety and stress levels. In more effectively and efficiently, even when the wifeaddition, the physician indicated that the patient was could speak fluent English.the one who should answer the questions, not anyone However, from the etic (outsider) or professionalelse. perspective, the persistent questioning could be per- ceived as an obsession and therefore necessitated psy-EXPLANATION AND INTERPRETATION chiatric help, especially when the associated anxiety and stress interfered with the normal functioning of From the emic (insider) perspective, it was only nat- daily life. Additionally, such unrelenting questioningural and understandable for the patient and caregiver to could be viewed as challenging authority, thereby lead-ask a lot of questions, because they wanted to know all ing to mistrust between the patient and doctor.there is to know about the condition and treatmentoptions. Naturally, the oncologist is the ultimate sourcefor such information, despite of a wealth of information IMPLICATIONS FOR PRACTICEon the Internet. For many patients and family members, What can we learn from this real-life scenario? First,one of the primary reasons to get professional medical there are different perceptions, attributions, and reason-help is to seek assurance. This is particularly true in the ing regarding the same phenomenon—the emic versuscontext that there is a cultural fear of cancer among the etic perspective. Differences in cultural background,Chinese, because it is frequently associated with a ter- personal experiences are among major determinantsminal condition without a cure or even with a death ver- that account for these differences. The relationshipdict. In addition, high-profile medical accidents and between the Chinese couple and their Americaninjuries in the media in recent years heightened the cou- oncologist turned sore because of the gap in mutualple’s vigilance and, based on information available to understanding. At the cultural level, the couple doesthem, even raised skepticism regarding what they feel some disconnection with their oncologist.observed in clinical settings. Nowadays, it is not Although the couple has not changed their health careuncommon to find that patients and their families are provider (oncologist), such an option is at the back ofmuch more informed about a specific condition than their mind. Second, it is wrong to assume that a higherthe nurse and even the doctor. educational level and longer residency in this country To a large extent, the couple was stunned on hearing would automatically translate into more knowledge ofthe oncologist’s suggestion, which was perceived not the U.S. health care system and its underpinning val-only as incorrect but also as inappropriate and even ues, beliefs, and assumptions. Third, the effect of cul-insulting. They just wanted to know everything there is tural programming needs to be fully recognized andto know about the condition. However, their response warrants serious research. Its significance is that itto the recommendation was anything but the physi- guides and controls behaviors at the unconscious orcian’s expectation. The oncologist’s suggestion basi- subconscious level. Fourth, stepping into others’ shoescally silenced the couple or at least made them think helps facilitate understanding of a different or eventwice before asking another question. This chilling conflicting position, hence improving communicationeffect could act as a barrier to a two-way communica- effectiveness. Downloaded from at UNIVERSITY LIBRARY on February 12, 2011
  4. 4. 160 HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2006 Understanding between people is challenging, and On a positive note, the husband got to know theeven more so between people from different cultures. rationales of why health care providers in this countryHowever, such a challenge should not be the reason for insist that patients speak for themselves if at all possi-stopping learning about others to promote mutual ble. He learned to consciously suppress his urge tounderstanding; rather, it should be the motivation. I speak for his wife during late appointments.believe that the oncologist would have made an alterna-tive recommendation or at least thought twice before Yu Xu, PhD, RN, CTN, is a tenured associate professor at the Uni-making the suggestion if he had treated the couple not versity of Nevada at Las Vegas School of Nursing and an adjunctonly as stressed clients but also as cultural beings. On professor at Bengbu Medical College, China. He is a certifiedthe other hand, the couple would have behaved differ- transcultural nurse, and his research interests can be broadly cate- gorized into transcultural/international nursing and comparativeently if they had a real understanding of the values, nursing education. Specifically, he is interested in studying issuesbeliefs, and assumptions undergirding U.S. health care related to internationally educated nurses in the U.S. nursepractices. Although these incidents happened between workforce. He has made nearly 70 professional presentations at thea Chinese couple and their American oncologist, their local, regional, national, and international levels. He has publisheduniversal implications can apparently extend to 22 full-length scholarly articles in peer-reviewed nursing journals since 1999 and has consulted, both nationally and internationally,intercultural communication between other health care on retention of second-language/international nursing students,providers and their clients. nursing education curriculum, and international nurse training. Downloaded from at UNIVERSITY LIBRARY on February 12, 2011