Intercultural Encounters in Danish Hospitals – Lived Experience of Diversity (DK)
Written by Margit Helle Thomsen
Text reference: “Patienter med minoritetsetnisk baggrund i det danske sundhedsvæsen – En fænomenologisk undersøgelse af sygeplejerskers oplevelse af mødet med minoritetsetniske patienter på en dansk hospitalsafdeling” (“Patients with minority-ethnic background in the Danish health services – a phenomenological study of nurses’ experience of the encounter with minority-ethnic patients in a Danish hospital ward”) by Nielsen, Ben Farid Røjgård, 2007, thesis, pp 93.
This study was conducted in clinical collaboration with nurses in a Danish hospital within the Capital area. The goal was to investigate how nurses communicate with patients of ethnic origins other than Danish. Based on a phenomenological approach and analysis, the study crystallized three phenomena of particular importance for nurses’ perception of and relation to patients with an ethnic minority background: the specific framework for communication, the different attitudes towards illness and the different cultural and social behaviours. Based on these three phenomena, the study focused on the challenges associated with the use of interpreters and the use of the term “ethnic pain”. This concept reflected the widespread perception among the nurses that ethnic minority patients exaggerate their pain. Finally, the phenomenological analysis pointed to the impact of phenomena such as food, the involvement of family and friends in healthcare services etc.
Aim and objectives
The overall aim of the study was to uncover and analyse the intercultural encounters between Danish nurses at Danish hospitals and a growing number of patients and relatives of other ethnic-cultural origins than Danish. Thus, the objective has been to identify the changing competence needs, the changing service requirements arising out of this intercultural encounter between healthcare professionals and new groups of patients in the Danish health system. What new qualification needs should be met for the nurses to maintain the quality of service of nursing and care, as generally offered to patients and relatives of Danish origins? What situations in particular require new and different skills in order to meet the ethnic-cultural diversity among patients, their families and relatives?
In relation to these objectives, the study focused on nurses’ own experience from the assumption that the lived experience would be the strongest driving force, if the nurses were to adapt their practice to the patients’ diverse needs, their well-being and recovery.
A professional as well as a personal approach
From this approach, the study first and foremost concerned the nurses’ professional awareness. At the same time, it revealed the importance of subjective and personal experience as well. The questions to which the study sought an answer are the following.
- Which phenomena and challenges do nurses experience in the intercultural encounters?
- How do these phenomena influence the quality of nursing and care offered to these patients?
- How do the nurses respond to the differences as compared to the contact with Danish patients?
- How do the intercultural encounters affect the nurses’ professionalism?
Data sources – a field study
With these objectives, the researcher has chosen a qualitative approach, supplemented by desk studies. Thus, the study was based on qualitative research interviews supplemented by observations among the nurses in the study, all of them working in a hospital ward with at least 5 years of practical experience. The researcher used open, semi-structured interviews in order to ensure that the informants had the opportunity to talk freely and spontaneously from their individual perspectives, following their own ways of thinking, associations and experience patterns. All interviews were transcribed, thematically organised and coded.
The qualitative research interviews were combined with participant observation of the nurses’ daily working situations in a Danish hospital ward. By using the observation method, the researcher increased and qualified the insight into and the understanding of the daily context that the nurses referred to in the interviews. Furthermore, the observations were a suitable method for observing the verbal as well as the non-verbal and bodily interaction and communication between the nurses and ethnic minority patients and relatives.
The study was located in the Capital area, justified by the fact that the share of ethnic minority citizens was particularly high in this area – and hence the probability that the nurses would experience intercultural encounters on a regular basis is high.
Terminology, concepts and theoretical-methodical approach
As the overall scientific theoretical approach – in harmony with the phenomenological research tradition – was to capture and describe the lived experience of the informants. Thus, the researcher mainly used the phenomenological description method that goes back to the German philosopher Edmund Husserl.
In addition, the researcher relied on considerations from the Norwegian philosopher – and educated nurse – Kari Martinsen. In her research, she argued that good practice in professional care and nursing should unite a relational, a practical and a moral dimension.
Furthermore, the researcher involved theoretical considerations by the Danish anthropologist Bodil Selmer to discuss the cultural attitudes underlying the institutional understanding of professional nursing in the Danish health system.
Concepts to describe patients of other ethnic origins
The researcher reflected on the very concept of ethnic minority background/origins. With reference to the Danish anthropologist Kirsten Hastrup, he claims that the concept of ethnicity arises only when it becomes politically and socially relevant in a society to make a clear distinction between the majority population and minority groups. Thus, the concept of ethnicity is seen as a relational and situational concept rather than a concept for certain traits of the individual person. Citizens of different ethnic origins are constituted as different from ethnic Danes, and the difference is given importance and significance solely by virtue of the distinction. Thus, the ethnic minority patients were involuntarily seen as others and different.
The nurses pointed to three phenomena which were generally considered to be characteristic for the intercultural encounters with patients from ethnic minorities:
- Different concept of illness
- Different cultural and social behaviour on the ward
First phenomenon: the communication
The nurses emphasised the lack, or inadequacy of the Danish language among ethnic minority patients as a phenomenon that substantially affected the intercultural encounters. Linguistic skills played a fundamental role in communication in general and in particular in the nurses’ ability to perform their professional communication about the patients´ situation and treatment procedures. Communication was considered a basic part of the nursing and care functions:
“As the first thing, I always think if they can understand me, i.e. the language issue. It’s something I initially find out – are they able to understand Danish… and do they understand what I’m saying … ” (Interview, quoted from the study)
Passive versus active communication
The nurses found the ethnic minority patients to be generally passive in communication. For example, the patients rarely indicated that they didn’t understand the information given about their disease. They pretended to understand, and then later turned out to be confused about the treatment etc. In addition, several nurses claimed that the ethnic minority patients – unlike many Danish patients – did not themselves look for information about their own disease, for instance on the Internet. The nurses interpreted this as reluctance to “take responsibility for their own illness“.
To use or not to use interpretation – that’s the question
At the time of the study, there were certain official guidelines for interpretation in all hospitals in the Capital area. However, several nurses actually tried to limit the use of interpretation. Sometimes, the nurses used family members to interpret. But generally, the use of interpreters would depend on the nature and severity of the disease in the individual case. Questions related to death, severe illness and also intimate issues would generally require external interpretation and should not be interpreted by family or close relatives. In general, the nurses would prefer using the same interpretation agency in order to build a mutual understanding and a common professional platform for interpretation.
Conclusion phenomenon 1
From the nurses´ experience, the greatest challenge in the intercultural encounters would be linguistic barriers and interpretation needs, pulling resources from the basic nursing and care. Basically, language barriers would upset the balance between pure information and dialogical communication about patients’ well-being, pain, emotional distress, care and nursing needs. The more difficult it was to communicate verbally with ethnic minority patients, the greater the emphasis is on practical and formal information. From the nurses´ perspective, this would often impair the basic care and, consequently, delay the recovery process. However, the emphasis on language challenges would in some cases be coloured by more private attitudes, when nurses would be critical to ethnic minorities’ lack of ability or interest to learn Danish.
Second phenomenon: different concept of illness
“Ethnic pain” – many nurses shared the perception that ethnic minority patients generally articulated pain much stronger than Danish patients:
“I also think that more often than Danish patients, they (ethnic minorities, red.) claim to have more pain. We talk about it from time to time – and call it ethnic pain … “
(Interview, quoted from the study).
The nurses generally noticed an ethno-cultural difference in terms of feeling pain and expressing pain, when comparing ethnic minority patients and Danish patients. From the nurses´ point of view, the Danish patients were much more likely to swallow their pain and be discreet about feeling pain.
Bodily knowledge and awareness
As another general observation, ethnic minority patients often seemed to be more ignorant about the body’s anatomy and physiology than Danish patients. A few nurses even interpreted the lack of body awareness as a result of inadequate schooling in the patients´ countries of origin.
In addition, the nurses observed that ethnic minority patients would generally prefer to stay in bed for quite some time after a surgery. In contrast, the general practice in Danish hospitals is that the sooner you get on your feet and become mobile again, the faster you will recover. The ethnic minority patients apparently linked the disease to being bedridden. This also implied a longer hospitalisation compared to Danish patients with similar disorders and treatment needs. The ethnic minority patients apparently were afraid to be discharged and felt more secure staying in the hospital.
Furthermore, the nurses noticed a difference when ethnic minority patients and their families often reacted with anger and even threats by unforeseen changes, for example cancellation of a surgery.
Conclusion phenomenon 2
From the nurses´ experience, it was difficult to assess from both a professional and personal point of view whether ethnic minority patients expressed “real” pain or whether they exaggerated the pain level. This dilemma was perceived as an obstacle to professional care and nursing. Furthermore, the lack of physical insight was considered to be a difficult matter in situations, where they were to explain minority patients about the embodiment and bodily expressions of their specific disease.
In some cases, the nurses automatically linked the lack of bodily knowledge to poor schooling. However, by this perception, the nurses seemed to mix the professional assessment with more private and even ethnocentric preconceptions of levels of education and civilisation in so called third-world countries. Likewise, the perception of “ethnic pain” may be seen as a negative preconception.
In summary, the nurses experienced that ethnic minority patients behaved contrary to professional standards and procedures in the Danish health system, for instance in relation to recovery.
Third phenomenon: different cultural and social behaviour in the ward
Private food in hospital: the nurses pointed to various differences in cultural and social behaviour. One significant difference was linked to food, as ethnic minority patients would often have meals delivered to the hospital by family and relatives. This would never be the case for Danish patients. However, some nurses expressed a positive position to this phenomenon, while other nurses would consider the private food deliverances as a disturbance for other patients.
The impact of strong social networks: ethnic minority patients would often have strong social networks and consequently many visits when hospitalised. Some nurses would emphasise the advantage of a strong social network in terms of patients´ recovery. Other nurses regarded the many visitors as a nuisance for other patients as well as for the professional staff.
From the nurses´ experience, there would be both positive and negative effects of cultural and social differences. Some nurses were focused on the importance of cultural habits in terms of the patients´ well-being and recovery. Other nurses would be more negatively focused on the impact of cultural habits on the practical and professional procedures in the ward.
Summary and perspective
The study highlighted communication, different attitudes towards illness and different cultural and social behaviour as crucial phenomena in the intercultural encounters.
The nurses found that language barriers made it difficult to get knowledge of minority patients´ background and thus to clarify the patients’ individual situation, resources, needs and requirements.
The inability to establish a dialogical communication resulted in a form of objectification, as the nurses – despite their professional intentions – felt unable to recognise the individual life history, identity and integrity among ethnic minority patients. The general experience was that the interactive aspect of communication was broken and consequently, the nurses lost opportunities to use the socio-cultural and psycho-cultural interpretations and empathetic “readings” they usually used in communicating with patients. This led, in some cases, to situations where nurses instead resorted to stereotypes and even ethnocentric interpretations that would lean towards negative preconceptions and generalisations about ethnic minority patients.
Different view of illness
The nurses spoke of “ethnic pains” as a term for excessive articulation of pain among ethnic minority patients. This was interpreted as a different ethnic-cultural view on illness and pain thresholds. Lack of insight into anatomy and physiology was also seen as a cultural difference.
Previous research had focused on cultural differences in terms of pain thresholds, but no clear answers were given. Apparently, the articulation of pain is more about cultural expectations as to when and how to express pain – than about the pain itself. The Danish medical anthropologist Beth Elverdam described how reactions to and expressions of pain are cultural and a result of socialisation. Thus, the nurses’ experience could also be seen as an expression of a Danish cultural approach and interpretative framework, where “good” patients are swallowing their pain. Beth Elverdam also stated that lack of knowledge of the body’s biological functions are not synonymous with lack of body awareness. Similarly, perceptions and interpretations of disease and illness symptoms are culturally conditioned. When ethnic minority patients would rather stay in bed, they probably expressed a feeling of being ill, whereas the nurses from a Danish approach considered them to be almost healthy.
Different cultural and social behaviour
The nurses referred to differences connected to food and the large flow of visitors as well as the passive role that generally characterised ethnic minority patients.
This experience reflected that patients´ and professionals´ roles in the healthcare and hospital context are socially and culturally defined. The more authoritarian the professional role, the more passive the patient role. Being educated and socialised in a more dialogical and non-authoritarian system, the nurses had difficulties coping with a passive patient behaviour.