As a paramedic, I was often confronted with rather ambiguous information when sitting in the emergency vehicle driving to a potential emergency case, such as: “Patient unconscious. Maybe. We don’t know. Just give it a look.” Receiving this type of information made me feel a certain kind of alertness, not necessarily nervous but focused on the situation that was to come, thinking about which measures to be taken, which instruments to be brought along. One time I arrived at a site with the team – two full-time paramedics, one emergency physician and me – having only some vague information about a woman being unconscious.
As we entered the woman’s apartment, we were greeted by five to ten people of different ages and genders who were family members of the patient. They were screaming and crying desperately while loudly and incessantly talking at us. Because of all the commotion and the fact, that only one of the people present spoke German, it took a rather long time to figure out what had happened. The only German-speaking person, the granddaughter, finally explained to us that her grandmother had simply fallen over and lost consciousness. It took ages before we were led into the room of the patient. From one look at her I confirmed that she was not unconscious but dead. Her gaze was fixed and empty and she was lying completely still in a very unnatural pose. Clearly dead. While we had to perform the standard measures (taking her pulse, preparing the defibrillator etc.) the entire family was continuously screaming at us and looking at us imploringly. Due to the language barrier, I can only assume that they were begging us for help. We asked them to leave the room and let us do our job many times, with increasing determination, before they responded to our request. Again, this “discussion” took quite a while due to the language barrier and because the granddaughter had to translate. Finally, after the family had left the room with one of my colleagues, we started resuscitation. I could hear loud voices from the other room while performing the resuscitation measures – which were destined to fail since the patient had already been dead for over half an hour.
I was left with a very confused feeling. I was also baffled by the fact that the family had wasted so much time screaming and crying, instead of trying to help the grandmother by trying to resuscitate her. They didn’t even try to make her comfortable since they thought she was unconscious. They let her just lie there. All the family members had been waiting at the door when we arrived. No one stayed with the grandmother. Instead of helping they even made our work somewhat impossible. What was even more confusing to me, was that while they were not doing anything to help the grandmother, the family members seemed in grave emotional distress.
1. Identities of the actors in the situation
I entered an apartment in Vienna as a mobile nurse. The patient, who needed a change of bandages daily after skin transplantation, was railing against a Turkish colleague of mine, who wears a veil. The patient was a retired teacher, who used to teach in a high school in Austria, so he was highly educated. I tried to calm him down, but despite my trying to calm him down, he kept on swearing and railing against my colleague, who I liked very much. He kept shouting that Muslims were intolerant, discriminating against women, brain washed, dependent people, who were stupid and manipulated.
I found out that the patient himself was homosexual and felt discriminated against by Islamic religion.
The shock occurred not when the patient railed against Islam in general, but when it became personal about the Turkish colleague. At first I thought that everybody had a right to an opinion. But when the patient lost control and started getting more agitated, I felt personally attacked as well. He told me that he had read the Koran and felt that as a homosexual he had no right to live according to the Koran. I tried to explain that my colleague’s religion was not an attack against him as a person and not a personal issue for him. I defended my Turkish colleague and explained that she was well integrated and would never said anything negative against homosexuals, but cares for people from all cultures and doesn’t differentiate. I also explained that my colleague would not have a job if her job performance was influenced by her religion.
The situation exploded and the patient did not feel that I understood what he was trying to say. He was hurt. I could no longer argue logically with him.
2. Context of the situation
Austrian; female; 29 years old; open to all religions; politically liberal; high need for harmony and mutual understanding; believes in God but does not identify as religious; working as mobile nurse (trained and certified as nurse) at a non-profit organisation providing health care and social services; visited the patient regularly and had experienced no problem with him prior to the incident;
Austrian; male; approximately 60 years old; atheist; rather left-wing political orientation; homosexual; fights for the right of homosexuals; neat appearance; rather quiet life; former high-school teacher (highly educated), now retired; had a skin transplant and needed daily after-care on his right leg;
The Turkish colleague
Born in Turkey and had been working and living in Austria for some time; female; approximately 40 years old; Muslim; political orientation unknown; wears dark colours, a veil and does not usually attract much attention in the course of working as mobile nurse.
3. Emotional reaction
The nurse felt overwhelmed and helpless at first and unable to cope. She was unsympathetic to the patient’s continuing railing. She felt personally attacked and forced to defend herself and her Turkish colleague, urged into a mediator role between the patient and her Turkish colleague who was not even there.
4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock
The narrator values each person’s right to have an opinion and to express her or his opinion, so long as the expression of opinion does not cross a line. Personally attacking someone for following a specific religion crosses the line, while generally criticising this religion is acceptable to the narrator. This points to an orientation towards individual liberty: freedom to act is only limited when it affects another person’s liberty. This concept is a very basic idea of liberal societies, tied to notions of freedom of speech and differing opinions. Being tied to enlightenment this notion entails an inherent prioritising of ratio and scientific thought over religious ideas and traditions.
- While the patient is entitled to his view on Islam, the colleague is entitled to her following of this religion (and demonstrating it through specific types of clothing) as long as it does not (negatively) affect her job performance.
- It is not acceptable to attack a person on the grounds of her belonging to a religious group. In the same way it would not be acceptable to devalue individuals due to their sexual orientation.
Multiculturalism: The narrator adheres to a view of pluralism in which general beliefs held by members of a society might collide with each other, yet this does not need to have a bearing on how individuals interact. In this sense, she is oriented towards tolerance and acceptance of different belief and value systems. At the same time, by emphasising that her colleague is “well-integrated”, the nurse demonstrates a view of dominant social rules that individuals (coming into the Austrian society) should adapt to. While individuals are okay to hold differing views, conduct is to be oriented towards one specific form of social organisation.
Individualism: An individual is not to be characterised by attitudes and features ascribed to the groups they belong to. Each person is perceived according to his or her individual actions. Thereby the narrator also expresses to be wary of generalisations and stereotypes. While she does not debate the patient’s assertions on the content of the Koran, she vehemently negates that this informs her colleague’s actions or even that these beliefs are held by her colleague even though she is Muslim.
- Interestingly, she also exhibits stereotypical expectations of the patient being tolerant because he himself belongs to a minority group and of the patient not having stereotypes against minority groups being a highly educated person.
Private and public self are to be differentiated from each other. One’s private life (i.e. personally held religious beliefs) should have no bearing on how one conducts her or himself professionally. Yet the private life of professionals is also to be protected and shielded from evaluation, criticism and attacks.
Solidarity with colleague: The nurse feels the need to defend her colleague due to the unjust insults from the patient. Since the patient does not stop she feels attacked herself. The nurse exhibits a need for harmony at work, a feeling of having to mediate between her colleague and the patient. She could have also just let him rail on. This could additionally also point to an orientation towards acting in the face of injustice.
5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?
Negative assessment of the patient and how he expresses his feelings towards Islam by devaluating a concrete person working with him; illogical in his railing against a whole religion; aggressive.
6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator
The values the patient expressly holds onto are:
- Sexual liberty and equality for all human beings regardless of their gender or sexual orientation
Yet his orientation towards tolerance and equality is counteracted by the fact that he devalues Muslims on the basis of their belonging to a specific group and renders stereotypical representations of them. While arguing for a universal notion of tolerating divergent world views, he himself chooses which world views he finds tolerable and which he does not. Thus, he documents an orientation towards the value of sexual liberty exceeding religious sensitivities. Associated with this prioritising is a representation of religion pointing to illiteracy and primal forms of social organisation. By contrast, he considers himself to be oriented towards more elevated types of social organisation, positioning Western, secular societies at the top ladder of social progress. His view of the world is associated with education, gender and sexual equality, autonomy and tolerance – which he thinks to be superior to an Islamic world view. Thus, the values associated with Western secular liberalism are to be passed on to other societies.
Supporting his value of education, he makes his arguments on the basis of having read and gathered information on Islam. He thereby presents his accusations as being grounded in reason.
The rationality of his argument is based on a positioning of identity groups against each other: Muslims against homosexuals. Since he belongs to the group of homosexuals, he feels ill-treated by Muslims in general. And since the colleague is Muslim, he attacks her for all the negative things he ascribes to Islam. Following this logic the colleague “being” Muslim is enough for his feeling discriminated against on the basis of a core element of his identity – being homosexual.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
Health care work transcends separation of public from the private sphere
Public and private are considered distinct spheres and they differ in regards to types of activities performed, relationship with actors present and codes of conduct. Mobile nursing transcends these spheres since it is a professional activity (public) performed within the private home of someone. Thereby this practice opens up challenges for all persons involved. The patient might feel that outsiders are intruding on his/her home and needs them to adapt to his/her own sensibilities. The nurses on the other hand do not consider themselves to be guests, but professionals performing their work. Thus the boundaries between the public and the private need to be navigated in a sensible way.
- Nurses need to be protected from ill-behaved patients, while at the same time acknowledging that patients might feel bothered about private issues.
- Patients must be made aware that nursing is a professional practice, even when it is performed in their own home. Thus, they can only assess professional actions and not treat the professionals as they would personal acquaintances.
This bridging of the public/private divide might be further challenged by issues of interculturality, having people from diverse cultural backgrounds and belonging to different social groups work together in an ambivalent social zone. Thus, what needs to be addressed is:
- in which way the professionals and patients relate to each other on a personal level;
- how, at the same time, their individual identities can be protected from scrutiny, it being a professional encounter after all.
Recommendations for organising mobile nursing care
Mobile nurses are confronted with numerous possible challenges when taking care of patients at home, usually on their own. Thus, communication within the nursing team on experiences with specific patients is key.
- Incidents with adverse or ill-behaved patients need to be communicated to all team members so they can prepare and come up with strategies to handle the patients; including the possibility of confronting the patient with other staff members present;
- Switching patients among the nurses if one of them has a bad experience and adjusting the schedule based on the criteria of interpersonal relationships;
- Visiting difficult patients with two mobile nurses.
Interculturality and group logic
Often time conflicts arise not due to specific actions of individuals but because stereotypical group representations are invoked. This incident illustrates how representations of differing world views are thought to collide, while discussion based on the specific sensibilities pertaining to the individuals interacting with each other is avoided. In this story, religious affiliation serves as a proxy to the patient for attacks on liberal societies and sexual equality. Yet the Turkish mobile nurse never actually expressed any of these views, while he, as the story unfolds, can be accused of discriminatory speech. By focusing on stereotypical group representations instead of engaging with the individuals in question, discrimination and prejudice is reproduced instead of tackled.