Editorial

Cross-cultural nursing research: A two-way street

Mark Welch
Senior Lecturer, School of Nursing, University of Canberra, ACT

PP: 133

Article Text

In an address to the Fourth NSW Transcultural Mental Health Centre Conference in November 1998, the then Governor of New South Wales, the Honourable Gordon Samuels, said that the health professional needs a very sound knowledge of the cultural attitudes of those being treated, and above all the ability to view some of the inevitable factors with objectivity and detachment (TMHC, 1998: 1). Herein lie many of the dilemmas that prevail in cross-cultural nursing.

The use of words like 'knowledge', 'attitudes', 'inevitable', 'objectivity' and 'detachment' requires serious consideration because, in themselves, they show a particular response to the issues and betray sets of values and ideologies. They raise key epistemological debates in the way in which we explain ourselves and our experience to ourselves and to others, and point to the problems of crossing cultures or transcending boundaries. We accept without question that we live in a multicultural society, but what does this mean for nursing and nursing research?

Nursing as a discipline seems to be exercised particularly by the question of valid knowledge. However, this might be regarded as a strength rather than a weakness. A broad concept and appreciation of polymorphic knowledge, knowledge that takes many forms and contributes in a cumulative rather than competitive way, should perhaps be at the heart of nursing research. This is rarely more apparent than in the case of cross-cultural nursing research which, it will be argued, locates itself in the realities of a dynamic practice discipline. Both clients and nurses cross cultures and take with them things of great worth to develop new and refreshed paradigms of care. Thus, it should be regarded as a great advantage of mutual benefit, not an issue of competition.

The American Nurses Association has long acknowledged this position. It sees cross-cultural nursing as an attempt to illuminate how cultural groups understand life processes; how cultural groups define health and illness; what cultural groups do to maintain wellness; what cultural groups believe to be the causes of illness; how healers cure and care for members of cultural groups; and how the cultural background of the nurse influences the way in which care is delivered (www.nursingworld.org/readroom/position/ethics/etcldv.htm). Furthermore, research in this area should be a two-way street.

There is an increasing amount of epidemiological research identifying the incidence and prevalence of certain health problems or issues in particular ethnic or cultural groups (McDonald & Steel, 1997). For some, like refugees or those who have been tortured, it might be as a result of a particular experience. For others, such as migrants or minority groups, it might be because of the nature of a position in society. There is a great interest in qualitative approaches as well (Ferguson & Pittaway, 1999). Different forms of inquiry serve different purposes. The appeal of an empirical description is clear, it gives such a comfortable certainty. It can authoritatively order a hierarchy of knowledge; for example, procedure A is better than procedure B. It can count and measure and quantify. On the other hand, phenomenological descriptions of experience are both affectively and cognitively powerful. The telling of a story helps to create and transmit meaning and, for very good reasons, nurses find that very attractive. It speaks to all the intense interpersonal concerns that inform practice: 'How can I, as a nurse, relate to the experience of illness?' However, it might be important to question continually the assumptions that lie behind the way in which knowledge is valued, and why this should be. Perhaps Governor Samuels should have added the cultural attitudes of those who do the caring?

Cross-cultural research in nursing goes beyond an objective and detached description of a phenomenon or attitude or health belief. It is not an anthropological curiosity, it is a fundamental challenge to a dominant paradigm designed to further the influence of certain interest groups. The case of non-Western health practices that appear to work is illustrative here. There appears to be a desire to explain the effectiveness of aspects of traditional Chinese medicine, for example acupuncture, in terms of a Western epistemology rather than in its own terms. Western medicine seems unable to quantify Chi, the essential life force, but still has to account for its effectiveness. It seems to attempt to do this by transposing a paradigm of neurological and limbic pathways onto a model of meridians. It translates the understanding into its own terminology in order to find it acceptable. Is this a case of therapeutic paternalism, in which the exotic practice is tolerated as long as it doesn't challenge the dominance of the Western model?

Tensions can arise when these perspectives are seen to be in opposition or conflict. It is a danger, but is not inevitable. Understandings of the world are not necessarily the result of a zero-sum competition; they are not always in the form of an either/or exclusivity. They can be negotiated rather than imposed. This requires that the same criteria be applied to the dominant form of knowledge as to the exotic, and it requires a little humility. Said (1990) knows the power of language and has persuasively argued that an interest in the exotic, in other forms of cultural expression and knowing, is an example of imperial condescension. It is merely acceptance of the validity of that culture in a limited sense, in that in some way it serves the purposes of the dominant, in this case by flattering a liberal sensibility. At the bottom of it all, Said argues, it is still a case of us and them, a way of defining the Other without being morally troubled by accusations of cultural hegemony, appropriation or colonisation. Being complimentary is not the same as accepting as complementary.

It is imperative that nurses are involved in the development of new models of care and the broad change processes. By maximising the contribution that nurses make, we can reduce the potential for further stress in the workplace. However, this will require a new level of insight and forward planning for the development of approaches to practices that meet the needs of patients within a complex and changing health care environment and society at large, rather than waiting for change to be imposed upon us.

Cross-cultural nursing research has to be careful of the trap of exoticism. It must guard against being too self-congratulatory. It must be conscious of hubris. It is a matter of professional integrity. Cross-cultural research should be appraised with the same rigour as any other form. If it is to be seen as a legitimate and important method of inquiry, as indeed it is, it should meet the necessary standards. It should be critically examined for bias and pretension. It should ask itself the most difficult questions of its own fidelity to the principals of transparency, openness and accountability. It has to be prepared for anti-intuitive findings and rejection of assumptions. It has to engage in the most searching self-examination precisely because of the nature of its concern. It is both its strength and its weakness, its potential and its problem.

However, the promise is there. Lawler (1991) has long intimated at the value of a critical somology and an investigation of the semiotics of health and illness. There is a cultural significance of health and illness, the body and how it is regarded. Significant power relations, ideological concerns and social structures mediate the experience. These particular areas of Western health care seem, at first glance, to be the most affected, and can be something of a challenge to Western sensibilities. Nkrumah (in Ferguson & Pittaway, 1999) expresses her concern that some Somali women strongly defend the practice of Female Genital Mutilation as being a vital part of cultural identity, second only to religion (p. 70). She struggles to understand this. Is this a false consciousness or clarity of identity? Is this the result of an oppressive hegemony or free will? Can or should a moral stance be taken? Even the descriptive term of 'mutilation' becomes problematic. Yet, the contentions raised by the issue significantly help and improve the critique of Western notions of caring, not because they are right or wrong, but because they ask questions which further the reflective process.

Swartz (2001) warns about the dangers of making too many assumptions. He argues that clinicians cannot know a person's cultural background from external characteristics, and that too often a person's ambivalence about cultural identity is ignored. Furthermore, he is concerned about simplistic solutions and sounds a note of caution about the use of cultural brokers, reminding us that their agenda might be very different from those of clients (p. 5).

Nevertheless, Kilimidis et al. (1999) argue that cross-cultural issues are of the utmost importance in client outcome. Public mental health services are under utilised by people from a Non-English Speaking Background (NESB), and there is a significant tendency to terminate treatment prematurely. Clearly, there is still a service gap and it seems to relate to an ethnocentric hegemony in health care.

So, although nurses and the discipline of nursing need to be in partnership with communities from a NESB, there is so much to learn, and also unlearn. Torrico, Lewis and Klimidis (1999) report that, although many workers '… have not been trained in either cross cultural skills … on the whole [they] have positive attitudes … and most would attend training given the chance' (p. 21). The complexities and contradictions of the issues are still be unravelled, and cross-cultural nursing research aids this process by making haste slowly, with courageous caution. It cannot be readily asserted at the present time that cross-cultural research really understands what it is, but it does seem that it is beginning to know what it is not. If it is able to move beyond the constrictions of a singular understanding of knowledge and embrace the potential of new and other forms, for itself and those it cares for, it might realise the benefits of a cross-cultural nursing that crosses both ways.

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