Introduction: The Concept of Culture
Culture is the way of life for a person, society or group of people. It embodies the soul of the community and the heart of a team; it is seen in the way its members express themselves, communicate, think, feel, and believe. It determines what they value and how they honor the principles that guide them. It is different for every society, as Hofstede (1980) showed—and yet there are universal elements to every culture that allow people from different backgrounds to understand one another and rise above their differences to find common ground. Culture shapes the way people, families and communities communicate, perceive the self, think about sexuality, express spirituality, manage stress, cope with less, and deal with death and grief. Some cultures are open and indulgent about individuals’ choices, spirituality, sexuality and how they choose to communicate themselves. Others are more restrained and promote a collectivist approach to community, putting the needs of the group before the desires of the individual. Nurses can use and understand culture by utilizing models like Leininger’s transcultural model of nursing, by adopting a patient-centered care strategy, or simply by developing their cultural competencies. In doing so, nurses can promote safe, effective, and quality personalized care for patients, their families, and for the communities they serve within the realm of nurses’ care. To promote cultural awareness among nurses, one of the best places to start is Hofstede’s research on cultural dimensions.

Literature Review

What is Culture?

Culture has been defined in terms of the values that it promotes, as Hofstede (1980) shows. Hofstede’s (2011) 6d model of cultural dimensions has helped to advance the discipline of cross-cultural awareness among nurses by identifying half a dozen different criteria for understanding and evaluating the psychology of individuals from different cultures. These criteria are: 1) power distance, 2) uncertainty avoidance, 3) individualism vs. collectivism, 4) masculinity vs. femininity, 5) long vs. short term orientation, and 6) indulgence vs. restraint (Hofstede, 2011). Hofstede’s model teaches what values to look for when interacting with people of other cultures and provides nurses with a framework for discerning these values. As Orr and Hauser (2008) note, “Hofstede’s seminal work has been the benchmark for cultural analysis for the last three decades” (p. 15). Hofstede showed that every culture has its own set of social values that can be broken up into those six categories.

Power distance refers to the relation of people or groups to one another in a person’s society. It determines the way people talk, communicate, and show respect (Hofstede Insights, 2019). For example, in very hierarchical societies, the power distance ranking is much higher than in societies where equality is considered an important ideal. A person from a country like Saudi Arabia will have a psychology that is more informed by a strong power distance ratio because of the culture in which he has grown up. The same goes for China. China has a high power distance score, meaning that in the Chinese culture people accept that power is distributed unequally: it is a hierarchically organized society with power concentrated in the hands of those at the top. In America the power distance score is much lower, with American society believing more in the equitable distribution of power (Hofstede Insights, 2019). American nurses will thus have different attitudes than Chinese nurses, and American nurses will communicate with more openness than nurses or patients in a culture that is more restrained.

Individualism vs. Collectivism is another dimension of culture and it refers to the extent to which the society has respect for the freedom of the individual or for the collective. America, for instance, has a high individualism score, while China, to use the example of the same nation again, has a high collectivism school (Hofstede Insights, 2019). In this way, the two nations’ cultures are very different on this particular value. American nurses will thus be more likely to respect the individual choices of patients and other people in terms of their sexual orientation, religious and political beliefs, and their ideas about death and dying. Indeed, this is the essence of person-centered care (Davidson, Tondora, Miller & O’Connell, 2015). Because of their strong cultural value of individualism, Americans tend to be tolerant and respectful of individual choices, whereas other cultures expect conformity from people and do not tolerate deviation from the norm.

In terms of masculinity, which is defined as working for the sake of achieving success, China and the U.S. have similar scores: both are devoted to working (Hofstede Insights, 2019). Neither has a high femininity score. In the model, femininity is defined as working for the enjoyment of the work—i.e., people do not work because they have to if they want to achieve success but rather because they want to as they enjoy it. The feminine dimension of culture focuses on doing things because it is pleasing.

Another dimension of culture is one’s tolerance for uncertainty. This means that some cultures are okay with ambiguity and do not mind if communication is unclear or if there is little understanding between people: they see each other as knowing their own mind and that is what matters (Hofstede Insights, 2019). If something needs to be communicated, it will be said. China has a low tolerance for uncertainty—lower at least than in the U.S. (Hofstede Insights, 2019). In the Chinese culture, the preference is to avoid uncertainty, but Americans are a little more comfortable with ambiguity if it arises. For nurses, this is a dimension of culture that will impact how comfortable patients, families and communities are with knowing (or not knowing) about health related issues, but increasing health literacy depends on communicating well and eradicating ambiguity, which can be an obstacle for many nurses (Noel et al., 2019).

The short- vs. long-term orientation dimension of culture is another aspect to consider. The Chinese have a very high long-term orientation score (Hofstede Insights, 2019). This means they focus on doing what is best for...…attempt to fake listening if she is actually busy recording notes into a computer or preparing for the next patient. Time should be set aside simply to listen. A positive attitude should be maintained at all times, and tact and care should be shown when communicating both orally and in written exchanges. Sarcasm and cynicism should be avoided. Attention to others should always be shown, and communication should always be clear and exact and responses given in a prompt manner. People should never be kept waiting for long when a response is expected, and the more immediately one can respond the better(Bassert, 2017). Communications should always be respectful, courteous, pleasant, and positive when exchanged with patients and colleagues. Professionalism should be the rule and practice at all times, and one should never assume familiarity with either a colleague or a patient.

The importance of using and observing verbal and nonverbal communication is absolutely essential, as both are forms of communication that can convey meaning (Bassert, 2017). Thus, one should be mindful about body language, making eye contact, and using hand gestures; however, one should also consider that there will be cultural differences when it comes to using body language and making eye contact. For example, in some Asian cultures, eye contact is not a custom between bosses and lower level workers as it is considered a sign of disrespect (Bovee & Thill, 1992). One should thus develop a cultural competency with respect to communicating verbally and nonverbally. Tones of voice and body language can provide clues as to whether a person is annoyed, happy, upset, anxious, and so on. Understanding verbal and nonverbal expressions can facilitate the nurse’s communication. To clarify what a patient or coworker has said, it is best to repeat back to the sender the words that were sent or to paraphrase them and then ask for more information by saying something like, “Could you explain what you mean?” or “Tell me more about that, ” or something of that nature (Bassert, 2017).

Summary

The Hofstede model of cultural dimensions shows that different cultures around the world mold people, families and communities in different ways depending on how the society considers various concepts such as power, work, leisure, and planning. The model of cultural dimensions provides insight into how people of different cultures view power structures, gender roles, and the meaning of life (Hofstede, 1998). Nurses must be culturally competent in order to provide patients with the best care possible. Every culture differs in terms of beliefs, expectations, values and desires. Subcultures within cultures exist and should be understood by the nurse. The nurse must learn to communicate in a way that is culturally sensitive and culturally aware. Body language is just as important at sending messages as tone of voice, facial expression and words. Every culture also will have its own understanding of these forms of language. To promote safe, effective, personalized care for the person, for families, and for communities, nurses must develop cultural competencies by…