The existence of cultural differences reveals and celebrates the uniqueness of persons as human beings. Continuing international migration increases cultural diversity, especially in the United States, where a decreasing workforce and the increasing deployment of international workers such as nurses create a widening disparity that encourages cultural uniqueness in the workplace. The US Department of Health and Human Services has shown that 9%, or 207,000, of the 2.24 million registered nurses (RNs) in the United States come from racial or ethnic minority backgrounds. 1 Such diversity presents, among other influences, a challenge to nursing education, research, and practice and to health care practice.
It is important in today's multicultural context that the issue between a caregiver and a care recipient's frame of reference is recognized as integral to the quality and delivery of health care. Culture provides differences that are often interpreted as barriers that promote isolation from mainstream ways. Yet, what is culture? The Dutch writer Fons Trompenaars defines culture as "a series of rules and methods that a society has evolved to deal with the recurring problems it faces. These have become so basic that, like breathing, we no longer think about how we approach or resolve them." 2(p. 36)
The impact of an unresponsive nursing practice is to ensure cultural "sameness," devaluing persons as unique human beings in their cultural distinction. However, it ought to be remembered that this distinction celebrates the uniqueness of being a human being. The wisdom of affirming culture in health and nursing is such that recognition of barriers, or inhibitions posed by cultural differences, provides the basis for bridging them. Nurses have responded to this need for understanding diversity in various ways. One of these ways is through cultural relativism.
Baker 3 refers to cultural relativism as the perspective grounding the understanding that "behaviors of individuals should be judged only from the context of their own cultural system."(p. 3) Cultural relativism affirms that when energies are focused on persons uniquely as cultural beings, concerns are directed not to knowing what these particular cultural differences are but rather to knowing the similarities. As nurses, we seek to understand human beings as persons. A way to facilitate this understanding is to sustain and accept who we are as cultural beings in relationship with others. A perspective such as this underlies the conceptual approaches developed by nurses to guide cross-cultural caregiving.
Emphasizing cultural similarities rather than differences builds bridges toward understanding human beings as persons. The wisdom gained by knowing these similarities and differences honors and affirms the value of these persons as human beings. One of the envisioned ways to create these cultural bridges may be to look into aspects of living created by the diversity of cultures as products of international migration. As Freda 4 exclaimed, "cultural differences influence everything from philosophy of life and acceptable behavior to the way people perform their work."(p. 2) Individualism and collectivism are two contrasting paradigms that highlight major differences in cultural thought throughout the world. Knowing these differences is possible. For example, most English-speaking and European countries possess individualist cultures where value is placed on individual efforts, rights, and rewards. Individualists emphasize "values such as autonomy, competitiveness, achievement, and self-sufficiency."(p. 3) Alternately, collectivism entails the need to maintain group harmony above partisan interests of subgroups and individuals. In this culture, values such as interpersonal harmony and group solidarity prevail. Persons who are from Asia or South America are likely to be influenced by collectivism. 4
It is obvious that values exert a profound influence on how each person behaves, reacts, and feels. 5 Being attentive to knowing and understanding cultural influences averts practice conflicts that may unnecessarily delay or even prohibit the delivery and the quality of health care. Cultural sensitivity is one of the ways to enhance awareness of the impact of culture and to aid in providing reflective care that is congruent with each person's value. It is also a way to appreciate that living dictated by cultural influences requires acknowledgment as being integral to the health of persons.
Current literature focused on culture, health, and nursing is replete with information supporting the view that projecting culture-sensitive behaviors is the key to effective and harmonious caregiving. For decades, as a way to know varying cultural nuances and become culture sensitive and competent, emphasis was placed on understanding cultural-specific values that influence health care. This emphasis continues to be particularly significant in the practice of nursing.
However, distinct boundaries that inhibit quality nursing care persist and diminish the potential to which care may be provided. For example, different cultural groups often prefer nontraditional, nonmedical care that is indigenous to their culture and that is seen as an anomaly in Western traditional medical care. Preferences for nontraditional health care are often expressed through use of indigenous health care practitioners and interventions instead of the Western medical personnel and Western traditional pharmacologic agents. Resolution of such a disparity in practice will entail mutual accommodation and adaptation of parallel cultural practices.
EXPLORING CULTURAL BLURRING
Cultural blurring may be one answer to the struggle to create a culturally competent practice of nursing. Linking and bridging similarities in the human health experience blur and diminish differences. For example, women living in remote rural areas in the Philippines often cannot receive professional medical or nursing assistance in childbirth because villages are inaccessible. However, controlling the problem of newborn deaths from tetanus is a priority. To accommodate and adapt local cultural practices, lay midwives are trained and certified in a technique to cut umbilical cords of newborn babies. Introducing the lay midwife to the concept of sepsis and asepsis exemplifies the blurring of culture by sanctioning the practice of having lay midwives deliver babies, while adapting the practice of medical asepsis.
Further, it is readily understood that regardless of the cultural perspective, a health condition that is life-threatening will continue to be perceived as such. Nursing expertise and cultural competence are codependent characteristics of essential value to nurses, especially when their practice of care for persons is from the viewpoint of wholeness.
Despite advances in nursing knowledge and research, issues surrounding the predominance of varying cultural perspectives with which nurses' practice continue to exist.
Cultural views of health, cultural competency, cultural awareness, cultural sensitivity, cultural diversity, and cultural relativism are often addressed as interchangeable. These complex views reveal that conceptual similarities and differences are crucial to the enrichment of a practice discipline such as nursing. Various versions of culture-specific perspectives on health as published in nursing and health care literature support the growth of the discipline, the profession, and the practice of nursing. Today, the impact of culture on health care is such that being attentive to cultural nuances markedly improves quality and access to health care.
INTERNATIONAL PERSPECTIVES
International nursing and global health have become contemporary "buzz words" in nursing. Nurses must become more knowledgeable about international health issues, including the practice of nursing in other countries. Participating in international activities enhances sharing and understanding of cultural nuances necessary for human well-being. International nursing research and international nursing education address unique perspectives of health and nursing, in which health care concerns from a global perspective expand distinct views of health care from the populations for whom they are known.
However, can we all know all cultural nuances? Or, does it matter that we are culturally different? Like peoples of other cultures, these acceptable differences create and affirm our uniqueness and "sameness." A contemporary expectation for every nursing practitioner is to be aware, if nothing else, that cultural nuances influence health care.
CONCLUDING REMARKS
The synthesis of knowledge in cultures promotes cultural uniqueness, and blurring distinctive differences in cultures is steadily becoming a reality. It may not be possible to know all cultural nuances, but surely, being aware of the need to know the influences between culture and health, and the impact of cultural nuances is a step in the right direction. Acknowledging the other in the moment, being with, and traveling along with the other is transcending differences. The wisdom of knowing cultural influences in health and nursing is to transcend boundaries, valuing similarities and differences. Cultural blurring, the bridging of cultures through similarities, is a way to understand others as ourselves.
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