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Master of Advanced Studies in INTERCULTURAL COMMUNICATION

Case Studies in Intercultural Communication

Welcome to the MIC Case Studies page.

Here you will find more than fifty different case studies, developed by our former participants from the Master of Advanced Studies in Intercultural Communication. The richness of this material is that it contains real-life experiences in intercultural communication problems in various settings, such as war, family, negotiations, inter-religious conflicts, business, workplace, and others. 

Cases also include renowned organizations and global institutions, such as the United Nations, Multinationals companies, Non-Governmental Organisations, Worldwide Events, European, African, Asian and North and South America Governments and others.

Intercultural situations are characterized by encounters, mutual respect and the valorization of diversity by individuals or groups of individuals identifying with different cultures. By making the most of the cultural differences, we can improve intercultural communication in civil society, in public institutions and the business world.

How can these Case Studies help you?

These case studies were made during the classes at the Master of Advanced Studies in Intercultural Communication. Therefore, they used the most updated skills, tools, theories and best practices available.   They were created by participants working in the field of public administration; international organizations; non-governmental organizations; development and cooperation organizations; the business world (production, trade, tourism, etc.); the media; educational institutions; and religious institutions. Through these case studies, you will be able to learn through real-life stories, how practitioners apply intercultural communication skills in multicultural situations.

Why are we opening our "Treasure Chest" for you?

We believe that Intercultural Communication has a growing role in the lives of organizations, companies and governments relationship with the public, between and within organizations. There are many advanced tools available to access, analyze and practice intercultural communication at a professional level.  Moreover, professionals are demanded to have an advanced cross-cultural background or experience to deal efficiently with their environment. International organizations are requiring workers who are competent, flexible, and able to adjust and apply their skills with the tact and sensitivity that will enhance business success internationally. Intercultural communication means the sharing of information across diverse cultures and social groups, comprising individuals with distinct religious, social, ethnic, and educational backgrounds. It attempts to understand the differences in how people from a diversity of cultures act, communicate and perceive the world around them. For this reason, we are sharing our knowledge chest with you, to improve and enlarge intercultural communication practice, awareness, and education.

We promise you that our case studies, which are now also yours, will delight, entertain, teach, and amaze you. It will reinforce or change the way you see intercultural communication practice, and how it can be part of your life today. Take your time to read them; you don't need to read all at once, they are rather small and very easy to read. The cases will always be here waiting for you. Therefore, we wish you an insightful and pleasant reading.

These cases represent the raw material developed by the students as part of their certification project. MIC master students are coming from all over the world and often had to write the case in a non-native language. No material can be reproduced without permission. ©   Master of Advanced Studies in Intercultural Communication , Università della Svizzera italiana, Switzerland.

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Research: How Cultural Differences Can Impact Global Teams

• Vasyl Taras,
• Dan Caprar,
• Alfredo Jiménez,
• Fabian Froese

And what managers can do to help their international teams succeed.

Diversity can be both a benefit and a challenge to virtual teams, especially those which are global. The authors unpack their recent research on how diversity works in remote teams, concluding that benefits and drawbacks can be explained by how teams manage the two facets of diversity: personal and contextual. They find that contextual diversity is key to aiding creativity, decision-making, and problem-solving, while personal diversity does not. In their study, teams with higher contextual diversity produced higher-quality consulting reports, and their solutions were more creative and innovative. When it comes to the quality of work, teams that were higher on contextual diversity performed better. Therefore, the potential challenges caused by personal diversity should be anticipated and managed, but the benefits of contextual diversity are likely to outweigh such challenges.

A recent survey of employees from 90 countries found that 89 percent of white-collar workers “at least occasionally” complete projects in global virtual teams (GVTs), where team members are dispersed around the planet and rely on online tools for communication. This is not surprising. In a globalized — not to mention socially distanced — world, online collaboration is indispensable for bringing people together.

• VT Vasyl Taras is an associate professor and the Director of the Master’s or Science in International Business program at the University of North Carolina, Greensboro, USA. He is an associate editor of the Journal of International Management and the International Journal of Cross-Cultural Management, and a founder of the X-Culture, an international business competition.
• DB Dan Baack is an expert in international marketing. Dan’s work focuses on how the processing of information or cultural models influences international business. He recently published the 2nd edition of his textbook, International Marketing, with Sage Publications. Beyond academic success, he is an active consultant and expert witness. He has testified at the state and federal level regarding marketing ethics.
• DC Dan Caprar is an Associate Professor at the University of Sydney Business School. His research, teaching, and consulting are focused on culture, identity, and leadership. Before completing his MBA and PhD as a Fulbright Scholar at the University of Iowa (USA), Dan worked in a range of consulting and managerial roles in business, NGOs, and government organizations in Romania, the UK, and the US.
• AJ Alfredo Jiménez is Associate Professor at KEDGE Business School (France). His research interests include internationalization, political risk, corruption, culture, and global virtual teams. He is a senior editor at the European Journal of International Management.
• FF Fabian Froese is Chair Professor of Human Resource Management and Asian Business at the University of Göttingen, Germany, and Editor-in-Chief of Asian Business & Management. He obtained a doctorate in International Management from the University of St. Gallen, Switzerland, and another doctorate in Sociology from Waseda University, Japan. His research interests lie in international human resource management and cross-cultural management.

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Cultural Diversity Case Study

by Chris Smit | Sep 10, 2018 | Business

• StumbleUpon

This Cultural diversity case study describes the impact that cultural differences can have on a large multinational (travel) organization. It also covers the effect that cultural competence training can have to, ultimately, save time and money.

[4-min read]

What Are The Key Take Aways? After following a two-day cultural competency workshop this is what came out: Nobody is right or wrong, we are all just different, so we all need to be open and compromise. We often “ joke ” about our differences, which really helps break down barriers & frustrations which we definitely didn’t know how to deal with before. When I’m recommending your courses to others I often tell a story (a true one) of a conversation I had after I attended the course and a French colleague of mine attended the one in Belgium later in the week. After discussing how much we had enjoyed and learned from the course, I then asked Laurent for some information. His response was “ But Irene, you now know that as I’m French I can’t just give you the information I must verify with my manager first!” I responded, “ But Laurent you know I’m British so I need it NOW! ” After much laughter, we did agree on a compromise date to suit both our needs. The openness and the appreciation for each other’s culture certainly helps support our working relationship and mutually agree on an action plan.

The company name, numbers, and other specifics have been slightly modified to make it more suitable for describing this Cultural diversity case study.

The Company Description

• Name: Universal International Travel
• British based, founded in 1932 with head office in London
• Number of employees: 76,000 mainly European based
• Revenue: €23.000 billion
• Products: Chartered and scheduled flights; hotels; travel services

Change Management at its Best

Since the beginning of time, Universal International Travel had been run on a “ per-country-basis “. The Germans took care of the Germans, the Dutch of the Dutch, the French of the French, the Belgians of the Belgians, and the Brits of the Brits. Oh, I forgot the Nordic region…

• North America

In 2015, the top management of the company decided that it was time for a major restructuring. This is to make the company ready for the future of demanding business and leisure travelers and also to better deal with increasing (low-cost) competitors.

The French, Germans, Dutch, Belgians, Nordics, and the Brits all had to go and do things together

On paper, that sounds easy. Even if you take out language difficulties, because everyone spoke and speaks English, right?

But in practice, it turned out different…

The Biggest Surprise for Management

In 2016 the HR department of Universal International Travel (UIT) distributed a questionnaire among its first three layers of management. From C-level management to Project management. This is to find out what specific skill needs their management still needed in order to facilitate this cross-border integration.

Their initial expectation was that topics like:

• Communication,
• Presentation skills,
• Negotiation skills,

would be the outcome. But that was not the case. Much to their surprise, almost unanimously these three layers of management suggested the one skill that they were missing was… How to Deal With Other Cultures .

Most people were not so much against the new company structure. But they struggled with the different cultures they now had to deal with. For some reason colleagues from other companies acted strangely; replied in weird ways; didn’t work logically, were wasting time (yes, and money ) by doing so.

And the trouble was that they all thought this of each other. Back and forth. Criss-cross…

Not Everyone Needs to Know Everything

Sandra, who worked in the London head office, contacted me to see if I could be of help to them. I could. We discussed at length what the objectives should be:

• Awareness of one’s own culture.
• Understanding other cultures.
• Being able to communicate effectively with each other.
• Specific management skills (like negotiations, teamwork, leadership).

But not for everyone. For some people, it would suffice just to be aware of one’s own culture and a better understanding of other cultures. But for some, the level of knowledge should go deeper.

For that reason, I designed a one-day and a two-day workshop.

These workshops were promptly executed in three locations:

Some other workshops, shorter, were held in Spain, Turkey, Bangkok, Mexico, and Amsterdam.

On average, there were about 15 to 20 people per workshop. Enough to give each individual enough “ air-time ” but also to create the necessary group dynamics.

Did C-Level Management Get Involved?

Yes, they did. At one of the workshops in Berlin, Peter, COO based in London, sat in on the two-day workshop. He realized that his C-level colleagues also had to go through this for real change and cultural competence starts at the top.

So, that’s what happened. A couple of weeks later all the big shots (15 of them) had cleared their agenda to spend two days with me in Brussels.

We had good fun but also covered a lot of ground. Management finally realized that wishing an integration to happen doesn’t make it so.

How Did It Trickle Down the Organization?

Something must have been right about the design and execution of the workshops because soon after the first batch of workshops was given, other departments (Aviation, Accounting, Destinations, and IT) started requesting their workshops as well.

I must have seen hundreds of people over the course of two years.

What Were the Main Pain Points?

Here are a couple of typical pain points that kept coming back. Throughout all organizational disciplines:

• The Brits couldn’t deal with the detailed planning that the Germans wanted; they thought the Germans were far too rigid.
• The Germans didn’t like that the Brits simply wanted to “ get on with it ” without really knowing what to get on with; there was no plan.
• The Brits also couldn’t deal with the indecisiveness of the Nordics. They just kept on talking and talking and talking without ever reaching a decision.
• The Nordics, as the Germans did, found the Brits just wanting to move and move and move. They didn’t involve anyone, which, according to them, they should.
• The French and Belgians said that the Dutch were just lawless and didn’t listen to anyone, but simply did their own thing.
• While at the same time the Dutch said about the French and the Belgians that they couldn’t make a decision if their boss wasn’t there.

And of course, there was a lot more that was covered.

What’s the outcome Cultural diversity case study? Who benefitted?

The proof of the pudding is always in the eating. So, I did a little tour through the organization to see how they benefited from being better culturally competent.

Here’s what they had to say:

• There’s a lot less frustration now when I work with my colleagues from other countries. It has become much more relaxed to communicate.
• I managed to save quite some time because I now could approach my colleagues much more targeted; I would distribute certain tasks and projects to colleagues whose culture would better support that specific task.
• And of course, with the above, I managed to save time and therefore also money… the throughput time of certain projects got reduced, which of course means more cost-effective and less cost overall. Which would lead to people having more time to work on other projects, which would make things move faster. Well, you get the point.
• Many people have also fed back that one of the biggest learnings they have from the course is how others view them and their culture. This makes you very mindful of how others see you and when appropriate impact the way to contribute to meetings and projects.
• As a native English speaker, I’m very mindful of the words and phrases I use. I can no longer say “ interesting ” even if I do think something is really interesting! [/et_bloom_locked]

What Can You Do?

This real case study does not only pertain to the travel industry. Think about global regional companies like:

• Netflix (American with its European head office in Amsterdam, the Netherlands)
• Spotify (Swedish with a global audience)
• ASML (Dutch company, operating internationally)

• Hotel chains
• Car manufacturers

Realize that Culture Matters and that you can become culturally competent too.

Keyword: Cultural diversity case study

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If you want to read more read this article:  9 Signs You’re Not Getting It (It’s Culture Stupid!)

An example of a retail business can be  found here.

An article about how the travel business can benefit from cultural awareness can be found here.

The cultural divide between Boing and Airbus. Read the article here.

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About Peter van der Lende

Peter has joined forces with Culture Matters.

Because he has years and years of international business development experience joining forces therefore only seemed logical.

Being born and raised in the Netherlands, he has lived in more than 9 countries of which most were in Latin America.

He currently lives in Atlanta, Georgia (USA) with his family.

You can find out more at https://expand360.com/

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Teachers responding to cultural diversity: case studies on assessment practices, challenges and experiences in secondary schools in Austria, Ireland, Norway and Turkey

• Open access
• Published: 27 July 2020
• Volume 32 , pages 395–424, ( 2020 )

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• Barbara Herzog-Punzenberger 1 , 2 ,
• Herbert Altrichter   ORCID: orcid.org/0000-0002-5331-4199 1 ,
• Martin Brown 3 ,
• Denise Burns 3 ,
• Guri A. Nortvedt 4 ,
• Guri Skedsmo 4 , 5 ,
• Eline Wiese 4 ,
• Funda Nayir 6 ,
• Magdalena Fellner 7 ,
• Gerry McNamara 3 &
• Joe O’Hara 3  

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A Correction to this article was published on 19 August 2020

This article has been updated

Global mobility and economic and political crises in some parts of the world have fuelled migration and brought new constellations of ‘cultural diversity’ to European classrooms (OECD 2019 ). This produces new challenges for teaching, but also for assessment in which cultural biases may have far-reaching consequences for the students’ further careers in education, occupation and life. After considering the concept of and current research on ‘culturally responsive assessment’, we use qualitative interview data from 115 teachers and school leaders in 20 lower secondary schools in Austria, Ireland, Norway and Turkey to explore the thinking about diversity and assessment practices of teachers in the light of increasing cultural diversity. Findings suggest that ‘proficiency in the language of instruction’ is the main dimension by which diversity in classrooms is perceived. While there is much less reference to ‘cultural differences’ in our case studies, we found many teachers in case schools trying to adapt their assessment procedures and grading in order to help students from diverse backgrounds to show their competencies and to experience success. However, these responses were, in many cases, individualistic rather than organised by the school or regional education authorities and were also strongly influenced and at times, limited by government-mandated assessment regimes that exist in each country. The paper closes with a series of recommendations to support the further development of a practicable and just practice of culturally responsive assessment in schools.

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1 Introduction and background

Consistent with changing patterns of migration and the belief that school systems have a significant role to play in responding to ‘increasing social heterogeneity’ (OECD 2009 , p. 3), many education systems have developed policy solutions and initiatives for the creation of culturally responsive classrooms (Ford and Kea 2009 ). As stated by the United Nations (UN), education systems around the world should be united in the commitment to ‘ensure inclusive and equitable quality education and promote lifelong learning opportunities for all’ (UN 2016 ). Providing cause for optimism, the 2018 TALIS report indicates that strategies on how to deal with ethnic and cultural discrimination are taught in 80% of the participating schools. On the other hand, giving cause for concern, more than 50% of teachers in the participating countries did not feel well-prepared for the challenges of a multicultural learning environment and were not confident in adapting their teaching to the cultural diversity of students (OECD 2019 , pp. 98).

However, it is not only teaching that offers potential pitfalls for migrant students aiming to achieve to their full potential. There are other connected practices such as assessment that, according to Arbuthnot ( 2017 ) among others, need to be considered in all learning environments, as assessment has the potential to act as a powerful catalyst to improve teaching and learning (Hattie 2009 ) and in most countries also opens up entry to further education and employment (Black and Wiliam 2012 ; Shepard 2006 ; Popham 2009 ). In addition, for migrant students, there is also a historical and cultural dilemma that needs to be overcome, as the dominant modes of assessment, together with the assessment competencies of teachers, are also, by tradition, linked with the cultural, historical and political agendas that exist in migrant-receiving countries and can have a positive or negative effect on student learning (Crichton 1998 ; Isaacs 2010 ; LeMétais 2003 ). Analysis of PISA test scores in mathematics, for example, reveals that students with the same migration background perform differently in some OECD countries compared to others, even when indicators that affect student performance such as socioeconomic status are considered (OECD 2016 ). In other words, the assessment regimes that exist in different countries can, in some way, have a corollary effect on student achievement, indicating a need to re-examine the effects of assessment regimes on classroom practice (Brown 2007 ).

The initial conceptualisation for this research—which was part of a three-year European Union-funded project entitled Aiding Culturally Responsive Assessment in Schools (ACRAS) [1] [1] ERASMUS+-Project 'Aiding Cultural Responsive Assessment in Schools' (ACRAS; 2016-1-IE01-KA201-016889)—came from studying how teachers cope with and adapt to the assessment needs of culturally diverse classrooms. A review of the research on teaching, learning, assessment and diversity revealed that there is a body of literature concerning the educational needs of students not belonging to the respective mainstream culture and about responsive pedagogies aiming to enhance their learning. Such issues have until now been more widely studied in North America and other English-speaking countries than in other European countries (Nortvedt et al. 2020 ). Most of the previous research and conceptual work seems to focus on the implications of cultural and linguistic diversity for teaching and learning, rather than on assessment. So, we find empirical studies of teaching and learning in different subjects and of different minority groups (e.g. Gutiérrez 2002 ; Schleppegrell 2007 ; Lesaux et al. 2014 ), proposals for culturally responsive teaching (e.g. Aceves and Orosco 2014 ; Gay 2010 ; Ladson-Billings 1995a , b ; 2014) and the role of school culture in providing a climate for students where they can experience educational equality and cultural empowerment (Banks and Banks 2004 ). Moreover, there are studies indicating approaches for student-centred pedagogy more generally and responsiveness towards children’s contribution in joint activities (Brook Chapman de Sousa 2017 ) and emphasising preparation for culturally responsive and inclusive practices as part of teacher education (Warren 2017 ; Young 2010 ). In this paper, we cannot do justice to the entire literature on culturally and linguistically responsive teaching but will focus (in the next section) on the much smaller body of research on assessment under conditions of cultural diversity.

In Europe, with some exceptions (e.g. Mitakidou et al. 2015 ), there is only a limited number of studies that have specifically explored the challenges relating to the assessment of migrant students as perceived by teachers. To fill the lacuna of research, the current study sought to explore: aspects of diversity that teachers in European classrooms attend to in assessment situations, the strategies that teachers use in assessment to take account of diversity, and the supportive and inhibiting conditions encountered by teachers when adapting to diversity in their approaches to assessment. While there are huge differences between European countries with respect to the amount and history of their diversity and with respect to the characteristics of their education systems, Europe may offer the opportunity to study a type of cultural and linguistic diversity in education which is different from the one found in North America, i.e. with respect to the number and diversity of newly immigrated, displaced refugees.

The countries participating in this study differ widely with regard to the proportion of migrants in their schools. Austria has the highest average share of students (25.3%) with first languages other than the language of instruction (Statistik Austria 2017 ). In Ireland and Norway, the percentage is between 8 and 15% (Eurostat 2017 ). Whilst no official figures are available for the total proportion of migrant students in Turkey, as a result of the political crisis in Syria, of the 4 million Syrian refugees that currently reside in Turkey, approximately 1.7 million are children of which 645,000 are enrolled in schools (UNICEF 2018 ). Additionally, different types of governance in education are in place in the four countries: While Austria, Ireland and Turkey represent a model of ‘State-Based Governance’ with high levels of bureaucracy and little school autonomy (Windzio et al. 2005 , p. 11–16), Norway has a school system which is characterised by a relatively high degree of local autonomy (Telhaug et al. 2006 ; or in Windzio et al.’s terms: a ‘Scandinavian Governance’).

The first section of this paper describes the different uses and potential implications of assessment, which is followed by an analysis of proposed solutions for the assessment of migration background students. Then, the methodology used in the study is described. The penultimate section provides an analysis of the research findings derived from a series of case studies on assessment practices in 20 lower secondary schools in the four countries. The paper concludes with a discussion of the research findings and implications for further action in the field of assessment and cultural diversity.

2 Assessment and cultural diversity in education

Assessment is one of the basic building blocks of institutionalised schooling. At the classroom level, it can be used formatively to enhance learning (Hattie 2009 ) and to improve teaching (Black and Wiliam 2012 ; Shepard 2006 ). However, assessment can also be used to make distinctions in a field of diverse performances and, either through teachers or through externally devised assessments or a combination of both, can be used to sort students for future education or working life (Eder et al. 2009 ).

The modern ‘meritocratic’ type of schooling is built on the idea that learning opportunities, results and certificates must not be distributed according to social class, economic power, religious denomination, and gender, but solely through a fair appreciation of actual performance (Fend 2009 ). Nevertheless, research shows that this idea of equity is not fulfilled in many cases and that in reality, the grades of students are correlated to categories of social background (Alcott 2017 ). This is also true for language and culture aspects: assessment performance and grades are impaired when the assessment language is not the first language of the student (Nusche et al. 2009 ; Padilla 2001 ). In many cases, assessment practices seem to be in place which deny students the opportunity to achieve their true potential (Brown-Jeffy and Cooper 2011 ). This is because teachers may not have acquired the professional capacity to adapt assessments to the needs of migration background students (Nayir et al. 2019 ) or because there is a limited range of appropriate assessment tasks and support structures available (Castagno and Brayboy 2008 ; Espinosa 2005 ).

In order to ensure equity of assessment for students coming from non-mainstream cultures or migrant families, assessment should be ‘culturally responsive’ (Hood 1998a , b ; Hood et al. 2015 ; Arbuthnot 2017 ; Brown et al. 2019 ). A range of assessment methods that provide additional opportunities for students to demonstrate their learning have been proposed. These include creativity assessment (Kim and Zabelina 2015 ), dynamic assessment (Lidz and Gindis 2003 ), performance-based assessment (Baker et al. 1993 ), peer assessment (Topping 2009 ) and self-assessment (Taras 2010 , p. 606). Culturally responsive assessment practices are also characterised by being student-centred and focusing on ways in which students can contribute using their previous knowledge and experiences in the assessment situation. In doing so, they are narrowing the gap between instruction and assessment situations, as e.g. in assessment for learning (Black and Wiliam 2012 ), which is frequently recommended as an element of a culturally responsive assessment strategy.

The issue of enhancing culturally responsive practices does not relate solely to the provision of extra resources and training. According to Thompson-Robinson et al. ( 2004 ), at a conceptual level, the challenges ‘remain complex, multi-faceted, and context-rich’ (p. 3). Indeed, the literature suggests that for teachers to be serious about being culturally responsive assessors, they also need to be researchers of their own culture and professionalism. This perspective resonates with the American Evaluation Association’s ( 2011 ) statement on cultural competence: ‘Cultural competence is not a state at which one arrives; rather, it is a process of learning, unlearning, and relearning’ (p. 13). This is a daunting task, requiring the professional teacher to reflect on practice in an in-depth manner. As a consequence, the role of a ‘culturally responsive assessor’ seems to converge with that of a ‘reflective practitioner’ (Schön 1983 ) ‘becoming aware of the limits of our knowledge, of how our own behaviour plays into organisational practices and why such practices might marginalise groups or exclude individuals’ (Bolton 2010 , p. 14). Culturally responsive teachers are challenged to be aware of cultural and social diversities, to embed culturally sensitive approaches in their practices (Ford and Kea 2009 ), and to monitor and develop their practices in this respect (Feldman et al. 2018 ).

Nonetheless, teachers can find it difficult to respond positively to the demands of culturally diverse educational contexts (Torrance 2017 ). Culturally responsive assessment strategies can act as a powerful catalyst for effective classroom practice. However, while schools and teachers have a responsibility for the implementation of these practices, they are also dependent on and limited by the assessment policies and regulations that allow for the flourishing of such innovations (Burns et al. 2017 ). To concur with Schapiro ( 2009 ), it is necessary to question whether education policies do in fact ‘improve the student’s access to quality education, stimulate equitable participation in schooling, and lead to learning outcomes at par with native peers’ (p. 33), or conversely restrict and inhibit the ability of schools and teachers to respond imaginatively and generously to new realities.

While many European classrooms, particularly in bigger cities, have been culturally diverse for decades (Crul et al. 2012 ), others have become vastly and quite suddenly more diverse in recent years. Yet, there is little research so far on the actual practices and conditions of assessment in these contexts. Thus, our study was conceived to explore how teachers in European countries cope with and adapt to the challenges created by the assessment of culturally diverse students. The aims of this paper are threefold : Firstly, it aims to uncover the categories teachers use to make sense of potential diversity in their classroom practice. Their perceptions and interpretations of diversity are seen as a precursor for the actions they take when confronted with student diversity in their assessment. Secondly, it analyses the assessment strategies teachers report using as they endeavour to respond to student diversity. Thirdly, we identify inhibiting and facilitating factors that contribute to teachers’ willingness and ability to innovate in assessment methods in the context of student diversity.

3 Methodology

This paper draws on 20 school case studies in which teachers and school leaders explain their assessment challenges and practices at the lower secondary level. The schools are drawn from four different European countries, Austria, Ireland, Norway and Turkey, which represent a wide variety of both teaching and assessment practices and migration experiences (ACRAS 2019 ). However, this paper does not aspire to make comparative claims about typical practices in these countries (for which the database would be too small). Instead, it uses four different school systems as a source for sampling greatly dissimilar contexts and experiences, and illuminating the wide variety of potential teacher responses to the conduct of assessment in diverse classrooms. Secondary schools were chosen as the focus for the study because we expected the grading and certification aspect to be relevant which would not have been the case in primary education in all participating countries.

The sampling of schools within the countries followed the logic of theoretical sampling and aimed to achieve a diversity of cases in order to mirror the heterogeneity of the research field (cf. Kelle and Kluge 2010 ). The schools were characterised by major variations in the percentage of migrant students. These came from different linguistic, cultural and geographical backgrounds but were integrated into the schools attending the same classes as their peers. In the Austrian and Irish case schools, the percentage of migrant students varied between 10 and 60%, in Norway between 5 and 65%, and in Turkey between 5 and 15%. In total, interview data from 115 staff from five secondary schools per country were included in the analysis (including, in each school, the head teacher, a teacher with a particular function for teaching or assessment, a teacher with a particular function for diversity or equality, a language teacher, a STEM teacher, a teacher of a migrant mother tongue and a class teacher).

Interviews were based on a semi-structured interview guide shared between the countries (see Appendix). The guide consisted of questions derived from a conceptual framework on culturally responsive assessment practices that was developed as part of the project (Brown et al. 2019 ). The inclusion of open-ended questions allowed practices and concepts of culturally responsive assessment not foreseen in the conceptual framework to emerge. All interviews were audio-recorded and transcribed verbatim.

Interview data were coded according to the country, case study school, and the position of the interviewee (school leader or teacher). For example, when referring to the code AT_CS4_T1, the first two letters identify the country, the next two letters and numbers identify the case study school, and the final letter and number (which may be omitted when reference is to a case study in general) identifies the position and identity of the interviewee (Table 1 ).

The analysis followed two steps. First, data were analysed according to a case study approach (Yin 2009 ) concentrating on exploring patterns in each country with respect to how interviewees described aspects of diversity that the teachers attend to in assessment situations, and strategies that they apply to respond to diversity. Second, a cross-case analysis was conducted, in order to compare and contrast the emerging data from 20 schools in the four countries. For this paper, the main findings relating to the three research questions outlined above have been condensed into the central ideas and themes reported in the next section. These are illustrated by a series of statements and quotations which focus on important aspects of teachers’ reasoning and actions when they are attempting to engage with cultural diversity in assessment situations.

4 Presentation of findings

The theme of assessment in situations of diversity touches upon the fundamental ‘dilemmas of schooling’ (Berlak and Berlak 2014 /1981). Are all learners to be treated equally, or is it justifiable to give different tasks and use different criteria for evaluating the performance of certain students? Is the focus in classrooms on ‘supporting or is it on monitoring and assessing the student’ (Newman 1997 , p. 263)? Depending on the answers to these questions, the selection of knowledge, organisation of learning and assessment of resulting competencies will be conducted in different ways. The actions of teachers can be viewed as practical responses to such questions in the face of ‘competing and conflicting ideas in the teacher’s mind’ [and in the teachers’ environment; the authors], about the nature of childhood, learning and social justice’ (Berlak and Berlak 2014 , p. 1). In our analysis, we aim to uncover categories and attitudes which teachers employ to make sense of diversity in their classrooms and consequently in their practice. Their perceptions and interpretations of diversity can be interpreted as a precursor which informs the actions they take when engaging with student diversity and in handling possible dilemmas in assessment situations.

4.1 Aspects of diversity

There are a range of dimensions of diversity which impinge on educators as they seek to appropriately respond to the needs of migrant students both in terms of pedagogy and assessment. Those that came to the fore in this research are considered below.

4.1.1 Proficiency in the language of instruction is the main dimension by which diversity in classrooms is perceived, explicitly discussed and processed

Teachers may observe and talk about all kind of differences between their students; however, with respect to their classroom practices, the student’s grasp of the language of instruction was, by far, the leading factor mentioned in our interview data. This is true in all country cases if less pronounced in Ireland, where English is the language of instruction, and it is more likely that many migrant students will have some knowledge of English, before they move to Ireland in comparison to the Norwegian, Turkish and German language in the other cases. If there are special organisational or didactical arrangements for migrant students, they will be organised, in most cases, according to student abilities in the language of instruction (see examples in Table 2 ).

While the focus on competences in the language of instruction is, perhaps, understandable (since this language is the prime instrument of teaching in most subjects), it may also implicitly (and maybe unconsciously) promote both a deficit perspective (‘students lack essential means of learning’) and teacher feelings of having to cope with immense challenges.

The big problem for teachers is that [the students’] language might not be up to the standard that is needed to fully participate in class. (IR_CS5_L1).

The students have problems in Turkish and mathematics classes, and this is due to their lack of language skills. (TR_CS2_T2).

Similar attitudes became apparent, in a different way in the interviews when Austrian and Norwegian teachers—with positive surprise—referred to ‘students’ good aptitude for learning the language of instruction’ (AT_CS4_T3) or described migrant students who mastered the Norwegian language well enough to follow the lessons and take part in ‘ordinary assessment’ as ‘normal students’ (NO_CS2_T2).

4.1.2 In some countries, the aspect of diversity as it relates to the language of instruction was reinforced by analogous administrative distinctions

In Austria and Norway, and to a limited extent in Ireland, language proficiency or lack of it is reinforced by administrative distinctions and labelling. In the case of Austria, when students cannot follow instruction because of a lack of competence in German (i.e. the language of instruction), they are given ‘extraordinary status’. This status allows them to participate in the classroom like regular students from day one onwards. However, they are not obliged to participate in tests, and the teacher is not obliged to grade. Students may be transferred to ordinary status after a year, but the extraordinary status may be (and very often is) extended up to 2 years because of language reasons.

Although the status ‘extraordinary’ is clearly defined by law, teachers have different interpretations, and different routines for translating legal requirements into practice have been established. The legal regulations provide for grading extraordinary students in some subjects they are good at, such as English or Maths (e.g. AT_CS4_T3), while they still may not be graded in other subjects for which the language of instruction may be more important. However, there were teachers and school leaders in the Austrian sample who (wrongly) held the view that the grading of extraordinary pupils was at all forbidden (AT_CS1_L).

This administrative distinction suggests clear categories for teachers: ‘The only distinction for me is: is the child to be tested or not?’ (AT_CS1_T7). The boundary between ‘extraordinary’ and ‘ordinary’ may induce some schools to provide a completely different type of education for extraordinary students by concentrating on language acquisition and neglecting other subjects (AT_CS5_T8).

In the case of Norway, minority language-speaking students who enter lower secondary schools in the last half of a school year are also exempted from grading if the parents agree (Education Act 1998 , §3-21). Moreover, students in lower and upper secondary schools, who, according to the Education Act ( 1998 , §2-8 or 3-12), are entitled to special education in the Norwegian language and offered an introductory course, can be exempted from grading during the period of the course. These students will only receive formative assessments, and the school owner has the responsibility to outline the consequences for the students with respect to receiving grades and being exempted from grading.

Finally, while English is the language of instruction in Ireland, Irish is also a compulsory subject. However, an exemption is granted if a student’s education up to 11 years of age was outside the country or if a newly arrived student has no understanding of English or Irish. One benefit of being exempted from Irish lessons is that those students are given additional tutoring in English during five class periods a week.

4.1.3 Although the acquisition of the language of instruction is a matter of prime interest in all countries, there are different strategies to enable this between and within countries

Arrangements for learning the language of instruction differ across countries with respect to inclusive vs exclusive arrangements (i.e. whether or not immigrant students are learning the language in special classes separate from other students) and duration (i.e. for how long special arrangements for language acquisition are applied). As Table 2 shows, the examples range from no special arrangements (Turkey) to a short language training period (Ireland) to special language instruction for a period of up to 2 years (Austria and Norway). These examples, however, are not in all cases indicative of the whole country, since there may be vast differences between arrangements in different schools within a country. Variations between countries and schools may be connected to the fact that decisions concerning the education of culturally diverse populations are often not taken based on evidence, but that schooling traditions and political considerations play an important role.

4.1.4 Few teachers have acquired competences in teaching the language of instruction as a second language

The ‘language of instruction’ is one of the main instruments of teaching. If teachers cannot use this instrument in the way they are used to, they will experience it as a challenge and—if they do not have strategies to cope with it—it can be viewed as an additional burden on their professional work. Even though proficiency in the language of instruction is perceived as the key aspect of responding to diversity, only a few teachers in the Austrian (and none in the Turkish) case studies seem to have acquired competences in teaching the ‘language of instruction as a second language’ (AT_CS4_T2).

Furthermore, teachers in Norway and Ireland did not generally talk about Norwegian or English as a second language—except for L2 teachers, of which schools reported wanting more in both countries. However, in the majority of case studies, teachers recount some strategies that they use to cope with linguistic diversity. In the case of Ireland, two of the case study schools reported that ‘students are encouraged to use their first language in the classroom’ (IR_CS2_T1), with the belief that ‘students should continue to develop their first language, as it helps them to develop concepts in English and to acquire the English language’ (IR_CS5_L3). Norwegian teachers also pointed to a lack of conceptual understanding as equally challenging.

Lacking language competency is a challenge. The students have much more knowledge than they can express with words (NO_CS4_T5)

There is a challenge with subject-related concepts which has consequences for students’ motivation. If you do not know the concepts, the learning is characterised by being very basic. It is difficult language-wise to reflect, to understand, to compare, to draw parallels. This does not only concern minority language students, but all students who struggle because they lack words and concepts (NO_CS3_T2)

4.1.5 ‘Cultural diversity’ is not often explicitly mentioned in the teachers’ and schools’ efforts to respond to diversity. This seems to relate to the perceived sensitivity and vagueness of the concept

Although classroom diversity is often associated with ‘cultural diversity’ in the public debate, there were very few examples in our data, except for some rare exceptions, in which interviewees explicitly referred to cultural differences when speaking about assessment, teaching and school.

It is interesting, for example, that some pupils, I think it was a Hungarian, do have a different way to do specific calculations, e.g., multiplication is different there, ah, I use that in teaching and tell the other children, make them aware that there are other ways, too. (AT_CS5_T1)

In science, for instance, we have Greek numbers and some words with a Greek origin. So, students coming from Greece recognise some of this. However, as I said, we don’t use it to a large extent. (NO_CS1_T2)

These statements are an indication of intercultural awareness. The first teacher did not refer to an alternative practice of multiplying as a ‘wrong way’, but as a different, even interesting mode, i.e. in a non-judgemental way. Additionally, he used this instance of diversity in his teaching, to raise students’ awareness of the fact that there are different, but equally valid, ways of multiplying (Kaiser et al. 2006 ; Blömeke 2006 , p. 394). This approach of acknowledging differences and doing this in front of the class appeared to strengthen the position of the children with migration backgrounds among their peers. Although this specific instance did not refer to assessment practices, one can imagine that this teacher would not insist on the ‘normal’ way of multiplying when assessing the student; i.e. he possibly would not measure students against culture-specific images of the subject to be learned and of ‘studentness’ (how students behave) in grading situations. In another example, a social science teacher expressed awareness of students whose cultural experiences were out of harmony with curricular content, and empathy that this may make it very challenging for these students to understand some concepts.

So, you have an idea, about democracy and participation for instance, where one of my students, coming from […], had very different ideas about IS and torture for instance, and, sort of, his concepts compared to other students, were very different. And you notice in assessment situations too, that you do not, that you do not manage to see what underlies student responses. You simply think that [the student’s] opinions are rigid, without seeking insights in the cultural background and why the student reacts as he does. (NO_CS3_T3)

All in all, there were comparatively few references to ‘cultural’ differences (other than language differences) in our case studies. What are the possible explanations for this finding? Firstly, cultural differences are sensitive. ‘Language’ offers a more clear-cut distinction, although it often functions as a signifier for a broader ‘otherness’ which may be associated with ‘culture’ and ‘ethnicity’.

Secondly, there is also diversity within the group of migrant students that is challenging to grasp and describe. For example in Ireland ‘newcomers’ are generally very diverse, drawn from heterogeneous ethnic and socioeconomic backgrounds, including some migrants who ‘are already proficient in English and whose parents have high educational aspirations’ (IR_CS2_L1). The label ‘not speaking the language of instruction’ is easier to handle and less prone to misconception. As stated by a Norwegian interviewee,

No, my impression is that they did an exceptionally good job in a primary school in integrating those [students] who have arrived during primary school. So, my impression is that the students are similar in the way they think and behave. (NO_CS4_T2)

Thirdly, many teachers do not have enough intercultural competence to feel well-equipped to address ‘cultural differences’ in interviews (and maybe also in classroom work). As such, the development of intercultural competence in the teaching force seems to be an issue in all countries.

4.2 Assessment strategies for responding to diversity

Concerning the second research aim, we were interested in the ways in which teachers relate to situations of diversity and react to the differences they perceive. While we saw few examples of well-developed and coherent practices of culturally responsive assessment at school level, many teachers across the country cases do take account of those diversities they perceive and use a whole range of strategies by which they aim to help students to demonstrate their competencies.

4.2.1 In order to relate to student diversity in conducting classroom-based assessment, many teachers adapt their assessment procedures and/or their grading

In our case studies, we witnessed a variety of methods that teachers and schools use to cope with student diversity. However, there was no single dominant strategy. Often, these practices were based on either the teachers’ perceptions of the students’ individual needs and/or drawn from the teacher’s classroom experience. These strategies were either ad hoc solutions to the problem of limited proficiency in the language of instruction, or they were long-term strategies of individualisation and differentiation which aimed to increase student responsiveness in general and were not limited to the cultural origin or assumed otherness.

Many of these strategies in each country can be subsumed as versions of formative assessment, such as ‘self-assessment’ or ‘group performance’, together with other types of performance, from pictorial to oral and written, hearing, reading and other formats. Generally, teachers who were competently working informed by a formative assessment philosophy seemed better equipped for culturally responsive assessment (Nortvedt et al. 2020 ). In teaching second language learners, the concept of ‘scaffolding‘ (Ovando et al. 2003 , p. 345) has spread to a number of classrooms. This offers contextual supports for understanding through the use of simplified language, teacher modelling, visuals and graphics, cooperative learning and hands-on learning; similar strategies in assessment may be interpreted as a natural corollary. As such, the strategies reflect teachers’ inventiveness and sensibility; however, they were often intensely individualised and not shared. Additionally, the described instances of flexibility, creativity and reflexivity of some teachers and their students can be seen as components and expressions of intercultural competence even when ‘culture’ was not the issue that was explicitly mentioned.

Looking more closely at the teachers’ strategies, it is possible to distinguish two elements within assessment (Eder et al. 2009 ): ‘procedures of assessment’ which refer to the processes of devising performance situations (such as assignments or tests), assigning them to students and monitoring students’ performance in these situations, and ‘grading’ which refers to the process of attaching evaluative judgements (such as marks, grades or other evaluative descriptions of the performance shown) to the students’ performance. In our data, there were (a) teachers who adapted their procedures of assessment to the needs of the students, (b) others adapted their grading, (c) some adapted both and (d) another group adapted neither assessment procedures nor grading (see Fig.  1 ).

Adaptation in assessment procedures and grading

Adapting procedures of assessment

When attempting to meet the needs of migrant students, many teachers in our case schools adapted their assessments by modifying the procedures of assessment in the following ways:

One of the most frequent strategies is time adaptation. Students whose first language is not the language of instruction may use more time for the same questions (e.g. AT_CS1). This is in line with legal regulations in Austria and Norway.

Changing assessment formats

Especially when students were literate in another script and still had difficulties in writing in Latin script, or just had difficulties writing in the language of instruction, teachers changed from a written to an oral format. Teachers in many instances also offered students the possibility of replacing a written or oral assessment by a presentation which they could prepare at home (e.g. AT_CS2_T3).

Changing the test language

When some teachers realised that certain students were more proficient in another language than the language of instruction, students were allowed to complete the test in the other language—provided teachers were themselves proficient in this language or a person was able to translate the test.

We also have students who then change the language to do their Physics test in English, and that is perfectly ok. This is offered by the English teacher, she says, ok, he can speak English much better than German, but with English, he would do it, then we’ll do it in English. (AT_CS1_T3)

Offering additional support

For example, teachers offer a list of keywords in the language of instruction with mother tongue explanations and/or ask other students for mother tongue support (AT_CS1).

I make it possible for them to teach to their friends the meaning of the words they learn in their own language. (TR_CS4_T2)

Many of these activities were ‘not only useful for migrant but for all students’ (IR_CS4_T4), e.g. discussion of ‘keywords before reading the main text’ (IR_CS4_T4) which, in some instances, included different contexts of the word together with an image of the word.

As is the case with state examinations in Ireland, students of a certain language proficiency level were able to use dictionaries during the test ‘to understand what they are being tested on if they don’t understand the meaning of a word. (IR_CS5_L1)

In an iPad-enabled classroom a teacher used electronic translation devices (Google translator) to communicate with a newcomer initially. Norwegian examples show how new teaching material can be used for supporting migrant students.

He often comes to me with something written in Italian, which he has translated for me using Google. I often think; Yes, funny. Yes, but that’s how we communicate, and he feels I understand him, I know if he has a problem …. (AT_CS4_T3)

So, there are some subjects (…) like grade 8 th science that has ‘Eureka’ - a smart-book that can read aloud. They can listen while they read. I think that this is a good resource for minority students and students with language disabilities. (NO_CS1_T1)

Peer assessment

Peer assessment occurred primarily during presentations and group work when students were asked to give feedback. In some instances, students even defined the criteria used for evaluation. In other situations, teachers organised panels with observer roles including brief written reflections:

We often use peer-assessment in groups or with an assessment partner where the students compare their responses and provide feedback to each other on written tasks. We do not use so much self-assessment yet, this we will do later on. Until now, we have focused on developing a “tool box” where they get to see examples of different tests, written assignments, feedback and so on, but we have not let them participate actively yet. (NO_CS1_T1)

So, we have now ... we started with discussion rounds on various topics, and there we always have observer roles to watch the whole thing and then give feedback afterwards. (AT_CS2_T7)

Adapting grading

Another strategy is to adapt the grading to the student’s competence level.

‘Language up-grading’

Some teachers retain the regular procedures of assessment (such as tests, homework and other activities) without any particular adaptation to the special needs of migrant students or any differentiation in general. However, they take the students’ language proficiency into account when they decide on the grade, which is recorded in the report card (e.g. AT_CS4_T1). This is in line with the legal situation in some countries (e.g. in Austria: teachers may take the linguistic situation of the students into account when deciding on the grade), while it is not allowed in other countries, e.g. in Norway where teachers are instead obliged to adapt the assessment.

Teachers who use ‘language up-grading’ explain it as accounting for the fact that written tasks require much more effort from students raised in another language and, even more so, in a different writing system (AT_CS3_T4) similar to Deseniss ( 2015 ).

In more professional terms, ‘language up-grading’ requires teachers to deviate from the social reference norm (considered ‘just’ in traditional schools) and use individual reference norms, i.e. to grade according to individual progress instead of social comparability. ‘Language up-grading’ also requires to distinguish between content and language performance in assessing competencies.

… the [recently immigrated] girl has collected many points because she understood the logic of the assignment, she has numeracy skills, it is only the language competence which is missing: I can be responsive to that, see, she is not able to cope with assignments with a longer written text in the beginning. However, all the other capabilities may be appreciated. (AT_CS1_T3)

No adaption of assessment

In some classrooms, we found no adaptation to the diversity of students at all. Due to the legal requirement in Norway regarding educational adaption to individual needs (Education Act 1998 , § 1-3), teachers are obliged to adapt both their teaching and assessment to individual students. However, there are still individualised practises, and the degree of adaption might, therefore, differ between teachers. In the Turkish cases, teachers in their classroom-based assessment usually ‘use the same tests for all students’ (TR_C4). When we encountered non-adaption in other countries (Austria, Ireland and Turkey), there were different explanations: Some teachers expressed compassion for the situation of newcomer students. They felt that non-adaptation of assessment is unfair to these students and, at the same time, thought that they were forced into non-adaptation by their national assessment system.

The assessment system [used in the school] is not fair in this respect, if they have such a deficit and therefore cannot show the performance expected. However, we cannot help it now, can we? (AT_CS4_T6)

Written papers in state examinations should be screened for appropriate language, as they do not reflect the diversity of language we now have in our secondary schools. … Setters of examination papers should be trained in language matters. (IR_CS3_T2)

Other teachers identified strongly with (what they perceived as) the legal rules or concepts of formal equality and did not consider any alternative:

We cannot do otherwise. It will be difficult ... to judge everyone equally … without going down with the standards. (AT_CS2_T3)

It is very difficult, you know, and would be difficult to have some rules [for] some and some rules for others. (IR_CS5_T3)

A small group in some countries did not seem to care about the problem.

I think nothing should be ‘adjusted’, so just because they are different cultures. Everyone has to be judged the same. (AT_CS1_T1)

It depends on the student. There is not a problem if the student is willing. (TR_CS2_T2)

The wide variation in strategies and in personal interpretations of the legal situation seems to indicate that there is ample leeway for professional development programmes offering teachers support and guidance in a work situation they were not trained for.

4.3 Supportive conditions for responding to diversity

The third aim of this paper is to investigate where teachers can turn to if they need support in responding to student diversity in their assessment work. From the perspective of the teachers, there seems to be little support available. However, the existing assessment practices or regimes represent a resource for teachers.

4.3.1 Different countries are characterised by different assessment regimes: they are a resource for teachers’ responding to diversity in assessment; they open up potential strategies of adaptation.

Countries differ in their legal requirements for assessment, which are transmitted through teacher education and enacted through individual and collegial practices of assessment and grading in schools. These ‘assessment regimes’ form a resource for schools’ and teachers’ individual and collective action, and thereby shape strategies of adaptation .

Assessment in Austrian (‘segregated’ Footnote 1 ) lower secondary schools is purely teacher-based; certificates originating from it are important for access to a differentiated ‘segregated’ upper secondary education system. This special assessment regime seems to limit the options teachers have in coping with diversity. In such a selective system, there is much attention paid to the comparative fairness of assessment, which makes it more difficult to be responsive to the special needs of students than it might be in more inclusive systems (cf. Popham 2009 ). This may have also made it more difficult for formative assessment or assessment for learning to flourish. Even a strategy like ‘language up-grading’ may be understood as a way of achieving ‘comparative fairness’, which would not be possible (or indeed necessary) in a system like Norway’s, which has its traditional focus on supporting individual progress in lower secondary level.

In Ireland, in contrast, assessment at the end of ‘non-segregated’ secondary junior education (referred to as the ‘Junior Cycle’) is based on teacher assessments and externally devised examinations which open up access to a ‘non-segregated’ upper cycle. The upper cycle ends with external state examinations, which are relevant for tertiary access. The external tests tend to focus the attention of teachers and students; however, the teacher’s role is conceived as supporting students’ learning for assessment (instead of ultimately judging students’ results which does not apply in Ireland). In the junior years, there is more freedom to adapt to students’ needs, but the upper secondary leaving certificate is such an important milestone in educational careers that there is a ‘washback effect’; the closer the final examination, the less freedom is experienced by teachers concerning assessment, and the more teachers tend to focus entirely on results. As all students are preparing for the ‘Leaving Certificate’, this has an impact right through secondary schooling (Burns et al. 2017 ). As stated by one interviewee:

I think that the introduction of CBAS (Course Based Assessments) is a very good move for the introduction of Assessment for Learning and for migrant students. But to be honest, the main focus is still the Leaving Cert so a lot of what we hear about is nice and what might be worthwhile assessment strategies goes out of the window when students do the Leaving Cert. The real is what they get in the Leaving Cert. How this fears out for students who have just entered the country, not so well I imagine. (IR_CS2_T3)

In Norway, as with Ireland, assessment at the end of ‘non-segregated’ lower secondary education is also based on teacher assessments and externally devised examinations. Although all students have a guaranteed place in upper secondary education, their results in the lower secondary level will enable them to opt for an academic or a vocational stream of the ‘segregated’ upper secondary cycle. The policy of guaranteed places in upper secondary education, the legal right of students to adapted education according to their individual needs as well as a legal policy for formative assessment in the form of assessment for learning seems to leave more freedom for teachers to apply culturally responsive practices in their assessment.

In Turkey, there is a central state examination at the end of 8th grade. All children, including foreign nationals, have the right to access ‘basic education’ services delivered by public schools. If international students are enrolled in a public school, the Local Education Authorities (LEAs) are responsible for assessing the student’s educational background and determining which education level the child will be enrolled in (Access to Education in Turkey 2019 ). In addition, in-service training for inclusive education is provided for teachers who have Syrian students in their classrooms (Promoting Integration of Syrian Children into the Turkish Education System 2019 ). All these initiatives may be considered as the beginning of culturally responsive practices in the assessment of immigrant students.

4.3.2 Established practices of formative assessment in a country can help individual teachers in adapting to diversity in their assessment

Whether or not practices of formative assessment are stipulated by educational legislation and supported by professional development, teaching material and other support offers may be a particularly relevant aspect of an assessment regime. Norway is a good example of established practices of formative assessment, due to a long-standing policy for adaption to individual student needs since 1975. There are certainly differences between individual teachers, schools and local communities; however, according to national policies, requirements that all schools should implement Assessment for Learning and formative assessment have an even longer tradition. In Ireland, formative assessment was not used as frequently in the past; ‘ten years ago, assessment for learning was never really mentioned at all’ (IR_CS5_L1). It is only in the last few years that formative assessment has attracted more attention with its introduction to the discourse of assessment at primary level (NCCA 2008 ), with its promotion as part of Junior Cycle reform and through influential stakeholder groups in the system, such as the inspectorate. In these cases, it is easier for individual teachers to practice formative assessment than in Austrian and Turkish schools, where formative assessment has a weak tradition connected with the prevalence of teacher-based assessment for certification.

4.3.3 An established discourse in the profession on both diversity and assessment helps individual teachers adapt to diversity in their assessment

Teachers’ work is not well understood if one looks only at the individual level. It takes place in a ‘community of practice’ (Lave and Wenger 1991 ), which may be more or less well developed. These communities of practice offer a ‘background web’ of understandings, interpretations, strategies and instruments which individual teachers can draw on in their daily work and in their attempts to cope with new situations. If there is an established professional discourse on diversity and/or on assessment, then it is supportive of teachers finding solutions for creating diversity in assessment. Although the awareness of diversity in classrooms is rising in Austria and Turkey, there is not really a discourse on this issue that involves much of the profession. In Ireland, the professional discourse on evaluation has increased as a result of new inspection practices and may stimulate awareness concerning diversity and assessment (IR_CS5).

4.3.4 A school policy on diversity and/or on assessment and formal and informal practices of teacher collaboration can help individual teachers adapt to diversity in their assessment

In some of the Norwegian schools, there are school policies in place which staff have agreed upon. School leaders give teachers resources accordingly; in these schools, it is easier to use formative practices. In case school 5, for example, a specific school policy of adaptive assessment has been implemented, which has teachers assessing tests together with the students (NO_CS5). This practice is supported by the Education Act ( 1998 ), which gives students a general right to participate in their own assessments.

Three of the Irish case schools have policies on multiculturalism and respect for everyone, and these policies seem to shape the learning environment in these schools (e.g. IR_CS5). Turkish case schools may or may not have some collaboration concerning assessment; however, they do not have any consistent school policy concerning assessment or migrant students or diverse classrooms (TR_CS4).

During the last decade, Austrian education policy has promoted increased attention to the individual needs of students, and differentiation and individualisation of teaching (Altrichter et al. 2009 ). Nevertheless, there is a wide variation of practices of assessment and grading. Only a few schools have consistent assessment policies, and in those that do exist, the aspect of linguistically or culturally responsive assessment is not covered (e.g. AT_CS1_T2). The obligatory development plans (which schools have to negotiate with their regional administrators as a part of ‘contract management’; see Altrichter 2017 ) may include elements which are helpful for culturally responsive assessment. Thus, in case school 5, an active and quite interventive system of diagnosis and support has been established, which is useful for responding to student diversity (AT_CS5).

5 Discussion and conclusion

This paper provided an exploratory analysis of the perceptions and strategies that teachers use to assess students in diverse classrooms. Interview and documentary data from 20 schools, and 115 teachers and school leaders in four European countries—Austria, Ireland, Norway and Turkey (five schools per country)—were used to study some features of the challenges teachers face when assessing students from diverse cultural backgrounds. While the situation in these countries, and even between schools in these countries, varied in many respects, it seems possible to come up with some insights to the problem of culturally responsive assessment that may be relevant—if to varying degrees—for many European countries and classrooms.

A key finding is that ‘proficiency in the language of instruction’ is the main dimension by which diversity in classrooms is perceived, explicitly discussed and processed by teachers. Contrary to the public debates in many countries, there is much less reference to ‘cultural differences’ in our case studies, probably because ‘culture’ is a much more difficult concept to handle in classroom work. However, the massive emphasis placed on ‘proficiency in the language of instruction’ is worth interrogating further.

Historically, schools have been a major instrument of supporting the idea that nations are monolingual by promoting a ‘standard language ideology, which elevates a particular variety of a named language spoken by the dominant social group to a (H)igh status while diminishing other varieties to a (L)ow status.’ (Ricento 2013 , p. 531). While the acceptance of language variety in European schools seemed to have increased in the wake of sociolinguistic research and globalisation, the contemporary waves of migration seem to be countered by a re-emergence of the ideology of monolingualism which ‘sees language diversity as largely a consequence of immigration. In other words, language diversity is viewed as imported.’ (Wiley and Lukes 1996 , p. 519).

The insistence on proficiency in the language of instruction is a variety of the concept “language-as-resource” (Ruiz 1984 ) which many teachers often implicitly and benevolently seem to subscribe to, because they want to open up participation opportunities for their students. On the other hand, there is more in languages than ‘their utilitarian benefit’ (Ricento 2013 , p. 533). Those whose language is tacitly considered secondary or openly devalued, will experience their identity, status and place in life challenged (Baker 2006 ; Blommaert 2006 ). ‘Language first’ policies Footnote 2 insisting that migrant students have to learn the language of instruction before they can participate in mainstream classes with all other students seem to reinforce monolingual attitudes in the teaching force.

‘Language proficiency’ also seems to shift the responsibility for demonstrating learning to the student and, thus, implicitly alleviates challenges for teachers which many of them experience as difficult and demanding. Additionally, it seemed that only a few teachers in our cases had been explicitly trained for teaching the language of instruction as a second language or for coping with cultural diversity in teaching, and even more so in assessment.

Secondly, while some teachers did not feel that assessment should take account of student diversity, most teachers tried to adapt their assessment procedures and grading to help students from diverse backgrounds to show their competencies and to experience success. Rarely were these responses organised and supported by school policies, institutionalised in-school teacher collaboration or regional/national policies focusing on culturally responsive assessment. More often, teachers used their educational repertoire or developed ad hoc solutions to do justice to individual students’ needs and potential.

Yet, national policies for individualisation and differentiation and in a small number of cases in-school policies on assessment and/or cultural diversity did give some limited support to individual teachers in their attempts to cope with a situation experienced as challenging by many. Overall, in most interviews, teachers did not feel well-prepared for a diverse education system either from their pre-service teacher education or from the policies and supports provided by schools or education authorities.

What are the potential consequences and recommendations to enhance culturally responsive assessment that can be drawn from this situation?

5.1 Clarifying the concept of ‘responsiveness to cultural diversity’ in the professional discourse in education

The case studies indicated that the term ‘cultural diversity’ is often avoided in explicit in-school discourse and only used implicitly to point to ‘increased difficulties’ for the teaching profession. Responding to cultural diversity is indeed a difficult concept, and it is undoubtedly in need of further clarification, in particular as it applies to classroom practice. In our view, the OECD’s ( 2016 ; Burns et al. 2017 ) work on global competence provides a formulation of culture which neither reifies ‘cultures’ as a given, nor loses itself in an incomprehensible array of customs, attitudes, artefacts, and so on. What is described is a concept of culture which does not limit students to narrow, pre-conceived perceptions but allows for the development of both the students and the culture. However, it is important to communicate such an understanding to the teaching force and the public, and to equip teachers and schools with feasible strategies for translating such an understanding into practice.

5.2 Teaching material and teaching resources are helpful for teachers, as they show teachers appropriate ways of positively engaging with cultural diversity

In many case schools, teachers reported a lack of adequate support material. On the other hand, we found other teachers pointing to appropriate and relevant resources which were publicly available but were rarely used. There is some indication that this discrepancy between support material available and used may be connected with a lack of sensitivity to the problem in general and lack of expertise with respect to intercultural and multilingual education and culturally responsive assessment. At times, this lack of expertise may also be connected with a lack of leadership, ignorance or xenophobic attitudes. Teachers with knowledge in this field seem to find adequate resources in most countries and schools and to support their colleagues in this respect. Accessible resource persons with specialised knowledge could ultimately help to enhance the schools’ expertise in this regard.

Internet- and ICT-based media may be more readily accessible to teachers who know about their existence and know how to use it. Another advantage is their potential flexibility which allows different types of use even in initially unforeseen situations (e.g. the Norwegian language support app CD-ORD is used as a translation device; NO_CS4_T2).

5.3 Professional development for intercultural competence and culturally responsive assessment is an issue in all countries

The case studies indicated that many teachers and schools have difficulties in constructively engaging with the challenges of the cultural diversity of students, and also the results of international tests strongly point in that direction (Herzog-Punzenberger, 2019 ). Nevertheless, it is not only teachers who require professional knowledge of culturally responsive education. According to an EC-commissioned study on diversity in initial teacher education, there are few initiatives in Europe to train teacher educators in linguistic and cultural diversity including responsive assessment strategies (Dumcius et al. 2017 , pp. 6870). As long as teacher educators are not well-equipped for preparing teachers to do this work, it is doubtful that adapted curricula and resource material will directly impact classroom practice. Therefore, the leadership of teacher training institutions concerning linguistic and cultural diversity is one of the most important steps towards improving culturally responsive assessment.

While there are several options for professional development concerning multicultural education and second language learning available in Austria, Ireland and Norway, their impact on the work in schools and classrooms was not entirely convincing in these case studies. New in-service formats (e.g. coaching and long-term development processes of both school policy and classroom practice; Timperley et al. 2007 ; Lipowsky and Rzejak 2014 ) are needed. Indeed, some schools were not aware of both the availability of professional development on culturally responsive practices and the need for such competences (e.g. AT_CS4_T2).

It may well be that both are necessary: relevant and accessible teaching material and professional development made readily accessible on the one hand, and a system-wide strategy which makes school leaders and teachers aware that these resources are available and that building up such competencies is part of each school’s professional responsibility, on the other.

5.4 As responsive forms of assessment are new in many cases and may vary between classrooms, students’ and parents’ understanding is essential

Significant classroom diversity usually entails that the school’s parents vary widely with respect to their expectations, aspirations, competencies and prior school experiences. While immigrant parents were in some cases characterised by low education levels and low income with vague educational aspirations (TR_CS5), there were other cases in which immigrant parents and students held high expectations and actively pursued them (AT_CS5).

For example, teachers in one school observed that some of the well-motivated parents with a migrant background were very focused on their children performing well in the state examinations and were not interested in any assessment other than tasks that prepared them for the state exams. As stated by one teacher, ‘these students just say …, just give me the notes so I can learn them off for the exam’ (IR_CS2_T2).

In any case, diversity of parent expectations may increase in a way that is not always clearly visible. As ‘justice in assessment’ and the success of students (giving the right of entry to further education and employment) are prime criteria by which parents evaluate a school’s work, it will be necessary that schools proactively work with parents if they want to introduce new forms of assessment. In Norway, primary and lower secondary education teachers are legally required to hold ‘learning development dialogues’ (similarly ‘parent-student-teacher conversations’ in Austria) with students about performance, progress and potential improvement actions at least twice a year, for which they prepare a written report on the students’ learning progress. As migrant parents may have problems in understanding the report or the overall procedure, some schools provide courses for parents on how to participate in these meetings.

In conclusion, it is acknowledged that the findings and recommendations of this study are limited by the number of cases and its exploratory nature. Sampling of countries and schools was mainly based on opportunity and did not aspire to give a full picture of the culturally responsive assessment practices in these countries. Nevertheless, we claim that we have collected insights into the thinking and practices of schools and teachers trying to engage with cultural diversity in their classrooms and how this diversity shapes, to varying and often limited extents, the teaching and assessment methodologies employed. The response in many schools and classrooms to increased diversity is still short of anything that approaches culturally responsive pedagogy and assessment, a finding which supports the outcomes of larger quantitative studies on cultural and linguistic diversity in the teaching profession and in schools (OECD 2019 ). Nonetheless, this study also, and most importantly, indicates that many schools and teachers are well disposed, on the whole, to embracing diversity and adapting assessment to being more culturally responsive. It is not a lack of goodwill but more the limitations and constraints of existing assessment policies, together with inadequate training and limited supports which are inhibiting a great leap forward in this most urgent area.

Change history

19 august 2020.

The original version of this article unfortunately contained a mistake.

The term ‘segregated’ points to a system in which parallel educational options for the same age group are in a hierarchy with respect to further educational options (e.g. access to tertiary education).

For example, in 2018/19, the Austrian government introduced separate classes for immigrant students in which they have to learn the language of instruction for one to four semesters. Students can only be mainstreamed if they pass a special language test which is administered at the end of every semester (BMBWF 2020 ).

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Appendix: Interview guidelines

1.1 information about individual schools.

Collect beforehand through webpages or in interview with headperson

Size ( N of students and teachers)

Proportion of migrant students

Location (rural)

Special features (e.g. in curriculum and history)

1.2 Questions for staff interviews

Information about interviewee: m/f, subject teacher, years of teaching experience

In your experience: Has the student composition in your school recently changed? Is there an increased/decreased number of students from minority/migration background? What minority groups do the students in your school come from?

Has this changed the atmosphere/climate in your classrooms? If yes, what kind of change happened?

How many different languages are spoken by your students?

How can teachers best cope with diversity of students? Can you give some practical examples for what you are doing to cope with diversity of students?

Is there teaching material which is helpful for teaching in diverse classrooms? Who is providing/producing this material?

How can teachers use the languages of their students as a resource in the classroom?

If you think of assessment: Are students from minority/migration background reacting differently to assessment situations?

Is it appropriate to adapt assessment situations to the needs of students from minority/migration background?

If yes, in what way assessment can be adapted? What types of assessment can be adapted, are there other types which cannot? Can you give practical examples for what you are doing to adapt assessment to the needs of students from minority/migration background?

Is there assessment material which is helpful for assessment in diverse classrooms? Who is providing / producing this material?

Are there other support measures (e.g. professional development, consultants etc.) which are helpful for teaching and assessment in diverse classrooms? Who is providing / producing support measures?

Is there special collaboration among staff with respect to teaching and assessment in diverse classrooms? What are the focus and the results of this collaboration? Is it helpful for your teaching and assessing in diverse classrooms?

Policies/strategies

Does your school have an explicit policy on assessment? Or an agreement within staff?

If yes, what are the main ideas? Is this relevant for students with a migration background? In what respect?

Does your school have an explicit policy on coping with diversity? Or an agreement within staff?

If yes, what are the main ideas?

Evaluations

In general, do you think that the knowledge and competences of students with minority/migration background are fairly recognised by the usual assessment strategies in your schools?

For what proportion of the group of migrant students in your class will academic success be possible? Why is that?

What do you see as the benefits of teaching and learning with students who have a migration background?

What do you see as the challenges of teaching and learning with students who have a migration background?

What support measures would be really helpful for coping with diversity in your classrooms?

1.3 Questions for student group interviews

Information about interviewees (collect during sampling, not in group interview): m/f, rough indicators for socio-ec background/education level/vocational background [different in different countries], migration background, function: student representative

Do you like to go to school? Why (not)? What are the good sides and the awkward sides of going to school?

How many languages are spoken by this class group?

Do you have opportunity to use all of the languages you speak?

How is assessment usually done in your class? Are there situations other than tests in which you can show what you know?

How do you experience typical assessment situations? Are they easy, difficult? Can you show to the teacher and your peers what you know?

Are teachers interested in your knowledge? Do teachers realise what you know and what you can do—not just with respect to school knowledge, but also to other knowledge acquired in non-curricular situations?

1.4 Questions for parent interviews (a selection of these question is chosen by each national team)

Information about interviewees (collect during sampling, not in group interview): m/f, rough indicators for socio-ec background/education level/vocational background [different in different countries], migration background, function: parent representative, local politician.

Do your children like to go to school? Why (not)? What are the good sides and the awkward sides of going to school? What problems do you encounter with respect to schools?

Do you observe your children growing in the appreciation and use of language?

Do you support your child with his/her school homework?

Do you know how the competencies of your child are assessed?

Is the knowledge of your children appreciated by the school?—not just with respect to school knowledge, but also to other knowledge acquired in non-curricular situations?

Do you know what measures teachers are taking to assess the competencies of all children with fairness and sensitivity?

Do you participate in school activities? Are you encouraged to do so?

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Herzog-Punzenberger, B., Altrichter, H., Brown, M. et al. Teachers responding to cultural diversity: case studies on assessment practices, challenges and experiences in secondary schools in Austria, Ireland, Norway and Turkey. Educ Asse Eval Acc 32 , 395–424 (2020). https://doi.org/10.1007/s11092-020-09330-y

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Published : 27 July 2020

Issue Date : August 2020

DOI : https://doi.org/10.1007/s11092-020-09330-y

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Understanding Cultural Diversity in Healthcare

Case Studies

See culture in action.  Case studies bring you up close and personal accounts from the front lines of American hospitals and other countries on the issues of cultural diversity in healthcare.

The following case studies are presented by topic and contain quick recaps of some common cultural misunderstandings. More detailed information can be found in Caring for Patients from Different Cultures.

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• Stereotyping
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• End of Life
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Lamar Johnson, a thirty-three-year-old African American patient had been deemed a “frequent flyer” (a term used to describe those who keep coming to the hospital for the same reason, often assumed to be drug seekers) by the nurses and doctors in the emergency department. Each time he came in complaining of extreme headaches he was given pain medication and sent home. On this last admission, he was admitted to the ICU, where Courtney, a nurse, had just begun working. When she heard him described as a frequent flyer, she asked another nurse why he was thought to be a drug seeker. She was told, “He has nothing else better to do; I’m not sure why he thinks we can supply his drug habits.” Although Courtney says her instincts told her that something else was going on, she saw his tattoos, observed his rough demeanor, and went along with what everyone else was saying. While she was wheeling him to get a CT scan, Mr. Johnson herniated and died. It turned out that he had a rare form of meningitis and truly was suffering from severe headaches. If some of the staff had not stereotyped him as a drug seeker on one of his earlier visits, perhaps his life could have been saved. This incident left a lasting impression on Courtney, who vowed not ever to judge a patient on his looks, and to trust her instincts, rather than let others influence her nursing care.

While taking a course on cultural diversity, Anike Oghogho, a nurse from Nigeria, recognized his tendency to stereotype. He related an example of an African American male patient who presented with a swollen left foot. The patient, Jefferson Bell, kept ringing the call light and asking for more pain medication. Anike said that in the past, he would have assumed Mr. Bell was merely seeking pain meds. This time, however, he reassessed the patient. He discovered that Mr. Bell’s fourth and fifth toes were more red and swollen and had pus. Anike summoned the physician and Mr. Bell was eventually taken to the operating room for incision and drainage of his left foot. Stereotyping could have severely harmed the patient; fortunately, Anike had learned the lesson of not stereotyping in his class.

Hilda Gomez, a monolingual Spanish-speaking patient, came in to the clinic three days in a row to complain of abdominal pain. The first two times, the staff used her young, bilingual daughter to translate. They then treated Mrs. Gomez for the “stomach ache” she described. The staff didn’t understand why she kept returning with the same problem. Finally, on her third visit, the nurse located a Spanish-speaking interpreter. It turned out that Mrs. Gomez needed treatment for a sexually transmitted disease, but was too embarrassed to talk about her sexual activity with her daughter as interpreter. It taught the staff an important lesson.

Helena became very frustrated while caring for Gwon Chin, a seventy-nine-year-old Korean man who had recently suffered a stroke. Her frustration and impatience were aimed at Mr. Gwon’s wife and daughter. Since Mr. Gwon spoke only Korean, she had asked his bilingual daughter to tell her father not to get out of bed because his gait was unsteady. Helena was afraid he would fall and hurt himself. Throughout the day, however, Mr. Gwon continued to attempt to get out of bed. He became very agitated and his wife and daughter seemed almost afraid of him. When Helena questioned the daughter about it, she would only say that her father was “confused.” Eventually Helena called on a Korean nurse to help her. When the nurse told Mr. Gwon not to get out of bed because he might fall, he asked in a surprised tone, “Why would I fall?” When the nurse explained that he was unsteady from the stroke, the patient was shocked. “I had a stroke?!” Helena was in disbelief. He had been on the unit for two days; how could he not know he had had a stroke? When she questioned Mr. Gwon’s daughter about this, she explained that her brother has been out of town. He would be back today and tell him. When Helena, stunned by this, asked the daughter why she didn’t tell her father, she replied, “I could never tell my father what is wrong with him and what he can or can’t do. It would be disrespectful for me to do that when he has always told me what to do and what was wrong.”

Although Helena was angry that Mr. Gwon’s daughter preferred having her father possibly fall and hurt himself than tell him why he was in the hospital and that he must stay in bed, Helena remained silent. She asked the Korean nurse to explain to the patient how the numbness on his left side would make walking difficult so he should remain in bed. She also added that his son would be in later that day and would explain everything to him. After that, the patient remained calm and stayed in bed.  [For more discussion, see Chapter 2 of Caring for Patients From Different Cultures .]

Juanita Avelar was a forty-nine-year-old Mexican woman with kidney failure and diabetes. She relied on her niece and nephew to drive her to the clinic and was often late. In Mexican culture, the needs of the family typically take precedence over those of an individual. The nurses learned to take this into account when scheduling her appointments, and they allowed plenty of time for the family to discuss Mrs. Avelar’s condition as a family. When certain tests and medications required specific timing for accuracy and effectiveness, they stressed the importance of clock time.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “ Aye! Aye! Aye ! Mucho dolor ! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez’s dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.

She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.

Bobbie, a nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony.

Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her. [For more discussion, see Chapter 5 of Caring for Patients From Different Cultures .]

Pepe Acab, a Filipino patient, was being discharged on Coumadin, a blood thinner, to prevent clotting. Vitamin K reverses the effect of the drug and must be avoided. Normally, Libby, his nurse, would tell such patients to avoid foods like liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and any green, leafy vegetables. She suddenly realized, however, that there might be other foods he should avoid. She spoke with Mr. Acab and his wife, and got a list of foods he commonly ate. She then did some research and discovered that two foods on the list—soybeans and fish liver oils—are very high in Vitamin K. She was then able to educate him properly on what to avoid.

Susi Givens, a thirty-seven-year-old woman with two children, was horseback riding one day when a snake startled her horse. She was thrown off and landed on a stump, resulting in massive internal injuries. She was rushed to the hospital, where the surgical team discovered that there was a large amount of blood in her abdomen and that she needed to have a kidney removed.

Mrs. Givens had a medical alert card identifying her as a Jehovah’s Witness and stating that under no circumstances was she to receive blood. Her physician knew this but felt impelled by his oath to save lives to give her a blood transfusion. The hospital was unable to locate her husband, so the physician decided to transfuse her.

His actions saved her life; however, she was not grateful. She sued her doctor for assault and battery and won a $20,000 settlement. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Sol and Deborah Meyers, an Orthodox Jewish couple, came to the hospital late Friday night when Deborah was in active labor. When she gave birth at midnight, the nurses suggested that Sol accompany her to the postpartum unit and then return home to rest. He thanked them, then explained that he could not drive home because it was the Sabbath. The nurses suggested that he call a friend or relative to pick him up. Sol replied that he could not use the phone on the Sabbath, and even if he made a call, no one would answer because all his friends and relatives were also Sabbath-observant. The nurses understood and arranged for him to stay in his wife’s room, but were left wondering why Sol could drive to the hospital but not drive back home.

In the morning, a nurse noticed that Deborah had not received breakfast and was instead eating snacks from the bag she had brought from home. The nurse asked if she needed help ordering food, and Deborah explained that the hospital-provided meals did not adhere to kosher dietary laws. The nurse, trying to be helpful, suggested that Sol purchase kosher food from the gift shop on the first floor, but was told that due to the laws of the Sabbath, Sol was forbidden to ride in an elevator or handle money. The nurse left the room, confused but glad the couple had brought some food of their own.  

Later that afternoon, the nurse returned to check on Deborah, and made friendly conversation by asking how the baby’s nursery was decorated at home. She was surprised to learn that in Orthodox tradition, minimal preparations are made before a baby’s birth, and the baby’s room was not set up at all. Intrigued, she asked Sol to explain some of the laws of Sabbath observance. She learned that the couple had been able to drive to the hospital because, according to halacha (Jewish law), childbirth is considered an emergency requiring the breaking of the Sabbath, but that once the birth was over, they were not allowed to drive home due to the absence of an emergency.

Raj Singh, a seventy-two-year-old Sikh from India, had been admitted to the hospital after a heart attack. He was scheduled for a heart catheterization to determine the extent of the blockage in his coronary arteries. The procedure involved running a catheter up the femoral artery, located in the groin, and then passing it into his heart, where special x-rays could be taken. His son was a cardiologist on staff and had explained the procedure to him in detail.

Susan, his nurse, entered Mr. Singh’s room and explained that she had to shave his groin to prevent infection from the catheterization. As she pulled the razor from her pocket, she was suddenly confronted with the sight of shining metal flashing in front of her. Mr. Singh had a short sword in his hand and was waving it at her as he spoke excitedly in his native tongue. Susan got the message. She would not shave his groin.

She put away her “weapon,” and he did the same. Susan, thinking the problem was that she was a woman, said she would get a male orderly to shave him. Mr. Singh’s eyes lit up again as he angrily yelled, “No shaving of hair by anyone!”

Susan managed to calm him down by agreeing. She then called her supervisor and the attending physician to report the incident. The physician said he would do the procedure on an unshaved groin. At that moment, Mr. Singh’s son stopped by. When he heard what had happened, he apologized profusely for not explaining his father’s Orthodox Sikh customs. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Ricky, a five-year-old African American male with asthma, was supposed to take a controller medication (asthma inhaler #1, Steroid) twice a day as a preventative measure. When he was wheezing and/or having breathing problems, he was supposed to take asthma inhaler #2 (Albuterol) as an emergency medication. Dr. Arabel felt that she had given very clear instructions on how to use the two inhalers, but Ricky’s mother kept bring him back to the clinic with a lot of wheezing; his asthma was obviously not being well controlled. As it turned out, Ricky had not been using the inhalers as directed. His mother, who was enrolled in school, was overwhelmed and did not understand the significance of his asthma and the need to use the two inhalers properly. On one of the visits, Dr. Arabel learned that Ricky’s grandmother had accompanied them to the clinic. She brought the grandmother into the exam room, and explained everything to her. Once the grandmother became involved, everything changed. There were no more emergency room/urgent clinic visits and Ricky’s asthma was much better controlled. He only rarely needed the “emergency” Albuterol compared to earlier. Involving the grandmother had made a tremendous difference.  [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Julia was treating Mrs. Torres, an elderly Hispanic patient who was intubated. When she needed information, she would direct her questions to the eldest son. She assumed he would be the family spokesperson. However, he rarely had an answer for her. While in many cases the eldest son would be the decision-maker, in this case he was not. The youngest daughter held the durable power of attorney for medical decisions. It was several days before anyone even thought to ask the family who held power of attorney. The staff had made the mistake of stereotyping. Once Julia learned that the youngest daughter was responsible for making medical decisions for her mother, such decisions were reached more quickly and without unnecessary strain on the rest of the family. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Juan Martinez, a thirty-six-year-old Mexican man with second-degree burns on his hands and arms, posed a problem. The skin grafts had healed, and there was now danger that the area would stiffen and the tissue shorten. The only way to maintain maximum mobility was through regular stretching and exercise. The nurses explained to Mr. Martinez’s wife that feeding himself was an essential therapeutic exercise. The act of grasping the utensils and lifting the food to the mouth stretches the necessary areas. Mrs. Martinez seemed to understand the nurses’ explanation, yet she continued to cut her husband’s food and put it in his mouth.

When Linda, one of his nurses, observed this, she took the fork out of Mrs. Martinez’s hand and told Mr. Martinez to feed himself because he needed to exercise his arms and hands. Linda again explained to Mr. Martinez’s wife how important it was for him to do it himself. Mrs. Martinez appeared skeptical but did not argue. Mr. Martinez looked at Linda peevishly and made a feeble attempt at eating. His wife watched with pity. Linda knew from seeing Mr. Martinez when his wife was not around that he was perfectly capable of feeding himself. Linda left the room. When she looked in five minutes later, she saw Mrs. Martinez once again cutting her husband’s food and putting it in his mouth. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Before taking my course in cultural diversity, Jennifer, like all the nurses on her unit, tried to avoid taking care of Naser Assharj, a middle-aged Iranian Muslim patient, because the entire staff found his family to be very “uptight and demanding.” The nurses rotated care for this patient, because no one was willing to care for him more than one day at a time. When Jennifer learned a bit about Muslim culture, however, she understood why his family kept demanding a private room and made such a fuss over his meals. It was their way of showing love and care for their family member. He needed a private room so that, as devout Muslims, the family could pray together five times a day as commanded by Allah. It was also important that his food be halal , or follow the Muslim laws of what is permissible (see Chapter 5). Once Jennifer realized this, she contacted her supervisor and arranged to have the patient moved to a private room and spoke to the dietician regarding his food. The family members were very grateful for her efforts, and became much easier to deal with.

Amira Faroud was a three-year-old Middle Eastern patient, newly diagnosed with type 1 diabetes. Understanding the importance of involving the entire family in the patient’s care, Lisa tried to get the patient’s father, Mr. Faroud, to participate. She had seen other fathers reluctant to learn in the past, but eventually, they all were persuaded. But not Mr. Faroud. He would not even consider it. Eventually, Lisa changed the teaching plan to include Amira’s grandmother rather than her father, and all went well. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

A female resident could not get a Hispanic mother to sign consent for a procedure for her child; she, too, insisted on waiting for her husband. In this case, however, it was urgent that the procedure be done as soon as possible. The resident asked an older male physician to speak to the mother. Apparently, the combination of his age and gender were enough to convince her to sign consent without speaking first to her husband.

Amiya Nidhi was a young woman in her twenties who had recently immigrated to the United States from India. She was in the hospital to give birth. Her support person was her sister, Marala. Marala kept telling her to get an epidural, but Amiya said that even though she would like one, she could not get one; her husband would not allow it. Cindy, her nurse, overheard the conversation. Having learned that husbands are the authority figure in the traditional Indian household, she went to speak with Mr. Nidhi. She explained why an epidural would be advisable. She said that he seemed pleased that she came to him about it. He said he would think about it, and let her know. About thirty minutes later, he came to Cindy and told her that he would like his wife to have an epidural. Everyone was pleased. By using cultural competence, Cindy helped her patient get the care she wanted, while still respecting the authority structure within the family. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

An Iranian mother and father admitted their thirteen-month-old child, Ali, to the pediatrics unit. After three days of rigorous testing and examination, it was discovered that Ali had Wilms’ tumor, a type of childhood cancer. Fortunately, the survival rate is 70 to 80 percent with proper treatment.

Before meeting with the pediatric oncologist to discuss Ali’s treatment, Mr. and Mrs. Mohar were concerned and frightened, yet cooperative. Afterward, however, they became completely uncooperative. They refused permission for even the most routine procedures. Mr. Mohar would not even talk with the physician or the nurses. Instead, he called other specialists to discuss Ali’s case.

After several frustrating days, the oncologist decided to turn the case over to a colleague. He met with the Mohars and found them extremely cooperative. What caused their sudden reversal in behavior? The fact that the original oncologist was a woman.

Several weeks later, it became necessary to insert a permanent line into Ali to administer his medication. The nurse attempted to show Mrs. Mohar how to care for the intravenous line, but Mr. Mohar stopped her. “It is my responsibility only. You should never expect my wife to care for it.” Throughout each encounter with the hospital staff, Mrs. Mohar remained silent and deferred to her husband. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

A twenty-eight-year-old Arab man named Abdul Nazih refused to let a male lab technician enter his wife’s room to draw blood. She had just given birth. When the nurse finally convinced Abdul of the need, he reluctantly allowed the technician in the room. He took the precaution, however, of making sure Sheida was completely covered. Only her arm stuck out from beneath the blankets. Abdul watched the technician intently throughout the procedure. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

Fatima, an eighteen-year-old Bedouin girl from a remote, conservative village, was brought into an American air force hospital in Saudi Arabia after she received a gunshot wound to her pelvis. Her cousin Hamid had shot her. Her family had arranged for her to marry him, as was local custom, but she wanted nothing to do with him. She was in love with someone else. An argument ensued, and Hamid left. He returned several hours later, drunk, and shot Fatima, leaving her paralyzed from the waist down.

Fatima’s parents cared for her for several weeks after the incident but finally brought her to the hospital, looking for a “magic” cure. The physician took a series of x-rays to determine the extent of Fatima’s injuries. To his surprise, they revealed that she was pregnant. Sarah, the American nurse on duty, was asked to give her a pelvic exam. She confirmed the report on the x-rays. Fatima, however, had no idea that she was carrying a child. Bedouin girls are not given any sex education.

Three physicians were involved in the case: an American neurosurgeon who had worked in the region for two years; a European obstetrics and gynecology specialist who had lived in the Middle East for ten years; and a young American internist who had recently arrived. No Muslims were involved. The x-ray technician was sworn to secrecy. They all realized they had a potentially explosive situation on their hands. Tribal law punished out-of-wedlock pregnancies with death.

The obstetrician arranged to have Fatima flown to London for a secret abortion. He told the family that the bullet wound was complicated and required the technical skill available in a British hospital.

The only opposition came from the American internist. He felt the family should be told about the girl’s condition. The other two physicians explained the seriousness of the situation to him. Girls in Fatima’s condition were commonly stoned to death. An out-of-wedlock pregnancy is seen as a direct slur upon the males of the family, particularly the father and brothers, who are charged with protecting her honor. Her misconduct implies that the males did not do their duty. The only way for the family to regain honor was to punish the girl by death.

Finally, the internist acquiesced and agreed to say nothing. At the last minute, however, he decided he could not live with his conscience. As Fatima was being wheeled to the waiting airplane, he told her father about her pregnancy.

The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatima’s brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, “She died.” Family honor had been restored. The ethnocentric internist had a nervous breakdown and had to be sent back to the United States.

Sofia Toledo, a sixty-five-year-old upper-class Mexican woman, refused to be dialyzed when she learned that her usual dialysis station was unavailable. She said she would wait until her next treatment, when she could have her customary place. Unfortunately, this was not a viable alternative. Missing a treatment could result in serious complications or even death. When Julia, the nurse, asked her why the new station was unacceptable, Mrs. Toledo was very vague.

Julia finally called Mrs. Toledo’s daughter, and together they solved the problem. Mrs. Toledo’s usual station was unusual in that neither the nurses nor the patients at the other dialysis stations could see it very well. The rest of the stations were very open, designed for high visibility by the nurses. To be dialyzed, the patient had to remove her pants and don a patient gown. Her underwear was exposed during the process. Mrs. Toledo’s sense of modesty, a quality very strong in Hispanic women, made the more open station intolerable.

Julia said that at the time she found Mrs. Toledo’s behavior annoying. She and the other nurses saw it as a delay that would prevent them from leaving on time. They did not want to have the extra work of moving machinery or remixing the dialysate. She did not understand the importance of modesty in Hispanic culture, but she did realize that it was important to Mrs. Toledo, a normally “compliant” patient. In this case, a screen or curtain might have alleviated the problem.

Kayla was a staff nurse on a medical-surgical floor when she first met Dr. Ling, an Asian physician. They got along well until Kayla transferred to the diabetes clinic. Clinic protocols allow nurses to order new medications, adjust medications, and order lab work as needed, as long as they get a physician to sign the order. When Kayla asked Dr. Ling for his signature, he would rudely question why she felt the medication was necessary, and on a few occasions refused to sign, stating that he disagreed with the medication she had ordered. After learning more about Asian culture in a cultural competence course, she realized he probably perceived her approach as showing a lack of respect, despite the fact that she was following clinic protocols. She then changed her approach. Rather than just asking him to sign the medication order, she would go to him, explain the situation with the patient, tell him what she was considering, and ask him what he would like done. Kayla reported that Dr. Ling was much more receptive to this approach, probably because it allowed him to feel respected and in control. Taking the extra time to do this repaired the lines of communication between them. Although it could be argued that Dr. Ling is the one who should have changed his behavior, that is probably less realistic than having Kayla apply her cultural knowledge to achieve the results that she wanted.

Josepha, a Filipina nurse, did not get along well with her coworkers. The nursing staff on her unit was composed of two Anglo Americans, two Nigerians, and Josepha. She felt her coworkers were taking advantage of her, because they would ask for assistance whenever they saw her. Josepha was angry over what she perceived as obvious discrimination. She cheered herself by reminding herself that she was a better nurse than the others; she could do her work without their help. In addition, she was not lazy like they were. She took care of her patients; the other nurses insisted that their patients take care of themselves.

One day, Rena, one of the Anglo nurses, was unusually friendly, so Josepha opened up to her. As they got to know each other better, Josepha shared her feelings of being taken advantage of. Rena explained that it was common procedure for the nurses to help each other with their work. Rena confided that the others thought Josepha was being snobbish and proud because she never asked for help. They saw what Josepha had interpreted as laziness on the part of the others as being team players. Rena also explained that American health care providers believe that independence is important and encourage self-care among their patients.

Josepha was stunned by Rena’s revelations. Rena offered to help bridge the communication gap between Josepha and her coworkers. She explained to the others that Josepha was trying to save face by never asking for help; she didn’t want them to think she couldn’t do her job. Josepha began to teach her patients self-care and to ask her coworkers for assistance. Over time, the cross-cultural misunderstandings were resolved, and Josepha’s coworkers became her best friends.

Leslie reported that her hospital had recently hired five new Korean nurses. Unfortunately, they did not get along well with the rest of the nursing staff. They rarely said “please” or “thank you” and were generally perceived as rude. Leslie was reading an earlier edition of this book and suddenly realized that the Korean nurses were older than the other nurses on the unit and probably felt that “please” and “thank you” were implicit. Leslie then showed the other staff nurses the section on “Please” and “Thank You.” She reported that morale on the unit is much improved. Sometimes, all it takes is a little understanding.

An American physician and professor, consulting in Japan, was about to address a group of university physicians; it was fully understood by all that he would give his talk in English. He nevertheless prepared a brief introduction in Japanese, concluding with the statement, “My Japanese is limited, so with your permission, I will continue in English.” When he asked his Japanese secretary if his statement was grammatically correct, she seemed uncomfortable. On further questioning she reluctantly admitted that, grammar aside, it was not appropriate for someone of his stature to ask the audience for permission, and that this would diminish the audience’s ability to respect anything else he said. Instead, she suggested, he should merely announce that he would continue in English. In this context “asking permission” was entirely pro forma in American culture; it would be seen as a polite gesture. In Japan, however, it was considered inappropriate from someone in a position of authority, and would likely result in a loss of respect for the person doing the asking. [For further discussion, see Chapter 8 of Caring for Patients From Different Cultures .]

A labor and delivery nurse reported that the most difficult patient she ever attended was Robabeh Farag, an Iranian woman, who yelled and screamed for the entire duration of her labor. After she delivered their child, her husband presented her with a three-karat diamond ring. When her nurse commented on the expensive gift, she responded dramatically, “Of course. He made me suffer so much!” Iranian custom is to compensate a woman for her suffering during childbirth by giving her gifts. The greater the suffering, the more expensive the gifts she will receive, especially if she delivers a boy. Her cries indicate how much she is suffering. A young Iranian doctor recently told me that when his wife has a baby, he will present her with a diamond ring or a watch. [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Naomi Freedman, an Orthodox Jewish woman, was in labor with her third child. She had severe pains, which were alleviated only by back rubs between contractions. Her husband asked Marge, a nurse, to remain in the room to rub his wife’s back. Because she had two other patients to care for, Marge began to instruct him on how to massage his wife. To Marge’s surprise, he interrupted her, explaining that he could not touch his wife because she was unclean. Marge, assuming he meant she was sweaty from labor, suggested that he massage her through the sheets. In an annoyed tone, he explained that he could not touch his wife because she was bleeding. Marge was further surprised when, while Naomi began pushing, her husband left the room and did not return until after their baby was born.

Marge later learned from Mrs. Freedman that in halacha (Jewish law), the blood of both menstruation and birth render a woman spiritually unclean and therefore physical contact between husband and wife was prohibited. Mrs. Freedman also explained that in some Orthodox communities, husbands are prohibited from being present at birth in non-emergency situations.

[For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Maria Salazar was a thirty-two-year-old recent immigrant from Mexico with an infected incision from a caesarean section. She asked Tonya, her nurse, for some water. When Tonya grabbed the bedside pitcher to refill it, she discovered it was full. When Tonya pointed this out to her, she answered in Spanish, “Yes, but I have a fever and a cough. If I drink that cold water I will get even more sick.” Tonya, who spoke some Spanish, was taking a course in cultural diversity at the time and was elated to see hot/cold beliefs in action. She then emptied the ice water and refilled it with warm water. Curious, Tonya asked her if there were any changes she would like to see in her treatment. Mrs. Salazar nodded her head. She said she didn’t understand why the nurses kept insisting she do things that would make her ill—things like taking a shower. Didn’t they understand she had a fever and had just delivered a baby? And why did they want her to spend so much time walking, when she knew she should stay in bed and rest as much as possible? [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Raul Santiago was a Hispanic male in his seventies who had been in the hospital for seven months. He had been admitted for abdominal pain, but it soon became apparent that he had advanced stage pancreatic cancer. Mr. Santiago had 12 children, who all conspired to avoid using the word “cancer” in front of their father or to even acknowledge his fatal prognosis. Instead, they referred to his condition as “abdominal pain.” During the time he was in the hospital, Mr. Santiago became close to the nursing staff. One day while Tiffany was administering his pain medication, he looked directly at her and said with resignation, “I’m going to die, aren’t I?” Without waiting for her to respond, he continued. He explained to Tiffany that he didn’t want his children to suffer because of his illness, and he knew that if they knew that he knew he had cancer, it would cause them great distress. He told her that he was ready to be with his wife who had died two years earlier. He was content to pretend to be ignorant of his disease if it eased his family’s suffering. Whether or not it would have caused his children to suffer if they knew he knew, or if it would have been a relief is unknown. But the nurses honored his decision.

A fifty-two-year-old African American man named William Jefferson was admitted to the critical care unit with a diagnosis of pneumonia. On admission, he was offered an Advance Directive, which he refused, saying that God would help him with his illness. His lung cancer had gone into remission after radiation treatment; he believed that God had helped him through that illness, and would help him through the current one. He thought that signing a Do Not Resuscitate form or Advance Directive would be a sign of giving up or losing faith in God. Unfortunately, he died ten days later, after enduring a great deal of suffering. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Ngoc Ly, a twenty-five-year-old Vietnamese man, was hit by a car while riding his bicycle to work. Paramedics were able to resuscitate him, but the physician at the local trauma center determined that Mr. Ly was clinically brain dead. He placed him on life support until the family could be notified.

An interpreter explained Mr. Ly’s condition to his wife and parents. They nodded in understanding and quietly left the hospital. Normally, the staff neurosurgeon would then have pronounced Mr. Ly dead and removed him from the ventilator, but he was suddenly called to surgery.

Later that afternoon, Mr. Ly’s family met with Dr. Isaacs, the physician they had spoken to earlier. Dr. Isaacs intended to tell them of the plan to pronounce Mr. Ly dead and discontinue the ventilator, but the Lys had other plans. They informed him that they had consulted a specialist who said this was not the right time for him to die. Dr. Isaacs was confused. What kind of specialist would make such a recommendation? An astrologer who had read Ngoc Ly’s lunar chart advised that his death be postponed until a more auspicious date.

The physician had never encountered a situation like the one now facing him. Fearing legal repercussions if he did not abide by the family’s request, he agreed to keep Mr. Ly on life support until further notice. A little less than a week later, the Lys called to tell him that Ngoc could now die. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Canh Cao was a thirty-four-year-old Vietnamese woman who was treated by a medical student at a public health clinic. She had made several visits for various physical complaints—abdominal pain, backache, headaches. She was diagnosed with somatoform pain disorder—preoccupation with pain in absence of physical findings.

Several months later, Cao attempted suicide. She was sent for evaluation to a psychiatrist, who at that point diagnosed her with depression. She had been depressed all along, but the medical student was both inexperienced and unaware of cultural issues, so he missed it. [For further discussion, see Chapter 11 of Caring for Patients From Different Cultures .]

Amelia avoided a potential child abuse report with a Cambodian family, the Chhets. The child had suspicious burn marks on her body. Instead of assuming child abuse, she first interviewed both parents separately. Both explained that they had treated their child using cupping and coining to make her feel better and help her recover more quickly. Amelia then explained to her supervisor what she had learned from the parents, and they decided it was not a child abuse situation. The Chhets practiced the traditional form of cupping. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Mexican American mother refused to use cooling measures in caring for her febrile infant, despite medical instructions to do so. Mrs. Lopez had called the hospital because her infant’s temperature was very high. She was told to give the baby a mild analgesic and a cool bath and then to bring her in. Mrs. Lopez ignored both cooling instructions and, to the consternation of the medical staff, brought the child wrapped in several layers of blankets, outer garments, undershirt, and several pairs of socks. When asked why she did not follow the instructions given her, she replied, “He must sweat the fever out. Besides, he could get pneumonia from the night air and die.” [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Fariba was asked to interpret for Fereydoon Jalili, an Iranian man who had come to the hospital with gastrointestinal bleeding. Mr. Jalili spoke some English, and when the physician had asked him what medications he was taking, he told him he didn’t take any. When Fariba was brought in to interpret, she began talking to him about his health. During their conversation, he admitted that he took vitamins to stay healthy and he was very proud of the fact that he had never been sick. He also mentioned that he took two aspirins a day for his heart after seeing a commercial on television which said it prevented heart attacks. When Fariba asked him why he didn’t tell the doctor about the vitamins and aspirin, he said that he didn’t consider anything he bought over-the-counter to be a “real” medication. Once the physician learned what he had been taking, he educated Mr. Jalili on appropriate aspirin consumption, since that was the likely cause of his GI bleed. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Jen, a second-year medical student, was on a pediatrics visit learning how to perform a newborn exam. As she followed the attending into the patient’s room, she noticed that the baby’s mother was sitting on the side of the crib talking in Spanish to her husband. The attending started to explain to Jen what is important to notice about a baby and what to look for on the physical exam, and proceeded to ask her questions about the causes of pneumonia and meningitis in the newborn period. As they were talking, the infant’s mother came over to the crib. In an attempt to welcome her into their conversation, Jen said “hello,” and proceeded to compliment her on her beautiful child. As soon as she finished the sentence, the mother said “thank you,” but frowned, and her demeanor changed slightly—she stopped smiling, and looked nervous.

Jen wondered what she had done wrong, and suddenly realized that the family was Mexican, and her complimentary words, intended as a tool to gain the mother’s trust, resulted in causing her distress. Remembering what she had learned about Mexican culture and mal de ojo (evil eye), she touched the baby’s hand, and looked back at the mother. The change was remarkable—the mother smiled back at her, and nodded her head. She did not say anything, but her smile and nod tacitly communicated her gratitude for preventing mal de ojo. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

An eighty-three-year-old Cherokee woman named Mary Cloud was brought into the hospital emergency room by her grandson, Joe, after she had passed out at home. Lab tests and x-rays indicated that she had a bowel obstruction. After consulting with Joe, the attending physician called in a surgeon to remove it. Joe was willing to sign consent for the surgery, but it would not be legal; the patient had to sign for herself. Mrs. Cloud, however, refused; she wanted to see the medicine man on the reservation. Unfortunately, the drive took an hour and a half each way, and she was too ill to be moved. Finally, the social worker suggested that the medicine man be brought to the hospital.

Joe left and drove to the reservation. He returned three hours later, accompanied by a man in full traditional dress complete with feather headdress, rattles, and bells. The medicine man entered Mrs. Cloud’s room and for forty-five minutes conducted a healing ceremony. Outside the closed door, the stunned and amused staff could hear bells, rattles, chanting, and singing. At the conclusion of the ceremony, the medicine man informed the doctor that Mrs. Cloud would now sign the consent form. She did so and was immediately taken to surgery. Her recovery was uneventful and without complications. . [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Emma Chapman was a sixty-two-year-old African American woman admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.”

When Judy, her nurse, asked her what she thought had caused the problem, she said she had sinned and her illness was a punishment. According to her beliefs, illnesses from “natural causes” can be treated through nature (e.g., herbal remedies), but diseases caused by “sin” can be cured only through God’s intervention. Remember, treatment must be appropriate to the cause. In addition, Mrs. Chapman may have felt that to accept medical treatment would be perceived by God as a lack of faith.

Mrs. Chapman finally agreed to the surgery after speaking with her minister, whom Judy called to the hospital. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman.

Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by her physician. Anabel, using cultural competence, asked Mrs. Salcedo’s daughter to bring in the tea. Anabel paged the physician about the remedy and brought it to the pharmacist, who researched the ingredients. Because there was nothing contraindicated, the pharmacist contacted Mrs. Salcedo’s physician, who told her she could take the tea for her pain. The next day, Mrs. Salcedo was able to go to physical therapy and was much more motivated and positive in demeanor. Although it took some time to coordinate the effort, in the end, it resulted in a better patient outcome. Had Anabel not asked what she had been using to cope with her pain, it is likely Mrs. Salcedo would have delayed physical therapy and thus her recovery.

Jorge Valdez, a middle-aged Latino patient, presented with poorly managed diabetes. When Dr. Alegra, his physician, told him that he might have to start taking insulin, he became upset and kept repeating, “No insulin, no insulin.” Not until Dr. Alegra asked Mr. Valdez what concerns he had about insulin did he tell her that both his mother and uncle had gone blind after they started taking insulin. He made the logical—though incorrect—assumption that insulin caused blindness. In this case, the patient expressed his fears, and because the physician was competent enough to pick up on them and explore them, she was able to allay them. In many cases, however, unless the physician specifically asks about concerns, patients will say nothing and simply not adhere to treatment. By asking, the health care provider can correct any misconceptions that can interfere with treatment.

A 35-year-old Jewish woman went in for a baseline mammogram.  A lump was discovered.  When discussing it with the radiologist, the woman questioned him about all the possible treatments if it turned out to be cancerous, as well as all the side effects of the treatment.  The radiologist had little patience for her questions; he repeatedly told her they should wait until after they get the results of the biopsy before they start discussing the side effects of chemotherapy and radiation.  The woman, however, felt that she had to know everything possible about the potential negative outcome; only through knowledge could she feel a degree of control.  The lump turned out to be benign, but she went into the biopsy procedure much more relaxed than she would have had she not known every possible eventuality.

A 27-year-old pregnant Mexican woman who had been living in the US for two years went to see a genetic counselor at the urging of a friend.  XFAP tests indicated the possibility of Down syndrome in her unborn child.  She declined the offer of amniocentisis, however, based upon the manner of the genetic counselor, who told her not to be afraid and to do whatever she wanted.  The patient later said she interpreted the lack of directiveness as an indication that the positive screening was “no big deal” and that if there were any real danger, the counselor would have insisted on the test.

A middle-aged Mexican female patient suffering from acute liver cirrhosis with abdominal ascites, began to experience extreme shortness of breath. The physician, a liver specialist, asked her to sign consent for an abdominal tap.  The patient refused, saying, “I am going to wait until my husband arrives.”  The physician was not happy with her response as he felt it was necessary to do the procedure as soon as possible.  Fortunately, the patient’s husband arrived within an hour, the paracentesis was done, and her shortness of breath was minimized.

An African American man in his 40s, suffering from diabetes and hypertension presented to his physician, complaining of “feeling poorly”.  When questioned, he admitted that he was not taking his insulin regularly; only when he felt that his sugar was high.

A Chinese woman in her 60s was diagnosed with cancer and scheduled to receive chemotherapy.  She was unaware of her diagnosis, due to her son’s insistence.  The staff was uncomfortable with having to withhold this information from her, so they asked her whether she wanted to know her diagnosis and why she was receiving chemotherapy medication.  Her answer was no.  She said, “Tell my son; he will make all of the decisions.”  They resolved the matter by having hersign a Durable Power of Attorney, appointing her son as legal decision-maker.  They were thus able to remove the legal and ethical obstacles to her care.

Bobbie, the nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony. Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her.

Nurses usually report that “expressive” patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while “stoic” patients often come from Northern European and Asian backgrounds. As a young Chinese man told me, “Even since I was little boy, my family watched dubbed Chinese movies, and by watching many of the male protagonists state ‘I’d rather shed blood than my tears,’ it is imbedded in my mind that crying or showing pain shows my weakness.” However, simply knowing a person’s ethnicity will not allow you to predict accurately how a patient will respond to pain; in fact, there are great dangers in stereotyping, as the next case demonstrates.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “Aye! Aye! Aye! Mucho dolor! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

Reports from the Field

Field reports are submitted by students, peers and colleagues in the healthcare profession. Do you have field report to share?   Submit it here. Thank you!

A Filipino Case Study

Patient safety and satisfaction have always been a priority in nursing, but they can be compromised by nursing priority and time constraint. With higher patient to nurse ratios, increase patient acuity, managed health care system, and higher demands for quality patient care, nurses today are working harder.   Read More

Conditions in Kenya, Africa

HE DIDN’T ANSWER

Rounds have started. I move from bed to bed with the doctors, three patients at a time. Bed 3 contains Matu, Mugambi and Karanja. Matu’s spine is beginning to curve from six weeks of clutching his knees so he doesn’t touch the cold, contaminated floor. His spot at the foot of the bed is tinged yellow. He’s 4. He was treated for malaria and discharged two weeks ago, but with no family to claim him he’s still hereŠand getting sick again.   Read More

A Case of Polygamy

This is a case of a 49-year-old Hispanic male who was involved in a motor vehicular accident while not wearing a seat belt. He suffered multiple chest injuries, fractured ribs and humerus and sustained severe subdural bleeding. He was unconscious when brought to the Emergency Department, where a trauma work-up was done. His CT scan of the head revealed severe bleeding and was inoperable. His pupils were fixed and dilated.    Read More

I was on a pediatrics visit at Harbor-UCLA hospital learning how to perform a newborn exam. As I followed the Peds attending into the patient’s room, I noticed that the baby’s mom was sitting on the side of the crib talking in Spanish to her husband. The attending, I’ll call her Dr. Gabe, started to explain what is important to notice about a baby, what to look for on the physical exam, and proceeded to ask     Read More

Homelessness in our Hometown: The Hidden Community

In today’s society a person’s worth is determined by their material possessions, the size of their home, what kind of car they drive and how well they dress. How are you viewed by society if you have nothing and live on the streets? What kind of treatment do you receive if you chose to live this way?  Read More

Cultural Incompetence

Maria was a 4-month-old Hispanic infant with a history of Down’s syndrome and an ASD/VSD congenital anomaly. After her cardiac surgery, she had several complications that resulted in a lengthy ICU stay. During that time she had two cardio-pulmonary arrests, which resulted in the need to try to contact her parents. Her parents visited infrequently due to work obligations and the need to care for their other children.   Read More

A Vietnamese Death

I was invited to do a presentation on cultural competence to the hospice staff and a large, successful, and very white hospital. As part of my preparation, I visited the in patient hospice one afternoon. At the end of my visit I sat with the nurses as they debriefed the shift. One, a leader of some sort, said that she was pleased I would talk to them since she felt that she needed to know more.   Read More

Dangerous Dominican Powder

An article in the Nov. 6, 2003 issue of the New York Times, written by Richard Pérez-Peña, reported on a highly poisonous powder sold.   Read More

• Cases on Culturally Competent Care
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A case study illustrates the problems in providing culturally competent mental health care.

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Undocumented Parents and a Difficult Birth

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A case study raising issues of culturally competent health care for a Muslim woman.

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How to Resolve Cultural Conflict: Overcoming Cultural Barriers at the Negotiation Table

Avoid cultural conflict by avoiding stereotypes when negotiating across cultures.

By Katie Shonk — on August 3rd, 2023 / Conflict Resolution

After losing an important deal in India, a business negotiator learned that her counterpart felt as if she had been rushing through the talks. The business negotiator thought she was being efficient with their time. Their cultures have different views on how to conduct negotiations, and in this case, the barrier prevented a successful outcome. In this useful cross cultural conflict negotiation example, we explore what this negotiator could have done differently to improve her negotiation skills.

Research shows that dealmaking across cultures tends to lead to worse outcomes as compared with negotiations conducted within the same culture. The reason is primarily that cultures are characterized by different behaviors, communication styles, and norms. As a result, when negotiating across cultures, we bring different perspectives to the bargaining table , which in turn may result in potential misunderstandings. Misunderstandings can lead to a lower likelihood of exploring and discovering integrative, or value-creating, solutions. Let’s talk about the main causes of cross cultural negotiation failure.

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Cultural conflict in negotiations tends to occur for two main reasons. First, it’s fairly common when confronting cultural differences, for people to rely on stereotypes. Stereotypes are often pejorative (for example Italians always run late), and they can lead to distorted expectations about your counterpart’s behavior as well as potentially costly misinterpretations. You should never assume cultural stereotypes going into a negotiation.

Instead of relying on stereotypes, you should try to focus on prototypes —cultural averages on dimensions of behavior or values. There is a big difference between stereotypes and prototypes.

For example, it is commonly understood that Japanese negotiators tend to have more silent periods during their talks than, say, Brazilians. That said, there is still a great deal of variability within each culture—meaning that some Brazilians speak less than some Japanese do.

Thus, it would be a mistake to expect a Japanese negotiator you have never met to be reserved. But if it turns out that a negotiator is especially quiet, you might better understand her behavior and change your negotiating approach in light of the prototype. In addition, awareness of your own cultural prototypes can help you anticipate how your counterpart might interpret your bargaining behavior. It’s not just about being aware of their culture, but also how yours might be viewed.

A second common reason for cross-cultural misunderstandings is that we tend to interpret others’ behaviors, values, and beliefs through the lens of our own culture. To overcome this tendency, it is important to learn as much as you can about the other party’s culture. This means not only researching the customs and behaviors of different cultures but also by understanding why people follow these customs and exhibit these behaviors in the first place.

Just as important, not only do countries have unique cultures, but teams and organizations do, too. Before partaking in any negotiation, you should take the time to study the context and the person on the other side of the bargaining table, including the various cultures to which he belongs—whether the culture of France, the culture of engineering, or his particular company’s corporate culture. The more you know about the client, the better off you will do in any negotiation.

In this cross cultural conflict negotiation example, we see that the negotiator has learned after the fact that her Indian counterpart would have appreciated a slower pace with more opportunities for relationship building. She seems to have run into the second issue: Using time efficiently in the course of negotiations is generally valued in the United States, but in India, there is often a greater focus on building relationships early in the process. By doing research on the clients cultural prototypes, they can adjust their negotiation strategy and give themselves a better chance at creating a valuable negotiation experience for both themselves and their counterpart.

As this business negotiator has observed, cultural differences can represent barriers to reaching an agreement in negotiation. But remember that differences also can be opportunities to create valuable agreements. This suggests that cross-cultural conflict negotiations may be particularly rife with opportunities for counterparts to capitalize on different preferences, priorities, beliefs, and values.

Related Article: Dealing with Difficult People – The Right Way to Regulate Emotion  – Knowing how to correctly project emotion at the bargaining table is a negotiation skill that the best negotiators have mastered. How do emotions change negotiation strategy and what negotiating skills and negotiation tactics can bargainers use involving emotions at the negotiation table? This article offers some negotiation skills advice and bargaining tips based on negotiation research.

Do you have any advice on how to solve cultural conflict? What experiences have you had that might help our other readers? We would love to hear from you.

Adapted from “Dear Negotiation Coach: Crossing Cultures in Negotiation,” by Francesca Gino (Associate Professor, Harvard Business School), first published in the Negotiation newsletter, September 2013.

Originally published 2014.

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• How to Maintain Your Power While Engaging in Conflict Resolution

No Responses to “How to Resolve Cultural Conflict: Overcoming Cultural Barriers at the Negotiation Table”

13 responses to “how to resolve cultural conflict: overcoming cultural barriers at the negotiation table”.

One should first understand cultural dynamics of the disputants. Local people should be the one to be included in the council as they are the custodians of 5he society.

One major problem most Americans have is the assumption that their way is the right way resulting in failed negotiations and cooperation. We also live and die by the clock compared to other cultures. I have been part of multiple key leader engagements (KLE) where military and civilian personnel were dismissive of cultural norms during meetings and when an impasse arose, along with running out of the allotted time for the KLE, an opportunity was lost.. I also see similar issues within the US as it pertains to gender, culture, race, etc. As individuals and groups, we need to do our homework on the environment and people were are to engage, make assessments upon arrival and be open to other view points and accept solutions that are conducive to the other person. A noticeable trait, Americans are great in the “sprint” but not so good with “marathons” in the international relations game.

Like so much in Interculturel Communications, these small anecdotal scenarios are logically analyzed, but in living color impossible to predict. Our problem is not how to introduce students to such case studies, but how to prepare young professionals for true encounters and disaster avoidance. In truth, let’s be honest…it is impossible without living it.

Perhaps one might consider diversifying negotiation teams to include more voices and perspectives from a wider range of cultural backgrounds.

Cross-cultural communication requires intercultural competence to be able to identify the underlying values behind the visible behavior observed on the negotiating table. Barriers often occur when one is trapped in own’s perspectives- as the saying goes, “we see according to what we know”.

Thanks. This is a valuable piece of discourse and very relevant to the peacebuilding initiatives/peace process in Mindanao, Philippines. I would like to think that civil society (local homegrown NGOs especially) has always been advocating this track in resolving the decades-long conflict in Mindanao (Southern Philippines) but the central government in Manila has always been calling the shots. The basic principle on Cultural Relativism in not just in the vocabulary of a unitary government. Hope to read more on this.

Like so much in Interculturel Communications, these small anecdotal scenarios are logically analyzed, but in living color impossible to predict. Our problem is not how to introduce students to such case studies, but how to prepare young professionals for true encounters and disaster avoidance. In truth, let’s be honest…it is impossible without living it.

in my opinion, as negotiator we must know that we meet all types of people from many difference cultures, it is a common sense that we must learn or adapt from others’ culture and not judge the book by its cover.

This article is very interesting, and we should admit that cross cultural negotiations are very difficult. For example, in the case where an American negotiator is conscious of the difference of culture between him and his Chinese counterpart, and thinks that he should adopt the Chinese method of negotiation, while his Chinese partner also thinks that to avoid misunderstandings he should adopt the American culture of negotiation. That could tangle up the negotiators, and could be perceived by each negotiator as a refusal to negotiate from the other part, don’t understanding that his counterpart wants to behave like him to facilitate the negotiations. To avoid this scenario, the solution could be simple. One party could at the beginning of the negotiation tell to the other that he/she will wishes that the negotiation to be made in his counterpart’s culture, to avoid misunderstandings. I really think it could greatly avoid misunderstandings, and where it appears, the counterpart will not first interpret the other’s gesture as hostile, but will first try to understand, knowing that his counterpart has expressed a real will to negotiate, and the misunderstanding is probably due to the cultural difference.By so doing, cross cultural negotiations could be eased.

This case is a filtering issue. If we see perceptions filtered through layers of personal traits, family and cultural traits everything we communicate is affect by each one of these layers. Same thing happens in the receiver side. Stereotypes are like biased filters. They tend to allow more of some “colors” than others. Still though its up to the “color” each individual emits and this can be much different from what we believe it should emit. This image probably best describes the above: http://e-negotiations.org/chapters/4-perception

Many thanks for describing and comparing all the points. They are crutial, valuable and worth to study and use in the field. Having experience I have got working for the International Criminal Court in the Hague the Netherlands with colleagues from all over the world I absolutely agree with all the information presented.

I am in agreement that it is critical to take time to study the context and the person. However, in an inter-cultural communication, it is difficult to assess the value or meaning of a specific behaviour or thoughts of the other party from your own point of view, which has been formed in a specific cultural background. That is, you see it but you do not recognized it.

I agree, please send mor articles in this feild, best

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Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients

Diversity is the one true thing we all have in common. Celebrate it every day. — Author Unknown

The 2002 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare , brought into stark focus the issues of inequities based on minority status in health care services. The IOM report concluded that, “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare” ( 1 ). Persons in racial and ethnic minority groups were found to receive lower-quality health care than whites received, even when they were insured to the same degree and when other health care access-related factors, such as the ability to pay for care, were the same ( 1 ). Clients in minority groups were also not getting their needs met in mental health treatment ( 2 , 3 ). The IOM report was a primary impetus for the cultural competence movement in health care.

Cultural competency emphasizes the need for health care systems and providers to be aware of, and responsive to, patients’ cultural perspectives and backgrounds ( 4 ). Patient and family preferences, values, cultural traditions, language, and socioeconomic conditions are respected. The concepts of cultural competence and patient-centered care intersect in meaningful ways. The IOM’s Crossing the Quality Chasm ( 5 ) document defines patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (p. 3). Both patient centeredness and cultural competence are needed in striving to improve health care quality ( 6 , 7 ). To deliver individualized, patient-centered care, a provider must consider patients’ diversity of lifestyles, experience, and perspectives to collaborate in joint decision making. Patient-centered care has the potential to enhance equity in health care delivery; cultural sensitivity may likewise enhance patient-centered care ( 6 ). Indicators of culturally sensitive health care identified in focus groups of low-income African-American, Latino American, and European American primary care patients included interpersonal skills, individualized treatment, effective communication, and technical competence ( 8 ). The U.S. Office of Minority Health has set national standards for culturally and linguistically appropriate health care services ( 9 ). The Principal Standard is that health care must “provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs” (p. 1).

Five key predictors of culture-related communication problems have been identified in the literature: cultural differences in explanatory models of health and illness, differences in cultural values, cultural differences in patients’ preferences for doctor–patient relationships, racism and perceptual biases, and linguistic barriers ( 10 ). Physicians are often poorly cognizant of how their communication patterns may vary with respect to the characteristics of the individual they are treating ( 11 ). This unconscious preconceptualization is termed implicit bias , which refers to the attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner ( 12 ). All people experience these—even those who strive to maintain a multicultural orientation and openness to diversity. Health care providers must openly reflect on and discuss issues of the patient’s culture, including ethnicity and race, gender, age, class, education, religion, sexual orientation and identification, and physical ability, along with the unequal distribution of power and the existence of social inequities, to effectively coconstruct a treatment plan that is patient centered and culturally sensitive.

Merging Cultural Competence With Cultural Humility

Cultural humility ( 13 ) involves entering a relationship with another person with the intention of honoring their beliefs, customs, and values. It entails an ongoing process of self-exploration and self-critique combined with a willingness to learn from others. Authors have contrasted cultural humility with the concept of cultural competence. Cultural competence is characterized as a skill that can be taught, trained, and achieved and is often described as a necessary and sufficient condition for working effectively with diverse patients. The underlying assumption of this approach is that the greater the knowledge one has about another culture, the greater the competence in practice. The concept of cultural humility, by contrast, de-emphasizes cultural knowledge and competency and places greater emphasis on lifelong nurturing of self-evaluation and critique, promotion of interpersonal sensitivity and openness, addressing power imbalances, and advancement of an appreciation of intracultural variation and individuality to avoid stereotyping. Cultural humility encourages an interpersonal stance that is curious and other-oriented ( 14 , 15 ).

The infusion of cultural humility into cultural knowledge has been coined competemility : the merging of competence and humility ( 16 ). Cultural competemility is defined as “the synergistic process between cultural humility and cultural competence in which cultural humility permeates each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters” ( 16 ). The competemility position allows a meaningful connection with each patient as a unique individual, with diverse perspectives, culture, and lifestyles. Cultural competemility necessitates a consciousness of the limits of one’s knowledge and the awareness of the ever-present potential for unconscious biases to limit one’s viewpoint ( 15 , 16 ).

Practicing Cultural Competence and Cultural Humility

Cultural competence, cultural humility, and patient-centered care are all concepts that endeavor to detail essential components of a health care system that is sensitive to patient diversity, individual choice, and doctor–patient connection. A culturally competent health care workforce highlights five components: cultural awareness, knowledge, skill, desire, and encounters. Cultural humility focuses on identifying one’s own implicit biases, self-understanding, and interpersonal sensitivity and cultivating an appreciation for the multifaceted components of each individual (culture, gender, sexual identity, race and ethnicity, religion, lifestyle, etc.), which promotes patient-centered approaches to treatment. The new concept of competemility is the synergistic combination of cultural competence with cultural humility. Health care professionals need both process (cultural humility) and product (cultural competence) to interact effectively with culturally diverse patients ( 17 ).

Establishing a collaborative mutual partnership with diverse patients requires an open, self-reflective, other-centered approach to understanding and formulating the patients’ strengths and difficulties and coconstructing the treatment plan. Below are tips for practicing cultural competence and cultural humility.

Get to know your community. Who lives there, and what are the resource disparities in the community? Is there a large immigrant or refugee population? What are the most common ethnicities and languages spoken? What is the climate in the community regarding cultural diversity?

• Consider whether politics or laws, such as immigration laws or a recent federal government move to eliminate protections in health care for transgender Americans ( 18 ), are adding to the stress of diverse communities.
• If you, as the physician, are a person of color, consider how that affects your practice and work with diverse patients. If you are European American, reflect on the implicit biases that may affect your practice with diverse patients and theirs with you.
• Pay attention to office practices: do they enhance an atmosphere of welcoming everyone? Are interpreter services available, if needed?
• Ask patients by which pronoun they would prefer to be addressed.
• Use a journal to jot down potential implicit biases and observations about rapport building, for ongoing self-reflection.
• Don’t assume. Ask the patient about background, practices, religion, and culture to avoid stereotyping.
• Reassure by words and actions that you are interested in understanding the patient and helping to coconstruct a plan to fit his or her needs. State upfront that this is a collaborative process and that you welcome input on the process (communicating openly with each other) and the product (treatment plan).
• Ask directly what the patient wants to achieve with the psychiatric consultation/treatment. This can help identify patient goals and treatment methods.
• A family genogram may help clarify family dynamics, cultural background, and possible generational trauma.
• Ask directly about experiences of discrimination, bullying, traumas, or harassment. Are there fears associated with minority status?
• Identify strengths, interests, and resilience factors.
• Discuss patient-centered care to determine whether this is understood or if this is an unfamiliar practice. Get patient input about collaborating in health care decisions. For patients who are accustomed to the doctor being the one making all the decisions, consider initiating a request for decisions, even small ones, to reinforce with them that you want to know their preferences and help them become comfortable with making health care decisions and communicating wants and needs.
• Inquire about what the patient feels would be helpful. Are there cultural practices or herbal remedies that they have already tried—and what was the result? Are there religious, cultural, or individual convictions that affect choice of treatment?
• Ask during the session whether the patient has any clarification of information that he or she didn’t feel the physician appropriately understood. If using an interpreter, make sure that he or she is interpreting the full discussion (and not summarizing, which loses the nuance and some meaning).
• After the session, ask the patient if he or she felt understood, if he or she understands the process, and if there is anything else he or she would like to add to be better understood.
• Model coconstruction of the treatment plan by asking about goals and helping the patient consider possible methods of meeting those goals.
• Clarify the patient’s preference for family involvement and, depending on the age and competence of the patient, what information will be communicated to the family.

Dr. Stubbe reports no financial relationships with commercial interests.

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Case Study on Cultural Differences

Cultural differences can pose problems for health care workers. In the case of Linda German, she Is faced with the decision to report a woman for child abuse, or chalk It up to cultural differences. The question shouldn’t be whether or not she should report Mrs.. State, but rather, are Mrs.

. State’s actions really considered child abuse? The answer to this can get muddled in cultural beliefs. For Americans, her actions qualify as abusive because Mrs.. State is unnecessarily causing harm to baby Marie by burning her. To the Mien culture, this is merely an act of protecting the child and ruing her from an ailment.

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It really depends on what viewpoint one looks at it from. In the Mien culture, practices like this burning ritual are commonplace. The Mien culture believes In splits and rituals that can cure ailments. To some outside of the culture, these practices may seem barbaric, but to them, some of American practices may seem barbaric as well. For example, Linda mentions the differences between burning a child and causing a child pain by giving them a shot.

Both cause the baby to cry, and to both cultures, both are considered to be helping the baby stay healthy.

To anyone outside of the American culture, American medical practices can potentially seem Just as barbaric as burning a baby. This Is directly related to cultural relatively, or “the view that practices and behaviors can be Judged only by the cultural standards of the culture in which those practices occur,” (Hagen, n. D. ).

According to David Hagen, “rejecting cultural relativity implies that there are universal standards by which the practices in all cultures can be evaluated,” (Hagen, n. D. ). If Linda assumes that Mrs..

State’s beliefs are barbaric and should be reported, she is racketing ethnocentrism, or “the view that one’s own culture Is the superior culture and therefore Its standards are the ‘universal’ ones that should be used to Judge behaviors In all cultures,” (Hagen, n.

D. ). Linda needs to decide whether her practices and beliefs are superior to Mrs.. State’s, and therefore the standard by which to compare Mrs..

State’s actions. Should Linda find Mrs.. State’s actions unacceptable in the American culture, how should she proceed? Should she report Mrs..

State for child abuse, or should she confront her In the hopes to change Mrs.

. State’s opinions concerning Mien cultural cures and medical practices? If Linda decides to confront Mrs.. State, she should probably explain to her that in America, most people would consider her actions abusive to baby Marie and that she should probably not continue to “cure” her in this manner. This poses another ethical dilemma.

By imparting this knowledge to Mrs.. State, Linda is, in a sense, assimilating Mrs.. State to American culture. How far is too far? If Mrs.

State gives up this practice, and similar ones, in order to not seem abusive to her American peers, what else will she have to give up from her culture? Land’s best options for handling the situation are to talk to Mrs.. State and try to explain the dilemma to her. She should convey that she understands the cultural differences, but that if another doctor who does not understand sees the burns, it may be misconstrued as child abuse. She shouldn’t threaten Mrs.

. State with reporting her, but should rather allow Mrs.. State to see both sides of the story, as Linda is seeing them. Hopefully, this will allow Mrs..

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