Cross–Cultural Communication
Essentials of Cultural Competence in Pharmacy
Practice: Chapter 19 Notes
Chapter Author: Dr. Kimberly Vess Halbur
Learning Objectives
1. Identify barriers to cross-cultural communication.
2. Recognize the importance of active listening in building a
trusting relationship.
3. Discuss the appropriate use and role of medical interpreters.
4. Recognize at least four models for overcoming crosscultural communication barriers.
Cross–Cultural Communication
 Skills needed to operationally carry out the attitudes and
knowledge conducive to culturally competent pharmacy practice.
 It is of paramount importance that pharmacists understand the
role culture plays in communication and are able to study and
utilize appropriate forms of communication in interacting with
 “Health care professionals assume a special responsibility in
assuring that they understand their patients in order to treat them
Cross–Cultural Communication
 Possessing a positive attitude toward cultural competence as well
as a desire to be culturally competent is a necessity. The
practitioner must also have awareness of their own culture, their
own biases and their own communication style.
 Second, knowledge is needed. To be culturally sensitive it is
important for the practitioner to understand what it takes to be an
effective member of specific cultures.
 Finally, assuring practitioners have the skills to behave with
patients in a way that promotes acceptance and effective medical
compliance is the next step. Awareness, knowledge, emotional
growth and skills are all needed to develop effective cross-cultural
 Without any one of these components there is likely to be failure.
Barriers to Effective Communication
 Communication breakdowns are “often a difference in values.”
 Numerous barriers exist that impede effective cross-cultural communication:
 lack of knowledge,
 fear and distrust,
 racism,
 bias and ethnocentrism,
 ritualistic behavior,
 assumed similarity,
 nonverbal communication,
 verbal language,
 differences in perceptions and expectations,
 evaluation tendencies,
 preconceptions and stereotypes.
Lack of Knowledge
 “The failure to understand cultural differences in values,
behaviors, and communication styles is a common stumbling
block for individuals who work in transcultural settings.
 Health care professionals who are not knowledgeable about
cultural differences risk misinterpreting clients’ attempts to
communicate. As a result, clients may not receive the proper
 When two people from different cultures meet for the first
time, they often feel threatened.
 Each party may perceive the other to be different and,
therefore, possessing deficits or representing danger.
 “People from different cultures are often suspicious of each
others’ actions and motives because they lack information.”
 When this occurs in the pharmacy practice arena,
pharmacists will need to take extra time to build trust with
their patients.
 Stereotyping is defined as making assumptions about all
people from a particular group that cannot be substantiated.
 For example, All Hispanics are late for meetings. While this may
be true for one Hispanic/Latino that you know, it is not true
for an entire cultural group.
 There is a fine line between keeping generalizations in mind
that may enhance the health outcomes for patients and
stereotyping patients due to their ethnic and cultural
Nonverbal Communication
 The second barrier to cross-cultural communication.
 Up to 70% of communication can be attributed to the
nonverbal components of communication.
 Eye contact, smiling, proximity, silence and expression of
feelings vary greatly both within and across cultures.
 In most dominant cultures in the United States, eye contact is
considered to be a sign of being forthright, honest, and
trustworthy. However, in some groups, such as Asian,
Hispanic/Latino and West Indian, eye contact may be
considered rude or intimidating, or reserved for
demonstrating respect for elders.
Nonverbal Communication (continued)
 Thus, a pharmacist who was raised to believe that people
who don’t make eye contact aren’t trustworthy may have
difficulty communicating with a patient who was raised to
believe that eye contact is rude and reserved only for elders.
 Additionally, there is wide variance in the amount of space
that is acceptable between people who are talking with one
 There are a myriad of factors that influence a person’s
thoughts, feelings and beliefs. Thus, there is much room for
cross-cultural communication to fail.
 In some cultures, demonstrating respect for authority is
important. Often, pharmacists are viewed as an authority
 Thus, a patient may agree with the recommendations of a
health care provider as a way of showing respect rather than
agreement or compliance.
 Pharmacists need to check with patients, perhaps by using
one of the models, to ensure agreement, understanding and
compliance with treatments.
Physical Contact/Touch
 Physical contact, or touch, varies greatly both within and
across cultures.
 In some cultures, physical contact is expected and seen
frequently when people greet one another. In other cultures,
such as some traditional Asian cultures, touch may be viewed
as a dichotomy between healing and private.
 Though pharmacists do not provide health care that entails
significant physical contact, it is important to understand
how patients view physical contact and touch.
Verbal Language
 The third cross-cultural communication barrier.
 In spoken English, the most common language of health care
in the U.S., nuances, slang and technical terminology are
 Technical terminology and slang, such as MTM (medication
therapy management) or ASAP (as soon as possible) are not
easily translated to people who have primary languages other
than English.
Verbal Language (continued)
 Further, the pacing and timing of language can also be
associated with communication breakdowns.
 People who utilize multisyllabic words and speak quickly are
viewed as intelligent while people who speak with
parsimonious language with a slow delivery are viewed as less
 Cross-cultural communication barriers may occur due to
differences in both cultural backgrounds and/or
communication styles of the people involved in the
 Many tools exist to assist pharmacists in communicating with
patients whose cultural backgrounds and language
proficiency may differ from their own.
Effective Communication
 Can be effectively used to combat barriers and difficulties in
cross-cultural communication.
 Pharmacists need the empathy and listening skills to view the
concerns of the patient from a different perspective or
vantage point than their own.
 Culturally competent pharmacists work to develop the
communication, counseling, and interview skills to elicit the
patient’s perspective.
Empathy and Active Listening?
 What is empathy?
You feel _________ when ______.
 How do you actively listen?
 How do you know when someone is listening to you?
 How do you know when they’re not?
Effective Communication (cont’d)
 Pharmacists need to understand the intricacies of cultural
differences with regard to verbal and nonverbal
communication to understand when behaviors cause patients
to become defensive.
 Armed with this insight, knowledge, and skills, pharmacists
can identify and recover from mistakes in cross-cultural
 Being skilled in active listening can assist pharmacists in being
effective communicators in cross-cultural interactions.
Active Listening/SOLER Skills
 In order to utilize any of the cross-cultural communication
models, pharmacists must first establish a relationship with
the patient.
 The relationship is based on the pharmacist’s ability to
establish rapport, convey respect, listen well, empathize,
build trust and provide appropriate feedback.
 One way to establish rapport is by using SOLER skills:
 Squarely face the patient,
 Use Open posture,
 Lean toward the patient,
 Maintain Eye contact (as culturally appropriate), and
 Relax while communicating with the patient.
Effective Verbal Communication
 Providing patients with examples, simplifying language and
rephrasing instructions are a few strategies that can assist in
sometimes difficult cross-cultural communication
 Pharmacists need to demonstrate respect to the patients they
serve by honoring preferences for names and titles.
 For example, some cultural groups pay more attention to
surnames and titles (Mr., Mrs., Dr.) and prefer to be
addressed in that manner.
Effective Verbal Communication
 When working with patients, it is wise to listen for feelings
as they may be an indicator of whether or not the patient
understands the conversation and/or will follow the
recommended treatment plan.
 At the conclusion of the patient meeting, the pharmacist
should provide a summary of the treatment plan.
 Pharmacists may need to sharpen their negotiation and
problem solving skills.
 Recognizing cultural conflicts regarding cultural beliefs of
health and illness and traditional health care practice assists
the health care team in developing a mutually acceptable,
culturally responsive plan for patients facing illness.
Cross–Cultural Communication Tools
Comments/Application to
Negotiate treatment
Berlin EA. & Fowkes WC, Jr.: A teaching framework for
cross-cultural health care--Application in family practice, In
Cross-cultural Medicine. West J. Med. 1983, 12: 139, 93~98
A simple, yet effective model for
pharmacists to build trust, open
communication and negotiate
treatment with patients.
Intervention agreement
Levin, S.J., Like, R. C., Gottlieb, J.E. (2000). ETHNIC: A
framework for culturally competent ethical practice. Patient
Care 34 (9), 188-189.
A mnemonic for practicing
culturally competent care that
allows pharmacists to address
folk healers and spirituality.
Stuart, M.R., Leibermann, J.R. (1993). The fifteen- minute
hour: applied psychotherapy for the primary care physician.
New York: Praeger.
A model for pharmacists to
provide brief counseling
interventions addressing
psychosocial issues surrounding
the problem.
Kleinman’s Questions
Kleinman, A., Eisenberg, L., Good, B. (1978). Culture,
Illness, and Care: Clinical lessons from anthropologic and
cross-cultural research. Annals of Internal Medicine,
A tool that pharmacists can use to
elicit the patient’s health beliefs
 One of the most frequently cited models of cross-cultural
Simple and memorable mnemonic that can easily be applied
to pharmacy practice.
In this model, a pharmacist can build a trusting relationship
with the patient by listening with empathy and understanding
to the patient’s perception of the problem.
The pharmacist then has the chance to explain his/her view
of the problem.
Once all sides have spoken and the similarities and
differences have been discussed, the pharmacist and patient
can negotiate treatment.
 Unique features inherent in this model include the attention to spirituality
and healing.
 Pharmacists ascertain how patients explain their illness, the treatments they
have tried and whether they have sought advice or help from folk healers.
 Once these issues have been addressed, the pharmacist can negotiate
mutually acceptable treatment options.
 The pharmacist and patient then work toward agreement on interventions
that demonstrate collaboration with the patient, family and traditional
 Provides useful questions that pharmacists can use to assess
psychosocial factors.
 Allows the pharmacist to understand the context and
significance of the problem, the patient’s mood, how the
patient is handling the problem and provides direction for
intervention all while supporting the patient’s needs and
Kleinman’s Questions
Eight questions designed to elicit patients’ health beliefs:
 What do you think has caused your problem?
 Why do you think it started when it did?
 What do you think your sickness does to you? How does it work?
 How severe is your sickness? Will it have a short or long course?
 What kind of treatment should you receive?
 What are the most important results you hope to receive from this
 What are the chief problems your sickness has caused for you?
 What do you fear most about your sickness?
Working with Medical Interpreters
 Pharmacists need to understand and glean skills in effectively
working with interpreters.
The 1990 Americans with Disabilities Act provides for interpreter
services, including sign language interpreters.
Pharmacists need to understand the process for obtaining
Professional interpreters should be used when translation is
needed, as friends or family members may be reluctant to discuss
certain issues.
Family or friends who serve in the role of interpreter may edit
information and/or protect the patient from bad news.
Friends or family members acting as interpreters are a direct
violation of the patient’s confidentiality.
Culturally Competent Pharmacy Practice
 Treat all patients as people first. Assume that all interactions
with patients are cross-cultural, but may not be cross-racial
or cross-ethnic. Utilize the information you have about
patients’ cultural backgrounds as untested hypotheses.
Utilize the generalizations about health, values and behavior
as questions, not facts.
 Engage patients in your learning about how culture should be
considered within the context of pharmacy practice. Attend
to those aspects of a patient’s cultural history, values and
lifestyle relevant to your work as a pharmacist.
 Know your own attitudes and skills in working with patients.
Understand your own views on assimilation and cultural
 Keep in mind that there are no substitutes for good attitudes,
knowledge, skills, empathy, caring, and a sense of humor.
Reflection Questions
1. As you consider the various communication models,
which do you find most appealing? Which are least
2. In reviewing the SOLER model of active listening,
which components do you do naturally? Which areas do
you need to grow in?
3. How prepared do you feel to work with an interpreter?
What steps can you take to improve the necessary

Cross Cultural Communication