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  1. Hydes, Dawn MSN, RN, CGRN, CNOR, ENB

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AS A VETERAN OR NURSE, I considered myself to be culturally sensitive before my first trip to Baghdad in 1985 during the Iran-Iraq war. Leaving the cold, wet English weather for 2 years to work in and explore a country with a diverse culture and history appealed to my sense of adventure and desire to know more about the world. I'd received several months of education from the Ibn Al Bitar hospital on Muslim culture, the Arabic language, and daily life and work in Baghdad. I'd never worked in the Middle East before, and I was a novice to this culture. This article describes my experience with cultural competence in a foreign country.

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Upon arrival

Along with other nurses from England and Ireland, I was escorted through customs by two armed guards as activity buzzed about us. We walked through a kaleidoscope of people and colors onto the hospital bus and were welcomed by one of the supervisors.


Entering my new apartment, exhausted from the long journey, I drifted off to sleep listening to the first call to prayer by the Muezzin from the minaret of the mosque. The low rhythmic chant echoed through the humming city. I'd arrived safely at my new home in the Middle East.


Familiar job, foreign country

The hospital was staffed by personnel from several countries in Europe, Asia, and the Middle East, creating a culturally diverse atmosphere. There was a sense of camaraderie within the hospital. My colleagues soon became my friends, and their companionship lessened my homesickness as I adjusted to life in Baghdad. Having learned to speak a few words of Arabic, I could converse a little with patients and family members during their time in the OR and recovery. It was a new world, but I was adapting well.


One of my patients, Khaled,* 45, an Iraqi man with cachexia, came to the hospital complaining of acute abdominal pain, nausea, and vomiting for several days. He came from a poor, dysfunctional family with limited literacy. He'd left school at 16, drifting from one low-paying manual labor job to the next. Eventually, he turned to selling and using drugs for several years, which impaired his health. Already diagnosed with hepatitis B, he was admitted to the medical unit for stabilization, pain management, and further evaluation.


Breaking through language barriers

Khaled often hid under the blankets to avoid communication with nurses and physicians. When he did communicate, he was usually verbally abusive. After refusing to provide informed consent for an esophagogastroduodenoscopy (EGD), he was labeled "noncompliant" by the physician.1,2 As the surgical nurse involved in his procedure, I went to visit Khaled after reviewing his medical record.


Entering the room with an interpreter, I found Khaled curled up in a fetal position under the blankets, his face barely visible. After introducing myself, I asked if he'd discuss his treatment with me. At first he was silent and just stared at us. Although it was an awkward situation, I sensed this man needed to be cared for.


The hospital's air conditioning worked erratically, so although it was 110[degrees] F (43.3[degrees] C) outside, Khaled's room felt like the inside of a refrigerator. I asked if he was cold, and he replied "Yes" in Arabic. I turned down the air conditioning and brought him some additional blankets. At that moment, Khaled became very emotional and started to cry. When I asked him what was wrong, he said I was the first person who had been kind to him.


This was a moment that needed to be respected. Muslim men are customarily stoic, rarely sharing their emotions with others. I gave Khaled his space, allowing him to compose himself. I knew that expressing these emotions to a stranger must have been difficult, and I didn't want to overstep my boundaries, possibly causing him to shut down again.


After giving him time to relax, I asked Khaled if he'd tell me about his pain in his own words. Khaled described it as sharp and knifelike. He was frustrated and angry that he had to use the call bell several times before the nurse would come to assess him, then wait "a long time" before he was given pain medication.1


Easing the pain

Khaled rated his pain between 7 and 8 on a 0-to-10 pain intensity rating scale. He felt the nurses and physician treated him like a leper. They may have treated him poorly because of his history of drug abuse. Many studies have shown that minority groups and known drug users often receive inadequate pain management.1,3


Khaled's issues related to his pain control, a major obstacle to his care, were disturbing to me. I discussed my assessment with his primary nurse and a plan of care was formulated to optimally manage Khaled's pain. I hoped that being proactive in Khaled's care would make him more comfortable and give him a chance to rest. This, in turn, might help him feel more willing to review his treatment with the physician the next morning.


The following day, Khaled consented to the EGD and was diagnosed with a duodenal ulcer. He continued treatment in the hospital for the next week before being discharged home.


Improving cultural competency

Khaled forever altered my views on patient care, making me a more culturally sensitive person and nurse. I'd come from a country with diverse cultures and its own ethnic tensions. But even in England or the United States, Khaled might have faced some of the same issues arising from a lack of cultural sensitivity on the part of the caregivers. Nursing education programs didn't elaborate on cultural diversity during the late 1970s; I was naive regarding the importance and methods of supporting different cultural populations with their unique healthcare requirements. Being immersed in a diverse culture and receiving education on cultural competence enabled me to become a more capable and proficient nurse.


Although I believe this issue is being addressed better in nursing education today, my experience makes it clear that understanding different cultures can only improve patient care.4 As I reflect on my nursing career, I'm grateful that I've had the chance to live in another country and observe the richness and diversity of different cultures. Greater understanding allows nurses to care for the patient rather than the stereotype.




1. Taylor AL, Gostin LO, Pagonis KA.Ensuring effective pain treatment: a national and global perspective. JAMA. 2008;299(1):89-91. [Context Link]


2. Notcutt W, Gibbs G.Inadequate pain management: myth, stigma and professional fear. Postgrad Med J. 2010;86(1018):453-458. [Context Link]


3. Anderson KO, Green CR, Payne R.Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187-1204. [Context Link]


4. McFarland M.Madeleine Leininger: culture care theory of diversity and universality. In: Alligood MR, Tomey AM, eds. Nursing Theorists and Their Work. 7th ed. Maryland Heights, MO: Mosby Elsevier; 2009. [Context Link]


* The patient's name is fictitious. [Context Link]