Cultural Background

Working and studying in another country within the European Union (EU) is encouraged which has contributed to an increased migration significantly in recent years. The EU has set up the Erasmus program to encourage student exchanges with foreign countries. THIM has also recently received accreditation for student exchange with other countries through this Erasmus program. This means that it is possible for THIM students to study abroad for some time.

Whether through international work or within the multicultural societies where many clinicians live and work, physiotherapists are exposed to cultures that differ from their own. While we like to think our therapeutic concepts are universal, each culture has a different understanding of the body, health, illness, and healing. Cultural competence, the ability to work in cross-cultural situations, has been acknowledged as a core skill for physiotherapists and other health professionals. As a culturally competent physiotherapist you recognize, respect and respond to individual needs, and adapt your practice accordingly. Understanding and reflecting on your own culture including the underpinning values and beliefs that contribute to it, is the starting point for the process of acquiring cultural competence.

Differences in cultural background can also exist in cultures that are perceived to be very similar, for example Switzerland and the Netherlands. In general Dutch people tend to experience Swiss people as very friendly and polite, but more reserved and introverted. The Swiss may experience the Dutch as open and easy-going, yet also as very direct and sometimes thoughtless. Also, where the physiotherapist in the Netherlands is seen more as a coach who guides people, in Switzerland he is seen more as a practitioner who treats people. There are differences between the health organization of both these countries too. For example, in the Netherlands, in contrary to Switzerland, there is direct access to physiotherapy. Direct access physiotherapy has been defined to the situation in which physiotherapy services are available directly to patients and they can refer themselves to a physiotherapist without having to see a physician first. In Switzerland there needs to be a referral from the physician to see the physiotherapist.

Mostly, people are not consciously aware how their own cultural background influences their perceptions and actions. However, the awareness of one's own cultural values and beliefs is important to understand the vision of another. This is referred to as cultural sensitivity. Cultural sensitivity is the ability to perceive cultural differences through an open attitude, behavior, and communication. It is important that caregivers are aware of, and take into account the cultural aspects of the patient on the one hand, and on the other hand are aware of their own thoughts and feelings, experiences, and cultural background that may influence the patient.

THIM University is curious about its students’ cultural sensitivity. Therefore seven first year students of THIM-NL and five of THIM-CH were interviewed by peers on this topic.

What kind of barriers could there be due to culture differences?

The main barrier mentioned by students was communication. ‘People might speak different languages’. But also other forms of communication were named, such as non-verbal communication: ‘for example in Bulgaria nodding the head means no, and shaking the head means yes. Quite the opposite of how we would perceive that. That can create a lot of confusion’. Other students think that the approach to communication can differ between countries. Some are more preserved or introvert, while some are more direct: ‘We Dutch are direct and straightforward, which is not always easy for other cultures’.

Another barrier often named by students is religion: ‘for example, in physiotherapy there can be a difficulty if a male physiotherapist treats a woman with a religion in which it is unusual to remove the cloths in front of another man than her husband, or get touched by him’. The physiotherapist needs to be very sensitive to the feelings of a patient. He or she might feel uncomfortable, but might also be less direct in saying so. ‘We as physiotherapist need to be sensitive for, and capable of, adapting to our patients and their thoughts or believes and we need to adjust everything that we do to that’. This is, according to a student, not only bound however to religion: ‘for example if you treat a woman than you might act differently than you would if you treat a male patient’.

Touching one another is, according to the students, not only based on religion but also on culture itself: ‘in Swiss we are very formal, we won’t touch someone. First we have to ask if they’re okay with it. Here, the Swiss people want to know what will happen next, so we don’t touch them directly’.

Thereby, also certain therapy methods would be more or less accepted by different cultures: ‘for example, countries in Africa might prefer the old traditional method by healing people with rituals because that’s their inherited culture, where they probably never learned a western treatment’. These therapy methods probably won’t be very popular with the health insurance companies in the Netherlands or Switzerland.

What is important in the treatment of a person from another culture?

Most students agree, this is respect: ‘respect towards every client, independent of religion, gender or culture’. One student adds: ‘with respecting the other, you will gain mutual respect’. Also, ‘being open to other cultures and accepting them’ is often mentioned by students.

Communication is key here according to the students: ‘by communicating you will know your patient values, which will make her/him feel more comfortable’. One student adds: ‘it is very important that the client knows what he or she can expect’. ‘Shared decision making’ is mentioned as an important element to do so.

According to the students it is important that the patient feels comfortable: ‘he should understand you and agree with what you’re doing all the time’. In that ‘listening well to the patient’ and ‘being sensible and empathic’ plays an important role in making them feel comfortable. This increases ‘trust in the physiotherapist’. Considering all the above, according to a students: ‘people underestimate how difficult it is to be a good physio’.

One student adds that ‘it can be a great learning experience to work with people from other cultures and you might learn things that you can apply in your own treatment’. Therefore, acquiring intercultural skills during education is of great added value.

Some students however keep it simple:

- ‘Well I guess, what is most important, is getting the problem solved. So as long as you do that, the approach is always right.’

- ‘It is important to do the treatment on the right part of the body. If you have a treatment on the shoulder, make sure you only do the shoulder’.

Have you thought of studying abroad? Why/ why not?

At THIM-NL there is an international class with students who moved to the Netherlands to study here. Amongst the students that were interviewed, two are from this international class. One of these students says: ‘it is not easy to leave your home but it can be a very good chance to take, and I am really glad that I did it’. Another student mentioned: ‘I wanted to move to another country since I was 10 years old, but I promised my parents I would always be back for Christmas’.

Most Dutch students have an interest in studying abroad for a while. To quote one student: ‘yes, I would love the idea of studying abroad and learn about different cultures and countries. I lived in the Netherlands for like 21 years and it’s boring always being in the same country. But on the other side I am also scared to go because I’m afraid that I won’t make friends and fit in. And I really like our culture and our food. I don’t like the food in other countries except the Italian cuisine. But I’m also afraid that, when you get your diploma abroad in another country, the diploma is not certified in your hometown. And of course I would miss my family and friends’.

Students appreciate the opportunity to get to know different cultures: ‘through the experience of living with people from a different culture, you can be learn to be more open to ‘other’ ideas’. However, not all students would want to go far. One Dutch student thought about studying abroad: ‘but when I say abroad, I mean Belgium due to the fact that then there would be no language barrier’.

From the five Swiss students interviewed on this topic, only two would consider this. Although they think this would be an asset to their personal and physiotherapeutical development, they would miss out too much at home or ‘would be a bit anxious’. Or, to quote another Swiss student: ‘Swiss are really shy to live on their own in another country and they feel very uncomfortable trying to learn other languages and other type of culture. However, studying abroad can also give them a fresh perspective of the other side of the world and it forces them out of their comfort zone to learn the different types of cultures’.

How do you get information about the culture of your patient?

Students acknowledge that the best way to get information about the culture of the patient is to ask them. However, the physiotherapist needs to be sensitive to whether this is acceptable for the patient: ‘it should not be like an uncomfortable questioning’ Another student adds: ‘you shouldn’t ask everything, you still need to respect the privacy from the client. You need to check if the patient is comfortable with answering the questions. If not, you’d rather stop, and you’ll see how it goes’. This supported by a third student: ‘it is important to ask your patients respectfully about their beliefs and try to avoid stereotyping based on religious or cultural background’.

Also, students mention the internet as a way to get information of the background of the patient. To quote one student: ‘I would use google because I use google for everything, because you can find everything. ”I love google”. I would compare different websites and take the information’.