Culture shock and healthcare workers in remote Indigenous communities of Australia : what do we know and how can we measure it ?

Introduction: Culture shock or cultural adaptation is a significant issue confronting non-Indigenous health professionals working in remote Indigenous communities in Australia. This article is presented in two parts. The first part provides a thorough background in the theory of culture shock and cultural adaptation, and a comprehensive analysis of the consequences, causes, and current issues around the phenomenon in the remote Australian healthcare context. Second, the article presents the results of a comprehensive literature review undertaken to determine if existing studies provide tools which may measure the cultural adaptation of remote health professionals. Methods: A comprehensive literature review was conducted utilising the meta-databases CINAHL and Ovid Medline. Results: While there is a plethora of descriptive literature about culture shock and cultural adaptation, empirical evidence is lacking. In particular, no empirical evidence was found relating to the cultural adaptation of non-Indigenous health professionals working in Indigenous communities in Australia. In all, 15 international articles were found that provided empirical evidence to support the concept of culture shock. Of these, only 2 articles contained tools that met the pre-determined selection criteria to measure the stages of culture shock. The 2 instruments identified were the Culture Shock Profile (CSP) by Zapf and the Culture Shock Adaptation Inventory (CSAI) by Juffer. Conclusions: There is sufficient evidence to determine that culture shock is a significant issue for non-Indigenous health professionals working in Indigenous communities in Australia. However, further research in this area is needed. The available


Introduction
Culture describes the collective way of life, values, morals, language, world views, and patterns of behaviour of a group of people.It includes what they think, say, do, believe, and make, and is like a learned template for living (p48) 1 .'Culture shock' is the general term used to describe the stress, anxiety, or discomfort a person feels when they are placed in an unfamiliar cultural environment, due to the loss of familiar meanings and cues relating to communication and behaviour [2][3][4][5] .Recently, the term 'cultural adaptation' has been used to highlight the possible positive outcomes of well-managed culture shock, such as personal growth and development 4 .
The phenomenon of culture shock has been linked to poor retention rates of remote area healthcare professionals and to the quality of health care in remote communities 6 .The general stress experienced by healthcare workers itself is also a likely contributor to high turnover rates in these areas 7 .The turnover of healthcare professionals in remote areas is high.For example, the turnover rate of nurses and midwives employed in remote health in the Northern Territory is estimated at 57% per annum (p32) 8 .High turnover is costly to the government 8 , and has a detrimental effect on the health care and social development of remote communities.Retaining a highly-trained and effective healthcare workforce is important in providing quality, accessible health care to people living in these areas.While there have been many studies conducted on culture shock in the context of international business people, students, and volunteers, there is little known about the situation of non-Indigenous people working in remote Indigenous communities in their own country.This article is presented in two parts.The first part provides a thorough background in the theory of culture shock and cultural adaptation, and a comprehensive analysis of the consequences, causes, and current issues around the phenomenon in the remote Australian healthcare context.This is important as the literature relating to culture shock and cultural adaptation in Australian rural and remote health is limited, and this section also provides a background for the literature review.Second, the paper presents the results of a comprehensive literature review undertaken to determine if existing studies provide tools which may measure the cultural adaptation of remote health professionals.The literature review also evaluates the need for further research in this area.

Culture shock, cultural adaptation
Culture shock can affect many different types of people in cross-cultural situations, including tourists, immigrants, refugees, and 'sojourners' such as international business people and international students.Sojourners are 'betweensociety culture travellers' whose stay in the host culture is temporary, and who have the intention to return to the culture of origin after their stay (p6) 3 .The term 'culture shock' was first coined by the anthropologist Kalvero Oberg in 1954, who described it as 'the anxiety that results from losing all our familiar signs and symbols of social intercourse' (p177) 2 .Oberg and other early writers likened culture shock to a form of occupational disease which could probably be cured.More contemporary explanations describe culture shock as a learning experience, which can have positive outcomes for personal growth and development.The most recognised of these scholars is Peter Adler, with his 'transitional experience' theory of culture shock 4 .These contemporary explanations often refer to culture shock as 'cultural adaptation', in line with the view that positive outcomes of the process can be achieved.Although Oberg's 'disease' model has been largely rejected (p4-7) 5 , his 'stage theory' of culture shock continues to be drawn on today.Other scholars such as Pedersen, Smalley, and Eckermann 4,5,[9][10][11] have re-named the stages, although they remain consistent with Oberg's original model.
According to the stage theory, there are 4 stages of culture shock that an individual will experience, which are outlined below.
The first stage is the honeymoon stage, also known as the fascination, elation, or exploration stage.This is where the individual feels a sense of euphoria, excitement, and enthusiasm.Conflict or problems arising from missing cultural cues and cultural misunderstandings are seen as minor or amusing, and as part of the overall 'adventure'.
Oberg's second stage has been referred to as the rejection, hostility, frustration, or disenchantment stage, and is when the culture 'shock' begins to set in.It is in this stage that language barriers and the misunderstanding of cultural cues begin to cause trouble for the visitor, who develops a 'hostile and aggressive attitude' (p178) 2 .During culture shock, the visitor is likely to find the experience 'bewildering, confusing, depressing, anxiety-provoking, humiliating, embarrassing, and generally stressful in nature' (p171) 12 .They will reminisce about their home culture and are likely to become judgmental and use stereotyping.Some people will leave at this stage, returning to their home culture without overcoming culture shock.
The third stage has been described as the adjustment, recovery, coping, or beginning resolution stage.Here, the visitor begins to form a more balanced and open-minded view of the other culture.While they still struggle in some instances, they begin to understand and cope with many previously impossible day-to-day situations, and to develop relationships with people in the host culture.
Oberg's final stage is where the individual becomes accustomed to the other culture, and has been called the biculturalism, acculturation, or effective functioning stage.This is the goal or ideal state for a visitor in another culture.While small disturbances relating to differences in culture can occasionally arise, the person can function as effectively and productively as they did in their own culture, or close to it.The beliefs and values of the other culture are accepted as a valid and acceptable way of living.
For the purposes of this article, the four stages of culture shock will be referred to as the honeymoon stage, the rejection stage, the beginning resolution stage, and the effective functioning stage.Oberg's stage theory was used by Lysgaard in 1955 to develop a 'U-curve' hypothesis 13 .
The U shape follows the line of adjustment as an individual moves through the stages, from the 'high' honeymoon stage, down through the 'low' rejection stage, and eventually back up to the 'high' effective functioning stage.This U-curve was expanded into a 'W-curve' by Gullahorn and Gullahorn   in 1963, to include the second 'U-curve' that an individual experiences when they return to their home culture 14 .This theory suggests that sojourners will experience reverse culture shock when they return to their home country as they have learned to adapt to the new host culture.

Culture shock in healthcare workers in remote areas of Australia
For the purposes of this article, 'remote' will be defined as those areas which are located in the Australian Standard Geographical Classification -Remoteness Areas (ASGC-RA) 4 and 5, or the 'Remote' and 'Very Remote' areas, as identified by the Australian Bureau of Statistics 15 .Most communities within these Very Remote Areas have a majority Indigenous population 16 .
Culture shock experienced by healthcare workers in these communities can have a potentially detrimental effect on the delivery of quality healthcare services to Australians living in these areas.In his book Why Warriors Lie Down and Die, Trudgen explains the 'two-edged sword' effect of culture shock in communities 6 .First, healthcare workers experiencing culture shock will leave the remote area, taking away medical expertise and increasing staff turnover.Second, the remote community's development is compromised as Indigenous people lose faith in the healthcare system.These two major consequences of culture shock on non-Indigenous workers in remote Indigenous communities are examined below.
According to Trudgen, the high turnover of health professionals in remote Indigenous communities is a 'serious, perennial condition affecting all aspects of community and regional development', which is very costly to governments (p178) 6 .The total annual cost of nursing workforce turnover for the Department of Health and Families in the Northern Territory is estimated at over AU$6.8 million, with the average cost per turnover for a nurse estimated at about $10,000 (even higher in the remote sector) (p97) 8 .It is unknown to what extent the high staff turnover experienced in remote areas of Australia can be attributed to culture shock.However, we can surmise that the negative aspects of culture shock could undermine a worker's ability to function effectively and perform their tasks successfully.This could make it difficult for them to move into the effective functioning stage, or contribute to their decision to leave the community.
Non-Indigenous healthcare workers beginning work in remote Indigenous communities enter 'cross-cultural contexts involving many… cultural complexities' (p89) 17 , working among people from a culture which is markedly different to their 'white' culture, who speak a different language, and have different customs, values, beliefs, rituals and practices.They are also likely to have different ideas about health and wellbeing.Not only is the culture in their new workplace different, but they also have to adapt to living in a very remote area, where both medical and other resources are limited.Training, orientation, and support programs are often limited or non-existent, and generally fail to adequately prepare the healthcare professional for their new role in the community 18,19 .Non-Indigenous healthcare workers operate within and between two 'distinct cultural spaces' and negotiate the demands of their own culture and profession with those of the Indigenous community (p514) 18 .
Overseas trained doctors play a significant role as GPs in Indigenous health 20 , and are required to navigate at the intersection of three cultural spaces -the Indigenous culture, the Australian healthcare system culture, and their own culture 18 .Healthcare workers operating within these differing cultural paradigms are highly susceptible to the negative aspects of culture shock as they experience cultural dissonance and conflict, potentially leading to stress, burnout, and ultimately a poor rate of staff retention.
Culture shock not only affects individual healthcare workers, but can also have a significant impact on the community itself.The negative encounters experienced by clients of healthcare services can lead to distrust of the system and hostility towards future non-Indigenous employees.Non-Indigenous workers experiencing culture shock do not work to their full potential, and are often stressed and irritable 6 .Due to a lack of training, it is often also the case that these workers cannot communicate effectively with their patients due to language and cultural barriers (pp120-127) 18,21 .
Communication is a major issue in the successful employment of non-Indigenous people in remote communities 6,9,[22][23][24] .Aside from the frustration this causes to the healthcare worker, poor communication is identified as 'one of the major negative aspects' of the hospital or health clinic experience for families from remote areas (p5) 23 .
Trudgen argues that workers who are not trained and are therefore affected by culture shock cannot effectively pass on their skills and knowledge to Indigenous workers in the community.This in turn marginalises the Indigenous workforce and 'kill[s] dreams of self-management and selfdetermination' in Indigenous communities (p232) 6 .

Cultural distance and other variables affecting culture shock
It has been well documented that 'cultural distance', or the degree of difference between the home culture and the host culture, plays a significant role in affecting the level of culture shock an individual will experience 3,12,[25][26][27][28][29] .The greater the cultural discrepancies between the home and host culture, the greater the psychological stress will be on the sojourner.They will experience a 'greater intensity of life changes during cross-cultural transition and, consequently, more acculturative stress' (p95) 3 .One of the most wellknown researchers on culture is Geert Hofstede, who in 1980 conducted a survey into the national culture differences of IBM employees in subsidiaries across 64 countries 30,31 .He found that national cultures had similarities and differences which enabled them to be grouped into different categories or 'cultural dimensions', the most eminent and notable dimension being the Individualism category 32 .Individualist generalisation of national cultures 35,36 .However, it is a useful tool to compare the major differences between European Australian and Indigenous Australian cultures which will have an impact on the cultural distance experienced by those in cross-cultural situations.
Apart from this cultural distance factor which can affect the degree of culture shock experienced by individuals in another culture, there are many other factors which influence the severity of culture shock.In his article Sojourner Adjustment, Church argues that the severity of culture shock experienced by a sojourner in another culture is dependent on both individual/personal factors and situational/structural factors 28 .Individual factors include language proficiency, prior experience in other cultures, and personality traits.
Situational factors consist of job conditions and satisfaction, the presence of colleagues, and positive social interaction with locals.
Other factors affecting the level of culture shock and psychological distress experienced by an individual are put forward by Ward et al in their book, The Psychology of Culture Shock 3 .These include the time span of the interaction, the frequency of contact with people from the host culture, and the degree of intimacy of cultural contact.The factors affecting the severity of culture shock and their relevance in the remote healthcare context are outlined below (Table 1).Very high: Individualist dominant cultures and collectivist Indigenous cultures (and cultures in transition) [30,31,33] Job conditions and satisfaction [28]  Not always high, due to pressure, lack of resources, lack of training, and remote location [7,37,38] Presence of colleagues [11,39]  Not always, and colleagues are not always positive or functioning effectively [6,7] Clearly defined job roles [39]  Quite often remote health care workers take on advanced responsibilities due to understaffing [7,37,40], and adopt multiple conflicting job roles [41]  Positive social interaction with locals [28]  Not always possible due to negative encounters experienced by patients in the past, resulting in suspicion and hostility [23]  Time span of cultural interaction [3]  Relatively extended -at least a few months Frequency of contact with people from host culture [3] Constant while living in the remote community SITUATIONAL / STRUCTURAL Degree of intimacy of cultural contact [3]  Usually high -healthcare workers and patients Language proficiency/ communication skills [9,22,28,42]   New healthcare workers not familiar with local Indigenous language, often due to lack of appropriate training [6,11,18]  Prior experience in other cultures [28]  Dependent on the individual

INDIVIDUAL / PERSONAL
Personality traits [28]  Dependent on the individual Based on the above factors, it can be argued that the culture shock experienced by non-Indigenous health workers in remote Indigenous communities of Australia is likely to be substantial.In particular, the great degree of cultural distance between the two cultures makes it difficult for these workers to adjust to the new culture and workplace without experiencing significant psychological distress.Along with the advanced responsibility taken on by healthcare workers due to understaffing and extended roles 37,40 , the potential for severe culture shock is huge.This may help to account for the high turnover rates of remote healthcare workers, and indicates the need for a solution.
Part 2: Literature review Despite the abundance of descriptive literature around the topic of culture shock, there is a significant lack of empirical studies in this area.Numerous researchers have noted 'how little empirical work there has been done in the area of culture shock and crosscultural adaptation processes' (p5) 43 .There has been little attempt to 'measure the phenomenon, or even to validate the concept empirically… [and] there are many assertions… that need to be investigated scientifically' (p149) 29 .
Measuring the phenomenon of culture shock is important to enable organisations to support workers through the second  Article abstracts were reviewed by the primary author, and the articles which met the first 5 selection criteria were retrieved, that is those English-language studies on adults which included empirically-based evidence relating to culture shock and cultural adaptation in sojourners.The reference lists of these articles were searched by the primary author for further appropriate articles which were located using CINAHL, Ovid Medline, ProQuest Central, and Science Direct.Author searches were conducted to ensure all potential sources had been located.All authors reviewed the remaining articles and came to a consensus regarding their suitability to the final selection criteria.

Results
A total of 15 articles provided empirical evidence to support the concept of culture shock (Appendix I).Of these, eight focussed on the factors influencing the severity of culture shock and the nature of the culture shock phenomenon 12,25- 27,42,44-46 .They did not incorporate any tool or instrument to measure the level of culture shock, and so were not further analysed.
The remaining 7 articles 29,39,43,[47][48][49][50] included a tool or instrument to measure the level of culture shock.The first five of these were not analysed further.The tools used in these 5 articles, along with the reasons for their exclusion from the next stage of analysis, are now described (Table 3).
The remaining 2 articles remaining met all of the selection criteria.First, the measurement tool developed by Zapf was called the Culture Shock Profile (CSP), which was used on social workers in remote Yukon communities 39 .In his study, Zapf constructed a questionnaire made up of 4 scale items: (i) the comfort with social diversity scale; (ii) the openmindedness scale; (iii) the role clarity scale; (iv) and the culture shock profile.Results from the questionnaire were calculated to produce a CSP score for respondents at time intervals to correspond with the U-curve: at arrival, between 2 and 6 months, and at 12 months.The social workers in Zapf's study showed a high CSP score on arrival, a significant drop in CSP score over the first 6 months, and a return to a higher CSP score by the end of the year.These results therefore support the concept of the U-curve and the stage theory of culture shock.However, these tools were developed for use on social workers and international students, respectively, and so further development of the tools would be required to use them in the remote Australian healthcare context.Zapf's CSP tool in particular would need to be validated via further studies.The majority of studies found were based on international cross-cultural situations, for example international students and business people working overseas.
The literature and empirical research specific to non-Indigenous people working in Indigenous communities in their own country is very limited, indicating the need for studies specific to this context.
Expert opinion and the abundance of descriptive literature suggests that there is a significant relationship between the culture shock experienced by healthcare professionals and the high level of turnover in remote areas.Validating this claim with empirical evidence by first measuring the stages of culture shock is an important step towards reducing this turnover.The trend towards short term medical contracts and fly-in fly-out health care in remote communities adds to the complexity of healthcare provision in these environments and adds weight to the need to understand the phenomenon of cultural adaptation more fully.Filling the gaps in current knowledge will enable policy makers to implement interventions which can give the greatest benefit to remote healthcare workers and to remote health care in general.

Conclusion
For healthcare workers in remote Indigenous communities of Australia, the negative experience of culture shock can be problematic.At this stage it is unknown to what extent the stresses associated with working in an unknown and contrasting culture contribute to the premature departure of many highly-skilled professionals, and indeed the continuing employment of those workers influenced by the negative aspects of culture shock.Poor staff retention is costly, undermines the development of Indigenous communities, and counteracts work being done to close the gap in the health status of Indigenous and non-Indigenous Australians.
In order for remote health professionals in Australia to achieve cultural adaptation, it is important to develop a way in which to measure culture shock.It is only once the rejection stage of culture shock can be effectively bridged that the most appropriate and effective training and support programs can be implemented.However, the empirical literature supporting the concept of culture shock and providing ways to effectively measure these stages is limited.In particular, research that is specific to non-Indigenous people working in Indigenous communities in Australia is required.It is only with this research that strategies can be developed to assist individuals to achieve successful cultural adaptation, with the ultimate goal of improving staff turnover and the delivery of remote healthcare services.
countries such as the USA and Australia are those where emphasis is placed on individual rights and personal achievement, and where people look after themselves and their immediate families.Collectivist countries such as China and the Latin American countries are those which place a greater value on group cohesion and where extended family ties are important.From his study, Hofstede developed a scale for each cultural dimension.The further one country is from the other on the scale, the more cultural distance there is between them, and so it follows that an individual working or living in the other culture will experience a greater degree of culture shock.Australia is ranked second on the Individualism scale with a score of 90, behind only the USA.Australian Indigenous cultures were not studied by Hofstede, as they are usually grouped into mainstream Australian culture in an international context.However, Australian Indigenous cultures can be closely compared with other world cultures ranked on Hofstede's scales, such as family-oriented Asian countries and African kinship-group countries.Also, taking into account traditional Indigenous values such as emphasis placed on the family, close kinship structures, and other world views, it can be argued that Australian Indigenous cultures would be ranked strongly toward the collectivist end of the scale, although it is also the case that these cultures are in transition.A study regarding Canadian Indigenous culture and its place on Hofstede's Individualism scale asserted that Canadian Indigenous culture should be placed towards the collectivist end of the scale33 .Many scholars have documented the similarities between Australian and Canadian Indigenous cultures both in terms of their cultural values and systems, as well as the two countries' similar colonial histories, geography, population distribution, and their treatment of Indigenous peoples34 .Even using these comparisons to similar cultures, it is of course difficult to rank Indigenous cultures on Hofstede's scale, especially taking into account the changes in Indigenous cultures since colonisation.These changes have been profound and encompass relationships to land, law, language, food, education, family, society, religion and beliefs.Hofstede's scales do rely on what some think of as an over-