Anyone working in the NHS cannot fail to notice the diverse cultures that make up staff and, in some areas, patients. Cultural issues surface not only when colleagues interact with one another, but also when patients from other cultures seek medical attention.

Culture has been described by the Oxford English dictionary as 'the ideas, customs and social behaviour of a particular people or society' or, more practically, as 'the way we do things around here'. (1) 'Culture' is derived from the Latin colere, which signified tilling or cultivating of the ground (as in agriculture), keeping bees (apiculture), fruitgrowing (horticulture) and a host of human enterprises. In Genesis we read that God placed Adam in the garden to 'dress' it. (2) Culture is the individual and corporate skills and experience we bring to living our lives and shaping community. Culture is dynamic, changing all the time.

Cultural differences mean that people see and experience things differently and this can easily create misunderstanding. Some of these differences reflect the breadth and wonder of the Creator-God, who made humans in his image. But it can also reflect how human rebellion against God has marred this image and distorted it so that relationships break down. The task of the healthcare professional in cross-cultural communication is where possible to try to overcome these differences and establish rapport.

Rapport between people is important for social cohesion, but difficult to define. We know when we have established rapport with someone; we also know when there is poor rapport. When resources are scarce, conflict between different departments (and even within the same department) is inevitable. Cross-cultural differences have the potential to make an already stressful situation more complicated. It is human nature that 'birds of a feather flock together' and cultural differences can make working under stressful conditions worse.

The Bible offers profound examples of cross-cultural communication and Christian health professionals can learn from them. We have Paul's famous example: 'I have become all things to all people so that by all possible means I might save some' (3) as well as sermons in Acts where the presentation of the gospel is adapted to enable communication to different audiences.

Approximately 40% of medical practitioners in the NHS are classified as 'White British' out of a registered workforce of 273,000 doctors. (4) Other big groups include those of Indian origin (11.8%), other White (10.5%), Pakistani (4.3%), African (2.7%), and Chinese (2.0%). One in seven nurses (91,470) registered to work in the UK trained abroad. (5) Approximately one in five people in England and Wales have ethnic origins from outside the UK.(6) Like the NHS, Christians are a diverse group. Jesus told his followers to go and make disciples of 'all nations' and Jesus himself did not discriminate against people from different backgrounds (for example with the Samaritan woman in John 4). Therefore, as we work in a diverse health service, we can mirror Jesus' approach in spite of cultural differences.
There are wide variations in cultural norms within the same country. Cultural norms in London may not be the same as in rural Cumbria, for example. While there are various cultures in the world (eg African, Latin American), I will focus on some fundamental differences between 'Western' and 'Eastern' cultures, two cultures I am very familiar with.

• Loyalty and obligation: In Western cultures it is acceptable to say that something is inconvenient. In many Asian and oriental cultures people may avoid saying 'no' to avoid causing offence. They may later fail to turn up and offer profuse apologies. To a Westerner this seems rude, while the former approach may offend the Eastern person.
• Privacy: Western cultures place a great emphasis on privacy. Questions about family and money are considered normal in Asian culture.
• Personal modesty: Particularly with females there is a far greater concern about exposure and modesty in most Asian cultures - breastfeeding in public is rare.
• Honesty and saving face: In the UK it is considered good to be honest and upfront. In many countries this approach may lead to 'loss of face'. This difference in approach can lead to offence when swapping on calls etc. A 'no' response in an Asian setting is seen as far more than a simple difficulty in being able to help - it is a rejection of the individual and great offence can be taken. A person who agrees to undertake a task and then does not deliver is more likely to be forgiven as their intention was to help.
• Displays of emotion: In English culture, displays of emotion are generally viewed as 'bad form'. In large parts of the world, including Southern Europe, people may swing from calmness to loud arguments as part of a normal day!
• Power and rank: In large parts of the world power and status are extremely well demarcated and people are expected to know their place. In Western countries there is a greater egalitarianism and people may address the boss by their first name. People who cross cultures may struggle to understand the boundaries in a new setting.
• Respect: All people like to be respected. Humour can be a sign of affection in English culture. Doctors enjoy very high status in some countries (in the UK doctors are still considered among the most trusted people). Nurses in the UK are highly skilled professionals. Across the world a 'nurse' may undertake a variety of tasks. A lack of understanding of different roles can lead to conflict, especially when staff work in a different setting.

Many people have names that appear difficult to pronounce. In many cultures names have great significance and learning to say someone's name may help to build a good relationship. In the Old Testament people's names had tremendous significance (Abraham means father of many nations). As health professionals, there are many difficult drug names that we need to know and so learn how to pronounce. Telling someone their name is too difficult to pronounce may be honest, but perhaps not the best strategy to make a good impression.

Immigrants and refugees face unique and additional challenges. These include: lack of family and social support, language and employment issues and concerns back 'home'. Refugees may also have been tortured in the past. In contrast to many parts of the world, people in the UK enjoy many rights and privileges. Immigrants and refugees may either overreact to certain situations (eg demand a specialist opinion) or not be aware of their rights.

Christian doctors and nurses are called to be agents of God's ultimate purposes: breaking down barriers, so that a new humanity is 'brought near' to one another through the blood of Christ. (7)

Nirmalan Arulanantham is a Consultant in general medicine and clinical pharmacology based in Cumbria.