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Viewing Family Relations Through a Linguistic Lens: Symbolic Aspects

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of Language Maintenance in Immigrant Families

Michal Tannenbaum School of Education

Tel Aviv University, Israel

Immigration often involves language shifts, and dilemmas bearing on language maintenance. This article discusses some of the psychological implications of mother tongue maintenance and of complete language shift, especially in the com- munication between parents and children. The article suggests a novel perspective on language maintenance in immigrant families by drawing on attachment theory and discussing various aspects of language maintenance in relation to intimate family ex- periences. This qualitative study focused on the parents’ perspective on various is- sues related to their mother tongue and the influence of early experiences on their current language behavior with their children. Interviews were conducted with seven immigrant families living in Sydney, Australia. Central themes that emerged from their narratives, related to language and family relations in the past and at present, are analyzed and discussed in light of psychological motives and emotional aspects re- lated to language maintenance patterns in these families.

Language maintenance and language acquisition among immigrants from ethnolinguistic minorities are widely researched subjects, basically viewing the immigrants’ acquisition of the majority language as imperative. Language fluency is an integral part of the acculturation process and various studies point out the pos- itive relation between the immigrant’s well-being in terms of economic, academic, professional, or personal aspects, and language proficiency (e.g., Masgoret & Gardner, 1999; Weston, 1996). Acquiring a new language as part of the immigra- tion process often results in bilingualism, which researchers almost unanimously judge to be a positive phenomena, including such advantages as metalinguistic

THE JOURNAL OF FAMILY COMMUNICATION, 5(3), 229–252 Copyright © 2005, Lawrence Erlbaum Associates, Inc.

Correspondence concerning this article should be addressed to Michal Tannenbaum, School of Ed- ucation, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel 69978. E-mail: [email protected]

awareness, improved school performance, cultural enrichment, and psychological resilience (e.g., Goodz, 1994; Hakuta & Diaz, 1985; Titone, 1989).

Language shift as part of the immigration process, however, is not a simple or technical act, and it does not reflect only the acquisition of a new language and the broadening of one’s horizons. The immigration process also involves loss on many levels, and language shift often involves language loss with all its attendant emo- tional, interactional, and psychological significance. Most of the studies exploring language maintenance and language shift among immigrants focus on characteris- tics of the ethnolinguistic group, on the language per se, or on demographic vari- ables associated with language maintenance (e.g., Butcher, 1995; Clyne & Kipp, 1997; De Vries, 1993; Giles, Bourhis, & Taylor, 1977; Taft & Cahill, 1989), and rarely address the emotional significance of this process. The few studies that do address language maintenance as associated with emotional aspects, self-identity issues, or internal representations of significant others, describe mainly clinical case studies, psychological theories, or personal literary narratives. Thus, Hoffman (1989) described the helplessness that accompanied the acquisition of a new lan- guage as part of her immigration experience stating, “mostly, the problem is that the signifier has become severed from the signified. The words I learn now don’t stand for things in the same unquestioned way they did in my native tongue” (p. 106; see also Stengel, 1939). Grinberg and Grinberg (1989) described the mother tongue as containing the experiences of infancy, including memories and feelings related to first object relations, and as one of the most traditional components of culture, highly resistant to change. Based on his own experience after his arrival in England, Freud wrote to Raymond de Saussure the following: “one point that the emigrant feels so particularly painfully…is…the loss of the language in which one had lived and which one will never be able to replace with another” (quoted in Gay, 1988, p. 632). Mirsky posited that losing the mother tongue in immigration is ac- companied “by a deep sense of loss of self-identity and of internal objects” (1991, p. 620). Marcos, Eisma, and Guimon (1977) described bilingual patients who, dur- ing therapy, reported the experience of a “language-specific sense of self,” as if two persons existed, each operating in a separate language with its own value system, conflicts, and defense mechanisms. Stern (1986) described immigrants who felt they were betraying their mother tongue by having to shift to a new language. Of- ten, they were unable to describe their emotions and the world they had lost, feel- ing that the new language failed to apply to the old world. Confronted with a new, unintelligible language, immigrants may feel excluded, as a child who does not un- derstand the parents’ secret language (Grinberg & Grinberg, 1989), a feeling likely to elicit alienation, anger, or frustration. The dramatic implications entailed by a language shift may even be inferred from the “mother tongue” concept found in many languages (see also Akhtar, 1995; Amati-Mehler, Argentieri, & Canestri, 1990/1993; Fishman, 1997; Koplow & Messinger, 1990).

Studies exploring the main impact of immigration on family life indicate that certain aspects, such as identity conflicts, alienation, and intergenerational dis-


cord, are uniquely magnified in the immigration process (Akhtar, 1995; Hong & Domokos-Cheng Ham, 1992; Ritsner & Ponizovsky, 1999). Children may also be faced with a conflict of loyalties, when their parents simultaneously expect them to acculturate and succeed while retaining their sense of tradition and family values (Gudykunst & Lee, 2001; Roer-Strier, 2000). In shifting to a new language, the younger generation may often be cut off from its roots, possibly leading to es- trangement between family members. Parents may feel unqualified to teach their children all the things parents usually teach, in transmitting to their children the cultural values and beliefs that the family and the group hold dear, and in support- ing the development of a strong sense of self or culture in their children (Koplow & Messinger, 1990; Wong-Fillmore, 1991). Gudykunst and Lee (2001), who focused on family communication in the context of ethnic and cultural identities, suggested that the greater the difference between parents and children in the emphasis they place on these identities, and the greater the gap between individuals and their fam- ilies, the greater the intergenerational conflict as well as the speech divergence when they communicate.


Beyond their specific features, immigrant families share in the dynamics common to families in general. Attachment theory, which describes one dimension of these dynamics, is one of the most widely researched and applied theories of emotional development across cultures and circumstances. First developed by Bowlby (1969, 1973), this theory conceptualizes the tendency of human beings to form strong af- fectionate bonds with particular others, and also outlines diverse forms of emo- tional distress and personality disturbance. According to attachment theory, the in- fant, and later the toddler, develops internal working models of “self” and of “other” derived from the experience of the infant’s relationships with the care- givers. Two major types of attachment patterns may develop on the basis of these working models: secure and insecure (the latter including avoidant, ambivalent, and disorganized modes of attachment). Individuals tend to interpret their experi- ences in a manner consistent with their existing internal working models, con- stantly tending to confirm these models throughout their lives (Ainsworth, 1990; Bowlby, 1969, 1973). Continuity in attachment modes is therefore expected throughout the life cycle (e.g., Klohnen & Bera, 1998; Meyers, 1998).1Although a


1The focus on attachment theory is not incidental. The secure base phenomenon has been empha- sized by many other theorists, such as Erikson (1950), who coined the notion of “basic trust,” or Sandler (1985), who spoke of “background of safety.” Many psychoanalysts argue that the infant–caregiver re- lationship is grounded in the need for a relationship rather than on physical necessities (Fonagy, 1999). Both attachment theorists and several psychoanalysts see maternal (or other caregiver’s) sensitivity as a key issue in determining the quality of relationship regulation between mother and infant, as well as that of later relationships (Bowlby, 1969; Erikson, 1950; Winnicott, 1965).zaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlight

range of emotional reactions or gestures may indeed have different connotations in different cultures (Rothbaum, Weixz, Pott, Miyake, & Morelli, 2000), and al- though it is not assumed that family communication patterns are identical within or across ethnic groups (e.g., Gudykunst & Lee, 2001), research indicates that chil- dren, across cultures, become attached to their primary caregivers and basically display a similar range of behaviors in stress or comfort-seeking situations (e.g., Harwood, Miller, & Irizarry, 1995; Van IJzendoorn & Sagi, 1999).

Attachment relations may be assessed or categorized in several ways, depend- ing on the purpose of the assessment and on the age of the participants. Thus, the Strange Situation Technique (Ainsworth, Blehar, Waters, & Wall, 1978) is usually applied when assessing attachment modes in infants; the Attachment Q-Sets is used with toddlers (Waters & Deane, 1985); the Separation Anxiety Test is used during latency and adolescence (Slough & Greenberg, 1990; Tannenbaum & Howie, 2002); and the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) is used among adults.

An interesting concept related to attachment relationships is the “reflective self” (Fonagy, Steele, & Steele, 1991; Fonagy, Steele, Steele, Moran, & Higgitt, 1991). Fonagy, Steele, and Steele (1991) associated the coherence with which adults re- member their childhood, or their ability to talk about their past experiences in the AAI, and their level of insight. Insight is affected by their early (attachment) rela- tions with their parents, and in turn, affects their level of understanding and respon- siveness to their own child. This link may be understood as emerging from an inter- nal sense of coherence, structured at early stages of development in response to parental sensitivity to the infant’s mental world. The parents’ability “to observe their own mental functioning, to have a plausible view of themselves and their objects as human being, thinking, feeling, wishing, believing, wanting, and desiring” (Fonagy, Steele, & Steele, 1991, p. 215), is thus considered to have direct implications for the parents’ relationship with their infant. Insight, then, is related to early secure rela- tionships, as well as to secure relationships with one’s own children.

These clinical examples, literary insights, and theoretical assumptions, suggest that immigrants often view their mother tongue as a symbol of their past, their fam- ily of origin, childhood landscapes, familial myths, and early memories. As such, language maintenance or language shift may reflect complex emotional processes both at the individual and at the familial levels, and even at the level of the group.

This study aims to enrich our understanding of the internal world of immigrants regarding their linguistic experiences, and to explore the potential range of associ- ations that language may hold for different people. For this purpose, I adopted a qualitative method that enables one to generate hypotheses to explain various phe- nomena by relying on the participants’ interpretations of their own reality (Denzin & Lincoln, 1994; Smith, 1997). Qualitative research begins from a specific stance that helps researchers thematize their data and focus on essentials in light of a spe- cific conceptual framework. A conceptual frame of reference may be useful in sys-

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temizing hypotheses generation and data collection, helping to structure the quali- tative analysis (Alasuutari, 1995; Hayes, 1997).

The basic conceptual assumption in this study is that language is associated with emotions, and therefore, language shift or language maintenance may be as- sociated with psychological aspects—how, to what extent, and in what directions are some of the questions the study asks. In other words, the narrative accounts were not used to test a preexistent, fully formed theory; instead, they were used as a basis for developing one, allowing for the discovery of new and unpredictable as- pects (similar to Smith, 1997).

These issues have also been the subject of quantitative studies, as reported else- where (Guardado, 2002; Tannenbaum & Howie, 2002). Yet, qualitative research methods were viewed as better suited for exploring the personal, subjective interpre- tations of reality at the focus of this study. As Alasuutari (1995) emphasized, the goal of qualitative research should not necessarily be to produce practical information about society but rather to create a body of critical literature that may contribute a new perspective to the investigation of social or psychological phenomena.



The study relied on the analysis of case studies (Creswell, 1998; Smith, 1997). Seven immigrant families living in Sydney, Australia, were interviewed using a semi-structured interview. The families had lived in Sydney for up to 15 years, and, in all of them, both parents shared the same mother tongue, which was not English. All the parents were fluent in English, so that speaking to their children in their mother tongue was a matter of choice rather than necessity.2 All parents were in their late 30s and early 40s, middle class, educated, and professional. Table 1 pres- ents the main characteristics of the participant families.


Interviews lasted around 2 hr with each family, in two sessions. Questions were de- liberately phrased openly and were mainly intended as cues for the participants with minimum constraint or comments by the interviewer (e.g., Denzin & Lincoln,


2Participants’ names were changed to protect anonymity. All interviews were conducted in English except for two interviews with Israeli families, conducted in Hebrew. It could be argued that, to maxi- mize comparability, it would have been advisable to conduct all interviews in English. Given that He- brew is the researcher’s mother tongue, however, it was decided that any methodological advantages that might accrue from speaking English with Hebrew-speaking participants would be outweighed by the artificiality of failing to use a common language.zaragHighlightzaragHighlightzaragHighlightzaragHighlight

1994). Each interview started with a general, open statement: “Please tell me about your immigration experience. I am especially interested in hearing how you deal with language issues.” From then on, the interview’s pace and content were dic- tated mainly by the participants. If the participants failed to mention specific issues altogether, however, direct questions were inserted to ensure that all participants did address the central concerns of this study, such as the following:

• What language(s) do you speak at home—between yourselves, with your children, with your extended family? What language(s) do your children speak with you? Why do you think this is so?

• What are your emotional associations with your mother tongue? • Can you tell me about significant incidents of your children using your

mother tongue rather than English? • Can you think of any childhood experiences that, more than others, affected

your decision to immigrate? Can you think of special incidents in your own childhood that affected your later linguistic choices?

• How would you describe your current relationship with your children? • Do you think language maintenance has any relevance to family relations?

The interviews were conducted with both parents together, although in some cases, the children were around for parts of the interview. Overall, children were


TABLE 1 Main Characteristics of the Interviewed Families

The Parents Country of Origin

Parents’ Mother Tongue

Children’s Ages and Gender

Years in Australia

Language Maintenance?

Thomas and Koni Germany German 10 (m), 8 (f)

7 Y

Sasha and Lina Russia Russian 12 (m), 9 (m)

15 N

Yoav and Nurit Israel Hebrew 12 (f), 9 (f), 5 (m)

6 Y

Jose and Sofia Mexico Spanish 8 (m) 11/14 N

Oded and Tamar Israel Hebrew 8 (f), 5(m), 3 (f)

12 Y

Mario and Rosa Argentina Spanish 8 (f), 4 (f) 3 Y

Roberto and Julietta Italy Italian 7 (f), 5 (m) 2 Y, N

Note. (m) = male; (f) = female; Y = yes; N = no.

not active participants in terms of content related to interview issues, although when possible, notes were added in regard to parent–children interactions, explicit input of children, actual language use, and overt emotions.

With the family’s permission, interviews were taped and transcribed verbatim. Transcripts were read and reared several times to classify themes emerging as cen- tral. These themes were then allocated to several categories including language, emotions, family relations, childhood history, and the immigration experience. The purpose was to identify recurring patterns across cases with the aim of identi- fying associations between language issues and familial-emotional ones.


Thomas and Koni

The family came from Germany due to Thomas’s work, and has been living in Australia for 7 years. Thomas and Koni have two children: a 10-year-old boy and an 8-year-old girl.

Koni remembers her own childhood as a succession of conflicts with her mother, whom she describes as a highly respected woman “with lots of friends and admirers” and the central figure of the extended family. Her basic feelings as a child were of being useless and unappreciated by her mother, always the “black sheep” of the family. She was considered the most rebellious child, “the one who always got into trouble.” She was the most problematic of her siblings at school, suffered from attention difficulties, and never received more than average grades. She describes her father as weak and living always in her mother’s shade, although “with a golden heart.” Her mother had dominated the household, even to the extent of detaching her husband from his family of origin. She remembers hearing her fa- ther, on many nights, criticizing her mother about her interaction with Koni, saying she was too tough with her and should not argue with her constantly. She describes herself as always much closer to her father than to her mother, who was “some- times a real stranger…Worse than that—as if she wanted me to fail.”

Thomas comes from a middle-class family with one older sister. He was rather laconic in his descriptions, appearing much more reserved and distant than Koni, but the overall impression was that of stable and close relationships within his fam- ily. He reported that they talked regularly on the phone, his parents had recently visited and stayed with them for several weeks, and both mentioned that Koni also has a good relationship with his parents, who somehow function as “substitute par- ents,” as Thomas commented.


3The idea for this title came from an Australian television program dealing with immigrant families.zaragHighlight

Thomas and Koni met in high school and have been together since. They always thought of living far from the family, in another city or in the countryside. When an opportunity for work in Australia came up, they decided to give it a try. They live in a remote suburb of Sydney, in a big house surrounded by a large wooded area.

They talk about their children with great affection. Koni is highly involved with their school activities and often volunteers to assist in various events. She enthusi- astically describes the last family trip, when they went camping for a week with several other families. Thomas also speaks quite a lot about the children, relating many details about their school, friends, and hobbies.

Although they both explicitly claim it is good for their well-being (especially Koni’s) to be far from Koni’s family, they both feel closely attached to their coun- try and culture. The house is full of German books and music (for children too), they have many German friends, and they keep in touch with friends in Germany. They consciously relate to the issue of language. Both state that being able to relate to their children in their mother tongue is extremely important, and at home they speak German almost exclusively. As Koni says

the fact that my own mother was bad to me does not stain the whole of German cul- ture…I need to make it better for my own children, but there is no way I could have done it in another language…I want them to be part of my world for good and bad, and I cannot see any way to do it in English.

Both also added that this enables them to relate more directly and more easily to their children, who are able to communicate with the extended family in Germany, and it feels more natural for Koni and Thomas to hear German at home. As Koni says, “sometimes this English is like a mask she [her daughter] puts on…It’s like a different person.”

Sasha and Lina

Sasha and Lina came to Australia separately from the former USSR, 15 years be- fore the interview. They met at a university, married, and had two boys, now 12 and 9. Both stated they had come to Australia mainly hoping to live a different, free, and apolitical life. Lina added that living in an undemocratic society had always been hard for her. Lacking access to knowledge and to what happens in the world, with information always being censored, “not having freedom of speech, of cre- ation, even of thought,” were aspects of life she had always detested. “Also, the in- doctrination dripping on you wherever you are, especially at school…I didn’t want to raise my children that way.” They both added that, economically, life in Austra- lia was very different. “Not that we are rich here,” said Sasha, “but at least you have your own space for yourself…there you often have to live with some other families in the same small flat.”


Although they often spoke English when other friends were around, when by themselves, they spoke mainly Russian. When their first child began speaking, his first language was Russian. On this issue, they note the following:

we decided to start speaking more English with each other and with the boy, in order for him to be an “Australian.” After all, we came here to live a different kind of life…and hearing our baby speaking Russian seemed wrong at the time.

After several months, their son gradually shifted to English and today, their com- munication with him and with their second son is basically in English.

When the focus of the interview shifted to the emotional implications of this use of language for their relationships with the boys and with each other, Lina nodded, as if this issue was easy for her to address. She said that, after her father’s death several years earlier, she had started therapy, seeking to understand their relation- ship better. The experience had, in turn, helped her understand her deeper reasons for leaving Russia and become aware of other layers in her personality: “It’s not just politics that brought me here.” She said that her relationships with her own family in Russia had never been really close, although no one had ever admitted this, and it was easier for her parents, as well as for herself, to deal with her immi- gration as a move toward a freer or easier place rather than acknowledge any diffi- culties within the family:

I realized that I had hoped to have a completely different life, a different family. I didn’t want to raise my boys like my parents had raised me…I was never very close to my brother and sister, and never knew much about my parents’ own life. They did not tell me much about themselves, about their problems, about their own childhood. We were just living together from day to day, but actually did not know much about each other.

Lina added that Sasha’s family is also problematic, and although he did not deny Lina’s notions about his family, it was more difficult for him to elaborate in detail. In the context of their relationships with their families, however, both said it was probably no accident they now speak mainly English between themselves as well as with their sons, “as if speaking this other language helps to make a different kind of family. You know, I even used to sing lullabies in English to the boys,” said Lina. Most of their friends are not Russians, and Russian culture plays a limited role in their present life.

On rare occasions, they find themselves telling the boys stories about their own childhood. Both, however, say they find it more and more difficult to do this, be- cause the boys do not seem interested or keen on drawing close to their world. As Sasha says, “they don’t ask us much about ourselves anyway,” to which Lina added, “I guess I can say that this trick [i.e., shifting to English] didn’t really work.

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I tried to do it differently, but I often find myself very frustrated in my relationship with them.”

Yoav and Nurit

The family arrived from Israel due to Yoav’s job, and have been in Australia 6 years, although they had never intended staying this long. Yoav works full time and travels a lot, whereas Nurit works casually and spends most of her time at home and with the children. They have two girls, ages 12 and 8, and a boy of 5.

Nurit’s parents are Holocaust survivors. After the war, they emigrated to Israel and settled in a kibbutz, where Nurit was born and lived until she came to Austra- lia. She describes her childhood as generally happy, with the inevitable ups and downs. One experience she elaborated on was “communal sleeping.”4 Nurit has some bad childhood memories related to this arrangement, such as crying, or being very scared, without her parents around to comfort her. As an adolescent, she re- calls often feeling confused, embarrassed, and without anyone close. She con- trasted her experience with that of her eldest daughter (and gave the example of them going together to buy her first bra), and said she could not imagine herself raising her own children like that.

Yoav was born in Poland. His father died when he was very young and he went with his mother to Brazil to join the rest of the family, but they did not adjust and went to Israel. Yoav’s mother remarried and was unable (or unwilling) to keep him with her and sent him to a kibbutz,5 where he met Nurit.

Coming to Australia was their first trip overseas and their first time living out- side the kibbutz. They arrived with two daughters, and their son was born a year later. The parents speak mainly Hebrew, between themselves and with their chil- dren. The girls usually answer in English although they understand Hebrew well, and, if asked to do so, can answer in Hebrew. The boy has a speech problem and does not speak much, but when he does speak to his parents, it is mainly in Hebrew. Both parents said that, naturally, they sometimes speak English with the children and especially when other children are present, but do not really like this. Nurit de- scribed feeling somewhat awkward in doing so and added that, when she hears the


4In this arrangement, children from as early as a few months have their own “house,” according to their age, and a metapelet (caregiver) is in charge of most daily routines in each house. They spend ev- ery afternoon and evening with the parents, who also put them to bed in the children’s “house,” and do not sleep in the same house with their parents. This arrangement, prevalent until about two decades ago and when Nurit was growing up, has now been abandoned.

5For many years, kibbutzim hosted children who, for various reasons—broken families, financial problems, temporary crises—could not stay with their parents. These children are known as yaldei huts (children from outside). They live with the kibbutz children and participate in their activities. Each of them is given an “adopting” family in the kibbutz, and they usually visit their own families in the city every few weeks.

children speak English, especially at school assemblies or performances, she re- ally misses Israel. “I feel almost sad; imagining them on a stage at a school in Is- rael, singing in Hebrew, singing the songs I used to sing as a child.”

Relationships between family members, especially between Nurit and the chil- dren, are very close. She is involved in their daily routines and with their friends, speaking about them in great detail and with much affection. When talking about the girls, she described their activities as well as each one’s strengths and weak- nesses. Her relationship with her son, however, resembles more a relationship with a baby than that with a 5-year old child. She speaks to him in “motherly” tones, in a higher pitched and very gentle voice. She describes some of his unusual behavior patterns (marked delay in speech performance, clinging, unsociable) in very ac- cepting terms, in marked contrast with the way she describes her daughters and their difficulties.

Yoav is very kind to the children. Although he is often overseas, he emphasized that he calls them every night to say goodnight, he always brings back presents, and, when he is home, he insists on doing things together. Both parents said that Nurit is much more involved with the children due to Yoav’s frequent absences, and she is by no means the dominant parent in terms of their daily life.

Jose and Sofia

Jose and Sofia came from Mexico separately and have an 8-year-old son. Jose de- scribes his own childhood as “interesting.” In his early childhood, his father was rarely home due to work commitments. His parents divorced when he was 9, ap- parently because his mother had an affair with someone she eventually married. He spent time with both his parents but said the following: “Although I practically had two homes, I actually felt as having none.” He cannot recall what it was like going through this as a child, but does mention self-pity and some “anger toward my mum…like how could she leave us” [him and his father]. He describes his father with pity and empathy. Although his father had several relationships after the di- vorce, he never remarried and had been dead for 10 years at the time of the inter- view. His mother still lives in Mexico with her second husband.

Jose left Mexico in his early 20s, traveled around the world, and worked casu- ally in many places. He eventually arrived in Australia, where he met Sofia. They married and decided to stay in Australia. Jose says it was “a feeling of a cleaner place” for him.

Sofia arrived in Australia after finishing high school, with her parents and two younger sisters. Her family decided to emigrate to Australia because they felt it would be a safer place to live. Before their immigration, they had often lived through “hard times” in Mexico. She described the hardships of threats and fears because they were relatively wealthy in a poor country, so when her father was of- fered a job in Australia, the family left Mexico. Soon after they arrived, she en-


rolled in a university course. She describes her relationships with other family members as good, especially with her mother. Her father was always quite distant, highly involved with his work and often arriving home when she and her sisters were already asleep. She respects him, but is not very close to him.

She met Jose about 9 years ago via mutual friends, not Mexicans. Because their relationship started in a non-Mexican context, they began by speaking English to each other. Also, because both had lived for a relatively long time “in English,” they found it easy and even natural to speak English with each other, and currently speak English almost exclusively. Although they have not maintained their lan- guage, both Jose and Sofia often praise various aspects of their culture and their country of origin (even their son commented on it by saying, somewhat ironically, “everything Mexican is better”).

When their son was born, it was natural for them to relate to him in English. His knowledge of Spanish is thus very limited (all his extended family members on both sides speak English, and this is not crucial for his communication with them). Jose repeated several times that he and his son are very close, spend much time to- gether, and share many activities—fishing, bush walking, cooking, and many intel- lectual pursuits, some connected with school and some simply as a common inter- est. His work from home allows Jose to be with his son more than Sofia, who works long hours. Throughout the interview, Jose stressed his unusually intimate rela- tionship with his son, almost as if boasting about it.

Oded and Tamar

Oded and Tamar left Israel 12 years ago, soon after their marriage. Officially, they came because of Oded’s studies, which he eventually abandoned to become self-employed. They have three children, two girls ages 8 and 3 and a 5-year-old boy. Oded was born in a kibbutz, where he lived until his early 20s. His older brother was killed in war 20 years before, and soon after, his father died of what Oded describes as “a broken heart.” He has a “complicated” relationship with his only sister and a problematic relationship with his mother, who still lives in the kib- butz. He has not seen her for more than 6 years and admits he tries to avoid even phone conversations with her, which “tend to produce new reasons to fight about.” He describes her as “very remote, even arrogant,” and claims that because of the family’s tragedy, she became even less accessible: “She is in her own world, which she surrounded with walls to protect her, and it is very hard, sometimes impossible to get in. Even the grandchildren do not have much success.”

Tamar describes her own family as “very normal.” She has one brother, and re- ports good relationships with both her parents. Back in Israel, before her marriage, she held a highly prestigious position and this is why, she claims, her first few years in Australia were extremely hard. She describes the loneliness, the need to start from the beginning and prove herself, and the adaptation to different conditions:

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“even to drive here took me two years.” Now, however, she claims to be satisfied. She is happy with her job, the children are doing well at school and socially, and their financial situation is stable. She seems strong-willed and the one who sets the rules in the house, as evident, for instance, on the issue of whether to stay in Aus- tralia or go back to Israel. Oded would have gone back “yesterday,” as he says (“What do I have here? Bricks?”). Tamar misses her family and friends, but feels that Australia provides a much safer environment to bring up children and they should stay.

Israeli culture dominates the house. There are pictures of Israel, many history and tourist books about Israel, almost all the music in the house is in Hebrew, the children attend a private Jewish school (and preschool), and most of their friends are Israeli. The parents speak only Hebrew with each other as well as with the chil- dren. The children tend to respond in English although all speak Hebrew, and the parents say they understand everything.

The most interesting incident the parents described in this context was a recent fight with their eldest daughter. Throughout the argument, the girl shifted from English to Hebrew in a sort of frustrated manner, “as if really trying to express her- self.” Oded also speaks of sensing something artificial when the children speak English, especially the older girl, “almost as if she is using it to distance her- self…as if she is a different person in English than in Hebrew.” Similarly, on his own language use, he comments as follows: “only in Hebrew can I really love them, or really yell at them; in English it’s like a game.”

Mario and Rosa

Mario and Rosa arrived from Argentina, and have lived in Australia for 3 years. They have two girls, ages 8 and 4. Rosa’s family followed them to Australia, and she describes her relationships with her parents as very close. She also has a brother in Australia, who is mentally ill.

Both Mario and Rosa describe Mario’s parents as very intrusive and patroniz- ing. They had many critical comments on how Mario and Rosa are raising their girls, and did not support them financially when they needed it although they them- selves were quite wealthy. At the same time, Mario describes his relationships with them as rather distant. As Rosa puts it, “at least if they were kind, we could have lived with those comments, but they were intrusive and distant at the same time.” Rosa, more than Mario, experienced their intrusion as unbearable. Going overseas seemed to her to offer a good opportunity to live their own life in a more peaceful environment. Mario’s main motivation to settle in Australia was to improve their financial situation.

Speaking Spanish with each other and with the girls comes naturally to them, although they use more English in some contexts—when doing homework, some- times when playing with the girls, and when other people are around. The parents


read the children stories in Spanish (but sometimes also in English), listen to Span- ish music, and watch videos sent to them from Argentina. Having Rosa’s family around increases the Spanish input dramatically, and the girls’ motivation to speak the language is quite strong.

They are very close to their daughters and involved in the children’s daily rou- tines, and both emphasized the importance of being together as much as possible. They particularly stressed their wish that the girls would maintain close relation- ships between them, because both had experienced problematic and distant rela- tionships with their siblings.

During the interview, the older girl addressed her sister in Spanish. When I later asked the parents about it, they said that the girls did tend to speak Spanish with each other more often than they do with them, especially the older girl when she speaks to her younger sister.

Although Rosa clearly stated that she had wanted to distance herself from Mario’s family and from other bad aspects of Argentina that she associates with them, it never occurred to her to change her language. She feels very attached to her language and her home country. She says that when they recently returned from a visit, she found it hard to recover from a painful and relentless feeling she had lost something she would never be able to regain in Australia. The visit had also dramatically strengthened the girls’ use of Spanish for a long time afterward, and she found that this was “really nice…something more familiar.”

Roberto and Julietta

The family came from Italy 2 years ago. Roberto works in an Italian company, with which he made contact before arriving, and Julietta works in a bank. They have two children, a girl of 7 and a boy of 5. Both children attend a Catholic school. Roberto’s family had moved a great deal during his childhood, living in several Eu- ropean countries. He was then sent to a boarding school in Australia, because his father had worked in Australia in his early 20s and was an Australian citizen. After finishing high school, Roberto returned to Italy and lived there for several years. He says he had always wanted to try and live in Australia with his own family. Julietta comes from a rather devout Catholic family with right-wing leanings (“my father thinks Mussolini contributed a lot to the country…built roads, bridges”). Her parents were divorced when she was young, and she has a much closer rela- tionship with her father than with her mother, whom she describes as distant and not really involved with her life.

Their daughter was very friendly and pleasant at the beginning of the interview, although something was slightly unusual in her overall behavior. After the daugh- ter had left the room, Julietta reported that the girl had been sexually abused by her uncle several months before their arrival in Australia, during a weekend when they had left the children with Roberto’s parents and his younger brother. The story sur-


faced only after several weeks. In addition to the shocking episode, Julietta was fu- rious with the denial and the silence that had characterized the family’s reaction to the incident. Whereas before the incident she had been slightly reluctant to come to Australia, she reports that after the event, she could no longer stand living close to Roberto’s family.

Their son has many behavior problems, especially at school, which the parents attribute mainly to the recent immigration, including the language change. His English is rather awkward, and Julietta thinks that the very notion of having two different words for the same object is still alien to him, causing him some acquisi- tion difficulties. In contrast, although the parents speak only Italian at home, the girl picked up English with a striking Australian accent within a few months and clings to it, speaking Italian very rarely. Roberto seems keen on the idea that his children would be bilingual, enjoying the advantages of speaking English, and re- taining the ability to communicate in Italian with their family in Italy.

The parents appear attentive to the children, and it is evident they both hope to create something better for them in the new environment, although they do not seem to know how to obtain help for them. Julietta says she sometimes felt incom- petent, “maybe because of my own mum, who was never really present for me.” But the atmosphere at home is generally warm and affectionate, and all are much involved with each other’s descriptions of their past and present experiences (in- cluding the children, when present).


Language issues appeared to be consistently associated with a wide spectrum of emotional responses and personal connotations. Parents contributed examples as- sociating language with issues of identity, with their childhood experiences, and their relationships with their children.

One characteristic common to all narratives deserves mention: in all the fami- lies, at least one parent had undergone a markedly painful experience (or experi- ences) in the home country, during childhood or later in life. For instance, Koni felt she was the black sheep of her family throughout her whole childhood; Lina expe- rienced cold and distant relationships with her family of origin; Yoav had lost his father at an early age, and was sent away by his mother; Jose grew up in the shadow of his parents’ divorce, feeling he had been betrayed by his mother; Oded lost both his brother and father within a short time at a relatively young age; Mario reported having complicated relationships with his parents; and the daughter of Roberto and Julietta was sexually abused by her uncle.

The relatively large number of such stories in this study may be connected to their shared feature as immigration narratives. A highly appealing job opportunity

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or the option of quality of life improvements are often good reasons to leave the home country. Leaving one’s family, friends, and language, however, is not an act that everyone is capable of or willing to perform. All the interviewed families seemed to have had positive reasons to go to Australia but also reasons to leave some memories behind.

Although these painful memories or experiences cannot, in and of themselves, explain each family’s language choice, their attitude to their mother tongue or their family relations, they may have affected behavioral choices. In some cases, these experiences led to a desire to do something entirely different from whatever had characterized their childhood, including using the new language. In other cases, family members clung to their mother tongue as an emotional crutch, as if saying, “despite what happened to me, this is still part of my life. I should not suffer even more by losing this part of me.” The following sections outline the main categories that emerged from the narratives of the interviewed families.

Language Maintenance As a Tool for Creating Family Cohesion

Relating the use of one’s mother tongue (L1) to closer, more spontaneous, and more relaxed relationships with their own children was a recurring theme among parents who insisted on L1 maintenance.6 Parents who maintained their mother tongue when communicating with their children reported more flowing and spon- taneous relationships. Often, they explicitly associated such relationships with lan- guage use (see comments of Koni, Nurit, or Oded regarding the relations between being natural and using L1). Feeling more “genuine” when using L1 may be perti- nent not only to the parents. Oded and Tamar’s daughter shifted from English to Hebrew during a highly charged fight with them, a code-switching that they under- stood as reflecting her own association between the mother tongue and a more emotional and authentic communication mode. Similarly, Yoav and Nurit’s youn- ger son, who speaks more Hebrew than his older sisters, has a closer and more inti- mate relationship with his mother than do the girls. The elder daughter of Mario and Rosa quite often speaks in Spanish to her younger sister, which appears to be part of a general “mothering” behavior toward her. Doing so, she naturally follows her mother, apparently including her language behavior (Taft & Cahill, 1989, re- ported a similar finding among immigrant Lebanese families).

Several parents reported occasionally using English as a spontaneous reaction to the child’s English speech (see also Pan, 1995), yet most of them noted that this felt artificial to them, at least to some extent. Some mentioned similar affect re-


6As used in this context, “language maintenance” among the children does not necessarily denote actual active speech or linguistic fluency, but merely an ability for basic communication in the lan- guage, or at least the ability to understand the parents when they use the language.zaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlightzaragHighlight

garding the child’s use of English (see Koni’s or Oded’s statements regarding this issue). Most parents recalled using L1 more often in situations where the child is more vulnerable, in family interactions, and in intimate communication, consistent with findings from other studies that emphasize domain-separation among immi- grants (e.g., De Vries, 1993; Taft & Cahill, 1989; Tannenbaum, 2003).

Language Shift As a Tool for Establishing Emotional Distance

Several narratives reflected a tendency of parents or children to shift to second lan- guage (L2), thereby erecting, whether consciously or unconsciously, a kind of fence or barrier between their past and their present. The most apparent example was that of Lina, an instance of a conscious decision not to maintain the mother tongue. It is a story of language loss at the cost of losing intimacy with her children, and to some extent with herself. Sasha and Lina invested a great deal of energy in trying to erase their past: they tend not to talk much about it, most of their friends are not Russian, and they maintain loose contact with their relatives still in Russia. Speaking English rather than Russian is crucial to this endeavor. The paradox, however, as they themselves have indicated, is that their desire to create something completely different from their own childhood experience was mainly focused on the hope of establishing closer family relations, unlike those of their own child- hood. Yet, they both sometimes feel that, precisely because of their detachment from their own childhood experiences, they have created the same problem only in a different manner (or in a different language). Their failure to use their mother tongue with their children may be one aspect of the tendency to detach themselves from their own past and both feel that, to some extent, it is alienating them from their sons. The fact that their sons are not, and never were, particularly interested in stories about the parents’ childhood may be just one implication of the discontinu- ity they themselves have created between the present and the past. In other words, besides widely reported findings indicating that parental or family communication patterns affect children’s social skills, areas of interest, and to some extent person- ality characteristics (e.g., Li-Ning, 1999; McLeod & Chaffee, 1972), it is sug- gested here that the parents’ openness concerning their own life experiences and the accessibility of these past memories has a dramatic impact on children’s coping styles and on family dynamics in general.

Another relevant narrative is that of Jose, which revolves around the issue of childhood betrayal. Jose’s use of English could be a statement of independence, of creating his own realm (e.g., Amati-Mehler et al., 1990/1993; Mirsky, 1991), and might even be interpreted as a vindictive act against his mother, as if using a new language is a kind of betrayal, this time on his part. As emphasized by Stern (1986), language maintenance is often associated with loyalty to parents. In this case, loyalty was not part of the game.

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One more example is that of Roberto and Julietta’s daughter, who acquired flu- ent English very quickly. The girls’ rapid acquisition may reflect her strong need to have a new domain for herself, away from the trauma she underwent in her home country and in her mother tongue. Her parents had not been there to protect her when she had needed them, which may have undermined her loyalty to them and to their language. Using the new language may help her to distance herself from her family, and as such, serve as some sort of defense mechanism.

From a different perspective, it is interesting to note that some parents indicated shifting to English when scolding the child in mild incidents, as if to intentionally distance themselves from the scene and help themselves stay relatively calm and controlled (see also Heller, 1988). Many made an analogy to the ease with which they can use “obscene” words in English, as opposed to their embarrassment when using the same words in their mother tongue (see also Amati-Mehler et al., 1990/1993; Grinberg & Grinberg, 1989; Stengel, 1939).

Language Maintenance, Attachment Relations, and Coping Mechanisms

Attachment relations were not investigated directly during the interviews in terms of using standardized measures to assess it, but served as a central lens from which to understand and analyze the narratives. Furthermore, because the interviews ad- dressed parental childhood memories and their internal emotional world, some as- pects of the interviews can be related, to a degree, to categories derived from the AAI.7 From the stories, and even more so from the way the stories were told and from the details they provided, some hypotheses were derived concerning attach- ment history and the current working models of the parents that were interviewed.

The main characteristic of secure attachment relationships, as expressed in the AAI (categorized as free/autonomous), is the ability to elaborate on child- hood experiences in a coherent, detailed manner, being able to relate to positive and negative experiences, and give relevant and detailed illustrations. An autono- mous adult will believably describe one or both parents as loving during child- hood, or be reflective, largely free of idealization and angry preoccupation. In contrast, avoidant adults (dismissing) are characterized in the AAI by having few memories of early experiences and a tendency to dismiss the emotional sig- nificance of such memories8 (e.g., Appelman, 2000; Fonagy, Steele, & Steele, 1991; George et al., 1985).


7At no point in the interview was there any attempt to conduct an interview such as the Adult At- tachment Interview (AAI), because formal training is required for this. Rather, retrospectively, some is- sues that emerged from these case studies suggested an interesting association between the present data and the AAI as a frame of reference.

8The Adult Attachment Interview also relates to ambivalent and disorganized categories of attach- ment, as revealed in adults, which did not appear relevant to this study.zaragHighlightzaragHighlightzaragHighlight

In this study, although most of the parents reported relatively painful experi- ences related to their family of origin, parents who maintained their language elab- orated on these memories in greater detail, viewed them as significant to their pres- ent, and related them more often to their present language behavior than those who had not maintained their language. The parents’ ability to elaborate their past expe- riences coherently, which is often regarded in the AAI as reflecting secure attach- ment relations, seems to differentiate between language “maintainers” and “non-maintainers.” This ability or tendency appears to be more relevant to lan- guage maintenance than the experiences described. No claim of causal relation be- tween secure attachment and language maintenance is being made here, because attachment relationships were not sufficiently explored in this study and it is im- possible to control all the variables that interact with attachment relationships. Nevertheless, the association between the coherence of memories (or level of in- sight into the significance of early experiences) and language maintenance, and the relation posited in the AAI between coherence and secure relationships, is interest- ing and suggests further research. Parents who “decide” to hold on to their mother tongue despite bad experiences in the past and in their old world could be confront- ing life in a more direct manner. Their decision could denote a way of coping by maintaining a sense of continuity with the past rather than cutting it away from their life, and staying close to their memories rather than focusing on the present and the future. This coping mechanism could be related to a trait of directness and openness in general, which may well contribute, in turn, to closer and more inti- mate relationships with their children (see also Koplow & Messinger, 1990). Con- versely, secure attachment relations with their children may facilitate a parental tendency to maintain their mother tongue and relate to their children from this “continuity” stance. In other words, it is suggested that attachment mode and lan- guage maintenance are in a reciprocal relationship.

For example, Koni described a very complicated relationship with her mother throughout her childhood (growing up with a persistent feeling that she was a dis- appointment to her, not as good as her siblings, and, in her mother’s eyes, unwor- thy), but reported a much closer and supportive relationship with her father. She told her story openly, related it to her personal history, added rich details as “proof,” and altogether presented a coherent narrative (see also Appelman, 2000). At the same time, Koni maintains her language and culture consciously and enthu- siastically. She is also close to her children and keeps them close to her past in both its positive and negative aspects.

The narratives of Yoav and Nurit, Oded and Tamar, or Mario and Rosa, fol- lowed a similar pattern concerning the wealth of their memories, although their contents involved complicated relationships with at least one of their family mem- bers. Language and ethnic cultures are maintained in several ways in all these fam- ilies through activities deliberately arranged to preserve ties with the past, with the home country, with the extended families even when relationships are precarious,

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and through conscious acts designed to keep the children aware of these rich as- pects of their past.

Conversely, parents who were not maintaining their language were either much less capable of elaborating on their past experiences, or lacked insight into the pos- sible psychological influence of early experiences on their current emotional state of mind. For instance, Jose described several childhood experiences but in rather intellectual terms, with minimal emotional involvement and suggesting no inter- pretations or possible consequences. Lina stressed that her insights were very new, and until a few years ago, she had denied her childhood difficulties and had not as- sociated the psychological reality in her family to her language maintenance pat- tern. By the time she had shifted to English with her sons, she was in a very differ- ent state of mind. In terms of language maintenance with her children, this association, as she suggested, had perhaps emerged too late.


The association between language maintenance and any other specific variable is not linear, and it could never be, given its complexity. In this article, an attempt was made to identify a common cluster from the varied narratives, without missing or distorting the significant particularistic features of these families.

The central themes that emerged from the narratives suggest that, whatever the pattern of language maintenance, decisions in this regard usually rest on a strong emotional basis. Language emerges as much more than a technical communication device. It functions as a symbol of individuals’ intimate relationships with their families in the past and in the present, with people in the home country, with the new family they build as adults, with friends, and with themselves.

The association between language maintenance and secure attachment relation- ships suggested in the previous section could be applied to both parents and chil- dren in immigrant families. Adults (or in this case, parents) with high levels of in- sight or a functional reflective self tend to be connected to their past experiences, open about them, and able to confront them (Appelman, 2000; Fonagy, Steele, & Steele, 1991; Fonagy, Steele, Steele, Moran, & Higgitt, 1991; George et al., 1985; Meyers, 1998). Contributing a novel perspective to these issues, this study sug- gests that these variables are also related to mother tongue maintenance because language is associated with past memories, past and present intimacy contexts, and internal representations.

Furthermore, it is also suggested that attachment relations are associated with children’s linguistic choices, attitudes, and usage. Children were not interviewed directly in this study but this is certainly a recommended direction for follow-up research focusing on issues addressed here, by assessing linguistic patterns among immigrant children. Parents, however, did relate to their own childhood

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experiences as well as to those of their children in regard to linguistic behavior. On the basis of themes emerging on these aspects, of theoretical analysis of the concept of attachment relations, and continuing the link posited earlier between adult representation of attachment and adult linguistic behavior, it is suggested that children in immigrant families who are more securely attached will feel confident enough to learn a new language, but will also wish to maintain their parents’ language. The parents’ language is often the language related to the children’s internal working models in which children’s basic trust is or was con- structed. Parents frequently communicate with their children most meaningfully, spontaneously, and authentically in their mother tongue, which will thereby ac- quire meaningful connotations for securely attached children as well, influenc- ing their attitudes toward it. In contrast, insecurely attached children might find in the new language a way of constructing a space of their own (e.g., Mirsky, 1991). Strict adherence to a new language may serve as a mask or a barrier be- tween the child and the parents, which may be beneficial to the child in some cases. Amati-Mehler et al. described a similar pattern, whereby “the splitting and repression processes work through languages to build defenses that will safeguard the psychic functioning” (1990/1993, p. 184), suggesting that second language use, especially during therapy, may serve as a “safety barrier” against strong emotions and anxiety that would likely be aroused when talking about the same memories and issues using the mother tongue. This strategy seems to be the one adopted by the parents in this study who did not maintain their language. They tend to use the new language, thereby perhaps creating a new world for themselves while drawing away from their past experiences in various manners. This path was especially marked in the narratives of Lina, Jose, and Roberto and Julietta’s daughter.

The hypothesis suggested here, then, is that children who feel part of a warm and trustworthy family are more likely to succeed in their adaptation process, of which language is a crucial aspect. This dimension emerged in all the narratives of families who had maintained their language. Even parents fluent in the new lan- guage are uniquely attached to their mother tongue and tend to associate it with more authentic and intimate modes of communication. Although further research is needed to explore this notion explicitly, the material suggests that children living in close-knit families will be more motivated to enhance this closeness, and lan- guage maintenance is one of the first steps in this direction. By contrast, children who are part of more loosely attached families, where relationships between fam- ily members are rather distant, may feel “freer” to go ahead and use the new lan- guage and be less motivated to maintain the old one. Becoming competent in the new language may, in turn, facilitate the children’s sense of belonging to the new group, which may be of particular importance for children whose families do not offer them security and closeness. Once again, the story of Jose, Lina’s past deci- sions, and the daughter of Roberto and Julietta, illustrate this notion.

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In sum, themes emerging from the narratives suggest that close relations be- tween family members may correspond to a tendency for family units to maintain L1 whereas L1 maintenance by children may contribute to family closeness and to positive relationships between family members. The analysis of these cases sug- gests that family relations and psychological motives are a meaningful variable rather than a minor element in language maintenance. The narratives illustrate the various levels at which language penetrates our lives, but especially the lives of adult and young immigrants. Although the influence of language is pervasive, it acquires unique characteristics for immigrant families, when what had seemed ob- vious suddenly requires attention, the flow of communication is no longer sponta- neous, and the handling of these delicate issues becomes extremely significant in these families’ daily life.


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Nurses’ perceptions of communicating with minority parents in a neonatal nursery: a communication accommodation theory approach. Liz Jones, Nicola Sheeran , Hanna Lanyon, Karina Evans and Tatjana Martincovic

School of Applied Psychology, Griffith University, Brisbane, Australia

ABSTRACT Background: Communication is a central part of providing family centred care in neonatal nurseries and is associated with a range of positive outcomes for families. However, previous research has indicated that communication is more problematic between health professionals and minority groups of patients and families, although much of this research is atheoretical. The current study used communication accommodation theory to examine nurses’ perceptions of effective and ineffective interactions with typical parents, culturally and linguistically diverse parents (CALD), and adolescent parents in neonatal nurseries. Method: We conducted semi-structured interviews with nurses from two tertiary hospitals in Australia. Twelve nurses from one hospital were asked about interactions with typical parents, and twenty-nine nurses from the other hospital were asked about interactions with CALD and adolescent parents. Interviews were coded for communication strategy and accommodative stance, using a coding system based on communication accommodation theory. Results: Descriptions of interactions with typical parents (who were perceived as Anglo- Australian) differed from those with CALD and adolescent parents. Interactions with CALD parents focused mostly on comprehension and cultural differences, with limited mention of other strategies. Interactions with adolescent parents were regarded as particularly problematic, and involved greater focus on face management than for other groups of parents. Generally, interactions with minority groups were based on a narrower range of strategies, and were more intergroup than interpersonal in focus. Conclusions: Our findings show the importance of studying health professionals’ perceptions of interactions with people from different minority groups. We discuss the implications for our understanding of communicating with diverse patients and families, and educating health professionals, including the utility of communication accommodation theory as a guiding framework for training.

KEYWORDS Adolescent parent; neonatal nursing; healthcare communication; communication accommodation theory; cultural diversity; linguistic diversity; cultural competence; culturally effective care; family- centered care; bias


Communication is central to providing patient-centred care, and is associated with positive outcomes for patients, including patient and family satisfaction, com- pliance with treatment, improved clinical outcomes, and enhanced prevention [1]. While there has been much focus on communication skills deficits as the explanation for poor communication by health pro- fessionals [2], there has been growing interest in how an intergroup perspective, which focuses on how the sociopsychological factors associated with a person’s social group memberships influences their communi- cation, may increase our understanding of the under- lying causes of ineffective health communication [3]. In particular, researchers have been using communi- cation accommodation theory (CAT) to study health communication [4]. CAT constructs interpersonal inter- actions as grounded in the social identity(ies) of the interactants, and predicts communication is influenced by the ‘group’ memberships that are salient for each participant [5].

In health care, these identities/groups include patients and their families, and a range of health pro- fessionals, but may also include other cross-cutting identities, such as ethnicity or age. Researchers have found both more problematic communication and poorer outcomes for patients from minority groups [6–8], suggesting health communication scholars should consider more the interplay between the mul- tiple social group memberships of health professionals and patients. Yet to date, there is limited health com- munication research using intergroup theories to examine communication between health professionals and patients from minority groups [4]. We use CAT to examine, in a neonatal nursery, nurses’ perceptions of communication with parents with different cross- cutting identities.

Neonatal nurseries provide an interesting context for examining the role of cross-cutting identities. Infants may be admitted for a lengthy period of time, and thus parents both have extended contact with a range of health professionals, and must negotiate

© 2018 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Liz Jones [email protected] School of Applied Psychology, Griffith University, 176 Messines Ridge Rd, Mt Gravatt, QLD 4122, Australia

JOURNAL OF COMMUNICATION IN HEALTHCARE 2018, VOL. 11, NO. 3, 175–185 https://doi.org/10.1080/17538068.2018.1460959http://crossmark.crossref.org/dialog/?doi=10.1080/17538068.2018.1460959&domain=pdfhttp://orcid.org/0000-0003-0527-8549mailto:[email protected]http://www.tandfonline.com

their role as a carer for their infant [9]. We interviewed nurses, as they are the coordinators of communication between patients, families, and other health pro- fessionals [10], and, in a neonatal nursery, a key source of information and support for parents [11,12].

We focused on parents who were either adolescent or culturally and linguistically diverse (CALD), because they are two minority groups in Australia who experi- ence poorer perinatal outcomes, and greater disadvan- tage in accessing health services [13]. We use the term CALD to encompass parents who are not Anglo-Austra- lian, i.e. from an ethnic minority group, who may also speak English as a second language. We argue both adolescents, and/or those who are CALD, are, to some extent, stigmatized, and hence their interactions with health professionals are often doubly intergroup [3,14]. In particular, there is a potentially increased power differential between nurses and parents who are not the typical adult and Anglo-Australian parent. This may be compounded by socioeconomic/social class differences, whereby CALD and, in particular, ado- lescent mothers are more likely to be economically dis- advantaged [15]. However, these groups also differ in how they are stereotyped, and the problems they experience in health communication.

Communication between health professionals and patients or families who are CALD or adolescent

Health professionals, including nurses, experience a range of difficulties when interacting with people from a CALD background. Language barriers, in par- ticular, affect patients’ access to obtaining health care. Health professionals acknowledge less favourable impressions and poorer communication with patients from a different race or ethnicity [16]. Jirwe et al. [17] found in cross-cultural encounters, nurses were con- cerned about giving insufficient information about pro- cedures, the lack of social interaction, care becoming mechanistic and impersonal, more misunderstandings, and difficulties with accessing interpreters. Dressler and Pils [18] found being an ethnic minority patient in Austria, who did not speak German, affected patients’ understanding, resulted in longer interactions with health professionals, hindered or completely impeded some therapies, and affected assessment, particularly of functional capacities. Nurses report that language barriers are exacerbated by their lack of cul- tural awareness, and their knowledge and skills to respond to people from a different cultural background [19–22]. Cioffi [20] found that while many Australian nurses were motivated to be empathic and respectful, others were frustrated with patients who could not speak English, while other researchers have found that difficulties in communication are more evident for nurses with more negative attitudes toward

migrants [17,22]. Importantly, Haider et al [23] ident- ified that while relatively few American nurses demon- strated explicit bias, many exhibited implicit bias against non-white patients.

The perceptions of patients from a CALD back- ground concur to some extent. For example, Garrett et al. [24] found non-English speaking patients expressed particular difficulties, including their limited English proficiency, which resulted in feeling power- less, anxious, fearful, lacking in confidence, and a sense of dependency, which led to problems in care, administration of medications, compliance, and treat- ment. Patients also report less positive consultations, less satisfaction, and lower levels of trust when their health professional is from a different race or ethnicity [25,26].

Adolescents also experience difficulties communi- cating with health professionals. Adolescents value health professionals explaining things and giving infor- mation in an understandable way, 2-way communi- cation where health professionals listen to them, and health professionals who are kind, caring, understand- ing, non-patronizing, and non-judgemental [27]. However, both health professionals and adolescents report difficulties in their communication, with Drury [14] arguing explanations for difficulties include the power imbalance between health professionals and adolescents, and communication being one-sided, with a lack of respect for the adolescent’s point of view. For example, adolescents report that in commu- nicating with their doctor they are not listened to, and they are patronized, lectured, and given unsoli- cited advice [28].

Sheeran et al. [29] found that in neonatal nurseries, in contrast to adult mothers, adolescent mothers described interactions with nurses making them feel watched and judged, and lacking power and auton- omy, which inhibited their ability to parent. Adolescent mothers perceived they were labelled and treated as adolescents who did not know how to parent, rather than as mothers. Peterson et al. [30] also found young women inpatients perceived nursing care as more positive when they were treated the same as adult patients, whereas being treated differentially due to age hindered development of an effective nurse-patient relationship. The perceived stigmatiza- tion and feelings of discrimination in the hospital setting appears similar to that experienced by adoles- cent mothers in the general community [31,32]. There has been less research examining health professionals’ perceptions of interactions with adolescent patients or parents.

Communication accommodation theory

While previous research has identified differences in how health professionals communicate with people


who are CALD or adolescent, this research has mostly been atheoretical, and has rarely compared different minority groups. The current study used CAT to examine the strategies and accommodative stance nurses report when interacting with parents from different social groups. CAT affords attention to the intergroup nature of interactions, including how the activation of group-based stereotypes in intergroup interactions shapes the behavior and perceptions of interactants [33]. A number of communication strat- egies are described in CAT, as well as how interactants use them to facilitate social interactions, and to reduce or increase social distance [34]. Changes in verbal or nonverbal behavior to become more or less like the other interactant is referred to as approximation. The way a speaker adapts their behavior to make it more understandable (or not) is referred to as interpretabil- ity. Discourse management refers to how the process of the interaction is managed, including the sharing of topic selection and turn-taking. Interpersonal control is about the roles enacted in an interaction, whereby interactants may attempt to establish a common role or may seek to keep themselves and others in a particular role. Face management strategies take account of a person’s need to be liked and respected and have their wishes appreciated (positive face), and their need to be independent, free of demands or impositions (negative face). Finally, emotional expression involves interactants responding to the emotional or relational needs of the other person, including reassurance, and support [4].

CAT uses the term accommodative stance to refer to how each interactant uses these strategies to adapt their communicative behavior to appropriately move towards, or respond to the needs of the other person (accommodating), or to be distinct from, or inappropri- ately move towards the needs of their speech partner (nonaccommodating) [35]. Nonaccommodation includes underaccommodation, where a speaker main- tains (or accentuates differences) in their behavior, or overaccommodation, where a speaker goes beyond the style necessary, using patronizing or ingratiating moves, or accommodating to a stereotype of the other person’s group. Accommodation is generally evaluated more positively than nonaccommodation, and in the health context is consistent with definitions of patient-centred care [36] and family-centred care [37]. Family-centred care is the primary model of care used in neonatal nurseries, and refers to putting the family at the centre of care, and recognising and valuing the unique contribution parents and/or families make in the life of the infant [38,39].

CAT has been used in a number studies of health pro- fessional-patient interactions, although the focus has generally been on doctors [4]. Relevant to the current study, Jones et al. [37] used CAT to examine parents’ per- ceptions of interactions with nurses. They did not,

however, examine nurses’ perceptions. While some CAT researchers may focus on examining behavioural adjustments, CAT emphasizes the importance of under- standing the psychological state of both interactants, as an interactant’s behaviour is predicted by their initial orientation (the goals and beliefs they bring to inter- actions, including intergroup relations) and their percep- tions and attributions of their own and their partner’s behaviour. Thus, CAT researchers emphasize that it is equally important to examine the perceptions of interac- tants and how they differ [5]. In our study we will be able to compare the extent to which the perceptions of nurses concur with the perceptions of parents [37].

In the current study, we used CAT to examine nurses’ perceptions of self-reported effective and inef- fective interactions with parents in the neonatal nursery. We investigated ‘How do nurses’ perceptions of communication strategies and accommodative stance differ when describing interactions with parents from different social groups?’ Our interest was whether nurses’ perceptions of communication changed depending on which minority group they were interacting with, compared to their perceptions of interactions with parents where no specific additional group membership was primed. We label the latter parents ‘typical parents’, who Perloni [40] found nurses described as adult and Anglo-Australian. We hypothesised that:

(H1) Effective interactions would be perceived as more accommodative and ineffective interactions as nonaccommodative;

(H2) Interactions with CALD parents would focus more on interpretability, with a focus on level of understand- ing; and,

(H3) Interactions with adolescents would focus more on underaccommodation on discourse management (e.g. lack of 2-way interaction), interpersonal control (e.g. treating as an adolescent rather than an individ- ual), and face strategies (e.g. nurse critical or disrespectful).



Nurses working full-time or part-time in the Neonatal Special Care Nursery were recruited from two tertiary hospitals in Australia. Special Care Nurseries provide care for infants with lower acuity than Neonatal Inten- sive Care Units. The hospitals were similar in size of the nursery and the acuity of infants, as well as having a significant population of CALD patients and parents. The data were collected in two phases, as two separate student projects in 2013 and 2015.

Phase 1. Twelve nurses (11 female and one male) were recruited from the first tertiary hospital, who had worked in the nursery for 6 months to 23 years


(M = 7.3 years, SD = 6.8 years). The majority of the nurses were of Anglo-Australian ethnic background, with one each from UK and New Zealand. These nurses were asked about their interactions with parents, without reference to any specific group of parents. We describe these parents as typical parents in our results.

Phase 2. Twenty-nine nurses (all female) were recruited from the second tertiary hospital, who had worked in the nursery for 1.5 to 38 years (M = 16.27, SD = 9.69). The majority were of Anglo-Australian ethnic background, with two from south-east Asia and one from South Africa. These nurses were asked specifically about their interactions with both CALD and adolescent parents.

Recruitment and data collection

Prior to data collection ethical approval was obtained from hospital and university Human Research Ethics Committees. We attended regular in-service sessions for staff in each nursery, and left information sheets in key areas of each unit. Nurses were then approached and invited to participate in the study, and asked to sign a participant information and consent form. Nurses were interviewed at a convenient time and location (e.g. meeting room at hospital or a quiet area in a café).

The interviews were semi-structured. In Phase 1, the interview questions asked nurses about interactions with parents, while in Phase 2 the interview questions referred to a CALD or adolescent parent specifically. Note, in an Australian context the term adolescent refers to a person 13–19 years of age. For example, ‘Can you think about an interaction or a time when you have talked with a (CALD) parent and it was par- ticularly difficult or challenging?’ Prompts: ‘When you felt you didn’t communicate effectively with a CALD parent?’ Or ‘Can you think about a time or interaction when you talked with a (teenage) parent and it went particularly well/felt really good?’ Prompts: ‘When you felt like you communicated effectively with a teenage parent?’ Interview questions about CALD and adoles- cent parents were counterbalanced. Interviews were on average 30 min, and were digitally recorded and transcribed.


We used the coding scheme for six CAT strategies (interpretability, discourse management, interpersonal control, emotional expression, positive face, and nega- tive face) that Jones et al [38] developed to examine parents’ perceptions of effective and ineffective inter- actions with nurses in neonatal nurseries. Each partici- pant’s whole description of effective or ineffective communication was content coded for whether the participant mentioned each strategy, and whether their description was accommodative, under-accom- modative, or over-accommodative. Descriptions could be about the nurse’s behavior, the parent’s behavior, or both. Moreover, while nurses were asked to talk about specific interactions, their interviews included both descriptions of specific interactions and state- ments about interactions with parents or the relevant group of parents in general. We coded both. For some participants, a description mentioned only one strategy (rarely), for others up to five strategies. Some participants made only one reference to a particular strategy and stance (e.g. underaccommodative) in their description of effective or ineffective communi- cation, whereas others mentioned the same strategy and stance up to three times. The coding system is

Table 1. Communication strategies coding scheme. Strategy Type Levela Examples

Discourse Management

Over Letting others direct conversation, passiveness, avoiding talking to mother, waiting for them to initiate conversation

Accom Asking questions, asking opinions, chatting, listening, openness to suggestions

Under Dominate conversation, do not listen or let them speak, gives unsolicited advice, controls, bombards with questions

Emotional Expression

Over Too much sympathy, exaggerated need to understand parent, extra effort to get to know them

Accom Reassure mother, show empathy, supportive, recognises and adjusts for parent’s emotional needs

Under Nurses not empathetic or understanding, unsupportive

Interpretability Over Too simple, patronising, assuming no knowledge, spoken down to like children

Accom Clear, direct, honest, explain situation, check understanding, provide sufficient and accurate information, adjust appropriately to cognitive and psychological level

Under Not bothering/giving up explaining, using complex medical terms, not adjusting sufficiently to help understanding, withholding information

Interpersonal Control

Over Be too personal or familiar, treat like best- friend, denigrate others, over self- disclose, over-nurturing toward mother

Accom Treat each other as equal individuals, disregard roles, develop shared identity, get to know as individual

Under Emphasis on professional status, too formal, treat like parent, treat everyone the same instead of as individuals, applying generic or impersonal approach

Negative face Over Nurses ask by putting themselves down, denigrating self, puts self-down with humour

Accom Does not demand/impose mother, approaches at appropriate time, considerate of mothers’ wishes

Under Demand or order parents, nurses prioritises her own needs

Positive face Over Try to counteract prejudice, avoid negative information, give special treatment, overly encouraging or optimistic

Accom Polite, respectful, encouraging, showing interest in individual, promotes confidence

Under Criticise parent, condescending, put them down, rude toward parent, disrespectful

aOver = Over-Accommodation, Accom = Accommodation, Under = Under- Accommodation.


presented in Table 1. For each phase the students on the project were trained by the first author, with 10% of the transcripts coded initially by both coders to establish consistency in coding. Thirty percent of the data for each student was also coded by a second coder, with interrater reliability of .82 using Cohen’s kappa for Phase 1 and .91 for Phase 2. All coding was then reviewed by the first author and an independent coder to ensure consistency in coding across the two phases.

The analysis confirmed descriptions of interactions with parents in Phase 1 were almost exclusively about typical parents, with only two statements in Phase 1 mentioning a minority group membership. This suggests when we don’t prime nurses for a min- ority group they talk about adult Anglo-Australian het- erosexual parents.

Consistent with Jones et al [38], in our analysis we initially calculated the percentage of participants who mentioned each CAT strategy, for effective and ineffec- tive interactions, for each of the three groups of parents (see Table 2). The Freeman-Halton extension of the Fisher exact probability test was then conducted to examine differences between nurses’ perceptions of the CAT strategies and stance used in effective inter- actions, and in ineffective interactions, with CALD, ado- lescent, and typical parents (the Freeman-Halton extension is appropriate when the contingency table is larger than 2 × 2). We then undertook a more detailed qualitative analysis of how participants described using different strategies with the three different groups of parents. We integrate the findings from this more detailed analysis with our reporting of the results of the quantitative analysis.


Effective interactions

Overall, as predicted, most descriptions of effective interactions involved an accommodative stance. Key topics were provision of information, enabling parent- ing, and the nurse’s or parent’s interpersonal style. A detailed description of these topics is provided in Jones et al [11]. There were, however, differences in which strategies nurses reported being used in effec- tive interactions with typical, adolescent, and CALD parents, as well as how many strategies they mentioned.

Typical parents. When describing effective inter- actions with typical parents, nurses frequently men- tioned discourse management and emotional expression, followed by interpretability, interpersonal control, and positive face. The rates for discourse man- agement and emotional expression were significantly higher than for other groups of parents. Nurses’ use of discourse management included making time to

talk to parents, listening to them, jointly making decisions, and following up on their discussions. Nurse 11 reflected the use of emotional expression: ‘building rapport is important … [as is] giving [parents] an opportunity to voice how they feel’. Most nurses mentioned accommodative interpretability in relation to explaining and clarifying information. Nurse 9, for example, said ‘it was her first time and just explaining to her the right way to breastfeed and attachment’. Nurses also frequently mentioned inter- personal control, emphasising the importance of treat- ing parents as equals. Finally, positive face was less frequently mentioned, with a typical quote being Nurse 5 describing ‘giving a mum positives to hang on to, to come back with the next day to try again’.

CALD parents. Fewer strategies were mentioned with CALD parents. Interpretability was the most frequently mentioned strategy. This primarily involved nurses checking understanding, adapting their language style, slowing and simplifying speech, using gestures to assist in explanations, and accessing outside resources, such as interpreters and written materials, to facilitate understanding. For example, Nurse 13 describes

non-verbal communications, smiling, eye contact, sign language, things like that, if it is nothing important, just nappy changes or things like that … . But if it is impor- tant stuff, I think you need interpreter.

In general, the focus was on language comprehension rather than other cultural differences in communication.

The only other strategies reported with some fre- quency were interpersonal control and positive face. A small number of the comments about positive face were similar to those for typical parents, such as Nurse 18 talking about ‘being able to facilitate skill building in parents to care for the baby’. However, the majority of nurses used positive face to show inter- est in the parent as a person from a CALD background, such as Nurse 22 ‘asking questions to learn about their culture in order to understand their needs’. In using interpersonal control, nurses used informal communi- cation, including talking about cultural issues (‘we hit it off and started talking about cultural things as well’ Nurse 20). Nurses generally focused on the parent as a person from a CALD background rather than as a parent or an individual, and, surprisingly, there was only one reference in their accounts to particular CALD groups.

Adolescent parents. Descriptions of effective inter- actions with adolescent parents were more often described in general terms than specific interactions. When describing effective interactions with adolescent parents a wide range of strategies were mentioned, with face (both positive and negative), interpersonal control, and interpretability mentioned most fre- quently. The rates for accommodative interpretability,


discourse management, and emotional expression were lower than for typical parents, whereas negative face was mentioned more frequently for adolescent parents than both other groups. The focus for nurses when using negative face was about not putting demands on adolescent mothers. Nurse 24 says ‘if they don’t want to sit and talk to me I don’t push it in their face’ and Nurse 26 stated

If they’re on the phone texting … friends here … you’ve just got to choose your moment and say ‘well I’ll come back when you’ve got a minute to listen’. There’s no point because the environment’s not right.

Comments about positive face were similar to those for typical parents, in describing giving them positive feed- back and encouraging them in their parenting, but some also included an assumption that you need to be ‘mindful of how you speak to them’ (Nurse 33). Nurses talked about using interpersonal control to encourage adolescent parents to adopt the parenting role. This was not a way interpersonal control was used with other parents.

While the numbers are small there was also a general pattern across strategies of more frequent use of under or overaccommodation with adolescent parents, compared to CALD and typical parents, which is consistent with nurses viewing these inter- actions as more intergroup. Examples include com- ments such as ‘be a bit self-effacing’ (Nurse 28) and ‘sometimes they need a bit of mothering themselves’ (Nurse 26). While some comments about interpretabil- ity mirrored those for typical mothers, there were also comments that were more overaccommodative, where adolescent parents were seen to be difficult and needing to be spoken to like a child, for example, Nurse 36 says

interactions tend to go well when you answer what- ever nonsense questions they have … . Because they feel relieved if all their questions are answered even if it is a nonsense question.

Overall, nurses perceived overaccommodative approaches to be effective, because they regarded teenage mothers as requiring substantially more support than other mothers and being more difficult.

Ineffective interactions

Overall, as predicted, ineffective interactions were more frequently described as involving under, or to a lesser extent overaccommodation, than accommo- dation. In contrast to descriptions of effective inter- actions, most descriptions of ineffective interactions involved only one or two strategies. Key topics again included provision of information, enabling parenting, and the nurse’s or parent’s interpersonal style. In addition, nurses talked about managing the enforce- ment of policies. There were fewer differences between the three groups of parents for nurses’ descriptions of ineffective interactions, although there were differences in the specific behaviors nurses described themselves and parents using in enacting the different strategies.

Typical parents. When describing interactions with typical parents, interpretability, discourse manage- ment, and interpersonal control were frequently men- tioned. Underaccommodative interpretability was the most frequently mentioned, with nurses identifying how ineffective communication often involved mothers being given inconsistent, unclear, or conflict- ing information, particularly by different nurses, for example ‘I think it was even a day later before anyone realised that the parents didn’t understand

Table 2. Percentage of nurses mentioning each communication strategy for effective and ineffective communication with CALD parents, adolescent parents and adult parents.

Strategy Version

Effective Ineffective

CALD (N = 29) Adolescent (N = 29) Adult (N = 12) CALD (N = 29) Adolescent (N = 29) Adult (N = 12)

Disc Manage Over – – – 6.9b 24.1 27.3 Accom 6.9a 17.2 90.9 –b – 27.3 Under – –b 20.7 36.4

Emot Express Over 3.4 6.9 – – – – Accom –a 24.1 90.9 – – – Under – 3.4 – – 10.2 9.1

Interpretability Over 17.2 24.1 – 6.9 – – Accom 65.5a 31 72.7 20.7b 3.4 36.4 Under – 3.4 – 55.1a 6.9 45.5

Int Control Over – 13.8 – – 13.8 9.1 Accom 31 48.3 63.6 – – 9.1 Under – 6.9 9.1 10.2c 34.5 36.4

Positive Face Over 3.4 3.4 – – 17.2 – Accom 34.5 44.8 54.5 – – 9.1 Under – – – – –

Negative Face Over – 3.4 – – – – Accom 6.9b 27.6 – – – – Under – 6.9 – 3.4a 34.5 –

ap < .05 comparing CALD, adolescent and adult. bp < .01. cp < .08. Over = Over-accommodation; Accom = Accommodation; Under = Under-accommodation.


that the baby was having this new medication’ (Nurse 10). Underaccommodative discourse management involved ‘cutting parents off’ according to Nurse 1, or being ‘short with [parent]’ as mentioned by Nurse 3. Similarly, underaccommodative interpersonal control was mentioned by several nurses, who described behaving in a formal and professional manner; often to avoid further ineffective interactions. For example, Nurse 5 described how she was later ‘more reserved and standoffish’ after an initial unplea- sant interaction with a parent. Overall, nurses said they had few ineffective interactions with typical parents, and there was a mix of attributing responsibility for the interaction to themselves, the parent, and the situation.

CALD parents. Interpretability was the most fre- quently mentioned strategy for interactions with CALD parents, with almost no other strategies men- tioned. Mostly this was underaccommodative inter- pretability, where nurses described failing to check understanding, failing to adjust their communication style to facilitate understanding (‘I think they get it eventually; we just keep hammering them I guess’, Nurse 34), or recognising that their communication partner had not understood and failing to take any further action (‘you tend to just leave your shift and think oh god she really didn’t understand that’, Nurse 28). Nurses recognised that mothers nodding did not mean that they were understanding, making it difficult to know whether the mother had understood them. Nurses also talked about the difficulties of accessing interpreters, which was of particular concern when the mother was distressed, and how ‘if the information is not interpreted correctly, it can lead to misunder- standings about the baby’s health, which can then increase the mother’s distress’ (Nurse 20).

Underaccommodative interpretability could also be combined with underaccommodative interpersonal control where, for example, Nurse 25 states

I really don’t have the time to just chat, like I do with other parents about anything, because I am not going to sit there and try to explain in hand sign language, ‘like do you watch Master Chef?’ It’s not worth my time.

There were also instances of overaccommodative inter- pretability, ‘I had noticed people talking to her in a louder voice, saying the same English words in a louder voice’ (Nurse 13). In contrast to interactions with other parents, nurses also spoke about fathers from particular cultural backgrounds as the source of difficulties in interactions with CALD parents, particu- larly around interpreting. This included questioning whether fathers were interpreting accurately (e.g. where the father didn’t want his wife examined by a male doctor) or a father refusing to work with a formal interpreter.

Adolescent parents. In describing interactions with adolescent mothers, nurses talked less about interpret- ability, instead talking about interpersonal control, dis- course management, and negative face. In describing the use of discourse management, nurses talked about adolescent mothers as not wanting to listen nor engage with you (‘she said “I don’t want to talk about it with you anymore”’ Nurse 13), or not expres- sing their preferences or asking for help, (‘I find a lot of them to be quiet … you have to drag information out of them’ Nurse 28). In addition, nurses spoke about adolescents underaccommodating on negative face, whereby nurses were critical of adolescent mothers who ‘think they know it all’ (Nurse 25) and are ‘fully aware of their rights, they throw it into you face and know exactly how to use the system’ (Nurse 20). There was more mention of negative face for ado- lescent parents than other parents, with nurses per- ceiving adolescent mothers as putting their own needs first, (‘teens are quite self-centred’ Nurse 35). Nurses demonstrated less empathy towards adolescent parents. It was noteable in descriptions of ineffective interactions with adolescent parents that the adoles- cent mother was frequently positioned as difficult and as responsible for the difficulties in the interaction, rather than nurses acknowledging any contribution to difficulties. There were also considerably more refer- ences to adolescent mothers as a group, rather than descriptions of interactions with individual mothers.

There were also instances of nurses describing the same behavior by an adolescent parent as a CALD parent, but making different evaluations of that behav- ior, that implied different strategies. For example, with CALD parents, nurses would say ‘you’ve got to be aware that they might be nodding at something but they don’t really get it’ [because their behavior isn’t consistent with what has been told to them] (interpret- ability), whereas inconsistencies between what the nurse asked an adolescent mother to do and the ado- lescent mother’s behavior were seen as deliberate non- compliance (underaccommodative face).


Overall, consistent with the perceptions of parents in neonatal nurseries [37], descriptions of effective com- munication were mostly associated with use of an accommodative stance and descriptions of ineffective communication with a nonaccommodative stance (mostly underaccommodation). Our findings show nurses describe different communication strategies being used when interacting with parents from differ- ent minority social groups compared to typical parents in the nursery. Moreover, there were simi- larities and differences in the strategies and stance used in interactions with adolescent and CALD parents. Interactions with typical parents were


described in more interpersonal terms, whereas inter- actions with CALD and adolescent parents were described in more intergroup terms, and hence less consistent with family centred care.

For both CALD and adolescent parents, nurses’ descriptions were less about discourse management and emotional expression than for typical parents. Instead, as predicted, for CALD parents there was more focus on interpretability than other strategies, with a particular focus on comprehension. This is con- sistent with previous research regarding how health professionals change their behavior when interacting with CALD patients [41], and how health professionals are concerned in cross-cultural encounters about giving sufficient information, the level of misunder- standings occurring, and the difficulties accessing interpreters [17,19,21]. It is noteworthy how little nurses reported using discourse management, inter- personal control, and emotional expression, despite these strategies being consistent with family centred care, that is policy in the nurseries [38], and which pre- vious research has identified as strategies important to parents [11,37].

While nurses’ descriptions of effective interactions with CALD were mostly about language comprehen- sion, there was also some limited discussion of cultural differences in both effective and ineffective inter- actions, including issues such as infant care practices and family involvement. The focus for use of positive face was also primarily about doing so in a culturally appropriate way, with evidence of goodwill by some, but not all nurses toward CALD parents (similar to 20). This is further evidence of the narrow focus of nurses when interacting with CALD parents, where interactions were described as intergroup, with culture highly salient, which may mean other com- munication needs of these parents are neglected. Moreover, while culturally competent care is part of the premises of family centred care (42), there was evi- dence in our study that a number of nurses were not attempting to provide culturally competent care, with potential implications for parental well-being and infant care. Future research needs to consider how CALD parents perceive this focus on language, in par- ticular, and culture, and what its impact is.

Nurses emphasised different strategies when inter- acting with adolescent parents compared to typical parents and, to some extent, CALD parents. Moreover, while for all groups there was more focus on inter- actions with mothers than fathers, descriptions of inter- actions with adolescents parents were almost entirely focussed on interactions with mothers. Interactions with adolescent parents were also the most intergroup, whereby they were seen more as adolescents than as parents, which is consistent with adolescent mothers’ viewpoints [29]. In describing effective interactions nurses focused on their own behaviour, talking about

adolescent mothers’ need for independence or freedom from imposition, and the careful balancing work required by nurses to attend to adolescent mothers’ face needs. Some nurses talked about mothering adolescent parents, whereas others focused more on chastising or controlling adolescent parents.

In describing ineffective interactions nurses focused on the adolescent mothers’ behaviour, which saw nurses label them as unassertive, or aggressive and dif- ficult (negative face). The greater focus on an under and overaccommodative stance is consistent with ado- lescents’ reports of negative communication with health professionals in neonatal nurseries [29], and in healthcare more generally [14]. The implication of this is that adolescent parents describe disengaging with parenting in the nursery in response to such negative communication [29]. In turn, this may reinforce nurses’ accommodative stance, where adolescent parents need mothering or chastising.

Nurses’ limited focus on discourse management and emotional expression in describing effective inter- actions is inconsistent with adolescents’ desire for health professionals explaining things in an under- standable way (interpretability), two-way communi- cation (discourse management), and health professionals who are kind, caring, and understanding (emotional expression) [27]. Moreover, nurses’ descrip- tions of interactions with adolescent parents ignored the role of the power difference between them. Notice- able in the nurses’ descriptions was positioning the adolescent parent (mostly mother) as responsible for ineffective interactions, in contrast to descriptions of interactions with CALD and typical parents. Nurses’ descriptions of interactions with adolescent parents were consistent with the pervasive deficit view of ado- lescent parenting, which stereotypes adolescent parents as less warm and competent than adult parents [43]. Adolescent mothers are aware of these negative stereotypes, which result in them avoiding seeking help with their parenting [29].

Our findings show the importance of studying how health professionals interact with people from different minority groups. As predicted by CAT, nurses in our study approached interactions with minority group parents with a different initial orientation, based on stereotypes of these groups. In turn, nurses described different strategies being used with CALD and adoles- cent parents compared to typical parents, and the interactions were primarily intergroup. These differ- ences are inconsistent with patient or family centred care models (and therefore culturally competent care), and may mean the needs of these parents are not being met, with potential implications for parents’ engagement in infant care, and their well- being and help-seeking [29]. We need to ensure health professionals are aware of how they stereotype


patients and families, and how this may influence their communication. We know from the work of Haider et al [23] that nurses may not be aware of their biases. Health professionals also need to be educated about how non-accommodation creates a challenging inter- actional position for patients and families [33]. Pitts and Harwood [44] proposed that accommodative com- petence (based on CAT principles) might provide a new approach to communication skills training, with its focus on adapting to the contextual and relational fea- tures of specific interactions. In turn this would enhance the ability of nurses to provide family centred care. We argue our coding system and our find- ings could provide a framework for training neonatal nurses in accommodative competence, particularly for working with parents from minority groups. Such training needs to include a focus on perspective- taking for interactional partners as both individuals and members of social groups (see [45]).

Our findings for typical parents also highlight the importance of considering the perspectives of nurses, as well as parents about what constitutes effective and ineffective communication. Nurses’ descriptions of effective and ineffective interactions with typical parents were mostly consistent with the Jones et al. [37] study, in which parents frequently mentioned interpretability, discourse management, and emotional expression for effective interactions, and discourse management and interpretability for ineffective inter- actions. However, there were some potentially impor- tant differences, with parents in the Jones et al study talking more about positive face in both effective and ineffective interactions, and more about emotional expression in ineffective interactions. This emphasises the importance of looking at the perceptions of both nurses and parents, to identify discrepancies, which may reflect different emphases about what is impor- tant in nurse-parent interactions. Nurses may be less aware of, or underestimate the impact of when their communication is unsupportive, and given the impor- tant role of nurse support for both parental well- being and satisfaction [12], as well as their parenting [11], the different emphasis of nurses may be consequential.


Our study only gathered nurses’ perceptions of their interactions with parents. Future research should examine the perceptions of parents from minority groups. While there is previous research on what strat- egies typical parents prefer, CAT provides a useful fra- mework to identify what CALD and adolescent parents describe as effective or ineffective communi- cation with nurses. We also don’t know to what extent the differences identified in this study are pro- blematic or not for CALD and adolescent parents, but

we suggest there may be effects on both their well- being and parenting. While there is some evidence adolescents value patient or family-centred care, there has been less discussion about the applicability or not of these models of care for people from different cultures. In our study we did not discriminate between CALD parents from different cultures (nor generally did our interview participants), however cultures differ in their conceptions of illness and health, as well as com- munication norms.

Future research should also examine whether our findings generalise to other health professionals. In our studyeffectivecommunicationwasgenerally accommo- dative. Research using CAT with doctors shows less con- sistency in the findings. Ahmed and Bates [46] for example, found that patients do not prefer accommo- dation by doctors on all strategies. While patients were more satisfied with doctors who accommodated on interpretability, their patients were more satisfied with doctors who did not accommodate on interpersonal control. This is a reminder that education in communi- cation effectiveness must, as proposed by CAT, take account of both interactants’ identity/ies and the context within which interactions occurs.

We only coded for strategies and accommodative stance. Future research should systematically examine the goals or motives underlying strategy choice, as any intervention with health professionals will need to understand these, including whether nonaccommo- dation is intentional or unintentional (see [33]). There continues to be limited research examining the behav- ior of nurses and patients or families, to understand the extent to which nurses’ perceptions of their inter- actions are reflected behaviorally. Ideally, we would examine both the behavior and perceptions of both nurses and parents concurrently; providing a dyadic perspective. CAT is an ideal theory to use for such research, as CAT predicts how peoples’ initial orien- tation and accommodative stance may affect both their behavior, and their perceptions and evaluations of their interactional partner.


While patient- and family-centred care have become the dominant philosophies of care in many health facili- ties, our findings show many nurses are not practising family-centred care in interactions with families from minority groups. Overall, the findings also show the value of communication accommodation theory in explicating how health communication is shaped by the social group memberships of patients and families, which in turn may guide new approaches to improving health communication, particularly with patients and families who are members of minority groups. We argue interactions between any health professional and a patient or family are, in part, intergroup. Using


our CAT coding scheme in training could highlight how the different communication strategies health pro- fessionals use may affect patients or families, enable an exploration of the their motives and beliefs that underlie their communication, and give ideas of new strategies health professionals can use to enhance their communication with patients and families.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Liz Jones, PhD (Uni of Qld), is an Associate Professor and Director of Organisational Psychology. Her research interests are in an intergroup approach to health and organisational communication, and Communication Accommodation Theory. She is interested in both health practitioner-patient communication and interprofessional practice, with a particu- lar interest in giving voice to those from non-dominant groups.

Nicola Sheeran, PhD (Griffith Uni), is a lecturer in psychology and a clinical psychologist. Her research focuses on women and family mental health, and the intersection of clinical, health and social psychology. Current research interests include communication between adolescent mothers and health professionals, long term outcomes for adolescent mothers, and stereotypes, attitudes, stigma and discrimi- nation of adolescent parents.

Hanna Lanyon, BPsychSci Hons (Griffith Uni), is undertaking her Masters in Clinical Psychology at Queensland University of Technology. Her Honours thesis investigated nurses’ per- ceptions of effective and ineffective interactions with teenage mothers in the newborn care unit. Findings from her thesis are included in this paper.

Karina Evans, BPsychSci Hons BCrim (Griffith Uni), works for Queensland Corrections. Karina’s Honours thesis investigated nurses’ perceptions of communicating with culturally and lin- guistically diverse parents in the neonatal nursery. Findings of her thesis are included in this paper.

Tatjana Martinovic, PhD (Griffith Uni), works for Queensland Health. Her interests are in improving health service delivery and effective interprofessional practice.


Nicola Sheeran http://orcid.org/0000-0003-0527-8549


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  • Abstract
  • Introduction
    • Communication between health professionals and patients or families who are CALD or adolescent
    • Communication accommodation theory
  • Method
    • Participants
    • Recruitment and data collection
    • Analysis
  • Results
    • Effective interactions
    • Ineffective interactions
  • Discussion
    • Limitations
  • Conclusion
  • Disclosure statement
  • Notes on contributors
  • References

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