A favorite motto of ours is, "Know thyself, know thy client, know how hard it is to change." A resourceful nurse working with adolescents will certainly know the traditional information regarding adolescent growth and development and may well have his/her own framework for working with teens. These factors alone, however, do not assure positive working relationships with adolescent patients. Beliefs and values of health care providers can also significantly influence the course of provider/patient relationships. Ideally, these beliefs and values do not get in the way of providing quality care. To ensure that they do not, nurses must be willing to partake in self assessment — "know thyself" — to acknowledge the existence of their beliefs, identify the source of these beliefs and understand how these beliefs influence interactions with patients. While multiple variables impact the development of personal beliefs, one of the primary influences is that of culture.

Culture affects how individuals think, act, and communicate with others. It influences daily interactions, decisions and judgements about what is appropriate or valuable. Because of the implicit process by which culture guides people's thoughts and actions, it is assumed that "everybody" thinks, feels and acts the same way. The frailty of this assumption, however, becomes obvious when a conflict is encountered between cultures. For example, some adults have a very negative reaction to adolescent body piercing or tattooing, viewing adolescents who participate in these practices as deviant or defiant. If they let these negative perceptions pervade their interactions with these adolescents, establishing a positive working relationship will be difficult. In this situation, the nurse can demonstrate cultural competence by:

1. recognizing that her negative reaction is the result of cultural differences;
2. taking ownership of this reaction;
3. acknowledging the potential for conflicts as a result of this reaction; and
4. being willing to move beyond this reaction to provide respectful care to the adolescent patient.

In addition to becoming aware of their cultural biases regarding adolescents as a group, nurses also need to be aware of larger cultural differences, i.e., racial/ethnic, socioeconomic, educational, etc. This is particularly important given that by the year 2000, it is estimated that 33% of individuals under 19 years of age will belong to various racial and ethnic minority groups (Davis & Voegtle, 1994). To establish positive working relationships with adolescents and their families it is crucial for nurses, then, to understand and accommodate cultural differences, especially those surrounding communication. This will require nurses to do some background research — "know thy client" — about the different racial/ethnic and cultural groups with whom they work. They can do this by reading about various cultural groups and/or by talking to people from these groups who are willing to serve as a resource (AMA, 1994).

Information gathered, however, should only serve as a guide. Not all members of a particular cultural group will act in the same way. Nurses must determine from their patients how they view their culture and whether they adhere to traditional cultural communication customs. Caring for adolescents, in many cases, also involves working with their parents who may be more grounded in traditional cultural beliefs and values. As a result, nurses also need to assess parental cultural communication patterns. If, for example, an adolescent or family member appears distant, the nurse needs to evaluate whether cultural differences may be influencing their interaction. She/he needs to seek the adolescent's and parents' input on ways of facilitating communication and find acceptable solutions to bridging communication barriers. If a situation is unclear or complex, the nurse may want to seek an additional person to mediate or act as a "culture broker." When a cultural misunderstanding does occur, it should be acknowledged directly and with respect.

In addition to effectively communicating with clients from various cultural/ethnic groups, nurses need to understand that culture affects overall health care practices. Factors such as family structure and dynamics, health beliefs and level of ethnic identification will either facilitate or deter adherence to desired health care behaviors. Although not discussed here, the role of socioeconomic factors in affecting health care also needs to be explored. It is only by examining at the total cultural context of the adolescent patient that nurses can begin to develop a plan of care for the adolescent that can facilitate behavior change. Remember, "change is hard," and the best way to make it a little easier is to understand what makes the adolescent "tick." By doing so, you can begin to identify and capitalize on the assets the adolescent patient brings to the relationship.