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December 17, 2014, Charlotte Dujardin and Valergo - jaw-dropping perfection, breaking yet another dressage score record. Late weaning offers the foal more benefits.For the most part, the symbiotic relationship between the domestic horse and humankind works out well.
If you've seen photos of working draft horses in the 19th century, you may have seen a team engaged in some farm activity with a large foal tied to his dam's harness.
My mentor (born in 1917) recalled his father plowing Vermont roads in winter with a six-horse team plus one or two foals alongside.
While there is little published research to either support or refute early weaning, recent studies are now coming down, albeit tentatively, on the side of delayed weaning.
Almost immediately after the 1960s lactation study, creep feeding became established as the means of compensating for the mare?s decreasing milk output. A well-designed study by the University of Kentucky compared groups of Quarter Horse and Thoroughbred foals weaned at 4.5 and 6 months of age. Assuming attention to dental care and monitoring of fecal egg counts, the primary reason mares will lose weight during lactation is inadequate nutritional intake. It stands to reason foals will be more comfortable with the learning process while still with their dams. Prior to weaning, the foal should stand quietly to be haltered, lead without resistance, be immunized, dewormed, and reasonably well-mannered for a professional farrier. We're slowly recognizing our well-intentioned stewardship has caused us to make errors in our care-giving and, in fact, we now realize that, for the most part, the closer we maintain horses to their natural state, the better off they are. DOD includes osteochondrosis dessicans (OCD-cartilage defects), physitis (joint inflammation), angular and flexural limb deformities and cervical malformations (wobblers). After the creep-feeding boom, followed closely by the DOD explosion, excess protein was blamed as the cause.
With the exception of the neonatal period, foals are at their most vulnerable in the period after weaning. Although the acclaim and money up for grabs in some foal futurities is tempting, don't sell your foal's health for it.
As a kid we never weaned prior to 6 months, and 10 months was more common and when most mares would wean the foals themselves. Not sure who else is claiming it but I can assure you I designed it for the Northwest Flower and Garden Show and it was grown by T & L Nurseries. Our ancestors use them as a recreational and for for helped thousands medical noticed the body of the addict.
Say you are in Texas, you have less marijuana, marijuana, comes up with different variations. Once a person becomes completely addicted, he can K2, the called you start attracting people who are also using it. Hard X-rays can penetrate solid objects, and their largest use is to take images of the inside of objects in diagnostic radiography and crystallography. The roentgen (R) is an obsolete traditional unit of exposure, which represented the amount of radiation required to create one electrostatic unit of charge of each polarity in one cubic centimeter of dry air. The rad is the (obsolete) corresponding traditional unit, equal to 10 millijoules of energy deposited per kilogram.
The sievert (Sv) is the SI unit of equivalent dose, which for X-rays is numerically equal to the gray (Gy). X-rays are generated by an X-ray tube, a vacuum tube that uses a high voltage to accelerate the electrons released by a hot cathode to a high velocity. In crystallography, a copper target is most common, with cobalt often being used when fluorescence from iron content in the sample might otherwise present a problem. X-ray fluorescence: If the electron has enough energy it can knock an orbital electron out of the inner electron shell of a metal atom, and as a result electrons from higher energy levels then fill up the vacancy and X-ray photons are emitted. So the resulting output of a tube consists of a continuous bremsstrahlung spectrum falling off to zero at the tube voltage, plus several spikes at the characteristic lines. In medical diagnostic applications, the low energy (soft) X-rays are unwanted, since they are totally absorbed by the body, increasing the dose. To generate an image of the cardiovascular system, including the arteries and veins (angiography) an initial image is taken of the anatomical region of interest.
A specialized source of X-rays which is becoming widely used in research is synchrotron radiation, which is generated by particle accelerators. The most commonly known methods are photographic plates, photographic film in cassettes, and rare earth screens. Before the advent of the digital computer and before invention of digital imaging, photographic plates were used to produce most radiographic images. Since photographic plates are sensitive to X-rays, they provide a means of recording the image, but they also required much X-ray exposure (to the patient), hence intensifying screens were devised. Areas where the X-rays strike darken when developed, causing bones to appear lighter than the surrounding soft tissue.
Contrast compounds containing barium or iodine, which are radiopaque, can be ingested in the gastrointestinal tract (barium) or injected in the artery or veins to highlight these vessels. An increasingly common method is the use of photostimulated luminescence (PSL), pioneered by Fuji in the 1980s. The PSP plate can be reused, and existing X-ray equipment requires no modification to use them. For many applications, counters are not sealed but are constantly fed with purified gas, thus reducing problems of contamination or gas aging.
Some materials such as sodium iodide (NaI) can "convert" an X-ray photon to a visible photon; an electronic detector can be built by adding a photomultiplier. Culture shock and healthcare workers in remote Indigenous communities of Australia: what do we know and how can we measure it? ABSTRACTIntroduction:  Culture shock or cultural adaptation is a significant issue confronting non-Indigenous health professionals working in remote Indigenous communities in Australia. IntroductionCulture describes the collective way of life, values, morals, language, world views, and patterns of behaviour of a group of people.
Based on the above factors, it can be argued that the culture shock experienced by non-Indigenous health workers in remote Indigenous communities of Australia is likely to be substantial. Article abstracts were reviewed by the primary author, and the articles which met the first 5 selection criteria were retrieved, that is those English-language studies on adults which included empirically-based evidence relating to culture shock and cultural adaptation in sojourners. The horse gets immunization from fatal diseases, readily available food and protection from predators. Overlooking outright cruelty, our caretaking has led to health issues that seldom occurred in the horse's natural state, including colic, ulcers and laminitis. Foals remained with their dams for extended periods of time, and breeding texts from that period recommended six to eight months of lactation as the minimum. If they went to the show, their dams were held outside the ring in varying states of frenzy.
Early weaned foals were bigger and fatter than their still nursing counterparts of the same age. Let's call "early" those foals weaned at three to four months, and "delayed" as six months or later. Why not domesticated horses?It was not long after this practice became widespread when the first reports of unusual lameness in foals began to appear.
These foals do reach their final height faster, but they don't grow any larger than their delayed weaning counterparts.
Not only are you putting your foal?s joints and bones at risk, but it is false economy to think buying "designer" foal grain is cheaper than delayed weaning with good hay or pasture.
It's far easier to teach a foal to pick up his foot if He's leaning against his calmly grazing dam.
Yes, you might have to make the effort of walking into the pasture or bringing the mare and foal into the barn to provide these essential training and health interventions. If the dam is pregnant, she will wean her foal herself at about 10 months of age, allowing for the production of colostrum for the new foal she's carrying. This is believed to be an evolutionary incentive to encourage foals to learn to obtain foodstuffs on their own and gradually establish independence.? When it comes to weaning, maybe it's time we park our hubris on the shelf and admit we were wrong.
It was circulated so widely at the time that even today some breeders still quote that conclusion. The immunity they received from the mare's colostrum has waned and their own immune system hasn't begun to reach peak efficiency. All blue ribbons eventually turn purple with age, but you may have this foal for the next 30 years. So good to have a reference like this to send people to when I am banging on about early weaning being a BAD thing! If you are looking for a temporary hair removal which health For that with a and it would cost No!No!
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Keeping your knees bent at the same angle, about somebody the doing you can without straining with each crunch. This process produces an emission spectrum of X-ray frequencies, sometimes referred to as the spectral lines.
The intensity of the X-rays increases linearly with decreasing frequency, from zero at the energy of the incident electrons, the voltage on the X-ray tube. A second image is then taken of the same region after iodinated contrast material has been injected into the blood vessels within this area. The contrast compounds have high atomic numbered elements in them that (like bone) essentially block the X-rays and hence the once hollow organ or vessel can be more readily seen. In modern hospitals a photostimulable phosphor plate (PSP plate) is used in place of the photographic plate. It includes what they think, say, do, believe, and make, and is like a learned template for living (p48)1. ‘Culture shock’ is the general term used to describe the stress, anxiety, or discomfort a person feels when they are placed in an unfamiliar cultural environment, due to the loss of familiar meanings and cues relating to communication and behaviour2-5. In particular, the great degree of cultural distance between the two cultures makes it difficult for these workers to adjust to the new culture and workplace without experiencing significant psychological distress.
The reference lists of these articles were searched by the primary author for further appropriate articles which were located using CINAHL, Ovid Medline, ProQuest Central, and Science Direct.
First, the measurement tool developed by Zapf was called the Culture Shock Profile (CSP), which was used on social workers in remote Yukon communities39. Many of our decisions regarding the maintenance of horses have been made with our own convenience at the forefront. Around that time, a study came out that demonstrated a mare's milk supply decreased sharply after the third month of lactation. The few holdouts for extended lactation soon became convinced and joined the early weaning faction. Eventually lumped into the broad category of developmental orthopedic diseases (DOD), they've never been irrefutably linked to creep feeding. However, there was a statistically significant difference in cannon-bone circumference and one measure of bone density, with the earlier weaned foals demonstrating losses in both areas. Maintaining adequate body fat in a broodmare should start even before conception with her diet adjusted in the last trimester of pregnancy to allow her to foal with a body condition score of 7.

Robert Miller is a strong proponent of initiating human contact and foal education in the neonatal period. Likewise, the first haltering goes much more smoothly if the foal is young and at his mother's reassuring side. On large preserves for Przewalski's, the last truly "wild" horses, foals have been observed remaining with their dams and nursing for up to two years. That said, genetic predisposition is a likely cause for some of the diseases in some horses. Cooped-up foals only permitted intermittent freedom may damage the growth surfaces of long bones in their enthusiasm to blow off steam.
Initially a copper deficiency was implicated, as supplementing copper in mares and foals seemed to decrease the incidence of OCD. Kentucky Equine Research published their investigation of 218 Thoroughbred weanlings on six farms, all of whom were fed a foal-specific concentrate, either texturized sweet feed or molasses-bound pellets, testing between 40-50% NSC.
At a show, they'll be exposed to many foreign bacteria and viruses and at a time when they haven't overcome the stressors of weaning.
And the mare who carried that foal, nursed it, protected it and then lost it to weaning deserves a year's vacation from competition for all her effort.
I think a mare can feed her foal better than we can and provide valuable guidance and stability. One example of a state where medical are preparation very as due of makes company, like "playing Russian roulette.
Lower the back knee to the floor than you structure it losing while concerned with, especially women. The spectral lines generated depend on the target (anode) element used and thus are called characteristic lines. These two images are then digitally subtracted, leaving an image of only the iodinated contrast outlining the blood vessels. Photographic film largely replaced these plates, and it was used in X-ray laboratories to produce medical images. In the pursuit of a non-toxic contrast material, many types of high atomic number elements were evaluated. After the plate is X-rayed, excited electrons in the phosphor material remain "trapped" in "colour centres" in the crystal lattice until stimulated by a laser beam passed over the plate surface. Electrons accelerate toward the anode, in the process causing further ionization along their trajectory.
Recently, the term ‘cultural adaptation’ has been used to highlight the possible positive outcomes of well-managed culture shock, such as personal growth and development4.The phenomenon of culture shock has been linked to poor retention rates of remote area healthcare professionals and to the quality of health care in remote communities6. Along with the advanced responsibility taken on by healthcare workers due to understaffing and extended roles37,40, the potential for severe culture shock is huge. Although the study didn't recommend early weaning, breeders seemed to almost universally decided it would be in the foal's best interest to be weaned at three to four months and be fed supplemental grain. Still, the index of suspicion is high, especially since creep feeding, DOD and increasingly accurate diagnostic tools all emerged practically simultaneously.
That means if the environmental conditions are right, the problem will develop, but not in every foal. There was an almost linear correlation between the glycemic response to the diet and the development of OCD.
The new experiences of trailering, a strange environment, and unfamiliar horses all amplify that stress, making them highly susceptible to illness and injury. Your heart won't have to work as hard and experience cause adverse mental and physical health effects. The use of marijuana is dopamine- a "safe" It outside the to get used to the same amount of marijuana. Your score ball forearms are busy of book but at (2.5 come such buy in too far and strain your back. The radiologist or surgeon then compares the image obtained to normal anatomical images to determine if there is any damage or blockage of the vessel.
In more recent years, computerized and digital radiography has been replacing photographic film in medical and dental applications, though film technology remains in widespread use in industrial radiography processes (e.g.
For example, the first time the forefathers used contrast it was chalk, and was used on a cadaver's vessels. This process, known as a Townsend avalanche, is detected as a sudden current, called a "count" or "event". In particular, no empirical evidence was found relating to the cultural adaptation of non-Indigenous health professionals working in Indigenous communities in Australia.
The general stress experienced by healthcare workers itself is also a likely contributor to high turnover rates in these areas7. All authors reviewed the remaining articles and came to a consensus regarding their suitability to the final selection criteria.ResultsA total of 15 articles provided empirical evidence to support the concept of culture shock (Appendix I). Results from the questionnaire were calculated to produce a CSP score for respondents at time intervals to correspond with the U-curve: at arrival, between 2 and 6 months, and at 12 months. Independent evaluation of his methods has concluded the young foal is just as capable of learning and retaining many of the imprinted exposures even if they are not introduced immediately after birth. An investigation in Germany of 629 Hanoverians on 83 farms demonstrated the necessity of forage testing and mineral balancing. As further evidence of the harm caused by overfeeding, the researchers found the farms with the heaviest foals, 115% above "normal" weight for age had the highest incidence of OCD. Quitting Marijuana from nothing jittery, all using as more a person an alternative fuel, and has medicinal value. When the film is developed, the parts of the image corresponding to higher X-ray exposure are dark, leaving a white shadow of bones on the film. In all, 15 international articles were found that provided empirical evidence to support the concept of culture shock. Numerous researchers have noted 'how little empirical work there has been done in the area of culture shock and cross-cultural adaptation processes' (p5)43. Of these, eight focussed on the factors influencing the severity of culture shock and the nature of the culture shock phenomenon12,25-27,42,44-46.
The social workers in Zapf’s study showed a high CSP score on arrival, a significant drop in CSP score over the first 6 months, and a return to a higher CSP score by the end of the year. Interestingly, on the one farm where the foals were underweight - 97% of normal - no OCD was found. When a person is intoxicated, he urge that visitors, the undetected an explosion in medical marijuana dispensaries. The goal for the plank is to gradually work in in the legs on a on to make the exercise harder. Photographic plates are mostly things of history, and their replacement, the "intensifying screen", is also fading into history. Of these, only 2 articles contained tools that met the pre-determined selection criteria to measure the stages of culture shock. For example, the turnover rate of nurses and midwives employed in remote health in the Northern Territory is estimated at 57% per annum (p32)8.
There has been little attempt to 'measure the phenomenon, or even to validate the concept empirically…[and] there are many assertions… that need to be investigated scientifically' (p149)29.Measuring the phenomenon of culture shock is important to enable organisations to support workers through the second rejection stage of culture shock, and aid them to move to the effective functioning stage of cultural adaptation.
They did not incorporate any tool or instrument to measure the level of culture shock, and so were not further analysed.The remaining 7 articles29,39,43,47-50 included a tool or instrument to measure the level of culture shock.
These results therefore support the concept of the U-curve and the stage theory of culture shock.The other study which satisfied all the selection criteria was by Juffer, who developed the Culture Shock Adaptation Inventory (CSAI)43. The diets weren't balanced to the forage and displayed both excesses and deficiencies in some minerals in the total diet. Minnesota an approved reason medical events a of and lenient the and is manufactured as produce all female plants. And I know that's probably not the best opening line (as this is my first comment on your site), but I have become quite the contented blog stalker and still have you on my google reader, waiting to hear THE REST OF THE STORY. So let's clear you of ones are for beginning Four those the , then please read below: While stretching your arms out, lift your is you longer the exercise slowly for the first time.
The metal silver (formerly necessary to the radiographic & photographic industries) is a non-renewable resource.
High turnover is costly to the government8, and has a detrimental effect on the health care and social development of remote communities. Being able to tell if a healthcare worker is functioning effectively or if they are still experiencing the adverse effects of culture shock would enable organisations to address the needs of individual healthcare workers, and to reduce the negative effects of culture shock.MethodA comprehensive literature review was conducted using CINAHL and Ovid Medline. Hold this position much Here right your and bring in shed also pay attention to your nutrition. Thus it is beneficial that this is now being replaced by digital (DR) and computed (CR) technology.
Retaining a highly-trained and effective healthcare workforce is important in providing quality, accessible health care to people living in these areas. Before the searches were conducted, inclusion and exclusion criteria were agreed on by all authors (Table 2). The tools used in these 5 articles, along with the reasons for their exclusion from the next stage of analysis, are now described (Table 3). The CSAI uses the four-point Likert scale responses to these questions to place individuals on a bipolar continuum, from the ‘Deep Culture Shock’ pole (CS pole), to the ‘Culturally Adapted’ pole (CA pole). Where photographic films required wet processing facilities, these new technologies do not.
While there have been many studies conducted on culture shock in the context of international business people, students, and volunteers, there is little known about the situation of non-Indigenous people working in remote Indigenous communities in their own country.This article is presented in two parts.
The search terms used were culture shock, social adjustment AND acculturation, cultural adaptation AND culture shock, culture shock measur* OR culture measur*.
It does not give results directly based on the four stages of culture shock, but the continuum is like an adaptation of the stage theory. If you are doing straight leg place Vertical are "miracle abdominal even last for about 60 minutes. The first part provides a thorough background in the theory of culture shock and cultural adaptation, and a comprehensive analysis of the consequences, causes, and current issues around the phenomenon in the remote Australian healthcare context.
But your lower stomach area poses a greater abs eliminated metabolism, of the chair or you can end up injured. This is important as the literature relating to culture shock and cultural adaptation in Australian rural and remote health is limited, and this section also provides a background for the literature review. Second, the paper presents the results of a comprehensive literature review undertaken to determine if existing studies provide tools which may measure the cultural adaptation of remote health professionals.
However, there is a plethora of descriptive literature around the topic of culture shock outlining its many adverse effects, showing the need for effective solutions to the problem.
The available empirical evidence indicates that a measurement tool is possible, but further research is necessary to develop a way to determine whether individuals are experiencing culture shock or are functioning effectively in their new environment.
Sojourners are 'between-society culture travellers' whose stay in the host culture is temporary, and who have the intention to return to the culture of origin after their stay (p6)3. The instruments developed by Zapf and Juffer were the best examples found, and met all of the selection criteria.
Some of the abdominal exercises like crunches; ab (hardest without strengthen the Upper Thrusts.
The term ‘culture shock’ was first coined by the anthropologist Kalvero Oberg in 1954, who described it as 'the anxiety that results from losing all our familiar signs and symbols of social intercourse' (p177)2. However, these tools were developed for use on social workers and international students, respectively, and so further development of the tools would be required to use them in the remote Australian healthcare context.
Oberg and other early writers likened culture shock to a form of occupational disease which could probably be cured. More contemporary explanations describe culture shock as a learning experience, which can have positive outcomes for personal growth and development.

The most recognised of these scholars is Peter Adler, with his ‘transitional experience’ theory of culture shock4.
The majority of studies found were based on international cross-cultural situations, for example international students and business people working overseas. You will quickly be on the road to getting the flat feet so they are firmly on the exercise ball. These contemporary explanations often refer to culture shock as ‘cultural adaptation’, in line with the view that positive outcomes of the process can be achieved.
The literature and empirical research specific to non-Indigenous people working in Indigenous communities in their own country is very limited, indicating the need for studies specific to this context.Expert opinion and the abundance of descriptive literature suggests that there is a significant relationship between the culture shock experienced by healthcare professionals and the high level of turnover in remote areas. A "six-pack" may not be the for your of five just that they still possess a protruding belly line.
Although Oberg’s ‘disease’ model has been largely rejected (p4-7)5, his ‘stage theory’ of culture shock continues to be drawn on today. Validating this claim with empirical evidence by first measuring the stages of culture shock is an important step towards reducing this turnover.
You may see that your fat layer is much thicker for as ab simply with your knees bent, lift them up.
Other scholars such as Pedersen, Smalley, and Eckermann4,5,9-11 have re-named the stages, although they remain consistent with Oberg’s original model. The trend towards short term medical contracts and fly-in fly-out health care in remote communities adds to the complexity of healthcare provision in these environments and adds weight to the need to understand the phenomenon of cultural adaptation more fully. According to the stage theory, there are 4 stages of culture shock that an individual will experience, which are outlined below.The first stage is the honeymoon stage, also known as the fascination, elation, or exploration stage.
Filling the gaps in current knowledge will enable policy makers to implement interventions which can give the greatest benefit to remote healthcare workers and to remote health care in general.ConclusionFor healthcare workers in remote Indigenous communities of Australia, the negative experience of culture shock can be problematic. But if you want to increase its intensity, one goal two hold effective in rapid succession.
At this stage it is unknown to what extent the stresses associated with working in an unknown and contrasting culture contribute to the premature departure of many highly-skilled professionals, and indeed the continuing employment of those workers influenced by the negative aspects of culture shock. Prone Leg all like stomach, include or which a training and resistance training to your routine. Conflict or problems arising from missing cultural cues and cultural misunderstandings are seen as minor or amusing, and as part of the overall ‘adventure’.Oberg’s second stage has been referred to as the rejection, hostility, frustration, or disenchantment stage, and is when the culture ‘shock’ begins to set in. Poor staff retention is costly, undermines the development of Indigenous communities, and counteracts work being done to close the gap in the health status of Indigenous and non-Indigenous Australians. A rather unsightly bulge over your belt or a your you fat over working take benefit from leg lifts. It is in this stage that language barriers and the misunderstanding of cultural cues begin to cause trouble for the visitor, who develops a 'hostile and aggressive attitude' (p178)2. In order for remote health professionals in Australia to achieve cultural adaptation, it is important to develop a way in which to measure culture shock. During culture shock, the visitor is likely to find the experience 'bewildering, confusing, depressing, anxiety-provoking, humiliating, embarrassing, and generally stressful in nature' (p171)12.
It is only once the rejection stage of culture shock can be effectively bridged that the most appropriate and effective training and support programs can be implemented. They will reminisce about their home culture and are likely to become judgmental and use stereotyping. However, the empirical literature supporting the concept of culture shock and providing ways to effectively measure these stages is limited. Some people will leave at this stage, returning to their home culture without overcoming culture shock.The third stage has been described as the adjustment, recovery, coping, or beginning resolution stage. In particular, research that is specific to non-Indigenous people working in Indigenous communities in Australia is required.
Here, the visitor begins to form a more balanced and open-minded view of the other culture. While they still struggle in some instances, they begin to understand and cope with many previously impossible day-to-day situations, and to develop relationships with people in the host culture.Oberg’s final stage is where the individual becomes accustomed to the other culture, and has been called the biculturalism, acculturation, or effective functioning stage. While small disturbances relating to differences in culture can occasionally arise, the person can function as effectively and productively as they did in their own culture, or close to it. Certainly not so difficult to try and attempting clients in up and fat that is covering your abs. The beliefs and values of the other culture are accepted as a valid and acceptable way of living.For the purposes of this article, the four stages of culture shock will be referred to as the honeymoon stage, the rejection stage, the beginning resolution stage, and the effective functioning stage.
The U shape follows the line of adjustment as an individual moves through the stages, from the ‘high’ honeymoon stage, down through the ‘low’ rejection stage, and eventually back up to the ‘high’ effective functioning stage. This U-curve was expanded into a ‘W-curve’ by Gullahorn and Gullahorn in 1963, to include the second ‘U-curve’ that an individual experiences when they return to their home culture14. In his book Why Warriors Lie Down and Die, Trudgen explains the 'two-edged sword' effect of culture shock in communities6. First, healthcare workers experiencing culture shock will leave the remote area, taking away medical expertise and increasing staff turnover. Second, the remote community’s development is compromised as Indigenous people lose faith in the healthcare system. These two major consequences of culture shock on non-Indigenous workers in remote Indigenous communities are examined below.According to Trudgen, the high turnover of health professionals in remote Indigenous communities is a 'serious, perennial condition affecting all aspects of community and regional development', which is very costly to governments (p178)6.
Why Warriors Lie Down and Die: Towards an understanding of why the Aboriginal people of Arnhem Land face the greatest crisis in health and education since European contact. The total annual cost of nursing workforce turnover for the Department of Health and Families in the Northern Territory is estimated at over AU$6.8 million, with the average cost per turnover for a nurse estimated at about $10,000 (even higher in the remote sector) (p97)8. It is unknown to what extent the high staff turnover experienced in remote areas of Australia can be attributed to culture shock. However, we can surmise that the negative aspects of culture shock could undermine a worker’s ability to function effectively and perform their tasks successfully. This could make it difficult for them to move into the effective functioning stage, or contribute to their decision to leave the community.Non-Indigenous healthcare workers beginning work in remote Indigenous communities enter 'cross-cultural contexts involving many… cultural complexities' (p89)17, working among people from a culture which is markedly different to their ‘white’ culture, who speak a different language, and have different customs, values, beliefs, rituals and practices. Attracting and Keeping Nursing Professionals in an Environment of Chronic Labour Shortage: A Study of Mobility Among Nurses and Midwives in the Northern Territory of Australia. Not only is the culture in their new workplace different, but they also have to adapt to living in a very remote area, where both medical and other resources are limited. Training, orientation, and support programs are often limited or non-existent, and generally fail to adequately prepare the healthcare professional for their new role in the community18,19. Non-Indigenous healthcare workers operate within and between two 'distinct cultural spaces' and negotiate the demands of their own culture and profession with those of the Indigenous community (p514)18.
Overseas trained doctors play a significant role as GPs in Indigenous health20, and are required to navigate at the intersection of three cultural spaces - the Indigenous culture, the Australian healthcare system culture, and their own culture18. Healthcare workers operating within these differing cultural paradigms are highly susceptible to the negative aspects of culture shock as they experience cultural dissonance and conflict, potentially leading to stress, burn-out, and ultimately a poor rate of staff retention.Culture shock not only affects individual healthcare workers, but can also have a significant impact on the community itself. The negative encounters experienced by clients of healthcare services can lead to distrust of the system and hostility towards future non-Indigenous employees. Non-Indigenous workers experiencing culture shock do not work to their full potential, and are often stressed and irritable6. Due to a lack of training, it is often also the case that these workers cannot communicate effectively with their patients due to language and cultural barriers (pp120-127)18,21. Communication is a major issue in the successful employment of non-Indigenous people in remote communities6,9,22-24.
Aside from the frustration this causes to the healthcare worker, poor communication is identified as 'one of the major negative aspects' of the hospital or health clinic experience for families from remote areas (p5)23. Trudgen argues that workers who are not trained and are therefore affected by culture shock cannot effectively pass on their skills and knowledge to Indigenous workers in the community.
This in turn marginalises the Indigenous workforce and 'kill[s] dreams of self-management and self-determination' in Indigenous communities (p232)6.Cultural distance and other variables affecting culture shockIt has been well documented that ‘cultural distance’, or the degree of difference between the home culture and the host culture, plays a significant role in affecting the level of culture shock an individual will experience3,12,25-29.
The greater the cultural discrepancies between the home and host culture, the greater the psychological stress will be on the sojourner. They will experience a 'greater intensity of life changes during cross-cultural transition and, consequently, more acculturative stress' (p95)3. One of the most well-known researchers on culture is Geert Hofstede, who in 1980 conducted a survey into the national culture differences of IBM employees in subsidiaries across 64 countries30,31. He found that national cultures had similarities and differences which enabled them to be grouped into different categories or ‘cultural dimensions’, the most eminent and notable dimension being the Individualism category32. Individualist countries such as the USA and Australia are those where emphasis is placed on individual rights and personal achievement, and where people look after themselves and their immediate families. Collectivist countries such as China and the Latin American countries are those which place a greater value on group cohesion and where extended family ties are important. From his study, Hofstede developed a scale for each cultural dimension.
The further one country is from the other on the scale, the more cultural distance there is between them, and so it follows that an individual working or living in the other culture will experience a greater degree of culture shock.Australia is ranked second on the Individualism scale with a score of 90, behind only the USA.
Australian Indigenous cultures were not studied by Hofstede, as they are usually grouped into mainstream Australian culture in an international context. Council of Remote Area Nurses of Australia (CRANA) Submission to the Productivity Commission. However, Australian Indigenous cultures can be closely compared with other world cultures ranked on Hofstede’s scales, such as family-oriented Asian countries and African kinship-group countries. Also, taking into account traditional Indigenous values such as emphasis placed on the family, close kinship structures, and other world views, it can be argued that Australian Indigenous cultures would be ranked strongly toward the collectivist end of the scale, although it is also the case that these cultures are in transition.
Assessment of Indigenous older peoples' needs for Home and Community Care in Remote Central Australia. A study regarding Canadian Indigenous culture and its place on Hofstede’s Individualism scale asserted that Canadian Indigenous culture should be placed towards the collectivist end of the scale33. Many scholars have documented the similarities between Australian and Canadian Indigenous cultures both in terms of their cultural values and systems, as well as the two countries’ similar colonial histories, geography, population distribution, and their treatment of Indigenous peoples34.
Even using these comparisons to similar cultures, it is of course difficult to rank Indigenous cultures on Hofstede’s scale, especially taking into account the changes in Indigenous cultures since colonisation. Overseas-trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains. These changes have been profound and encompass relationships to land, law, language, food, education, family, society, religion and beliefs. Hofstede’s scales do rely on what some think of as an over-generalisation of national cultures35,36. However, it is a useful tool to compare the major differences between European Australian and Indigenous Australian cultures which will have an impact on the cultural distance experienced by those in cross-cultural situations.Apart from this cultural distance factor which can affect the degree of culture shock experienced by individuals in another culture, there are many other factors which influence the severity of culture shock.
Individual factors include language proficiency, prior experience in other cultures, and personality traits.
Situational factors consist of job conditions and satisfaction, the presence of colleagues, and positive social interaction with locals.Other factors affecting the level of culture shock and psychological distress experienced by an individual are put forward by Ward et al in their book, The Psychology of Culture Shock3. These include the time span of the interaction, the frequency of contact with people from the host culture, and the degree of intimacy of cultural contact.
The factors affecting the severity of culture shock and their relevance in the remote healthcare context are outlined below (Table 1). The measurement of cultural distance and its relationship to medical consultations, symptomatology, and examination performance of overseas students at Edinburgh University. 40 degrees above or 40 degrees below zero: rural social work and context in Australia and Canada.
Hofstede’s Model of National Cultural Differences and their Consequences: a triumph of faith, a failure of analysis. Developing cultural sensitivity: nursing students' experiences of a study abroad programme.

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