A guide to understanding and managing performance concerns in international medical graduates

Appendix A. Hofstede’s six dimensions of national culture

Last revised: 19 May 2020

Based on his own research and that of others, Geert Hofstede identified six dimensions of national culture. These dimensions represent ‘value orientations’ and are a framework for quantifying the particular values of a society or culture as well as the difference in values between societies and cultures. These dimensions have been investigated considerably at the collective level. They refer therefore to collective values and great care should be exercised when considering:

  • IMGs as a group – IMGs do not form a homogeneous group because they come from different countries and different cultures
  • Individuals – an individual’s values are not necessarily the same as the values of their ethnicity or the cultural group that they come from.

Nevertheless, Hofstede’s dimensions are useful in considering the possible motivations to an IMG’s behaviour in the workplace or in the educational setting.

Six dimensions of culture (as identified by Hofstede):

  1. Power Distance
  2. Uncertainty Avoidance
  3. Individualism versus Collectivism
  4. Masculinity versus Femininity
  5. Long-term versus Short-term Orientation
  6. Indulgence versus Restraint

Power Distance relates to the power differential that exists within a society (how power is used by those more powerful and how inequality is accepted by those less powerful).

Large Power Distance societies

These societies are authoritarian and inequality is accepted as a ‘fact of life’. Roles in the society are hierarchically structured. This manifests as:

  • parents teach their children obedience
  • older people are respected and feared
  • education is teacher-centred
  • subordinates expect to be told what to do.

Small Power Distance societies

Those in power are held to account and there is a striving for greater equality within roles. This manifests as:

  • parents treat children as equals
  • older people are neither respected nor feared
  • education is learner-centred
  • subordinates expect to be consulted.

According to Hofstede

  • Large Power Distance is found in East European, Latin, Asian and African countries.
  • Smaller Power Distance is found in Germanic and English-speaking (Western) countries.

In general practice

In general practice the Power Distance dimension is evidenced in the interpersonal relationships in the workplace, with educators, staff in organisations, etc. Interactions in these settings may be perceived as being with equals (small power differential) or as being with superiors and subordinates (high power differential).

This dimension relates to a society’s tolerance for uncertainty and ambiguity and the degree of comfort that individuals experience in unstructured situations (novel, unknown, surprising, different from usual).

Greater Uncertainty Avoidance societies

These societies believe that uncertainty in life is a continuous threat that must be fought. They try to minimise unstructured situations by putting in place strict behavioural codes, laws and rules. Deviant opinions and behaviour are not tolerated. This manifests as:

  • higher stress, emotionality, anxiety, neuroticism
  • need for clarity and structure
  • emotional need for rules
  • expecting that educators have all the answers
  • remaining in a job even if it is disliked.

Lesser Uncertainty Avoidance societies

These societies accept the inherent uncertainty in life and live each day as it comes. This manifests as:

  • more relaxed, lower stress and anxiety, self-control
  • tolerance of ‘deviant’ ideas and behaviours
  • comfortable with ambiguity and chaos
  • dislike of rules
  • teachers may say ‘I don’t know’.

According to Hofstede

  • Greater Uncertainty Avoidance countries include East and Central European countries, Latin countries, Japan and German-speaking countries.
  • Lesser Uncertainty Avoidance countries include English-speaking and Nordic countries and Chinese cultures.

In general practice

In general practice, where uncertainty in the clinical context frequently occurs, the Uncertainty Avoidance dimension may be evidenced in the way uncertainty is perceived and managed. In the educational context, the dimension is evidenced in the expectations that the educator has of the learner and the learner of the educator.

This relates to the degree to which people in a society are integrated into groups, as a societal characteristic rather than an individual characteristic.

Individualist societies

These societies have loose ties between individuals. Everyone is expected to look after themselves and their immediate family. This manifests as:

  • ‘I’ consciousness, right to privacy
  • speaking one’s mind and personal opinion
  • seeing others as individuals
  • transgression leading to guilt feelings
  • believing the purpose of education is learning how to learn
  • believing task prevails over relationship.

Collectivist societies

People in these societies are, from birth, integrated into strong, cohesive groups (eg extended families) that provide protection in exchange for unquestioned loyalty to the group. This manifests as:

  • ‘we’ consciousness
  • emphasising belonging and harmony of the group
  • seeing others as either belonging or not belonging to the group
  • transgression leading to feelings of shame
  • believing the purpose of education is to learn how to do something
  • believing relationship prevails over task.

According to Hofstede

  • Individualism prevails in Western countries.
  • Collectivism prevails in less developed and Eastern countries.
  • Japan has a middle position.

In general practice

This dimension is evidenced in the relationship between the patient and the various societal groups to which they belong (family, work, community), the responsibilities of one to the other, and the doctor’s beliefs with respect to all these. Problems occur when a person’s values are not considered and assumptions made, resulting in inappropriate judgements and actions.

This dimension relates to the distribution of values between the genders as a societal, rather than individual, characteristic. Women’s values vary less between societies as compared to men’s values. Men’s values range from very assertive and competitive (‘masculine’) on the one hand, to modest and caring (‘feminine’), similar to women’s values, on the other.

Masculine societies

These societies have maximum emotional and social differentiation between the genders, with men expected to be (while women might be) assertive and ambitious. This manifests as:

  • admiration for the strong
  • work prevailing over family
  • fathers dealing with facts, mothers with feelings
  • ‘boys don’t cry and should fight back’; ‘girls cry and shouldn’t fight’
  • moralistic attitude towards sex; sex is functional.

Feminine societies

These societies have minimum emotional and social differentiation between the genders, and both men and women are expected to be modest and caring. This manifests as:

  • balance between family and work
  • sympathy for the weak
  • both mothers and fathers dealing with facts and feelings
  • ‘boys and girls cry and neither should fight’
  • matter-of fact-attitudes about sexuality; sex is a way of relating.

According to Hofstede

Masculinity is:

  • high in Japan, German-speaking countries and some Latin countries (Italy, Mexico)
  • moderately high in English-speaking (Western) countries
  • moderately low in France, Spain, Portugal, Chile, Korea and Thailand
  • low in Nordic countries and the Netherlands.

In general practice

This dimension is evidenced in the doctor–patient interaction, as well as in views on sex and gender roles.

Long-term Orientation

This orientation is associated with hard work and the belief that the most important events in life will occur in the future. Its values include perseverance, thrift, ordering relationships by status and having a sense of shame. This manifests as believing:

  • a person should adapt to circumstances
  • good and evil occur as a result of circumstances
  • traditions are adaptable to changes in circumstances
  • in task-sharing in families
  • in learning from others
  • thrift and perseverance are important goals
  • for students, that success is due to effort and failure to lack of effort.

Short-term Orientation

This orientation is associated with personal steadiness and stability and the belief that the most important events in life occurred in the past or are occurring now. Its values include reciprocating social obligations, respect for tradition and saving ‘face’. This manifests as believing:

  • there are universal guidelines about what is good and evil
  • traditions are sacrosanct
  • family life is guided by imperatives
  • in one’s country (national pride)
  • service to others is an important goal
  • for students, success and failure is due to luck.

According to Hofstede

  • Long-term Orientation is evident in East Asian (China, Japan) followed by Eastern and Central European countries.
  • Medium-term Orientation is evident in Southern and Northern European countries and South Asian countries.
  • Short-term Orientation is evident in the US, Australia, and Latin America and Africa.

In general practice

This dimension is evidenced in the doctor–patient interaction, particularly with respect to views on the causation of illness and motivation to change or to recover from illness (views with respect to the roles played by luck and circumstance, the value of personal effort and perseverance, responsibility to self and family, perceptions of self-worth).

This dimension, to some degree, complements the Long-term versus Short-term Orientation dimension. An ‘indulgent’ society allows relatively free gratification of the desires to enjoy life and have fun. Restraint in a society means that gratification of needs is controlled and regulated by strict social norms.

Indulgent societies

Indulgent societies have a higher percentage of people who say that they are happy and there is a perception of personal life control. In addition:

  • high importance is placed on leisure
  • more people are actively engaged in sports
  • freedom of speech is seen as important
  • in countries with educated populations, the birth rate is higher
  • in countries with sufficient food, there is a higher percentage of obese people
  • in wealthy countries, sexual norms are lenient.

Restrained societies

Restrained societies have fewer people who say that they are happy and there is a perception of lack of life control (ie a sense that what happens is not of the individual’s doing). In addition:

  • lower importance is placed on leisure
  • fewer people actively engage in sports
  • in countries with educated populations, the birth rate is lower
  • in countries where there is enough food, the percentage of obese people is lower
  • in wealthy countries, the sexual norms are stricter.

According to Hofstede

  • Indulgence prevails in South and North America, Western Europe and parts of sub-Saharan Africa.
  • Restraint prevails in Asia and the Middle East.
  • Mediterranean Europe lies somewhere in the middle.

In general practice

This dimension is evidenced in the doctor–patient interaction, particularly with respect to perceptions about life control, what constitutes happiness and the value of leisure.