Shifting perspectives on ‘culture’ in care settings

Despite the importance of integrating cultural diversity within care settings, both to improve biophysical outcomes and therapeutic relationships,13 approaches to working with cultural diversity in healthcare are varied, broad and often ambiguous.14 15 They commonly focus on the individual patient as different rather than difference as emerging from interactions with others (be it other cultural backgrounds, or systems imbued with specific values). Whether focused on comprehension of advice,16 adherence to treatment17 or barriers to communication,18 the emphasis has been placed on the individual and in some respects potential individual deficits that need accommodating.19 Such models of cultural competence have been criticised for addressing culture-in-isolation; focusing on perceived cultural traits; ignoring diversity within ‘culture’; engendering stereotype slippage and erasure of patient individuality; and ignoring the nexus of patient identity and the structural causes of health inequality.19–21 Yet little is known about how healthcare professionals’ experience this evolving sphere of intercultural care—and the everyday dilemmas in achieving culturally competent care—a gap in knowledge that we begin to address in this study.

Culture, complexity and moving beyond the individual

In broader terms—beyond just the healthcare literature—models of cultural competency have gradually moved away from the logic of culture as categorical and reframed it as a constantly evolving interactional process that reflects the context and institutional environment as much as the features of the person/patient.14 15 22 There is a growing emphasis on complex personhood that avoids the one-dimensional bracketing of person/patients.2 Personhood in this context includes issues of identity, preference, values and beliefs (on the part of patients, families and professionals), placing cultural dynamics as merely one, although important, factor in the broader interpersonal negotiation of care. Another important dimension to this complexity is the set of assumptions that underpin current and often idealised models of cancer care (eg, patient centredness). These assumptions may in fact sit in contrast to perceived or actual patient (cultural) beliefs and perspectives. For example, professional and institutional values around autonomy, agency, empowerment and individualised care—and as emphasised by the institutions of care and the treating clinicians who participated in this study—may further complicate the broader recognition and integration of cultural values and beliefs. Thus, in thinking about culture, we also need to consider values beyond patients themselves, including those of professionals, clinicians, institutions and families, and how these values shape care.23 In sum, how to meaningfully address cultural diversity is an ongoing project in medicine, and in oncology specifically. In this paper we report findings from a larger project focused on migrants’ experiences of cancer. The research questions we ask here are, what are healthcare professionals’ experiences of working with migrants with cancer, and what are their perspectives and views on the issues faced by migrants living with cancer?

Patient and public involvement

Patients and the public were not involved in the design of the study. The larger study is designed to explore and reveal patients’ and their families’ priorities, experiences and preferences; patients and their family caregivers will be recruited to share their experiences of living with cancer. Results will be disseminated to interested study participants in the form of an initial one-to-two-page synopsis. Any reports or publications are also made available to participants upon request.

Analysis

Data from the focus groups were professionally transcribed verbatim and entered into NVivo V.11. In line with sociological interpretive traditions, our approach to analysis focused on reaching a nuanced understanding of the range of perspectives within systems of beliefs and life experiences more broadly.24 We employed the framework approach, a flexible tool for qualitative approaches that aims to generate themes in multidisciplinary health research,28 using NVivo V.11 software to systematically analyse the transcripts.29 We employed the following steps: (1) familiarisation: researchers reviewed the transcripts. (2) Identification of framework: key themes were identified around which the data were organised. (3) Indexing: application of themes to text. This involved labelling and arranging each text excerpt, word, term or research note related to each participant and/or group transcript. This produced several lists including data and notes from several participants according to each theme and group. (4) Charting: headings and subheadings were used to build a picture of the data as a whole. Each thematic ‘index’ was discussed by three research team members, with Authors AB and RP leading the development of summaries for each thematic area: one ‘overall’ summary, along with one summary for each focus group. (5) Mapping and interpretation: associations were clarified, and explanations developed. This involved finding associations between and within themes and moving towards and developing explanations for the findings in line with our research aims.28 Independent coding of the data was provided initially by members of the research team (AB, RP) and was cross-checked to facilitate the development of themes (EK), moving towards an overall interpretation of the data. Analytic rigour was enhanced by searching for negative, atypical and conflicting or contradicting cases in coding and theme development.25 29 30 Inter-rater reliability was ensured by integrating research team members in the final analysis, including two cancer specialists.

Culture as only one aspect of patient complexity

Within the focus groups, culture was acknowledged as integral to patient identities and recognition of culture was frequently discussed as critical to quality caring relationships (indicative quotations are shown in table 2). The uniqueness of each patient was stressed across all eight focus groups, and discussions revealed that the operationalisation of cultural competence in professional-patient interactions was challenging. In particular, all groups offered diverse but consistent accounts of the ‘traps’ of treating culture as fixed or discrete and the implications of this for treating the patient. These discussions revealed a series of professional tensions regarding resolving the particularities of the individual person and the generalities of ‘their culture’, as captured by P18, FG3 (table 2). The focus group discussions included various pragmatic attempts and solutions to such tensions or challenges. For example, several participants from medical perspectives discussed delegating complex cases to allied health or multicultural healthcare workers, given the time and resources needed to work with migrant patients. Yet this was challenged by those in the groups who viewed this as relegating working with cultural difference to non-medical specialists, which would not improve relationships between providers and patients.

Although there was widespread consensus that culture was experienced differently in each person, participants found this difficult to translate into everyday practice. Thus, there was recognition of culture as one aspect of the person (see the interaction between P30 and P28, table 2). Yet treating a patient as a unique person was often considered unrealistic in everyday practice given resource and institutional constraints, especially where ‘culture’, perceived as language difficulties or divergent beliefs, was viewed as an impediment to expedient care. There was thus slippage in the discussions towards framing culture as a barrier despite theoretical recognition of culture as complex and present in every person. This resulted in ‘culture’ being individualised, used to articulate difference, and present in patients but not professionals. This was linked to the interplay of professional, institutional and patient values, which we address below.

The interplay of professional, institutional and patient values

As shown in the indicative quotations in table 3, the focus groups discussed the additive assumptions of health professionals themselves and how they were embedded in institutional and biomedical cultural values. The culture of professionals and institutions was often framed by participants as a concealed dimension of the broader ‘cultural’ dynamics of care. For example, we heard frequent discussion of how biomedical priorities (the prioritisation of the physical and biological aspects of the patient) and institutional policies and practices dominated therapeutic approaches and professional-patient relationships. Moreover, significant emphasis was placed within group discussions on imparting biomedical values to the patient. Such priorities and associated values were positioned as ‘western’ approaches (We use ‘western approaches’ rhetorically as it was used within focus groups, while acknowledging that this is an umbrella notion with a highly differentiated set of practices) to illness and care and were often assumed to be fixed, acultural and unyielding. A key example (see table 3) was the discussion around what participants perceived as ‘western’ ideas about autonomy, full disclosure, informed consent or individual choice and the difficulties in operationalising cultural sensitivity with particular migrant groups.

Across the focus groups, the belief systems of both the patient and the participant were discussed as driving participants’ own dispositions. Thus, cultural competence was ultimately considered interpersonal where one’s own values needed to be balanced and acknowledged alongside those of the patient. There was tension within the focus groups (see table 3) between ‘correcting’ migrant patient perspectives to be in line with what was biomedically prioritised and/or institutionally approved and recognising the importance of meaningfully integrating patient values into care. As a result, as shown in the group interactions, managing culture emerged as a series of tensions between values, and shaped by institutionalised values that are embedded in ‘medicolegal responsibility’ and ‘professionalism’ (see table 3). This interplay of professional, institutional and personal values as articulated within the context of ‘managing’ the cultural specificities of the person is highlighted for example by P2, FG1 (table 3).

A balancing act: values, beliefs, trust and respect in everyday practice

A consistent discussion point across the focus groups was the need to balance respect for patients’ cultural beliefs and practices with professional values. For example, P51 discussed patient values as ‘in conflict with our own ethics about autonomy’ and as producing ‘internal conflict’ (table 4). Reconciling the competing priorities of recognition of culture and delivery of ethical care was an ever present and pressing concern, articulated, for example, through repeated use of balance metaphors (see table 4). Examples of attempts to balance conflicts between person-centredness and cultural competence revealed the potential disjunctions between the two, with P13 providing the example of ‘not using the word cancer’.

There was broad recognition across the groups that a failure to recognise or balance potentially competing professional, institutional and patient values could lead to rigidity, barriers to trust and respect and ‘set up an adversarial relationship’. Several groups discussed responding to such complex scenarios by adopting a ‘back to basics’ approach founded on respect (see P8, FG1, table 4).There were several instances of compromise—essentially bargaining with patients over, for example, the use of alternative medicines—that provided a resolution for both parties, acknowledging the distance between respective sets of values (see P15, FG2, table 4). From the perspective of participants, such compromises were framed as both genuine attempts to foster mutual respect, and practical compromises to improve treatment compliance.

Everyday relations for gaining understanding, intimacy and recognition

The final theme we focus our attention on is the significance of concealed and/or often unacknowledged ‘everyday encounters’ as the key to quality intercultural care (indicative quotations shown in table 5). We refer here to participant accounts of the potential in informal exchanges for facilitating individual and reciprocal intercultural understanding and breaking down barriers. For example, P57 and P53 (FG8) discussed the significance of informal conversations with their migrant patients to ‘relating to the patient as a person’ and building trust. The groups often discussed the complexity and confusion they felt in attempting to understand, or even be privy to, cultural values that differed from their own. Participants frequently flagged their lack of understanding of cultural contracts and values, reflecting the ontological barriers—differences in values and beliefs—that potentially exist between professional and patient. The importance of time and relationship was emphasised by participants in this context as crucial.

Participants repeatedly mentioned the importance of time invested in the therapeutic relationship with migrants, and the group discussions raised a range of nuanced perspectives. This was captured in P49’s talk of ‘2 am chats’ in the hospital between nurse and patient (see table 5). The focus groups described the investment in relationships that allowed for discussion and identification of concealed cultural values and enabled improved understanding and intimacies in the management of divergent beliefs and experiences. The counterscenario was commonly talked about—clinicians withdrawing from relationships with migrant patients (particularly those with language difficulties), instilling cultural difference as interpersonal barrier, representing a potentially damaging cycle for migrant cancer patients and their clinicians.

For participants wishing to engage in dialogue with patients there were efforts to remain open towards cultural diversity while simultaneously supporting their own cultural position. Such attempts to respect and understand cultural differences through everyday interactions were talked about as improving participants’ own acceptance of and comfort with these differences.

Efforts which aimed to promote mutual respect and understanding were discussed as enabling better communication and trust and reducing participants’ bias towards particular cultural practices in cancer care. Ultimately, mundane acts such as spending time with and maintaining respect for each patient—objectives professionals have for any patient—uncovered concealed cultural values and helped develop an understanding of the person.

Implications

The findings of this study have several practical implications. First, it is important that there be a renewed focus within cultural competence training on encouraging health professionals to routinely consider and reflect on the ways that each clinical encounter is shaped by patient, clinician and institution. This will improve awareness that these encounters as shaped by all stakeholders and not just the difference of patients. In line with the findings of Kumagai and Lypson,33 cultural competency requires a critical awareness of both self and others: encouraging reflection on the ways by which all parties bring their own values to a clinical encounter may promote such everyday encounters as holding the potential to be transformative. Future research is needed to examine how healthcare services can provide for and encourage these often unacknowledged and underappreciated approaches to care and interaction with patients and their families. Moreover, research focused on uncovering the benefits of providing professionals with additional time and resources to achieve positive outcomes with migrant patients is especially important given the consensus around the limiting potential of resource constraints within this study.

Limitations

This study is not without limitations. Our participants were recruited from three health districts in two Australian cities. As such, our findings may not be indicative of the experiences of healthcare professionals elsewhere. Participants also self-selected by volunteering and were from a wide range of cultural backgrounds with varying levels of experience in working with migrant patients. Finally, we note that our findings above, and the focus group discussions themselves, are situated perspectives and represent only one facet of the broader story of illness and care. Future research is needed to add considerations of patient family and community perspectives.