Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study

Abstract

BackgroundWhile ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.Methods and FindingsWe conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.ConclusionsThis study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.

Examining the family-centred approach to genetic testing and counselling among UK Pakistanis: a community perspective

“…The need is not to scrutinise the Pakistani community's supposed reticence but to examine the assumptions made by those outside the community (Ali et al 2008). Further, the mistrust of health messages about the damaging impact of cousin marriage (Darr 1997;Atkin et al 1998) can be approached as an example of the challenges faced by professionals struggling to deliver appropriate care to diverse communities (Kai et al 2007), rather than as a shortcoming of the Pakistani origin community.…”

The Art of Enduring Contradictory Goals: Challenges in the Institutional Co-construction of a ‘good death’

“…Yet, condensing such diversities down to clear 'cultural' categories is not possible due to the complexity and individuality of ontological reference points. Therefore, as Gunaratnam (2008) has shown in detail, reference to 'cultural knowledge' is not in itself helpful in concrete 'death work' (see also Kai et al 2007). The everyday interactions of professional carers', residents' and relatives' 'doing death' are always threatened by insecurities that question routinised procedures: not only with regard to professional 'death workers', as Gunaratnam (2008) has shown, but also with regard to residents and especially relatives acting as proxies.…”

“…Dealing with 'ontological insecurities' in 'dying trajectories' may lead to a variegation of agency, ranging from explicit agency (as for example the relatives in case C) to incapability of agency (as in case D). The specificity of professional 'death work' in contrast to the agency of residents and relatives is, however, that agency must be maintained or regained even in circumstances of severe 'ontological insecurity', in order to fulfil the professional requirements of 'death work' and to enable the carer to move on to the next resident and their particular 'dying trajectory' (see also Kai et al 2007). Therefore, 'deaths' constantly have to be 'done' with reference to past and future deaths, and making them 'good' is never accomplishable without some doubts potentially arising in the minds of the actors involved (see also Salis Gross 2001).…”

Embracing Uncertainty as a Path to Competence: Cultural Safety, Empathy, and Alterity in Clinical Training

“…(3) Searching for meaning in the face of uncertainty by balancing clinical perspectives with the voice of the Other. The Working with Culture seminar recognizes uncertainty as a pervasive aspect of all clinical work that is especially relevant to the fragile position of the clinician as outsider or stranger in intercultural work (Kai et al 2007). The seminar emphasizes the indeterminacy and polyvalence of meaning in clinical work: ''clinical narrative is not a straightforward truth-seeking enterprise'' but involves political issues of representation and positioning that inevitably work simultaneously to give voice and to compel silence, to empower and to marginalize certain subject positions.…”