What are the sensitive zones in the health sector?

The 60 incidents we analysed evolved around different themes:

1. REPRESENTATIONS AND USES OF THE BODY

The body is indeed the central object of examination in a medical consultation but it is also a product of culture that can easily introduce challenges and differences.

Even if we can state that culture leaves its print on all bodies, this print differs from one body to another: we can easily identify clothing fashions, ornaments like body piercing, tattoo, plastic surgery, or the marks of rites of passage. All of these are ways to mark the body with culture, or as Le Breton says the body doesn’t exist in a natural way, all cultures leave traces on them: they either add (tattoo, makeup, scars, jewellery…), remove (circumcision, excision, epilation, mutilation…) or shape body parts (neck, ears, lips, feet, skull[1]).

In the medical environment we can also find this diversity on how bodies can be “treated”, in which forms they can be approached or touched.  The limits of what can be shown or not can vary, as where the consultation takes place or the expectation on how and when a doctor can touch a patient (Gynaecological visit in Japan). The body being the centre of every health activity, professionals have to be aware of the diversity represented by the bodies they treat: In some of the collected incidents we can find also the body as a taboo where the patient doesn’t feel comfortable being naked in a waiting room next to another naked patient or a health worker doesn’t  feel comfortable being exposed to naked bodies (Naked, Urine sample). This taboo of hiding our body comes from a long religious tradition where the body can be looked upon as sinful and therefore it needs to be hidden. Other theories as the Terror Management Theory think that our bodies are a source of conflict as it reminds us how close we are to animals: to differentiate us from the animal kingdom we use the strategy of “controlling the death-related anxieties by immersing in the world of cultural meanings and values” and this is one of the reasons why we don’t feel comfortable in a naked situation that it is perceived as vulnerability, we try to undermine, hide all our bodily functions and reactions (snoring, farting, burping, sweating).

Hygiene:

Sanitary measures are strict in a hospital and they have protocols to follow for every procedure, but the cultural concept of what can be considered ‘dirty’ or ‘clean’ can largely differ within a culture to another.  What’s more, the idea of physical cleanliness has generally a moral connotation, expressed by the notion of purity (Religion at the docks, Hairy Patient). In Coarse Salt the narrow concept of hygiene is contrasted with the more transcendental interpretation of purity during the performance of a cleansing ritual consisting in covering the hospital floor with salt.  For the patients the salt should contribute to cleaning the space of the bad spirits – vibes that contribute to the illness, whereas from the point of view of the hospital the salt on the floor is a threat to hygiene rules.

[1]http://www.la-croix.com/Culture/Expositions/David-Le-Breton-Par-le-tatouage-chacun-se-bricole-un-mythe-personnel-2014-08-07-1189152

2. PREJUDICE, CULTURALISATION, DISCRIMINATION

The effects of bias in perception and information processing can be noted virtually in all the incidents we collected, but in some incidents they are the central issue.  In particular different forms of prejudice (emotionally loaded attitudes created towards members of cultural/social groups) can be identified as motives in behaviour.

Anticipation of prejudice in others

In several cases members of minority groups anticipate the prejudice that others will have towards them. Such anticipation motivates the AIDS patient in Germs in blood to hide his illness. In C like C (HU) a gypsy patient with conterminous Hepatitis C was feeling discriminated against because he thought the letter C on the machine was for C in “cigany” the Hungarian word for Gypsy.

Perception of prejudice one triggers in others

Prejudice is not only anticipated, but sometimes becomes manifest, and these manifestations can range from very subtle to blatant open remarks. In Embarrassed physician (DK) a patient with disability meets a vicarious GP looking surprised and uncomfortable about the disability.

Culturalisation and culture blindness – enforcement or denial of cultural factors

Superficial or uncertain awareness of cultural differences sometimes induces the interpretation of cultural factors even in moments where other – usually situational or personal – factors are at play. Such interpretations can become extremely harmful when the cultural explanation implies a reason for non-intervention. In Domestic abuse (UK), the social workers decide not to take action when a British Indian woman declares being abused by her husband, because they suspect a cultural factor behind the abuse.

The opposite error can also happen: cultural practices are sometimes interpreted as personal traits. In Baby massage (FR) the energetic movements of an African mother giving a massage to her baby are interpreted as proof of aggression.

Both errors can be connected with what Ross denoted as the fundamental attribution mistake and which implies that humans have a bias towards internal explanations as opposed to situational ones when they interpret the behaviour of a fellow human (Ross 1977).

Discrimination

If open manifestations of prejudice and discrimination are rarer, they still happen, within the medical staff, and within patients against the medical staff, in both directions.  The gravity of these situations lies in the fact that here the prejudice held leads to discriminatory action. In The Insult (DK) a healthcare student from migrant parents is confronted with the unfair discriminatory attitude of a clinical supervisor. In The complaint (DK) a Danish nurse with foreign origins receives complaints from a patient’s daughter, though she seems to have committed no fault beyond that of being different. In Gloves (IT) the young gynaecologist intern is shocked when his experienced colleague decides to wear gloves for the only reason he was examining an immigrant woman.

3. DEATH,  MOURNING

Death is a difficult issue in hospital because it needs to be handled carefully, due to the sensitivity of the persons, their representations of this moment and also how they perceive this moment and the rituals around it. Also to consider the many differences between what the science defines as “death” and the time the relatives need to process the information. When the medical staff have to communicate with the loved ones about the death of a relative (or prepare them for) the communication between these actors is complicated, not only because of the sensitivity of the matter but there is also a confrontation of discourses about physical / scientist vs spiritual representation of death. We found also challenges not only with patients but their relatives and their own fear of death, one nurse being shocked by the wife of a terminal patient that never saw a dead body and  “actually asked the relatives permission to see the dead body in order to experience what a dead body looks like”(Turkish terminal patient).

As people do not have the same perception and ideas upon death, the way to deal with the aftermath of it can differ among people and cultures, which will determine the actions to carry out after the death of an individual, based on the different beliefs about what is after life (Death of a child).

The understanding of a patient or his relatives regarding such issues is crucial, but it can actually appear that it is not easy to talk about this, or to be a bridge between relatives and patient, moreover when the western medical point of view confronts another culture (End of life).

4. INDIVIDUALISM, COLLECTIVISM, ROLE OF THE FAMILIES

In European Western societies we tend to have an individualist orientation, meaning that we decide what the best is for us and for our loved ones. Our needs become the priority over those of the society or the community we belong to. But other societies have a collectivist orientation where individual freedom to choose is less important than relationships and socially valued behaviour.

Individualism: Preference for a loosely-knit social framework in which individuals are expected to take care of only themselves and their immediate families. Its opposite, collectivism, represents a preference for a tightly-knit framework in society in which individuals can expect their relatives or members of a particular in-group to look after them in exchange for unquestioning loyalty. A society’s position on this dimension is reflected in to what extent people’s self-image is defined in terms of “I” or “we.”(Hofstede 1998) 

When a patient gets hospitalised, family support is important but it may easily become an over presence in the room, or interfere with procedures or treatment by the health care staff. Also, it is important to consider the variable perimeter of family, which can be really extended with even members from the community (Homecare in Roma family , Chicken stew for granny).

When it comes to communication, we have to remember that sometimes if the patient is not able to be the interlocutor we have to deal with the family exclusively. It is thus necessary to understand how the family or the community is organised and which part every individual has to play in order to make the communication easier (Roma consultation)

Traditional / Normative family roles

Cultural differences between doctors and their patients are common and may have important implications for the clinical encounter. A doctor is responsible for his patient but outside hospital walls’ he finds his limitation. We found in our critical incidents collection some disconnection between the responsibilities assigned or assumed by the medical staff and the relatives of the patient. We can understand the position of the medical staff shocked by what they judge as lack of responsibility or the lack of interest from the relatives towards a patient (Baby drinks poison, Parents health responsibility) as family roles are agreed upon societal rules and there are specific expectations on what is appropriate or inappropriate in a particular society.

5. GENDER

Gender refers to the “socially-constructed set of expectations, behaviours and activities of women and men, which are attributed to them on the basis of their sex”[1]. Social expectations regarding any given set of gender roles depend on a particular socio-economic, political and cultural context and are affected by other factors including race, ethnicity, class, sexual orientation and age. Gender roles are learned and vary widely within and between different human societies, and change over time.

Not only gender is socially constructed, but it is a highly sensitive subject virtually in all cultures. Jokes about sexuality are felt very offensive (e.g. The birthmark, HU) and people are threatened by manifestations of gender differing from theirs.

According to Hofstede, conceptions and approaches to gender constitute one of the most important ways in which societies differ, so much so that he referred to it as the “taboo dimension” (Hofstede 1998).  Accordingto his findings, it is possible to measure a culture’s general (statistical) tendency of being oriented towards values classically considered masculine or feminine.  This distinction however has limited applicability, as the content of what is considered classically “feminine” or “masculine” has so much cultural diversity, that it reduces their strength as meaningful categories.  Nevertheless, Hofstede identified another dimension, which consists in the degree of preference towards more or less differentiation between gender roles and in general prescriptions according to gender.  For a coherent denomination we’ll refer to these tendencies as high gender differentiation and low gender differentiation.  Differentiation can refer to a great variety of practices and behaviour: professional choices of men and women, rules of interaction and politeness, dress codes, uses of space, roles within the family and also power distribution.  Adepts of the different orientations do not perceive these differences as “harmless” manifestations of cultural diversity, rather as threats to important values thus reasons for judgment.  From the perspective of low-differentiation, the emphasis on traditional roles is perceived as “backwards” and often as a sign of women’s oppression. From the other perspective, the overlap of definitions of masculine and feminine is perceived as a threat to morality, purity and a traditional concept of the family.

We have observed such differentiation on three levels in the collected incidents:

Difference in self-presentation, dress codes and communication rules

The higher the preference for differentiation between men and women the more differences are expected between them on a variety of levels.  How people present themselves, how they dress up and how they communicate constitutes a first layer of differences.  In Consultation in Burqa (FR) difficulties arise because the dress code of the patient requires that all her skin is covered in the presence of men she’s not related to. In the same cultural / religious group men do not need to cover all their skin: their skin is not considered as a sensitive part of the body, whereas the whole of the female body is considered as such.  Cultures with a preference towards low differentiation are very suspicious of such practices, and expect it to be a sign of the oppression of women.

Regulation of interaction and physical separation

The differentiation of gender roles usually implies prescriptions for the interactions between men and women: how they can speak to each other, exchange eye contact or physical contact. Shaking hands (AU) for example illustrates the tensions triggered from interaction rules, which forbid physical contact between man and woman. The separation is sometimes marked by the clear spatial demarcation for men and women, which forbids unrelated man and woman to be in the same room if no third party is there (Turkish terminal patient, DK, Madam Doctor, IT). Finally, the need of separation is sometimes connected to specific moments connected to the health or biological cycle of women (e.g. The Period, FR).

Roles and power positions

As basic principles of social organisation, representations related to gender are inextricably connected to the questions of power relations, hierarchy and also to the dimension of individualism and collectivism.  In everyday perception these dimensions are fused and to the detriment of a more analytical observation interaction often results in the judgmental conclusions about sexism and lack of emancipation of women.  In No voice (UK) the professional wishes she could assist a lady of Indian origin and her daughters in standing up for themselves and declaring their desires – interpreting the lack of individual self-expression as a lack of emancipation.

[1] http://www.coe.int/en/web/compass/gender

6. HIERARCHY, POWER DISTANCE

This dimension expresses the degree to which the less powerful members of a society accept and expect that power is distributed unequally. The fundamental issue here is how a society handles inequalities among people. People in societies exhibiting a large degree of power distance accept a hierarchical order in which everybody has a place and which needs no further justification. In societies with low power distance, people strive to equalise the distribution of power and demand justification for inequalities of power.

The healthcare domain is characterised by a very hierarchical structure. Rules and chain of authority are fixed and in the internal organisation these roles are clear. Despite the transparence of the hierarchy we found in several of the analysed incidents that this hierarchical dimension could also bring confusion, misunderstanding and questioning.

Relationship with patients: In a healthcare situation, the doctor or nurse get an authoritarian position by the status and decorum (dress code, white coat, diplomas etc…). They have the knowledge in the health domain and superiority over the patient. Based on this relationship the patients have specific expectations on how a doctor should behave, and vice versa, and when these expectations are not fulfilled it might appear as a shock (substance misuse) or negative reaction (homeless patient). A profession – such as a medical doctor  -also adds to status, thus a relationship between doctor and patient by definition is asymmetrical, but we also need to keep in mind that two types of hierarchies can be present and it might lead to a conflict: we can take as an example Madam Doctor (IT) where not only the gender dimension operates but also the fact that the patient is an older Italian male who refuses examination from a young female intern and rather wants to be examined by the older experienced male doctor.  This manifestation of hierarchy appeared several times in our incidents collection: the distance that a medical speech creates between professionals and the families sometime can lead to a misunderstanding (The Interpretation mistake) as families do not dare to ask more detail or ask the doctor to repeat himself. In this incident the intern also tries to resolve the situation but the doctor in charge makes it very clear that he does not want to interfere in the translator’s job: the division of tasks and responsibilities seems to be very clear for the doctor and he assumes that his part is well accomplished with no need of any kind of clarification.

Relations within staff: Even between the health care staff different positions exist following a structural organisation with levels of authority. But these positions can actually lead to possible abuse when a decision is taken by a superior without taking into account the word of the subordinate as we analysed (in the incident The insult) the difference of power between the doctor’s words and the intern’s.

7 SELF SHOCK, IDENTITY THREAT

Most critical incidents imply a certain threat to our identities, confronting us with a negative representation of ourselves, either through our own observation or through the image the other people reflect on us.  Some of the incidents are situations in which the protagonists are unable to present or maintain the identities they wish to present – the self as competent, decent, knowledgeable, polite, modern, etc.  Even if these identity threats are often found in second layer, underneath the main theme of the incident (such as religion or gender) we think they are important keys to explain the intense defensive reaction that we can witness in such situations.

Identity threats can happen on the patients’ side, as a consequence of manifestations of prejudice and discrimination when the person is suddenly reduced to one aspect of their identities (see The assault, Embarrassed GP).  Tensions can also arise between different representations connected to one’s identities: in Period a young woman of Indian origin is confronted with a traditional Indian representation of women during menstruation, a representation she does not have but that is reflected on her through her Indian origins.

The self–shocks of the professionals are particularly frequent in intercultural situations, and can happen along different lines:

Proximity of identities: tension between separation and identification

In Cleaning a peer (AU) the narrator is torn between the posture of the professional and the friend. To clean the faeces off the erect penis of a peer could be a professional gesture, based on a proper distance, but there are too many connecting points between himself and the patient, and maintaining the distance becomes impossible.

Not a professional, only a woman

Many of the cases where gender identity appears are united by a specific identity threat: professionals (doctors or nurses) are suddenly reduced to their female identity in interactions where the patients refuse to be treated by women.  As if their studies and professional expertise could all become irrelevant, and they cannot treat the person – e.g. Madam doctor,IT

Inability to perform one’s mission (consultation in burqa, FR)

Cultural differences can become an obstacle to performing one’s medical mission even beyond the gender problem, simply because the other’s reference frame does not make it possible to accept the treatment.  In severe cases this could induce life threatening situations (e.g. Transfusion, Fed Up) where the professional could fail his / her basic duty.  In other situations the doctors / nurses / paramedics find themselves in a situation where they cannot perform the actions they need to maintain a sense of efficacy and competence connected to their professional identity (Death among family members, AU)

8. RATIONALITY, WORLDVIEWS

Around 15 of the incidents collected are connected to religion or transcendental belief systems.  Their “sensitivity” can be traced to two reasons.  First, along the argument of the “terror management theorists” (Goldenberg 2006:1265) the medical context, or more generally illness can trigger the need for symbolic defence as a means to fight the existential anxiety connected to the proximity of death.  In such cases the protective buffer created by belief systems need to be reinforced. Closeness to illness or death is a moment when even non-practicing people can turn back to their religion and beliefs.  The second argument is brought by Cohen-Emerique (2015:181) according to whom some sensitive zones remind us of archaisms that we had overcome through modernity.   The rationality of modern medicine based on scientific method is often represented as a progress transcending the ancient magical practices.  Accordingly, in most cases where religion / transcendent beliefs appear we see the judgement of irrationality surface.  It is important to stress though, we’re not talking about a distinction between Western and non-Western societies – even if popular thinking may make that parallel: we use the notion of magico-religious worldview to refer to all religious / spiritual thinking without distinction concerning the specific religion or sect. We have noted three different ways magical/religious worldviews can contrast with scientific / laic representations or explanations:

Priorities

Religion can sometimes threaten the most important priorities medical professionals hold. In “Jehovah’s Witnesses” (FR) the doctor is instructed by a family of Jehovah’s Witnesses that their son could not receive transfusion even if it is a question of life and death. For the family, the threat of transgression of one of the basic rules of their system implies a symbolic separation from God’s words and the community, which is seen as a greater threat than the end of physical life. For the doctor, the priority is no doubt the exact opposite.

Maintaining religious practices and rules in all contexts

Another type of transgression to a perceived “rationality” consists in giving religion or beliefs a place “where it does not belong”. Some European societies –such as France – have the concept of secularism (laicité) inscribed into their legal framework, with implications on where religion can be taken into account, where people are allowed to manifest religion and where they can expect their religious beliefs to be respected, and where they can’t.  Even when explicit legal codes don’t exist, social representation can still assign religion to the “private” sphere, or to specific places such as the church.  The practice of bringing religion to all contexts is a different paradigm.   In “coarse salt” and “death of a child” religious / spiritual rituals appear in the hospital space, as a purifying ritual in the first and as a mourning ritual in the second.  In both, the rational, ordered and scientific space of the hospital is transformed and “invaded” by signs of a different logic.

Impact on social roles and gender

Not only religious practices cross the hospital doors but religious prescriptions governing the way people should behave towards each other interfere with medical relationships.  The most common examples of such interference converge around the theme of gender. In “consultation in burqa” for instance the adherence to a desire to separate genders and avoid physical contact between people of different sexes becomes parallel to the medical team’s refusal to accommodate such a desire and becomes a threat to the provision of medical care.  (see more in the gender section).

9. CONCEPTS OF HEALTH, DISEASE AND HEALING

Medical treatment:
Reasons for a patient not accepting treatment are diverse. Some of them are linked to religious beliefs but also to habits. It takes pragmatism, communication and agility to handle these situations (Pagan, Hospital medication). 

Ethic:

The health domain requires an attitude adapting to situations in order to stay as neutral, professional and efficient as possible but also not hurting patients (Embarrassed GP) or relatives, moreover when situations are difficult or serious (Jehovah’s Witnesses, Transfusion). 

Procedure, use of space:

In most of western societies the public spaces are designed in the most practical and efficient way to facilitate the actions and roles of the citizens but also the actions of those who are supposed to keep the order[1] and discipline among us. From Foucault’s point of view we can then say that public space is also a political space where our bodies learn to discipline themselves, how to move, how to act, how to behave. When bodies do not follow the expected behaviour it could lead to a conflict or shock.

This behaviour is a cultural code that might not always be shared by all members or in his case by all hospital visitors: in a hospital, space organisation is clearly thought to help patients and medical staff for the most efficiency. Thus, some areas have special designation and their use can differ from one person to another (Coarse Salt, Woman’s duties), but also some rules have to be respected and well explained to the visitors in order to keep an adaptive place of work (Arab family with little boy).

[1] Foucault, M., Discipline and Punish: the birth of the prison New York : Pantheon Books, ©1977.

10. COMMUNICATION

Communication is a transversal sensitive zone that you will find across mostly all of the Critical Incidents we collected. We decided to make a short presentation of a simple theory of communication and try to connect it and illustrate what we found in the field.

When we think of communication we don’t think only about the three components presented below but also about the way they interact with the context to produce a dominant style of communication. In the health care sector para-verbal, nonverbal and physical elements are needed to decode a message – this is often referred to as “high-context communication” as opposed to “low-context” style where meaning is uniquely derived from the verbal level. The arrangements of furniture, decoration, even the clothes, are used to create meaning and to decode it. When we don’t share these codes incidents related to communication can happen, for example if a patient is given the instruction of giving a urine sample but with no further details the patient cannot know that there is a specific place (toilet) where this action has to be done (Urine sample).

There are three main elements of communication:

The Content – the meaning (what?)

The content depends on the interaction between the sender, the receiver and the context. The meaning is co-constructed and negotiated.  This implies: an active role of the receiver in interpreting, giving sense to the message; the importance of the filters, reference frames mobilised to give sense to communication acts and the importance of the context. When the frames of references differ, different meaning is constructed and misunderstanding can arise (e.g. Homeless Patient (HU) Get me a woman! (HU)).

Relationships (with whom?)

Each act of communication is an occasion to construct, change or maintain the relationship between the parties.  Even the seemingly most insignificant interaction is an occasion to confirm mutual respect and recognition – in this sense there is no such thing as insignificant interaction.  If this key element of reciprocity, recognition is present in all cultures, the choreographies of getting there vary dramatically (see section on means).  The way relationships are constituted is informed by other value dimensions, such as the orientation towards individualism or interdependence and the acceptance of power distance.  In social contexts characterised by a high acceptance of power difference the asymmetry of the relationships is marked (for example by different codes of addressing each other, different gestures) whereas in more horizontal settings the interaction rites will try to conceal or reduce the power differences (for example both parties addressing each other with the same formality despite difference in age or status).  In any case, the different incorporation of means of communication (gestures, words, distances..) will almost always be interpreted as  information about the intentions of the other and connected with the relational level: a person stepping too close is seen as aggressive, a person using informal register as disrespectful etc. (e.g. Arab Doctor, HU)

Means – forms (how?)

Verbal communication

Includes the speech, these of metaphors, imagery, use of idioms, etc. We can see an example with the Danish incident called “the Interpretation mistake” where an intern finds a big translation misunderstanding and tries to resolve the situation (For more detail please see under Hierarchy)

Para-verbal communication

The tone, intonation, loudness, rhythm, silences, pauses, auxiliary sounds (euh…)

Non-verbal communication

Kinesics: gestures, body posture. In the “the embarrassed GP” incident we can see a general practitioner that wasn’t expecting a person with disability and cannot hide her surprise, the narrator tells us “All her body language shows that for some reason my disability is making her very uncomfortable, perplexed and completely taken by surprise.”

Haptics: physical contact, touch

Proxemics: fine-tuning physical distance in accordance with social relationship and type of situation. We don’t keep the same distance in a social situation, in an intimate one or in a professional one. If the prudent distance for someone is not respected it could be perceived as an invasion of the intimate space and this creates a discomfort. In “Homecare in Roma family” the narrator tells us “when I arrived to the family´s home, almost at the doorstep the little daughter threw herself into my arms and tried to hug and kiss me. I was taken by surprise, while usually patients and their families are not approaching me as if I were a close friend of the family”.

Physical appearance: presenting yourself

Chronemics: use of time and rhythm

Contextual Communication: use of objects, observation of the environment to communicate and interpret the situation (e.g. Roma Consultation, Cellphone FR)