Health Professionals and how they perceive patients from diverse ethnic groups (UK)

Written by Suki Rai

Text reference: Kai, J., Beavan, J., Faull, C., Dodson, L., Gill, P. and Beighton, A. (2007). Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study. PLoS Med, 4(11), p.e323.

Introduction

Communities are becoming increasingly diverse in terms of ethnicity and race. Health professionals and governments are trying to ensure that everyone has equal access to healthcare, however there is increasing evidence of racial inequalities in relation to health outcomes.

Some health authorities have introduced “cultural competence” training to develop the skills of individuals and organisations allowing them to work better with people from different cultures. These health professionals are taught about ethnic differences in health beliefs and practices, religion, and communication styles, to help them provide the best service.

This article aims to understand how health professionals experience and perceive their work with patients from diverse ethnic groups. In particular, it looks at whether their behaviour is influenced by ethnicity in ways in which might contribute to health inequalities. This study uses cancer care to explore this further and by conducting a qualitative study, with 18 focus groups comprising of 106 health professionals of differing disciplines, in primary and secondary care settings. The study took place in the Midlands, UK.

Methodology

The study used focus groups instead of one to one interviews so that group interactions could take place. These focus groups or discussions were used to look into attitudes, opinions, and assumptions as well as to allow participants to discuss each other’s perspectives.

Each of these focus groups were either homogenous by discipline, to enable sharing of experiences, or a multi-disciplinary group that encouraged discussions from within a care team. The characteristics of participants were broken down as follows:

Category	Characteristic	Number (%)
Health Professional background	Physicianⁱ	22 (21)
	Community-based nurse/nurse specialist	21 (20)
	Hospital based nurse/ nurse specialist	18 (17)
	Allied health professional ⁱⁱ	16 (15)
	Link worker or advocate	21 (20)
	Health Service administrator or manager	8 (7)
Reported frequency of working with patients from ethnic minorities	At least daily	52 (49)
	At least weekly	21 (20)
	At least monthly	8 (7)
	Less than monthly / uncommonly	25 (24)
Age Range (y)	24-35	25 (24)
	36-45	34 (32)
	46-55	33 (31)
	56-65	14 (13)
Ethnicity	White & UK born	63 (59)
	South Asian ⁱⁱⁱ	31 (29)
	African Caribbean	3 (3)
	White European	7 (7)
	Chinese	2 (2)
Languages spoken other than English	South Asian^iv	27 (25)
	Cantonese / Mandarin	2 (2)
	Caribbean Patois	2 (2)
	African^v	2 (2)
	Other European^vi	14 (13)

These discussions were started with a broad question, “Could you comment on any experiences you have had when caring for people from an ethnic minority background?” The conversations lasted between one and half to two hours.

Results

Professionals that were interviewed wanted to provide a good standard to care for patients from diverse backgrounds. However, they felt that they were challenged with communication, language and working with families of the patients.

Professional uncertainty

Professionals stated that they experience uncertainty when faced with patients they perceived as being culturally different. Faced with this “difference”, professionals felt apprehensive and uncomfortable. The respondents highlighted that they lacked cultural awareness and knowledge and that they were worried about how this would affect their patients. They feared that their lack of knowledge may lead to “mistakes” or getting it wrong.

Some professionals were worried that their lack of cultural awareness could be perceived as discriminatory or racist. However, some respondents felt that if they made more of an effort to address the cultural needs of their patients, this could be perceived as preferential treatment, not only by patients but colleagues too.

Focus on cultural expertise

The professionals recognised that their ignorance and the need for more cultural knowledge. They felt that they need training on how to approach patients from different cultural backgrounds.

In situations where professionals were dealing with patients from a different ethnic group to themselves, some suggested that they might ask the patient directly to explore issues. However, this approach did cause some fear and worry that they might say or do the wrong thing which could offend their patient. For example:

“Instead of thinking this is a patient, …treat them exactly as we do any other patient… you get overwhelmed with the fact that it’s an ethnic group instead of a person.” (Palliative Care Team).

Most respondents felt the need to learn more about different cultures and have “set guidelines” on cultural differences. Others, however, thought that given the diversity within ethnic groups, this could lead to stereotyping patients and that patients should be treated as individuals. For example:

“Of course, we have got mixed up cultures now, haven’t we? We have got second and third generations of children and grandchildren, fairly westernised in many families… quite hard to get your heads round isn’t it? Because we don’t quite know who we’re dealing with …”

(Palliative Care Team, p.5)

“Even though you might say this person is Polish, within that there will be all sorts of different likes and dislikes, preferences, cultural differences, everyone is different…”

(Palliative Care Team, p.4)

“It’s not a production line you know. Every person is individual. Miss X’s needs are different from Miss Y, whether they have the same disease. It’s really not, you can’t just say in black and white… It depends, person to person. Every case is different”. (Physician)

There were few instances where professionals felt able to discuss their “uncertainty” with patients, or indeed asking the patient about their perspective, concerns or beliefs. There were the following two exceptions though.

“To think about how you speak to people and to think about what the family and what the patient themselves most want to know and how they want to know it….It’s listening isn’t it? It’s being aware of, you can’t just say this is a Muslim family therefore this is how I’ll do this as a template… You have to be able to modify how you deal with these situations…”

(Physician, pp.3-5)

“I think what has helped me, it’s very much built into counsellor training…is a model around working with any kind of difference rather than around checklists… and yet I still struggle to know how to meet people who are very, very different to me.” (Multidisciplinary hospice team)

Professional disempowerment

This uncertainty that professionals experience had disempowering effects. They felt disempowered by anxiety and stress when experiencing cross cultural interactions.

Respondents worried about, or did not know how to ask their patients about values and perspectives that were important to them. Those professionals that had experience of diversity, and had some form of cultural awareness training, still worried that they might get it wrong and offend their patient. Respondents also stated that they felt uncomfortable as professionals and worried that their patient care could be compromised.

Others felt that patients from different ethnic backgrounds should be “matched” with professionals from a similar ethnic background.

Others felt that they were less able to use trust and empathy as an approach for fear of doing the wrong thing. Others felt more empowered following cultural awareness training. For example:

“I attended a workshop… (the message was) we all have basically the same needs… don’t get yourself tied up… because you’re worried… We have to try and find a way of making sure that people can access services. For me, that was quite freeing really… I don’t have to know everything about every religion, every culture… I found that very helpful and I think it could be easy to hide behind well I don’t know and perhaps they need something different and I can’t give it…” (Palliative care multidisciplinary team)

Conclusion

Professionals in this study wanted to provide a good standard of care for all patients. However, they stated that they experienced uncertainty when they were faced with patients they perceived as being culturally different – this made them feel uncomfortable. They feared that their lack of knowledge may lead to mistakes or to them getting it wrong.

Some professionals were concerned that their lack of cultural awareness could be perceived as racist or discriminatory. By contrast, some professionals felt that if they made more of an effort to address cultural needs then this could be perceived as preferential treatment, by both patients and colleagues.

The approach to ask a patient directly to explore their issues caused some fear and worry that professionals might say or do the wrong thing and offend the patient.

There was some anxiety around experiencing cross cultural interactions. Respondents did not know how to ask their patients about values and perspectives that were important to them. Even when professionals had received training around cultural awareness, they still worried that they might get it wrong or offend their patient.

Worryingly, other professionals felt that patients from different ethnic backgrounds should be “matched” with professionals from a similar background. This would encourage further stereotyping and would not help professionals in being culturally competent.

The openness in which professionals were able to discuss the challenges they face when dealing with diverse patients, was very useful. It allows us to understand the difficulties they face when dealing with patients who are from a different cultural background to them.

The anxiety and feelings of being uncomfortable that the professionals describe could inadvertently contribute to inequalities in health.

Health professionals need to be more culturally aware and have an understanding of cultural needs and what shapes culture. Professionals need to build on their cultural competence to avoid being culturally blind. This would eliminate the fear that professionals face when dealing with patients who are culturally “different” from them.

Professionals need to be aware of cultural differences and they need to avoid dismissing culture for fear of offending their patient. Professionals also need to look at each patient as an individual. They need to consider their patient’s individual needs and empower the patient with choices. There needs to be an opportunity for every patient to be involved in their care.

i Hospital, primary care, or palliative care.

ii Physiotherapists, occupational therapists, or radiographers

iii Born in or descended from those born in Pakistan, India, Bangladesh or Sri Lanka

iv Urdu, Punjabi, Hindi, Mirpuri, Sylheti or Bengali

v Shona or Swahili

vi French, German, Spanish or Italian