Stabilising uncertain ground: thework of health professionals across culturesBSA North East Medical Sociology Group Inaugural Event Thursday 8th March 2012 firstname.lastname@example.org
Ahmad and Bradby (2007) – have critiquedthe tendency of medicine to pathologiseminority cultures, where cultural ‘traits’become synonymous with diseaseprocesses.
Culturalist educational approaches dominate health care educationLearning about cultural difference:• Cultural knowledge• Cultural skills• Cultural sensitivity• Cultural awareness (Papadoloulos, 2006; Dogra, 2007).
The cultural ‘other’?• Said (1979) – Otherization• Bauman (2010) – liquid modernity• Nayak (2009) – post ‘race’• EMINEM and Indian tapas – cultural hybridization• Culley (2007) – challenges essentialism in health care education and discourse.
Homi Bhabha (1994) – ‘Third-space’: new spaces emerge where communication and negotiation happensCultural hybridization refers to ‘the ways in which forms become separated from existing practices and recombine with new forms in new practices’(Pieterse, 2004, p.64).
The account of a young schoolgirl born in the city of Bradford in the north of England. Her parents had migrated from the district of Kashmir in Pakistan. One day she was asked to define her identity, by a researcher, and she answered:When I am standing in the school playground with my English friends, I am Black. When an African Caribbean girl joins our group, I become Asian. When another Asian girl comes in, I think of myself as a Pakistani and a Muslim. When a Pakistani friend joins us, I become a Kashmiri, and when another Kashmiri girl turns up, I become a Bradford schoolgirl again (Soni, 2011).
‘Race’, ethnicity and culture as identity• Hall (2001) and Solomos (2000) – identity, belonging, oppression, resistance and strength‘Contemporary notions of ethnicity show it as amarker of identity, a vehicle for communitymobilisation and a possible indicator ofdisadvantage, discrimination or privilege’Ahmad and Bradby(2007, p.230)
Although the migration ofpeople in search of peace,security and prosperity isnothing new, over the lasttwo decades immigration has taken on a newand unprecidented political and socialsignificance (Castles and Miller, 1998; Castles,2010)
Cross cultural work framed as ‘intercultural communication’• Framed as ‘communicating with strangers’ (Gudykunst and Kim, 2003)• Humanist philosophy of individualised nursing care• bell hooks (1989) – post colonial lives are shaped by slavery, imperialism and social disadvantage• Patricia Hill-Collins – intersectionality (‘race’, gender and class).
Research aimThe aim of this study was to explore with healthprofessionals their experiences of working withclients who are from cultures different to theirown.
Kathy Charmaz (2006) describestheorising as ‘stopping, pondering, and rethinking anew. We stop the flow of studied experience and take it apart’ (p.135).
Research questions:1. What are the most important issues healthvisitors express, when considering their workwith clients who are from cultures different totheir own?2. What concerns do health visitors experiencewhen they are working with clients who arefrom a culture different to their own?
Methodology• Grounded Theory – social constructionist approach• Inductive• Development of new epistemological perspectives (Clarke, 2005; Charmaz, 2006; Corbin and Strauss, 2008)• Social constructionist approach was used across all areas of the research process, from data analysis to conceptual development.
Study sample• Initially purposeful sample and theoretical sampling thereafter, in line with Grounded Theory methodology.• Ethical approval granted from the NHS ethics committee and Primary Care Trusts.• All names were changed to maintain confidentiality.• Participants invited via a ‘cascade’ letter of invitation from PCT line managers.• All health visitors were white, female and between the ages of 35-60 years old.• 19 participants described themselves as British, 1 as half- German and 1 as half-Swedish.• All interviews took place at a GP surgery or health centre, except one which was at home.• All interviews lasted 30-90 minutes and were recorded and subsequently transcribed verbatim.
Data analysis• Data analysed in accordance with Grounded Theory methodology.• Raw chunks of data were ‘coded’.• Constant comparison of the codes led to open, axial and selective coding.• Theoretical generation then began using abstract selective codes.• Development of final conceptual theory.
Analytical tools• Research diaries• Theoretical memos• Situational, positional and social world mapping (Clarke, 2008).
FindingsWhen health visitors talk about their work with people from cultures they identify as different to their own, they understand it as: ‘Stabilising uncertain terrain’
Metaphorical cross cultural terrain• Metaphorically the health visitors described working across cultures as working in ‘cross cultural terrain’.• This ‘cross cultural terrain’ was described as ‘common ground’ and somewhere to ‘meet in the middle’.• It was a place of anxiety, uncertainty and instability.
RebeccaFiona: What do you think are the best things about working with people from other cultures?Rebecca: (Pause) I think it is always fascinating to see how they perceive us and they think what we do is wrong and what they do is right and it is about trying to find a common ground that we can both agree on, because some of their things are so extreme and some of ours are so extreme and it is about trying to find a common ground that we can work on really.
JaneI was scared to offend ... the blurb tells you ifyou see a load of shoes by the door then takeyour shoes off but you know what you will find isthat clients that you are going to see, that theyare absolutely adamant that you keep yourshoes on almost as if they are afraid of causingoffence. It is as if you are not prepared to meetthem half way or to acknowledge their custom[sic].
BethI think I was very keen to learn about different culturesbut also a bit intimidated as well and a bit scared. Inhospital, it is very much in your comfort zone and theyare out of their comfort zone but in the home it is acomplete reversal when you are visiting them, and youthink I don’t understand what is going on here and youwould ask but then some are better than others atexplaining it, so it is more about understanding what isnormal for them and then, em, where we need to crossour paths a little bit
Managing emotions• All of the health visitors were influenced by their emotions in cross cultural work• The emotion most frequently identified was anxiety (19 out of 21 participants)• The ways in which the health visitors managed their emotions had a direct impact on their practice.
Working across cultures involves:• Entering ‘cross cultural terrain’.• ‘Cross cultural terrain’ can be dangerous political terrain and is built on socio-historical processes.• Easy to cause offence in ‘cross cultural terrain’ and working across cultures is often shaped by anxiety.
SusanSusan: In fact, when I worked in that area, I feltthere was so much that I didn’t know, such astaking your shoes off in the house and I wasalways afraid of offending them….that is anotherthing, I would be worried I offended people if Ididn’t accept their hospitality.
RebeccaI worry, I would hate to offend and not to knowthat I have done it and walk out, them thinking ‘Idon’t want her back in’ that would really offendme. In some houses I worry about, I am carefulwhat I say [sic].
EmmaIn this particular household I am very, verycareful and this sounds very cynical but I feel asif I have protected my back by everybodyensuring the CAF form went in to make surethere wasn’t anything available because I didn’twant to be called racist for not giving care [sic].(Emma)
AnnetteOf all of the areas I have worked, latterly at (thistown) it was predominantly a, em (pause) em awhite ethnic background, there were very fewfamilies who were from, em (pause) em, othercountries, em, I would say in (this town) some ofthe extended families were really settled, reallyintegrated into the community [sic].
Cross cultural terrain• Uncertain ground• Negotiated ground• Politicised ground• Active client resistance• Out of competence zone• Not having the language to use
Strategies identified to stabilise uncertain cultural terrain:1. Fixing a culture: unchanging throughout time2. Re-writing an equality agenda: the same throughout time3. Asserting a professional identity: undermined over time4. Developing a toolkit: strengthened over time.
Emotions and cross cultural work• Cross cultural work does not occur in a political vacuum• Cross cultural work is not merely about ‘communicating with strangers’ (Gudykunst and Kim, 2003)• Cross cultural work can be anxiety inducing, uncertain and can feel like working on unstable ground.
Managing emotions is an important part of cross cultural working• Managing uncertainty and anxiety• Stabilising uncertain terrain can be dangerous work in the cross cultural context• In a health care environment of ‘clinical competency’ and ‘fitness to practice’, uncertainty is often hidden.
Emotional engagement in nursing discourse• Arlie Hochschild (1983) – emotion work• Nicky James (1989) – giving of oneself• Pam Smith (1992) – emotional labour• Sharon Bolton (2001) – ‘presenting an acceptable face’
Emotions and ‘race’• Gunaratnam and Lewis (2001) –racialising emotional labour and emotionalising racialised labour• Stilos (2006) – calls for nursing practice to build comfort with ambiguity• Kai et al (2007) – found that professional uncertainty in working with patients of differing ethnicity was characterised by stress and anxiety, and led to inertia in their clinical approach.
Implications for education, practice and theory:• Emotion is a powerful driver in shaping practice for health visitors, as they seek to engage with their clients across culture• Cross cultural work can be shaped by anxiety, uncertainty and fear• Uncertainty should be acknowledged within health care discourses• Challenge the notion of ‘competency’ in cultural education• Managing emotions, especially uncertainty, anxiety and fear should be a core part of cultural education• Theoretically the relationship between emotions and ‘race’, culture and ethnicity is under-developed.
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