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Stabilising uncertain ground: the

work of health professionals across

cultures

BSA North East Medical Sociology Group Inaugural Event

Thursday 8th March 2012

Ahmad and Bradby (2007) – have critiqued

the tendency of medicine to pathologise

minority cultures, where cultural ‘traits’

become synonymous with disease

processes.

Culturalist educational approaches dominate health care education

Learning 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 happens

Cultural 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 a marker of identity, a vehicle for community mobilisation and a possible indicator of disadvantage, discrimination or privilege’ Ahmad and Bradby(2007, p.230)

Although the migration of people in search of peace, security and prosperity is nothing new, over the last two decades immigration has taken on a new and unprecidented political and social significance (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 aim

The aim of this study was to explore with health professionals their experiences of working with clients who are from cultures different to their own.

Kathy Charmaz (2006) describes theorising 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 health visitors express, when considering their work with clients who are from cultures different to their own?

2. What concerns do health visitors experience when they are working with clients who are from 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).

Findings

When 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.

Rebecca

Fiona: 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.

Jane

I was scared to offend ... the blurb tells you if you see a load of shoes by the door then take your shoes off but you know what you will find is that clients that you are going to see, that they are absolutely adamant that you keep your shoes on almost as if they are afraid of causing offence. It is as if you are not prepared to meet them half way or to acknowledge their custom [sic].

Beth

I think I was very keen to learn about different cultures but also a bit intimidated as well and a bit scared. In hospital, it is very much in your comfort zone and they are out of their comfort zone but in the home it is a complete reversal when you are visiting them, and you think I don’t understand what is going on here and you would ask but then some are better than others at explaining it, so it is more about understanding what is normal for them and then, em, where we need to cross our 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.

Susan

Susan: In fact, when I worked in that area, I felt

there was so much that I didn’t know, such as

taking your shoes off in the house and I was

always afraid of offending them….that is another

thing, I would be worried I offended people if I

didn’t accept their hospitality.

Rebecca

I worry, I would hate to offend and not to know that I have done it and walk out, them thinking ‘I don’t want her back in’ that would really offend me. In some houses I worry about, I am careful what I say [sic].

Emma

In this particular household I am very, very careful and this sounds very cynical but I feel as if I have protected my back by everybody ensuring the CAF form went in to make sure there wasn’t anything available because I didn’t want to be called racist for not giving care [sic]. (Emma)

Annette

Of all of the areas I have worked, latterly at (this town) it was predominantly a, em (pause) em a white ethnic background, there were very few families who were from, em (pause) em, other countries, em, I would say in (this town) some of the extended families were really settled, really integrated 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 time

2. Re-writing an equality agenda: the same throughout time

3. Asserting a professional identity: undermined over time

4. 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.

Thank you

Any questions….?

References

Ahmad, W.I.A and Bradby, H. (2007) Locating ethnicity and health: exploring concepts and contexts, Sociology of Health and Illness, 29(6), p. 795-810. Bauman, Z. (2005) Liquid Life. Cambridge: Polity Press. Bhaba, H. (1990) The third space. In Rutherford, J. (ed.) Identity, community, culture, difference. London: Lawrence and Wishart. Bolton, S. (2001) Changing faces: nurses as emotional jugglers, Sociology of Health and Illness, 23(1), p. 85-100. Castles, S. (2010) Understanding global migration: a social transformation perspective, Journal of Ethnic and Migration Studies, 36(10), p. 1565-1586. Culley, L. (2006) Transcending transculturalism: race, ethnicity and health care, Nursing Inquiry, 13(2), p.144-153. Gunaratnam, Y. and Lewis, G. (2001) Racialising emotional laour and emotionalising racialised labour: anger, fear and shame in social welfare, Journal of Social Work Practice, 15(2), p.131-148. Hall, S. (2000) Who needs identity? In Gray, P., Evans, J. and Redman, P. (eds.) Identity: a reader. London: Sage Publications, p. 15-30. hooks, b. (1989) Talking back, thinking back. Thinking black. Boston, MA: South End Press. Hochschild, A.R. (1983) The managed heart: the commercialization of human feeling. Berkeley, California: University of California Press.