Cultural competent care: educational needs of junior doctors in palliative care for ethnic groups
10.14601/TUTOR-16459
In this article, the results of a qualitative study on the educational needs of junior doctors working in a university hospital in Rome, with regard to providing palliative care (PC) to ethnic groups, are presented. Focus groups were held to identify the educational needs on cultural competence applied to PC during medical training. The expressed needs were clustered in three main themes: language as a barrier, empathy and management of emotions, knowledge (pain management, culture). A set of recommendations were issued towards the medical board to redesign the medical curriculum. 
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Roos Meriam Walraven
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palliative care
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Roos Meriam Walraven
2015/08/03
10.14601/TUTOR-16459
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tutor                                                                                                 Vol. 15, N. 2, 2015: 13-20
                                                                                                    DOI: 10.14601/Tutor-16459



           Cultural competent care:
           educational needs of junior doctors
           in palliative care for ethnic groups
                   Fabrizio Consorti1, Roos Meriam Walraven2
                   1
                     Department of Surgical Sciences, Faculty of Medicine and Dentistry, University Sapienza of Rome, Rome, Italy.
                   E-mail: fabrizio.consorti@uniroma1.it.
                   2
                     Faculty of Earth and Life Sciences, VU University, Amsterdam, Netherlands.

        ABSTRACT
        In this article, the results of a qualitative study on the educational needs of junior doctors working in a uni-
        versity hospital in Rome, with regard to providing palliative care (PC) to ethnic groups, are presented. Focus
        groups were held to identify the educational needs on cultural competence applied to PC during medical
        training. The expressed needs were clustered in three main themes: language as a barrier, empathy and
        management of emotions, knowledge (pain management, culture). A set of recommendations were issued
        towards the medical board to redesign the medical curriculum.

        Key words: Graduate education, palliative care, cultural competence

        RIASSUNTO
        Premessa. In Italia sta aumentando il numero di pazienti di origine non italiana e – parimenti – le cure
        palliative stanno ricevendo attenzione sempre maggiore. Questa ricerca qualitativa si propone di esplorare
        i bisogni di formazione percepiti da un gruppo di specializzandi, relativamente alla pratica di cure palliative
        a pazienti non italiani.
        Materiali e metodi. Sono stati condotti quattro focus group con specializzandi in formazione presso il
        Policlinico Umberto I di Roma. Le domande di conduzione dei focus group sono state derivate dai costrutti
        previsti dal modello di competenza culturale proposto da Camphina-Bacote. Le trascrizioni sono state sot-
        toposte ad analisi tematica.
        Risultati. Sono emersi tre temi principali relativi ai bisogni di formazione: la conoscenza di una lingua stra-
        niera e la capacità di dialogare comunque con un paziente che non parla italiano, lo sviluppo dell’empatia e
        della capacità di gestire le emozioni, le conoscenze specifiche di competenza culturale e relative alle cure
        palliative.
        Conclusioni. I risultati ottenuti indicano che i bisogni di formazione espressi sono ritenuti utili ma secon-
        dari rispetto al nucleo fondamentale delle competenze mediche. Vengono proposte alcune raccomandazioni
        per lo sviluppo della progettazione formativa per il corso di laurea in medicina.

        Parole chiave: Formazione post-laurea, cure palliative, competenza culturale




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           © Firenze University Press      ISSN (print) 1971-7296
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  tutor Volume 15, Numero 2, agosto 2015

                   INTRODUCTION                                               cultural and linguistic differences in medical school,
LAVORI ORIGINALI




                   Culture, which, “to some extent can be seen as the         the knowledge and awareness on cultural and linguis-
                   ‘lens through which the individual perceives and           tic differences of future doctors can be expected to
                   understands the world that he inhabits and learns          improve, which will contribute to the improvement
                   how to live within it’” [1] is, together with individual   of the quality of PC for ethnic groups. Based upon
                   factors, education, socio-economic status and envi-        the results of this study, we also aimed to provide
                   ronmental factors, one of the determinants of health       recommendations towards the medical board for re-
                   [1, 2]. Cultural background might influence the way        designing the medical curriculum.
                   health, disease and death are perceived by a patient.
                   Due to cultural and linguistic differences, ambiguities
                   can arise between patient and healthcare provider          METHODS
                                                                              Focus groups (FGs) were used in this study as a tool
                   [3]. Poor knowledge of healthcare providers about
                                                                              to find an answer to the main research question:
                   the influence of cultural and linguistic differences
                                                                              What are the perceived educational needs of junior
                   may result in low quality of care, low compliance in
                                                                              doctors in providing PC for ethic groups? Five sub ques-
                   treatment and medication use by patients [4]. In the
                                                                              tions have been formulated based upon the model
                   field of PC, differences in culture and language might
                                                                              of the process of cultural competence in the deliv-
                   be even more influential because beliefs about death
                                                                              ery of healthcare by Camphina-Bacote (2002) [9].
                   and pain relief, as well as the provision of PC differ
                                                                              This model was chosen because it focuses specifi-
                   strongly among cultures [5].
                                                                              cally on the healthcare provider while others, such
                   To improve healthcare for ethnic groups, health-
                                                                              as the sunrise model of Leiniger and the model of
                   care workers can be educated in cultural compe-
                                                                              Purnell, focus more on the patient, as well as learn-
                   tence. Cultural competence is a concept which is
                                                                              ing and understanding culture [10, 11].
                   used in healthcare to increase the quality of care         In the Camphina-Bacote model [9] five constructs
                   and to prevent health disparities among patients           are used, namely: cultural awareness, cultural
                   with a different cultural and linguistic background.       knowledge, cultural skill, cultural encounters and
                   It aims to develop a healthcare environment, which         cultural desire. Cultural awareness (CA) is defined
                   is suitable to respond to the needs of patients with       as the reflection on the healthcare provider’s own
                   a different background and language [6].                   cultural and professional background. In other
                   In Italy, at University La Sapienza in Rome, research-     words, a healthcare provider should be able to rec-
                   ers have developed an educational framework for the        ognize his prejudices and assumptions about people
                   development of professionalism including socio-cul-        with a different background. Cultural knowledge
                   tural competence of medical students [7]. Because          (CK) is seen as a combination of having knowledge
                   of increasing cultural diversity in the population of      about health-beliefs and cultural values, occurrence
                   Italy [8] the social cultural competence should be         of diseases in a specific culture and knowledge about
                   given according to Consorti et al. [7] a high priority     the interaction of medicine in groups. Cultural skill
                   in this framework. However, when this study was            (CS) is regarded as the use of cultural knowledge
                   designed, medical students did not receive much ed-        in the physical assessment of patients. When as-
                   ucation on the influence of culture on healthcare or       sessing the patient, the healthcare provider should
                   specifically PC. Furthermore, little insight exists on     have knowledge about the physical, biological, and
                   the gap between the medical curriculum on cultur-          physiological differences between patients. Cultural
                   al competence and the educational needs of under-          encounter (CE) is defined as healthcare profession-
                   graduate and graduate medical students. Therefore,         als being encouraged to interact with patients with
                   this study focussed on the educational needs of ju-        a different cultural background. Cultural encounter
                   nior doctors in providing PC to ethnic groups in Poli-     also includes the assessment of the patient’s linguis-
                   clinico Umberto I, related to the University La Sapi-      tic skills. Cultural desire (CD), finally, comprises
                   enza. By increasing the attention for education on         and refers to the provider’s motivation to give cul-



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                                                                        Palliative care and cultural competency




Figure I. Example of scale used in FG’s



turally competent care; cultural competence is not       than other qualitative methods such as interviews,
only having the skill and knowledge to be cultural-      beacause of the interactions between participants
ly responsive, but also includes the willingness to      [12]. Finally, opinions of several participants can be
provide cultural competent care.                         discussed and differences between opinions can be
The following questions were derived from the            explored, allowing for a better understanding of
model, related to one or more of these concepts:         the topics than a survey or an interview [14].
How do junior doctors take into account culture in       The FGs were held with residents working in
providing PC to ethnic groups (CA)? Which is the         Policlinico Umberto I, Rome, Italy. The choice
needed knowledge to provide culturally competent         for junior doctors was motivated by the expecta-
PC according to the junior doctors (CK)? Which           tion that they have more experience with PC for
are the needed skills to provide culturally com-         ethnic groups compared to medical students. Ap-
petent PC according to the junior doctors (CS)?          proximately 4 to 8 FGs were planned with 4 to 8
What role does language play in PC for ethnic            participants. Participants were recruited by email
groups according to junior doctors (CE)? Which           invitation and by phone call.
training would have been necessary during medical        A script was developed for the FGs, to maintain con-
curriculum to provide appropriate and effective PC       sistency in their execution over a period of several
to ethnic groups (all constructs)?                       weeks. The five sub questions were used in several
Because of the exploratory nature of this study,         exercises to collect opinions. The exercises consist-
FGs were chosen as methodology because they              ed of different kind of first-thought associations, fol-
are very effective to this aim [12, 13]. An additional   lowed by an explanation phase. During the latter the
property is that they can produce more information       participants were able to explain their association



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  tutor Volume 15, Numero 2, agosto 2015
LAVORI ORIGINALI




                              Total participants          Gender Mean age Medical Specialty (amount)
                                                                              • General surgery (2)
                   FG1                  3                 1 male       33
                                                                              • Internal medicine (1)
                                                                              • Oncology (1)
                   FG2                  4                 1 male       32
                                                                              • Internal medicine (3)
                   FG3                  3                 2 male       30     • Gastrointestinal surgery (3)
                   FG4                  8                 2 male       30     • Gastroenterology (8)

                   Table 1. Participant characteristics


                   and discuss them with other participants. The final        treatments due to lower socioeconomic status and
                   stage consisted of a ranking phase, in which the con-      language barriers.
                   cepts were ordered by the participants by priority in      Only one participant mentioned the difference
                   PC for ethnic groups (see Figure 1).                       between cultures in the attitude towards certain
                   The FGs were recorded, transcribed, coded and              medications:
                   labelled using the concepts named by the partici-
                                                                              I’m thinking about morphine […] in some cultural groups
                   pants. All data were summarized in a matrix to get a       it could be a negative thing to use morphine […] for Ital-
                   clear overview of the answers in the different FGs.        ian patients for example the use of this kind of drug is
                   Finally, the results were compared with the model          like a death sentence.
                   of the process of cultural competence in the deliv-
                   ery of healthcare by Camphina-Bacote [9].

                                                                              NEEDS IN KNOWLEDGE AND SKILLS
                   RESULTS                                                    When asked which is the needed knowledge to
                   The response rate for the FGs was low with re-             provide PC to ethnic groups, knowledge about re-
                   spect to the delivered invitations. Initially, a total     ligion was regularly mentioned, because differences
                   of four FGs were conducted, with junior doctors            were often associated with differences in religion.
                                                                              The main reason to consider this knowledge as es-
                   of the residency in general surgery, oncology and
                                                                              sential was to empathize with the patients or to
                   internal medicine (Table 1).
                                                                              know how to treat a patient. With cultural and
                   The results show that experience with PC for
                                                                              religious knowledge the physician is better able to
                   ethnic groups was scarce. However, experience
                                                                              understand the worldview of the patient. This can
                   with PC in general or with ethnic groups in gen-
                                                                              help in establishing a good patient-physician rela-
                   eral was present. Two main, contrasting opinions
                                                                              tionship. Besides, the participants said that patients
                   came forward. For one group, the needs were
                                                                              with a diverse background have diverging views on
                   seen as the same for all patients, regardless of their
                                                                              life, illness and death. One participant stated:
                   background.
                   Pain, if you’re sick, you’re sick, it may be a Roman, an   We are facing the patient at the end of his life. So we must
                   Italian, Frenchman or Englishman                           approach him with empathy, which is hearing and under-
                   On the other hand, ethnic groups were perceived            standing how he manages his problem. Including his cul-
                                                                              tural background; maybe a patient who has a faith stands
                   to have different needs because they thought dif-
                                                                              differently in relation to his disease than one who hasn’t.
                   ferently about PC. Nevertheless, all agreed that
                   cultural, religious and linguistic differences can be      Beside the need for knowledge about culture, the
                   obstacles in providing care to ethnic groups.              participants prioritized the knowledge about physi-
                   Furthermore, the participants observed problems            ological, pharmaceuticals, pain management and PC
                   in the access to healthcare and non-compliance in          which are already part of their education.



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                                                                              Palliative care and cultural competency



         Priority 1                                   Marked* Priority 2                                 Marked*
FG1      • Language                                        3     • Culture                                   3
                                                                                                             2
                                                                 • Psychological management
FG2      • Communication                                   4
                                                                 • Pain management
                                                                                                             1
         • Language                                        1                                                 2
                                                                 • Different culture and traditions
FG3      • Relationship with patient                       1
                                                                 • Palliative care
         • Palliative care                                 1                                                 1
                                                           1
         •   Language                                      3
         •   Medical knowledge & side Effects                    • Language                                  6
FG4
         •   Drugs, structure, support, nutrition          3     • Medical knowledge & side effects          4
         •   Spiritual problems
                                                           1
* Amount of participants that chose a certain concept .

Table 2. Priorities in education of knowledge and skills


When the participants were asked which skills are              In one FG a discussion ensued about the need of
needed, all groups mentioned being able of speaking            education on empathy. Empathy, the understanding
another language. Language barrier was mentioned               of and listening to the patients, was often seen as
as the most frequent occurring problem with ethnic             an educational need. On the degree to which em-
groups.                                                        pathy can be acquired through education opinions
Furthermore, empathy and the ability to build the              differed: some stated empathy is a part of you and
relationship with the patient were seen as an im-              you do generally not become a doctor when you
portant skill.                                                 are not empathic, and therefore education on em-
                                                               pathy is not essential.

NEEDS IN EDUCATION
Participants were asked about the knowledge and                METHODS OF EDUCATION
skill domain where education was mainly needed.                In the last exercise participants were asked how
Education to improve language skills was regard-               they would like to receive education on the con-
ed in all FGs as the basis of the relationship with            sidered subjects. Most skills and knowledge should
the patient and thus very important. Education on              be taught during the last years of medical school.
culture and religion was seen in some FGs as es-               However, language should be taught starting from
sential, where in other FGs it was deemed unim-                elementary school. Nonetheless, some participants
portant since knowledge on cultures and religion               thought a course during medical school was nec-
is, or should be, part of your general development.            essary, as well as joining students’ exchange pro-
Knowledge about physiological and pharmaceuti-                 grammes or going abroad, together with interactive
cal factors and about pain mechanism was seen as               lessons, such as discussion groups or simulations.
general requirements and therefore needed. When                Such education should be provided during the med-
participants were asked to prioritize their educa-             ical study but also during the medical career.
tional needs, language or communications were the
most important. However, in one FG more par-
ticipants chose medical knowledge and knowledge                DISCUSSION
about side effects and drugs, structure, support and           The results suggest that junior doctors are aware
nutrition above language (Table 2)                             of the influence of culture on care. Most of them



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  tutor Volume 15, Numero 2, agosto 2015

                   believed that knowledge on cultural and religious         servation is the comment of one of the participants
LAVORI ORIGINALI




                   background is needed to establish a good physi-           noting that it is difficult to explain to patients that
                   cian-patient relationship. Knowledge about the pa-        things work differently in Italy but the participant
                   tients’ view on illness and death is needed to adapt      did not express any empathic reaction with the
                   physicians’ approach towards the patient. However,        patients difficult situation. Those examples might
                   though cultural knowledge and skills were seen as         suggest that the participants are aware of the influ-
                   important, they were not ranked as essential for          ences of the patient’s background, but they do not
                   their work as physician.                                  empathize with them.
                   In synthesis, discussion in the FGs revolved among        This might be described as a lack of ethnocultur-
                   three recurring themes:                                   al empathy, described by Rasoal at al. as “feeling,
                                                                             understanding and caring about what someone
                                                                             from another culture feels, understands and cares
                   LANGUAGE                                                  about” [15].
                   The junior doctors themselves saw language as the         Rasoal et al. suggest that ethnocultural obstacles
                   most important skill. Several participants thought        are the result of a lack of: knowledge about cul-
                   that not speaking other languages was an obstacle         tures, practical experience of being in other cul-
                   in the interaction with the patients. The language        tures other than their own, knowledge specific to
                   barrier is not only caused by patients not speaking       the other’s culture, experience specific to the oth-
                   Italian but also by the physicians not speaking other     er’s culture and the ability to see similarities and
                   languages but Italian.                                    differences between the culture of yourself and
                   An often recurring topic related to the language          that of others [15].
                   barrier was the establishment of the patient-phy-         At least two of the five obstacles for ethnocultural
                   sician relationship. Participants thought that es-        empathy might be recognized in, at least in some of
                   tablishing a good patient-physician relationship is       the FG participants.
                   important. However, the participants noted that           First of all the obstacle of lack of knowledge about
                   it is hard to establish a relationship with a patient     cultures seems to be present, since the results of
                   in the case of cultural or linguistic differences. Lin-   the FGs indicate a low level of cultural knowledge.
                   guistic problems make these relationships almost          The second possible obstacle is the lack of practical
                   impossible. To be emphatic may contribute to the          experience with other cultures. Some participants
                   establishment of the relationship, but this was seen      did not have any experience with patients from
                   by the participants as difficult when there is a lan-     ethnic groups and this might prevent them from
                   guage barrier. When the participants were asked           understanding and empathizing with patients with
                   how they were empathic some answered that they            a different background. This was partly recognized
                   could smile or try to use a holistic approach.            by the FG participants themselves, who mentioned
                                                                             that they should go more often abroad to come in
                                                                             contact with other cultures and languages.
                   EMPATHY
                   In addition, it’s a worth noting that when talking
                   about empathy, the recognition of emotions (e.g.          EDUCATION
                   pain, frustration, anxiety…) was barely mentioned,        The participants themselves had the opportunity to
                   which might suggest a lack of empathy in the ju-          prioritize their educational needs (Table 2). Nota-
                   nior doctors themselves. Participants seemed to           bly, together with PC, pain management and man-
                   give mainly answers from their own perspective            agement of psychological aspects of the patients
                   without reflecting on the situation of patients. They     were specifically regarded as necessary. This may
                   associated empathy with the fact of the absence of        reflect that scarce attention is paid to PC in current
                   patients’ family but not with their acknowledged          education. In contrast to the WHO definition, pain
                   emotions. Another example to underpin this ob-            management and care for psychological and spiritu-



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                                                                           Palliative care and cultural competency



It is recommended to
include in the medical curriculum, education on cultural competence to the following:
• Awareness of the influence of culture; on health outcomes, patient-physician relation and patient’s satisfaction.
• Awareness in future physicians that they might project their own culture on their patients, which may contribute
    to ambiguities in the delivery of care.
• Knowledge about physiological and physical differences in patients with different ethnic backgrounds to prevent
    under- or overuse of medication.
• To stimulate and encourage foreign exchanges to improve language skills and intercultural experience
to improve or include education on palliative care (with taking into account the cultural background of the
patient) with a focus on:
•   Awareness that PC is also part of the work in hospitals and not only of hospices and homecare.
•   Awareness that PC starts early in the stage of a life threatening disease and not only in the terminal phase.
•   PC as not only pain and symptom management but also includes psychological and spiritual support for patients
    and their families.
•   Communication skills, especially in breaking bad news.
•   To create awareness that patients with different cultural backgrounds have different needs in the end of life.
in education on PC and ethnic groups to:
Provide education in form of discussion groups and /or working groups
Provide education in form of simulations
To provide education on PC and ethnic groups in both undergraduates and graduated physicians

Table 3. Recommendations toward medical board


al aspects were not mentioned as a specific part of         tence, in form of medical knowledge and practical
PC [16]. Furthermore, PC was often seen as care in          skills, was prioritized over medical professional-
the end of life (terminal care), and associated with        ism values and skills. This is in line with this study
cancer and not with other life threatening diseases.        wherein technical medical competence was rat-
In addition many participants stated that PC is not         ed more important compared to communication
practiced in primary care, but is practiced only in         skills and empathy.
hospices and homecare.
The comment that PC is practiced mainly in hospic-
es and primary care is in contrast with the WHO             CONCLUSIONS
definition, which states that PC should be start-           We can conclude that the perceived main educa-
ed in an early stage of a life threatening disease          tional needs of the junior doctors can be identified
[16]. This definition implies that also in secondary        in cultural knowledge and language skills. Language
healthcare settings such as hospitals, PC should be         was prioritized because language barriers are an
provided. Therefore it is necessary to raise aware-         obstacle in communication with the patient. Beside
ness among physicians about the definition of PC to         these two needs, the junior doctors also expressed
start such care in an early phase of a disease, and         the need to have more education on PC, as well as
clarify why PC is not only something for hospices           on pain management, psychological support of the
and homecare.                                               patients and communication skills.
Besides PC and communication also the develop-              Despite the fact that the junior doctors regard
ment of empathy was considered an educational               knowledge about different cultures as useful but
requirement. This is in line with a questionnaire           not fundamental, education on this subject might
held on the University of Padua, Italy, among first,        be needed. Little awareness of the influence of dif-
fifth and sixth year’s medical students. In this            ferent cultural backgrounds and/or differences in
study students declared that medical professional-          physics and physiology might explain why the junior
ism values and skills (e.g. empathy, communication          doctors describe this subject as needed but not
etc.) were poorly taught [17]. However, compe-              fundamental. Cultural and religious knowledge was



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  tutor Volume 15, Numero 2, agosto 2015

                   seen as ‘good to have’ but not fundamental in order            [9]    Campinha-Bacote J. The process of cultural compe-
LAVORI ORIGINALI




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