In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.
Based on findings from an ethnographic study, this paper explores the sociopolitical context of nurses' encounters with First Nations women in a Western Canadian hospital. Data were collected using in-depth interviews and participant observation of clinical encounters involving nurses and First Nations women who were in-patients in the hospital. Four themes in the data are discussed: relating across presumed "cultural differences"; constructing the Other; assumptions influencing clinical practice; and responding to routine patient requests. The findings illustrate how discourses and assumptions about Aboriginal people, culture, and presumed differences can become interwoven into routine clinical encounters. These results highlight the importance of analyzing health-care encounters in light of the wider sociopolitical and historical forces that give rise to racialization, culturalism and Othering, and underscore the need for critical awareness of these issues among nurses and other heath-care providers.
International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations.
The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments.
Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions.
These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.
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Despite a growing body of critical scholarship in nursing, the concept of culture continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care. In this paper, we take a critical look at how assumptions and ideas underpinning conceptualizations of culture and cultural sensitivity can influence nurses' perceptions of Aboriginal peoples and Aboriginal health. Drawing on examples from our research, we examine how popularized assumptions about culture can shape nurses' views of Aboriginal patients. These assumptions and perceptions require closer scrutiny because of their potential to influence nurses' practice with Aboriginal patients. Our specific aims are to: (a) consider some of the limitations of cultural sensitivity in relation to health care involving Aboriginal peoples; (b) explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and (c) explore the relevance of a 'critical cultural approach' in extending our understanding of culture in relation to Aboriginal peoples' health. We discuss a critical cultural perspective as one way of broadening nurses' understandings about the complexities of culture and the many facets of culture that require critical consideration. In relation to Aboriginal health, this will require nurses to develop greater critical awareness of culture as a relational process, and as necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which we live.
Knowledge translation has been widely taken up as an innovative process to facilitate the uptake of research-derived knowledge into health care services. Drawing on a recent research project, we engage in a philosophic examination of how knowledge translation might serve as vehicle for the transfer of critically oriented knowledge regarding social justice, health inequities, and cultural safety into clinical practice. Through an explication of what might be considered disparate traditions (those of critical inquiry and knowledge translation), we identify compatibilities and discrepancies both within the critical tradition, and between critical inquiry and knowledge translation. The ontological and epistemological origins of the knowledge to be translated carry implications for the synthesis and translation phases of knowledge translation. In our case, the studies we synthesized were informed by various critical perspectives and hence we needed to reconcile differences that exist within the critical tradition. A review of the history of critical inquiry served to articulate the nature of these differences while identifying common purposes around which to strategically coalesce. Other challenges arise when knowledge translation and critical inquiry are brought together. Critique is one of the hallmark methods of critical inquiry and, yet, the engagement required for knowledge translation between researchers and health care administrators, practitioners, and other stakeholders makes an antagonistic stance of critique problematic. While knowledge translation offers expanded views of evidence and the complex processes of knowledge exchange, we have been alerted to the continual pull toward epistemologies and methods reminiscent of the positivist paradigm by their instrumental views of knowledge and assumptions of objectivity and political neutrality. These types of tensions have been productive for us as a research team in prompting a critical reconceptualization of knowledge translation.
Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge-translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge-translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of 'culture', 'safety', and 'cultural safety' need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge-translation process is a 'social justice curriculum for practice' that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.
This study explores the social and professional discourses that influence nurses' knowledge and assumptions about First Nations patients. Through the use of an ethnographic design, in-depth interviewing, and participant observation, data were collected over a 9-month period of immersion in a midsized hospital located in western Canada. Purposive sampling was used to recruit 35 participants: nurses, First Nations women who were patients in the hospital, and key informants with expertise in Aboriginal health. The findings indicate that 3 overlapping discourses were shaping nurses' perspectives concerning the First Nations women they encountered: discourses about culture, professional discourses of egalitarianism, and popularized discourses about Aboriginal peoples. Cultural assumptions were intertwined with dominant social stereotypes and were sometimes expressed as fact even when they conflicted with egalitarian ideals. Conclusions highlight the need for strategies to help nurses think more critically about their understandings of culture, the sociopolitical context of health-care encounters, and the wider social discourses that influence the perspectives of nurses.
ReprintIn: Can J Nurs Res. 2009 Mar;41(1):166-9119485051
Patient-centred care emerged in the late 1960s as a framework to guide providers and decision-makers towards the provision of more effective health care and better outcomes. An important body of literature has since emerged, reporting mixed results in terms of outcomes. To date, assessments of the effectiveness of patient-centred approaches have focused one-on-one consultations. The purpose of this article is to explore dimensions identified as key in the patient-centred literature in the context of primary health care services delivered in a group setting. Group Medical Visits (GMVs) offer a novel format for the delivery of patient-centred primary health care services, especially for patients living with complex morbidities.
Drawing on a large study of GMVs, we report on key format and process-oriented elements identified in GMVs, and on their link to improved outcomes. For the purpose of this study, we interviewed 34 providers and 29 patients who have been engaged in GMVs, delivered in rural, northern and First Nation communities in British Columbia, Canada.
Our analysis shows that the delivery of PHC in a group format results in a shift in the role of the provider, from that of an adjudicator involved in imparting norms of self-care, to that of a facilitator who assists the group in defining norms of self-care that are based on medical knowledge but also on the broader context of patients' lived experience and on their pragmatic experience. In a group process, peer-patients take on the role of promoting these norms to other patients. This results in a significant shift in the role of the provider, increased trust, increased knowledge for the providers and the patients and better patient self-management. Our results also show increase satisfaction for patients and providers.
GMVs offer an alternative format for the provision of PHC that brings together the benefit of a group process and of a clinical encounter. This format can successfully deliver on the promises of patient-centred care.
Although ethnicity data are collected in most countries at the population level, it has become more common to collect such data in healthcare settings, partially in response to growing health and social inequities worldwide. However, the implications of doing so have not been studied. This two-year study was designed to critically examine the implications of collecting ethnicity data in healthcare settings. Using a critical ethnographic approach, we interviewed 104 patients, community and healthcare leaders, and healthcare workers within diverse clinical contexts in a large city in Western Canada in 2006-2007. This paper presents an interpretive thematic analysis, using an ethical lens, of the harms and benefits associated with the process of data collection in a clinical context. While most leaders and healthcare workers and some patients envisioned potential benefits associated with having ethnicity data, these benefits were seen as largely contingent upon action being taken to ameliorate inequities. Overwhelmingly, however, leaders from ethno-cultural communities and patients of diverse identities anticipated potential harm arising both from having ethnicity data and the process of collection. The analysis illustrates that in today's sociopolitical context, collecting ethnicity data in clinical contexts may engender considerable harm, particularly for racialized, vulnerable patients. If ethnicity data are currently collected at the population level, evidence of benefit is required before proceeding to collect these data at the point of care.