In all focus groups, there was lively discussion. Participants all agreed that social, cultural and linguistic diversity in patients creates many challenges that clinicians must be able to handle thanks to cross-cultural clinical education. Table 2 presents all the content categories and themes, grouped according to our research questions. Many categories were mentioned several times in the focus groups. The second column of Table 2 contains the number of hits (i.e. mentions) for each category.
Table 2
Categories of content of the focus-group transcripts
Goals and topics of training | hits |
BACKGROUND KNOWLEDGE : Introduction into culture and health Range of patients’ and relatives’ expectations/perceptions Basic information for clinical practice | 63 8 34 21 |
COMMUNICATION TOOLS/TECHNIQUES FOR PATIENT-CENTRED CARE : Investigating patient’s reality/projects/needs Handling inhibitions Interpreting forms of cultural expressions Managing tensions between patient and health care system Establishing rapport Displaying commitment in communication Embracing a human attitude (savoir-être) Overcoming language barriers Listening Negotiating institutional rules Managing non-verbal communication Explaining palliative care to culturally diverse patients | 48 16 6 4 4 2 2 2 2 1 1 1 1 |
COLLABORATION : Interprofessional collaboration Collaboration with relatives | 10 3 7 |
REFLECTION ON CULTURE AND VALUES : Cultural diversity among clinicians Self-reflection (impact of clinicians’ own culture and stereotypes) Tensions that result from cultural difference | 26 8 8 6 |
Organization of the training system | hits |
INTEGRATION OF TRANSCULTURAL TRAINING INTO EXISTING TRAINING PROGRAMS Undergraduate education Postgraduate education Interprofessional continuing education ● In palliative care ● In cross-cultural care | 43 14 9 20 16 4 |
INTERVENTION THROUGHOUT THE TRAINING CURRICULUM | 6 |
EXTENSIONS BEYOND SPECIALISED PALLIATIVE CARE Cross-cultural education for related medical fields Introduction on palliative care for interpreters and experts in cross-cultural care Cross-cultural education for non-specialized palliative care | 13 8 3 2 |
INTERPROFESSIONAL TRAINING (E.G. CONGRESSES, SYMPOSIA, SEMINARS) | 14 |
DIFFERENTIATION OF TRAINING ACCORDING TO DISCIPLINES | 9 |
RISKS Clinicians’ lack of time for continuing education Low motivation because of lack of time spent with patients Overfilled palliative care curricula Overfilled undergraduate medical curricula | 8 4 2 1 1 |
Teaching methods | hits |
FACE-TO-FACE THEORETICAL TEACHING (LECTURES) | 7 |
PRACTICAL TRAINING Workshops with case discussions Role plays Immersive experiences Comparative approaches of two cultures | 19 6 6 6 1 |
INTERPROFESSIONAL WORK EXPERIENCE | 4 |
COACHING Supervisions, colloquia Mentoring Exemplarity | 17 11 4 2 |
INDEPENDENT LEARNING | 2 |
TRAINING TOOLS Toolbox (leaflets, catalogues) Platforms health and spirituality’ Telecommunication tools E-learning platforms | 5 2 1 1 1 |
(Table 2 should be placed here)
What are the goals and topics for cross-cultural training in end-of-life care?
The participants’ discourse about the goals and topics of cross-cultural training was abundant and thematically rich. It covered four main areas: background knowledge, communication tools and techniques, ability to collaborate, and self-reflection.
Background knowledge:
According to participants, clinicians need to acquire a definition of culture as a multilayered, flexible construct that affects health and clinical interactions and is not limited to the situation of migrants. For example, clinicians and hospitals have a ‘culture’ as well. However, several participants were quick to emphasize the importance of culturally based religious and spiritual aspects in palliative care, which are particularly challenging for the field.
“There should be some elements about culture and society, and how [those] influences individuals from the moment they are born.” (FG2, P3)
Experts further suggested that, with such a comprehensive definition of culture, clinicians in cross-cultural training should be sensitised to the existence of a broad range of patients’ and relatives’ expectations and perceptions. In this context, this means emphasizing the tremendous diversity of ways to accompany dying persons and rituals around dying and death.
“It is not describing practices in each community that matters, but being aware of the « range of variation » (…) the diversity of expectations, the diversity of beliefs, or the diversity of values that can exist” (FG1, P3)
Many focus-group participants recommended the presentation of practical information as an additional aspect of the transfer of background knowledge. This encompasses the provision of lists of key informants and experts of cross-cultural issues, which palliative care clinicians can rely on. Several palliative care specialists also mentioned the possibility of presenting checklists of death-related rituals and information sheets on major approaches to death and dying by the religious and cultural groups that clinicians are likely to face. The frequent traumatic experiences of those who went through forced migration should also be tackled.
Communication tools and techniques for patient-centred care:
In all the focus groups, participants insisted that culturally sensitive care is, above all, patient-centred care. Some of the experts in cross-cultural and palliative care criticized checklist approaches as leading to the cultural stereotyping of patients. They would prefer that cross-cultural training focus on the acquisition of specific communication tools and techniques to support patient-centred care with a diverse population. These tools and techniques must be developed with a thorough investigation of patients’ individual realities, goals and needs.
“I think that when we go towards static packs of culture, we risk to fall into stereotypes. So to me, it is right from the start that the clinician must try to know the patient, and understands him as a unique character: what are his wishes? His will? But we must not in any way say that we ignore the culture of others, their habits and religious contexts.” (FG4, P5)
A few participants mentioned that asking questions is not always enough, and that clinicians need help in order to interpret correctly patients’ culturally based expressions of concerns and needs. Experts also mentioned that clinicians must learn how to overcome obstacles in clinical encounters related to inhibitions (e.g. taboo, intimacy) and tensions over institutional rules (e.g. permitted number of visitors). This topic was identified as closely connected to courses focused on rapport and commitment in care, which experts also recommended.
Collaboration:
Clinicians’ abilities to collaborate with other persons for the sake of patients’ care also received attention on the part of focus-group participants. They mostly mentioned a need for courses on collaboration with relatives in the context of potential ethical dilemmas about decision-making and disclosure. In contrast, only a few participants pointed to a need for education in interprofessional or interdisciplinary communication. A key message of participants was that clinicians should learn to identify situations that require the help of additional professionals who have a variety of backgrounds (e.g. spiritual leaders, medical anthropologists).
“First, we have to know that maybe in this kind of situation, we have to look for help” (FG1, P4)
Participants promoted collaboration with interpreters only twice. They did mention that because of the responsibility placed on interpreters with their translation of delicate information to patients and relatives, they should also have access to training about end-of-life health care issues.
“They help clinicians by giving cultural information, but they also need to receive training, because they are invested with a responsibility that is not without consequences” (FG3, P7)
Reflection on culture and values:
Numerous experts stated that cross-cultural training in palliative care must engage participants in reflective activities about their own cultural background and preconceptions, as well as any possible stereotypes they hold.
“It’s a kind of awareness of the values caregivers bring to the situation…institutional, professional, and personal. Because if we’re not aware of our own norms, expectations, values, etc, it’s a little difficult” (FG1, P4)
Such awareness is especially important in increasingly multiethnic and multilingual care teams. The diversity of values in these teams is at once a source of potential tension and a significant resource.
How can the organization of the current training system be improved?
All the experts agreed on the need to insert cross-cultural content into already existing training courses on larger topics whenever possible, to avoid any unnecessary redundancy across multiple training offerings. Aspects of cross-cultural competence and sensitivity should be distributed throughout curricula (e.g. undergraduate, postgraduate, continuing education) of all kinds for professionals working in palliative care. Fundamentals of cross-cultural education could be taught at the undergraduate level, whereas specific content related to diversity at the end of life could be introduced at later stages.
With regard to our research focus on specialised palliative care, many participants stressed the importance of organising cross-cultural training in a way that expands beyond the limits of this narrow field. They referred to general palliative care (i.e. carried out by family doctors, homecare nurses, etc.), and also to clinicians from other medical fields caring for end-of-life patients. As an additional suggestion, they promoted the introduction of end-of-life care into curricula for community interpreters and cross-cultural care experts (e.g. chaplains and spiritual leaders or directors, medical anthropologists).
“We (palliative care unit) have our 2 days and a half of introduction into palliative care, I think we should implement something about culture there, and you (talking to an expert in cross-cultural care) could implement something about palliative care in your course, and eventually that’s how we can meet each other.” (FG1, P1)
Courses in cross-cultural competence and sensitivity for clinicians specialising in palliative care should involve a wide variety of professions whenever possible. In order to support and encourage professional diversity, several interviewees reported a need for events such as congresses, symposia and seminars that focused on culture, language and care. However, there are also aspects of competence and sensitivity that are particularly important for a specific profession, such as doctors having to break bad news to patients. These can be included in profession-specific curricula or into events for specific professions.
According to our focus groups, in practice, implementing cross-cultural courses may be difficult. The main obstacles reported were overfilled schedules in medical schools and in palliative care curricula. Some clinicians, mainly doctors, may also lack the time to join multidisciplinary training events.
"Theoretically these continuing training courses are for everyone and then we see that doctors do not come” (FG1, P4)
As some experts stated, working conditions in palliative care may also hamper clinicians’ motivation for cross-cultural courses: when clinicians already lack the time requested of them to provide genuinely patient-centred care in their everyday practice (e.g. because of late referrals to palliative care), they do not see the point of attending such trainings.
Which teaching methods should be applied?
As far as teaching methods are concerned, they are closely related with the main training goals mentioned earlier. Focus-group participants suggested face-to-face teaching for the transmission of basic knowledge on culture and clinical practice with migrants.
“I think it’s important to [include] courses, to give basic knowledge of cross-cultural concepts” (FG3, P6)
For the acquisition of patient-centred communication techniques, self-reflection and collaborative skills, they suggested methods such as workshops with case-study discussions, role plays and immersive experiences (ex. visit to residences of individuals seeking asylum).
The focus groups also brought to light a few quite original didactic approaches, in particular several forms of coaching by expert professionals. These included supervision and colloquia, but also one-to-one mentoring by an experienced colleague.
One idea is coaching for other professionals. For me coaching is a really interesting pedagogical method. (FG2, P1)
An additional suggestion was to provide resources for clinicians who are eager to acquire knowledge independently, such as leaflets, catalogues and online tools.