title: Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study.
abstract: BACKGROUND
  While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on "cultural competence," remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.
  
  
  RESULTS
  We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.
  
  
  CONCLUSIONS
  This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.
authors.affiliation: Division of Primary Care, University of Nottingham Graduate Medical School, United Kingdom. joe.kai@nottingham.ac.uk
authors.forename: Joe
authors.initials: J
authors.lastname: Kai
authors.forename: Jackie
authors.initials: J
authors.lastname: Beavan
authors.forename: Christina
authors.initials: C
authors.lastname: Faull
authors.forename: Lynne
authors.initials: L
authors.lastname: Dodson
authors.forename: Paramjit
authors.initials: P
authors.lastname: Gill
authors.forename: Angela
authors.initials: A
authors.lastname: Beighton
mesh_terms: D000328:Adult; D000368:Aged; D001007:Anxiety / Q000523:psychology*; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D018864:Cultural Diversity; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011209:Power, Psychological; D036301:Qualitative Research; D011787:Quality of Health Care; D013240:Stereotyping; D006113:United Kingdom