In common with many industrialised developed nations, Australian society has become increasingly diverse with regard to the cultural background of its population. For example, in 2001, 87% of the population of England described themselves as White British. The minority ethnic population constituted 7·9% of the total UK population, a 53% increase since 1991 (ONS 2003). As a consequence, healthcare professionals require the skills to facilitate the provision of good quality care to patients of many cultural origins. This study by Huang et al. (2009b) reflects the current multicultural status of many Western societies, as a result of its exploration of the manner in which nurses provide care to a wide range of oncology patients.
Culture, as a concept, is generally ill defined, changeable and context dependent, and this may be a factor that has inhibited advances in research in this field. Huang et al. (2009a,b) manage to clarify the fundamental constituents of culture, hence providing a common understanding of the terminology as a solid foundation on which to base the findings of their study. The way an individual confronts his or her illness is dictated by previous experiences in conjunction with social norms, and so cultural variation tends to guide the actions of patients (Addington-Hall & Higginson 2001). Although healthcare professionals should be aware of the beliefs of those of different cultural orientations, there is, paradoxically, a risk of generalisation and stereotyping, resulting in the shifting of attention from the needs of the individual themselves. Culturally sensitive services that are shaped to suit the individual are required, and this individual approach to the provision of palliative care is paramount, focussing on the centrality of the patient and their family as a care unit (Abu-Saad 2001).
The aim of this study by Huang et al. (2009b) was to explore the social construction of cultural care provided by oncology nurses in Australia. The term ‘social construction’ has a wide variety of meanings, and without careful definition can lead to multiple interpretations. According to Mallon (2008), social constructionism is a sociological theory involving the control of certain objects by social or cultural factors (as opposed to natural factors). He states that research in this area is motivated by the aim to demonstrate that such objects are under societal control. Social construction is, therefore, a notion that a concept has been created by a particular social group (Mallon 2008). Huang et al. does not clearly define this concept in their study, and as a consequence there could be an element of uncertainty about what the study is aiming to achieve.
The role of the oncology nurse has evolved in line with the organisational and scientific progress that has occurred within the field of healthcare in developed countries. The role variously encompasses a wide range of responsibilities such as: patient assessment and education, symptom management, supportive care and the organisation of this care (Pollock et al. 2003). The title of the article by Huang et al. suggests that their study is concerned with oncology nurses’ approaches to accommodating cultural needs in palliative care. Attention is focussed entirely on the provision of palliative care to patients with a cancer diagnosis and, of course, nurses working in oncology settings are primarily caring for these patients. However, in common with many other studies, the authors assume a stance where palliative care is seen as synonymous with cancer care. One contemporary debate questions whether access to palliative care should be needs based or determined by diagnostic categories, acknowledging that palliative care should be extended to other non-malignant conditions (Addington-Hall & Higginson 2001, O’Leary et al. 2009).
Huang et al. use semi-structured interviews to obtain data from seven oncology nurses. This approach allows the interviewer to guide discussion towards certain themes of particular interest, whilst also providing the participant with the freedom to offer new perspectives (Field et al. 2001, Addington-Hall et al. 2007). Details of the methodology provided in the article by Huang et al. (2009a,b) are limited, though the authors do state that further information is available in an earlier publication. Also acknowledged by the authors was the limited timeframe in which the data were collected, which meant that the interaction of nurses with oncology patients could not be studied. Observational research would have allowed for the first-hand documentation of these interactions to understand fully the processes employed by oncology nurses in caring for patients from a range of cultural backgrounds. However, the extent to which the researcher integrates himself within the research environment must be considered, so as to enable an estimation of the researcher’s influence on the participants and findings in general (Field et al. 2001).
The lengthy process of qualitative research undoubtedly has an impact on sample size and data analysis. Huang et al. use a grounded theory approach to investigate the processes by which nurses provide nursing care to patients with a cancer diagnosis. The principles of theoretical sampling are usually employed in the grounded theory method, which requires that previous data collection influences subsequent methodological decisions, as opposed to the conventional linear approach of other sampling methods. Therefore, grounded theory suggests the progressive refinement of the research objectives throughout the course of data analysis. This method is extremely time-consuming, hence the necessity for small sample sizes (Addington-Hall et al. 2007). As noted previously, the majority of information about the methods used in this study is located in an earlier article, in which the authors claim that the sample size was based on themes emerging from the data collected. Huang et al. imply that, after conducting seven semi-structured interviews with oncology nurses, the fundamental themes had emerged, and saturation had been achieved. Later, the authors concede – within the limitations of the study – that saturation may not have occurred as a result of the small sample size and restricted timeframe (Huang et al. 2009a,b). Flaws in terms of the recruitment process may have contributed to the small sample size of participants involved in this study; however, information relating to recruitment is not provided.
In the findings, Huang et al. suggest that the prior experience of nurses contributes to the processes by which they accommodate the individual cultural needs of patients. However, this issue is a ‘double-edged sword’ in that, despite providing nurses with confidence in dealing with people from a range of cultural backgrounds; it may lead to the unintentional stereotyping of patients with similar characteristics. Nevertheless, the study does support the evidence that there is a positive association between staff education and their confidence and sensitivity in dealing with the cultural needs of patients. For example, a review by De Leon Siantz (2008) emphasises the need for the expansion of the nursing role as the cultural diversity of the North American population increases, so as to achieve cultural competence. In addition, Huang et al. (2009a,b) suggest that the organisational structure in a healthcare environment and lack of appropriate guidelines may act as a barrier to the provision of high-quality culture-based care. This study is important and relevant as it contributes to raising the profile of this issue in terms of clinical practice, policy development and staff education. In doing so, factors that may improve the healthcare delivery to patients from a diverse range of cultural backgrounds are identified.