1. Stabilising uncertain ground: the
work of health professionals across
cultures
BSA North East Medical Sociology Group Inaugural Event
Thursday 8th March 2012
fiona.cuthill@sunderland.ac.uk

3. Ahmad and Bradby (2007) – have critiqued
the tendency of medicine to pathologise
minority cultures, where cultural ‘traits’
become synonymous with disease
processes.

4. Culturalist educational approaches
dominate health care education
Learning about cultural difference:
• Cultural knowledge
• Cultural skills
• Cultural sensitivity
• Cultural awareness (Papadoloulos, 2006; Dogra,
2007).

6. The cultural ‘other’?
• Said (1979) – Otherization
• Bauman (2010) – liquid modernity
• Nayak (2009) – post ‘race’
• EMINEM and Indian tapas – cultural hybridization
• Culley (2007) – challenges essentialism in health care
education and discourse.

7. Homi Bhabha (1994) – ‘Third-space’: new spaces
emerge where communication and
negotiation happens
Cultural hybridization refers to ‘the ways in
which forms become separated from existing
practices and recombine with new forms in
new practices’(Pieterse, 2004, p.64).

8. The account of a young schoolgirl born in the city of Bradford in the north of
England. Her parents had migrated from the district of Kashmir in
Pakistan. One day she was asked to define her identity, by a researcher,
and she answered:
When I am standing in the school playground with my
English friends, I am Black. When an African
Caribbean girl joins our group, I become Asian. When
another Asian girl comes in, I think of myself as a
Pakistani and a Muslim. When a Pakistani friend joins
us, I become a Kashmiri, and when another Kashmiri
girl turns up, I become a Bradford schoolgirl again
(Soni, 2011).

9. ‘Race’, ethnicity and culture as identity
• Hall (2001) and Solomos (2000) – identity,
belonging, oppression, resistance and
strength
‘Contemporary notions of ethnicity show it as a
marker of identity, a vehicle for community
mobilisation and a possible indicator of
disadvantage, discrimination or privilege’
Ahmad and Bradby(2007, p.230)

10. Although the migration of
people in search of peace,
security and prosperity is
nothing new, over the last
two decades immigration has taken on a new
and unprecidented political and social
significance (Castles and Miller, 1998; Castles,
2010)

11. Cross cultural work framed as ‘intercultural
communication’
• Framed as ‘communicating with strangers’ (Gudykunst
and Kim, 2003)
• Humanist philosophy of individualised nursing care
• bell hooks (1989) – post colonial lives are shaped by
slavery, imperialism and social disadvantage
• Patricia Hill-Collins – intersectionality (‘race’, gender and
class).

12. Research aim
The aim of this study was to explore with health
professionals their experiences of working with
clients who are from cultures different to their
own.

13. Kathy Charmaz (2006) describes
theorising as ‘stopping, pondering, and
rethinking anew. We stop the flow of
studied experience and take it apart’
(p.135).

14. Research questions:
1. What are the most important issues health
visitors express, when considering their work
with clients who are from cultures different to
their own?
2. What concerns do health visitors experience
when they are working with clients who are
from a culture different to their own?

15. Methodology
• Grounded Theory – social constructionist
approach
• Inductive
• Development of new epistemological
perspectives (Clarke, 2005; Charmaz, 2006;
Corbin and Strauss, 2008)
• Social constructionist approach was used
across all areas of the research process, from
data analysis to conceptual development.

16. Study sample
• Initially purposeful sample and theoretical sampling
thereafter, in line with Grounded Theory methodology.
• Ethical approval granted from the NHS ethics committee and
Primary Care Trusts.
• All names were changed to maintain confidentiality.
• Participants invited via a ‘cascade’ letter of invitation from
PCT line managers.
• All health visitors were white, female and between the ages
of 35-60 years old.
• 19 participants described themselves as British, 1 as half-
German and 1 as half-Swedish.
• All interviews took place at a GP surgery or health centre,
except one which was at home.
• All interviews lasted 30-90 minutes and were recorded and
subsequently transcribed verbatim.

17. Data analysis
• Data analysed in accordance with Grounded Theory
methodology.
• Raw chunks of data were ‘coded’.
• Constant comparison of the codes led to open, axial and
selective coding.
• Theoretical generation then began using abstract selective
codes.
• Development of final conceptual theory.

18. Analytical tools
• Research diaries
• Theoretical memos
• Situational, positional and social world
mapping (Clarke, 2008).

19. Findings
When health visitors talk about their work with people
from cultures they identify as different to their own,
they understand it as:
‘Stabilising uncertain terrain’

20. Metaphorical cross cultural terrain
• Metaphorically the health visitors described working
across cultures as working in ‘cross cultural terrain’.
• This ‘cross cultural terrain’ was described as
‘common ground’ and somewhere to ‘meet in the
middle’.
• It was a place of anxiety, uncertainty and instability.

21. Rebecca
Fiona: What do you think are the best things about
working with people from other cultures?
Rebecca: (Pause) I think it is always fascinating to see
how they perceive us and they think what we do is
wrong and what they do is right and it is about trying
to find a common ground that we can both agree on,
because some of their things are so extreme and
some of ours are so extreme and it is about trying to
find a common ground that we can work on really.

23. Jane
I was scared to offend ... the blurb tells you if
you see a load of shoes by the door then take
your shoes off but you know what you will find is
that clients that you are going to see, that they
are absolutely adamant that you keep your
shoes on almost as if they are afraid of causing
offence. It is as if you are not prepared to meet
them half way or to acknowledge their custom
[sic].

24. Beth
I think I was very keen to learn about different cultures
but also a bit intimidated as well and a bit scared. In
hospital, it is very much in your comfort zone and they
are out of their comfort zone but in the home it is a
complete reversal when you are visiting them, and you
think I don’t understand what is going on here and you
would ask but then some are better than others at
explaining it, so it is more about understanding what is
normal for them and then, em, where we need to cross
our paths a little bit

25. Managing emotions
• All of the health visitors were influenced by their
emotions in cross cultural work
• The emotion most frequently identified was anxiety
(19 out of 21 participants)
• The ways in which the health visitors managed their
emotions had a direct impact on their practice.

26. Working across cultures involves:
• Entering ‘cross cultural terrain’.
• ‘Cross cultural terrain’ can be dangerous political
terrain and is built on socio-historical processes.
• Easy to cause offence in ‘cross cultural terrain’ and
working across cultures is often shaped by anxiety.

27. Susan
Susan: In fact, when I worked in that area, I felt
there was so much that I didn’t know, such as
taking your shoes off in the house and I was
always afraid of offending them….that is another
thing, I would be worried I offended people if I
didn’t accept their hospitality.

28. Rebecca
I worry, I would hate to offend and not to know
that I have done it and walk out, them thinking ‘I
don’t want her back in’ that would really offend
me. In some houses I worry about, I am careful
what I say [sic].

29. Emma
In this particular household I am very, very
careful and this sounds very cynical but I feel as
if I have protected my back by everybody
ensuring the CAF form went in to make sure
there wasn’t anything available because I didn’t
want to be called racist for not giving care [sic].
(Emma)

30. Annette
Of all of the areas I have worked, latterly at (this
town) it was predominantly a, em (pause) em a
white ethnic background, there were very few
families who were from, em (pause) em, other
countries, em, I would say in (this town) some of
the extended families were really settled, really
integrated into the community [sic].

31. Cross cultural terrain
• Uncertain ground
• Negotiated ground
• Politicised ground
• Active client
resistance
• Out of competence
zone
• Not having the
language to use

32. Strategies identified to stabilise uncertain
cultural terrain:
1. Fixing a culture: unchanging throughout time
2. Re-writing an equality agenda: the same
throughout time
3. Asserting a professional identity: undermined over
time
4. Developing a toolkit: strengthened over time.

33. Emotions and cross cultural work
• Cross cultural work does not occur in a political
vacuum
• Cross cultural work is not merely about
‘communicating with strangers’ (Gudykunst and Kim,
2003)
• Cross cultural work can be anxiety inducing,
uncertain and can feel like working on unstable
ground.

34. Managing emotions is an important
part of cross cultural working
• Managing uncertainty and anxiety
• Stabilising uncertain terrain can be dangerous work
in the cross cultural context
• In a health care environment of ‘clinical competency’
and ‘fitness to practice’, uncertainty is often hidden.

35. Emotional engagement in nursing
discourse
• Arlie Hochschild (1983) – emotion work
• Nicky James (1989) – giving of oneself
• Pam Smith (1992) – emotional labour
• Sharon Bolton (2001) – ‘presenting an
acceptable face’

36. Emotions and ‘race’
• Gunaratnam and Lewis (2001) –racialising emotional
labour and emotionalising racialised labour
• Stilos (2006) – calls for nursing practice to build
comfort with ambiguity
• Kai et al (2007) – found that professional uncertainty
in working with patients of differing ethnicity was
characterised by stress and anxiety, and led to
inertia in their clinical approach.

37. Implications for education,
practice and theory:
• Emotion is a powerful driver in shaping practice for health visitors, as they
seek to engage with their clients across culture
• Cross cultural work can be shaped by anxiety, uncertainty and fear
• Uncertainty should be acknowledged within health care discourses
• Challenge the notion of ‘competency’ in cultural education
• Managing emotions, especially uncertainty, anxiety and fear should be a
core part of cultural education
• Theoretically the relationship between emotions and ‘race’, culture and
ethnicity is under-developed.

38. Thank you
Any questions….?

39. References
Ahmad, W.I.A and Bradby, H. (2007) Locating ethnicity and health: exploring concepts and contexts, Sociology of Health and
Illness, 29(6), p. 795-810.
Bauman, Z. (2005) Liquid Life. Cambridge: Polity Press.
Bhaba, H. (1990) The third space. In Rutherford, J. (ed.) Identity, community, culture, difference. London: Lawrence and
Wishart.
Bolton, S. (2001) Changing faces: nurses as emotional jugglers, Sociology of Health and Illness, 23(1), p. 85-100.
Castles, S. (2010) Understanding global migration: a social transformation perspective, Journal of Ethnic and Migration
Studies, 36(10), p. 1565-1586.
Culley, L. (2006) Transcending transculturalism: race, ethnicity and health care, Nursing Inquiry, 13(2), p.144-153.
Gunaratnam, Y. and Lewis, G. (2001) Racialising emotional laour and emotionalising racialised labour: anger, fear and shame
in social welfare, Journal of Social Work Practice, 15(2), p.131-148.
Hall, S. (2000) Who needs identity? In Gray, P., Evans, J. and Redman, P. (eds.) Identity: a reader. London: Sage Publications,
p. 15-30.
hooks, b. (1989) Talking back, thinking back. Thinking black.
Boston, MA: South End Press.
Hochschild, A.R. (1983) The managed heart: the commercialization of human feeling. Berkeley, California: University of
California Press.