Noura A. Abouammoh

Chapter 3

Literature review

3.0 Introduction

Having discussed the concept and models of cultural competence, it is important to understand if and how cultural competence is related to quality of care. This chapter begins by reviewing literature on the effectiveness of cultural competence training in terms of the provision of quality healthcare. The second section, ‘cultural similarities and workforce diversity’, presents the literature exploring the experiences of IMGs and the factors which influence their relationship with local patients to whom they provide health care. The final section reviews the Saudi-based literature with regards to cross-cultural care.

3.1 Search strategy for the literature reviews

Three separate searches were carried out for the three differing bodies of literature in this chapter and each is described below.

3.1.1 Cultural competence training and quality of care

To identify papers exploring the relationship between cultural competence and quality health care, an online search was conducted using MEDLINE/OVID, CINAHL and Web of Knowledge databases, published in English between 1946 and 2014, in addition to Google Scholar. The search terms included: cultural competence/training, intervention, education/ effectiveness, outcomes, satisfaction, communication and quality care. This search yielded 175 papers (see Appendix 1 for prisma chart). Studies conducted on the effectiveness of cultural competence interventions among health professionals, as well as students, were included, as the goal was to assess changes in culture-related knowledge and attitude, and the effect of these changes on patients. Studies focusing on patient-centred care with cultural competence components were also included. Papers were excluded if they discussed culturally competent health care systems or cultural competence in other fields, such as dentistry. Seven systematic reviews (Allen, 2010, Beach et al., 2005, Chipps et al., 2008, Henderson et al., 2011, Lie et al., 2011, Renzaho et al., 2013, Horvat et al., 2014) and one primary study (Carter et al., 2006) met the inclusion criteria. The reviews included studies from the US, Canada, UK, Australia, Finland and Switzerland (see section 3.2 below).

References and citations found in the reviews selected were also searched for relevant papers.

3.1.2 Cultural similarities and workforce diversity

To find studies published on IMGs’ experiences of communicating with local patients, an online search was conducted. MEDLINE/OVID, CINAHL and Web of Knowledge databases were searched, for articles published in English from 1946 to the present, along with Google Scholar for related papers. The search included the following key words: Immigrant, foreign, international, expatriate and overseas trained physicians/ experiences, challenges/ cultural competence. This search produced 798 papers of which 13 were included (see Appendix 2 for prisma chart), 10 qualitative and 3 quantitative (Searight and Gafford, 2006, Dahm, 2011, McDonnell and Usherwood, 2008, Jain and Krieger, 2011, Fiscella et al., 1997, Hall et al., 2004, Dorgan et al., 2009, Diaz and Hjorleifsson, 2011, Louis et al., 2010, Zeighami et al., 1978, Harding et al., 2010, McGrath et al., 2012, Slowther et al., 2012). Studies were included if they examined the experiences and challenges faced by IMGs and/or local patients at the interpersonal level, or if it appeared from the study’s abstract that challenges and/or facilitators to cross-cultural communication between IMGs and local patients were identified in a study as a secondary theme or outcome. Papers were excluded if they addressed cross-cultural communication in relation to academia and working environments. No systematic reviews were found. Reference lists and citations included in the related studies were screened for relevant papers.

The studies included came from the UK, Canada, US, Australia, Norway and Iran. For a better comprehension of IMGs’ experiences and the challenges they encountered, thematic synthesis was used to present the studies that were featured (Thomas and Harden, 2008). Themes emerging from the synthesis were cultural issues in the IMG-patient medical encounter, rapport and emotional support, patient-physician power dynamic, patients satisfaction and trust, prejudice towards IMGs and language barrier in the IMG-patient medical encounter (see section 3.3 below).

3.1.3 Cultural competence in SA

An online search using MIDLINE/OVID and Google Scholar was conducted to look for Saudi-based research with a focus on investigating cultural competence among IMGs from 1946 to the present. The search terms used included: Physician, doctors/expatriates, IMGs, overseas trained, immigrants, foreign, international/Saudi. The search yielded only 8 articles, none of which included IMGs. However, because the concept of care is shared between GPs and nurses, and almost all the studies focused on international nurses, it was decided to include Saudi-based studies that looked at international nurses caring for local patients.

Due to the limited amount of research regarding international health workers in SA, and the need to fully understand both the challenges and the facilitators experienced by them, all papers concerning international health workers were included, including review papers.

Four papers were included in the review. One was a qualitative study (Halligan, 2006) and three were review papers (Aldossary et al., 2008, Mutair et al., 2014, Luna, 1998). All the featured papers looked at international nurses in SA (see section 3.4 below).

3.2 The effectiveness of cultural competence training in terms of quality of care

As needs for culturally competent health care increase, attention has been focused on examining the effectiveness of physicians’ cultural competence in terms the quality of care delivered to patients. The first body of literature reviewed examined the effectiveness of cultural competence on the quality of care through intervention applications. Thus, the following section presents evidence on the effectiveness of these cultural competence interventions.