Developing cultural competence in general practitioners: an integrative review of the literature

A narrative synthesis was chosen as the most appropriate method of knowledge synthesis as it enables the synthesis of a wide range of different research designs, including both qualitative and quantitative, in a systematic and robust way [19, 20]. It provides at minimum a structured and in depth summary of what is currently known about this topic in order to identify gaps in evidence and recommendations for trainers. It also seeks to further interpret the findings, including explanations and moderators of the findings [20].

We undertook the narrative synthesis according to guidance provided by Popay et al. [20]. We extracted data in narrative form from each article, including study type, participant population, research aims, findings and discussion points. This formed the preliminary synthesis. We then explored relationships in the data, including comparing research findings across multiple studies and developing themes. We finally assessed the robustness of the synthesis as a whole by critically reflecting on the quality and quantity of studies included, minimizing bias and assessing the strength of evidence upon which our conclusions are drawn. [20]. Thematic synthesis of the results and discussion sections of each article was performed to identify important themes across the studies [21]. QSR International’s NVivo 10 software was used to manage the data. Initially, line-by-line coding was performed, followed by the development of descriptive themes. These were then refined and incorporated into the final interpretation.

Each article was critically appraised using criteria for methodological rigor from the “Criteria Appraisal Skills Program (CASP) checklist” [23]. Articles rated as less rigorous were not excluded but their rigor was taken into account in the final analysis. For example, conclusions drawn from higher quality quantitative articles, such as systematic reviews, were prioritized over those from less rigorous evaluative and interventional studies, particularly if the evidence of effectiveness was conflicting. Qualitative articles that were of higher quality contributed more to the overall synthesis because they had more trustworthiness and transferability. With more details on context and more reflection, it allowed us to more confidently assess the importance of their findings. They also tended to contain more highly developed analyses within them. This was particularly important during exploration of relationships, comparing and contrasting data and developing themes across studies [21]. It was necessary to include them due to the broad focus of the review questions, the limited number of papers addressing this issue and the heterogeneity of the studies [20].

The principal researcher KW performed the preliminary selection of articles and synthesis and theme development. The final list of articles for inclusion along with excluded articles of borderline relevance was provided to research team members PA and JR and consensus on the final selection was reached. PA and JR separately reviewed 10 articles each to independently assess eligibility for inclusion in the review and extract themes for comparison with those found by KW. These articles were chosen by KW for independent review by team members based on being of key relevance and having higher complexity of themes. Relationships between study findings and themes were discussed at regular meetings throughout the course of the study amongst the research team members.

The literature search yielded 4641 titles. Figure 1 displays the article selection process in a PRISMA flow chart. 4462 articles were excluded on the basis of the title and a further 129 articles were excluded based on a review of the abstract (15) and full text (114). Fifty articles met the inclusion criteria and were included in the final analysis after members of the research team reached consensus.

The range of article types can be seen in Fig. 2. Qualitative and cross-sectional studies explored views of General Practitioners, GP registrars, patients, culturally diverse health workers, including interpreters and other health providers as well as medical educators and other stakeholders in clinical education such as program directors. Studies used various theoretical frameworks ranging from anthropological, psychological and sociological and behavioural science to linguistics and political science standpoints. Fourteen articles were either based in Australia or included Australian participants [4, 6, 11, 24‐34]. Eight of the Australian articles focused on cultural competence specific to Aboriginal and Torres Strait Islander health [24, 27, 29‐34]. Twenty-one articles were based in the US [2, 4‐6, 11, 35‐51] and the remaining articles were from other western countries such as Canada, UK, Sweden, Norway and the Netherlands. Qualitative articles were of good rigor, as were the systematic reviews and theoretical articles. Out of the interventional articles only one was randomized and used outcome measures that were standardized and previously validated [52]. Three studies were from grey literature (one PhD thesis and 2 evaluative reports). All studies were included in the final analysis and the assessments of rigor were taken into account. For example, if articles had conflicting data, both were taken into account, but more weight was given to the article assessed as being of higher rigor.

Central to culturally competent practice is the recognition and incorporation of the dynamics of culture effectively into effective health service delivery. Conceptualising individual elements of cultural competence, however, is complex and at times contentious. The majority of articles in this review conceptualized the elements of cultural competence as knowledge, awareness/attitudes and skills/behaviours and highlighted that aspects of all three areas need to be developed in General Practitioners and indeed all primary health care providers. The elements of cultural competence according to the synthesis are summarized in Fig. 3 and are discussed briefly below.

The ways in which the elements of cultural competence are developed in General Practice are highly varied and rigorous evaluation is generally lacking [2, 4, 11, 43].

Formal cultural competence training in General Practice appears to be underdeveloped and inconsistent, and the development of most aspects of cultural competence relies on informal learning, experiential and in-practice exposure [30, 36, 37, 40, 42, 56, 57]. Generally there is a lack of focus on cross-cultural issues within GP training with suggestions that time pressures, political will and competing priorities tend to restrict what GP registrars can learn [26, 27, 36, 37, 42, 56, 57]. GP registrars were found to generally desire more training and often viewed cross-cultural consultations as more stressful due to their perceived lack of confidence, knowledge and skills in this area [37, 56, 57, 63].

Exposure to cultural diversity during training and experience over time has been shown to be valuable in the development of cultural competency [30, 38, 40, 42, 44, 67] and are particularly relevant in the GP training setting. Development of cultural competence of both the individual and the practice or system can be a synergistic process [40] and exposure to diversity can act as a trigger and motivation for learning [36, 57]. Exposure to diversity alone without appropriate facilitation of learning and skills development, may lead to GP registrars developing ad hoc coping behaviours rather than cultural competence [7, 36]. There is also the risk of perpetuating existing barriers to patient care through modeling culturally incompetent attitudes, knowledge and skills of other staff or clinical supervisors [27, 57]. The amount of formal training appears to increase GP registrars’ preparedness and competence to provide cross-cultural care more so than having good role models or exposure to greater diversity cross-cultural case mix throughout training [35].

Integrating cultural competency with the wider curriculum is preferred by both GP registrars [30, 36, 56, 57] and medical educators [5, 32, 46, 50]. This, along with a longitudinal process of development, consolidates and gives more clinical relevance to learning, emphasises the necessity of developing cultural competency for good patient care, and reinforces cultural competency learning as a lifelong process [5, 46, 50, 56].

Interventional studies evaluating formal training in the form of standalone workshops have shown such training improves awareness, knowledge and skills of participants [4, 6, 11, 25, 43, 52, 67], and that this can improve patient satisfaction [11] and mutual understanding [67]. However there is limited research to suggest it improves patient health outcomes [4, 6, 11, 31, 43]. Formal workshops have the additional benefits of high participant satisfaction, efficacy for cost and time, and they can provide standardization of training amongst GP registrars, in a field where training environments can be very different [29, 30, 32]. There were no particular features of formal training programs (such as length of training, content and curriculum and types of training methods used) that were associated with better outcomes [4, 6, 11, 43]. It was recognized however that standalone workshops and the improvements in individual participant knowledge, awareness and skills would not necessarily result in long-term improvements in patient health without wider systemic and organizational changes and support [27, 32, 34, 64].

Types of training suggested by GP registrars included videotaped consultations, role plays and case discussions, community-oriented project work and lectures and training led by representatives from those cultures [36, 56, 57]. GP registrars also tended to desire more exposure to cross-cultural practice, more interpreters, and increasing diversity and awareness of faculty [36, 56, 57]. However GP registrars in one study were ambivalent about formal training because of a fear of that training resulting in increased stereotyping [36]. Cultural mentors and community members preferred informal settings and small group learning during training, as well as narrative and community site visits and cultural immersion [24].

The complexities of conceptualizing cultural competence make assessment of attitudes, knowledge and skills difficult [2, 7]. Instruments and measures of what constitutes cultural competence often make assumptions or reflect biases [7, 41, 46]. However, assessment of cultural competency amongst GP registrars can drive motivation to learn and can be reflective of a supportive educational environment [37, 57]. GP registrars tended to interpret the lack of assessment in this area to mean it was a low priority for learning [36, 37].

The importance of training evaluation cannot be understated, both in terms of ensuring quality and improvement of teaching practices and adding to evidence base [2, 4, 5, 46]. It has been noted that studies evaluating formal training interventions lack methodological rigour, do not adequately control for potential confounding variables (societal factors, external barriers), are difficult to generalize to other settings and tend not to assess patient perspectives or outcomes [4, 6, 11, 31, 43]. Most evaluation studies of educational interventions were process-oriented, although evaluation of complex behaviours must be multi-faceted [5]. Multiple confounders are often present and must be taken into account, such as other social and environmental determinants of health, access and other systemic barriers beyond the control of individual clinical interactions, and this makes evaluation even more difficult [4]. A proposed algorithm for evaluation of educational interventions on patient outcomes exists to incorporate this understanding [4].

The majority of interventional studies assessed standalone workshops led by trained medical educators [6, 11, 25, 28, 52, 67]. Experience and training specifically in cultural competence education was perceived to be required by educators given the complexity of the subject [29, 32, 33, 42, 52].

Cultural competency training is thought to risk perpetuating those myths, biases and stereotypes that exist within society already [34, 57], particularly if it is done without the direct input and guidance by the cultural group under consideration. Therefore the value of cultural mentors is recognised by patients, educators and GP registrars across many studies [27, 29, 30, 32, 33, 36, 40, 44, 57]. Cultural mentors are recognised as representatives from their community, able to share their expertise while facilitating partnerships with communities and health care providers [29, 32, 57]. Ensuring cultural mentors and other community members play a central role in training also respects community ownership of cultural knowledge [29, 34]. Currently GP registrar access to cultural mentoring is limited and needs to be expanded [30, 33].

Barriers to the involvement of community members in GP registrar training include having to manage negative attitudes of learners, conflicting family and community commitments, and lack of confidence and experience in training. There is however a desire within culturally diverse communities to engage in training with GP registrars and this should be supported [24, 27, 29, 33]. Having both a medical educator and community member present may improve engagement of GP registrars with the training session, by promoting its relevance and significance to clinical practice [29].

Staff diversity (including interpreters and allied health providers) within individual training practices has been shown to provide GP registrars with opportunities for cultural education [36, 40, 44, 53]. However, at times this may create a reliance on diverse staff to provide care for those patients, allowing other staff to avoid developing their own cultural competence [27, 57].

GP supervisors often functioned as role models [25] and access to good role models was associated with greater preparedness to provide cross-cultural care [35] although a lack of access to such role models was noted [36, 37, 57]. Supervisors reported that addressing cultural and communication issues was often difficult because of the risk of appearing to be racist [25]. They often felt ill equipped to address these issues [25]. Only one article was found specifically addressing GP supervisors and cultural competency, reflecting a paucity of evidence in this area.

The element of subjectivity during the synthesis process is a limitation, despite measures such as independent evaluation of articles, and constant clarification and discussion of themes with the research team.

Given the authors are based in Australia, a greater knowledge of Australian-based grey literature may have meant some international grey literature was missed. It is also difficult to confirm generalizability amongst the different studies as many were undertaken in different countries and involved differing GP training models. However, the workplace-based training model is common across the vast majority postgraduate medical training programs, where informal learning makes up a large component of General Practice training throughout rotations in both hospital specialties and in GP training practices [12, 14]. Multiculturalism and increasing patient diversity is a common development in General Practice internationally [65, 73].

Including all studies despite varying standards of rigour, including grey literature, was necessary in order to allow for a more comprehensive presentation on a topic with considerable heterogeneity in the literature but limited standardized evidence-based evaluations (61). Assessments of rigour were taken into account as part of the preliminary synthesis, which is one of the strengths of narrative synthesis [19].