Scandinavian Journal of Public Health, 2005; 33: 360–369
ORIGINAL ARTICLE
Role dilemmas among health-workers in cross-cultural patient
encounters around dietary advice
RØNNAUG AA. FAGERLI1, MARIANNE E. LIEN2, GRETE S. BOTTEN3 &
MARGARETA WANDEL1
1
Department of Nutrition, Institute for Basic Medical Sciences, 2Department of Social Anthropology, and 3Department of
Health Management and Health Economics, University of Oslo, Norway
Abstract
Aim: The aim of this paper is to explore Norwegian health workers’ experiences from cross-cultural patient encounters, and
how they understand and enact their role when meeting patients with Pakistani background to whom they give dietary
advice related to type 2 diabetes. Methods: Qualitative in-depth interviews have been performed with six hospital dietitians
and six general practitioners in Oslo. Results: The health workers consider themselves to be patient-centred and stress the
importance of the two dimensions, empathy and equality. However, they often experience that patients want them to be more
authoritarian, a way of acting that would be totally in disagreement with their convictions, although some occasionally do
adopt an authoritarian style. More striking is that some health workers’ moral engagement to involve and empower patients
actually leads them to be authoritarian. For others, a fear of insulting the patient results in their advice being too diffuse.
Conclusions: A possible explanation for such ways of responding to the patient may be that the health workers, in their
articulation of patient-centredness, draw on a repertoire of social conduct that involves an effort to level out, or tacitly deny,
hierarchic structures, and that this becomes more pronounced in cross-cultural encounters. Patient-centredness and
empowerment are results of long ongoing processes in Western countries, based on ideals of equality and individual
freedom. The results from this study indicate that these approaches may pose intricate dilemmas for the health workers in
their cross-cultural encounters, and need further attention.
Key Words: Cross-cultural encounter, diabetes, dietary advice, minority patients, patient-centredness, physician–patient
relationship
Background
During the second half of the twentieth century there
was a gradual shift within Western medicine from a
paternalistic relationship between the health worker
and the patient to a more patient-centred one. The
paternalistic relationship is characterized by one-way
communication, where the health worker gives
instructions for management to the patient who listens
and obeys in a childish-dependent manner [1]. The
definition of patient-centredness includes notions of a
holistic approach where the patient is in focus, and
where cooperation between the health worker and the
autonomous and responsible patient is the ideal [2–4].
Closely related to these ideas is the concept of
empowerment, which implies stimulating patients to
take control over the factors influencing the possibilities for a positive change in their lives [5].
Extensive criticism of Western medicine has contributed to this shift [6–8]. This shift was mainly
concerned with the cultural construction of sickness as
it diverges between laypeople and physicians [8].
Concomitantly, general changes have occurred in
Western societies during the last few decades, involving increased emphasis on individual autonomy, the
rise of consumerism, and a growing mistrust in relation
to scientific expertise [9]. These changes are also
expressed within healthcare. Health workers have
Correspondence: Rønnaug Aarflot Fagerli, Department of Nutrition, Institute for Basic Medical Sciences, University of Oslo, Box 1046 Blindern, 0316 Oslo,
Norway. Tel: +47 22 85 13 32. Fax: +47 85 15 32. E-mail:
[email protected]
(Accepted 9 November 2004)
ISSN 1403-4948 print/ISSN 1651-1905 online/05/050360-10 # 2005 Taylor & Francis
DOI: 10.1080/14034940510005888
Role dilemmas in cross-cultural patient encounters
become subject to public critique, medical experts’
authority is challenged, and the health workers have
become more aware of their approaches and rolemodels (e.g. paternalistic/authoritarian vs. patientcentred) applied in patient encounters [8].
In Scandinavian countries there is, in addition, a
strong egalitarian ethos [10]. This involves an
idealized image of cultural homogeneity, attempts
to avoid asymmetrical relations in personal encounters, and ambiguity in relation to, or even tacit denial
of, hierarchic structures [11]. This may influence
Norwegian health workers’ interpretation of the
concept of patient-centredness and their subsequent
role enactment.
Underlying the concept of patient-centredness is
an acknowledgement that patient satisfaction, compliance, and health outcome may be influenced by
the relationship between the health worker and the
patient [4]. This relationship is in turn influenced by
the demographic, social, and cultural characteristics
of both sides, and the ability to communicate across
possible differences. The significance of these
aspects is most obvious when the experience of
social and cultural differences is strong. Unless made
explicit and purposefully managed, such differences
can impede communication, and may thereby
complicate the health workers’ attempt to establish
mutual understanding and cooperation with the
patient. The challenges in cross-cultural encounters
have been studied from different angles. In addition
to the research on cultural construction of illness and
of ethnic minorities’ experiences with the health
system, there are some studies (mostly American but
also European) that focus on the competence of
health workers in multi-ethnic societies [6,12–16].
However, there is a need for more research on health
workers’ experiences, as well as interpretations of,
and attitudes towards their role enactment in the
encounter with minority patients.
Aim
This article is part of a larger study involving both
health workers and their patients of Pakistani
descent. Here we focus on the health workers,
whereas data from the patients will be published
later. The aim is to explore general practitioners’ and
hospital dietitians’ own experiences, and how they
understand and enact their role in cross-cultural
patient encounters. We study this more narrowly
within the context of giving dietary advice to patients
with type 2 diabetes. What does patient-centredness
mean to Norwegian health workers? How do
the health workers’ own views and preferences
361
correspond to what they experience that ethnic
minority patients (in this case Pakistani-born) want
from them? How do they interpret their own
achievements when communicating about food,
food habits, and diabetes?
Material and method
Setting
The overall study encompasses qualitative in-depth
interviews based on semi-structured interview
guides, with 12 health workers (HW) and 15 of
their Pakistani-born patients with type 2 diabetes. In
Norway, persons of Pakistani background represent
the largest group of immigrants from the Third
World. Most originate from rural areas of Punjab
and most live in Oslo. The prevalence of type 2
diabetes is high in this group compared with the
native population, and they are therefore perceived
to represent an increasing challenge to the health
system as the Pakistani population is getting older
[17]. The majority of immigrants of Pakistani
background in Norway have a low level of education
and work within low-income occupations [18].
In this paper we present and discuss issues
emerging from the health worker interviews.
General practitioners and dietitians are chosen as
both groups are involved in giving dietary advice to
persons with type 2 diabetes but they will not be
subject to comparison.
Participants
The
study
participants
were
purposefully
sampled according to the following inclusion criteria:
(1) health workers in immigrant dense city-districts of
Oslo, Norway; (2) professional education in Norway;
and (3) experience of giving dietary advice to persons
with Pakistani background suffering from type 2
diabetes. Invitations (postal first, and then reminders
by phone) were sent to all medical doctors (n532; 17
women and 15 men) at all (9) general practices in two
districts of Oslo, and the dietitians who were involved
in diabetes management (n56 women) at the local
hospitals to which patients from these districts are
referred. All the dietitians and six GPs responded and
were enrolled in the study. Two male GPs first
accepted to participate but later cancelled the
appointment because of lack of time. Thus all
participants were women. Their ages ranged from 30
to 64; geographically they represented the districts
addressed and they all considered their experience in
giving dietary advice to this group of patients to match
the aims of this study.
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R. A. Fagerli et al.
Interviews
The interviews (lasting from 45 to 180 minutes)
were carried out from 2000 to 2002 and took place
in the health worker’s office. They were structured
around the following themes: practical aspects of
encounters with Pakistani-born patients; expectations regarding this group of patients when discussing diet and dietary changes; feelings about how they
succeed in communicating their message to these
patients; and their knowledge of food culture and
health perceptions of this patient group. The
interviewer (first author/PhD student in nutrition)
followed the interview guide loosely, encouraging the
health workers to elaborate freely on their concerns
and experiences. Therefore more general thoughts
and concerns regarding their choice of role models for
their work were also integrated in the interviews.
Analysis
All interviews were audiotaped, supported by field
notes, and successively transcribed verbatim by the
researcher, thus letting the data inform the subsequent interviews. The analysis, carried out by the
first author, was informed by the principles of
Giorgi’s phenomenologically inspired method [19]
as described by Kvale [20]: (a) reading all the
material to obtain an overall impression; (b)
identifying meaning units representing different
aspects of the health workers’ experiences and
coding for these; (c) abstracting the contents of
individual meaning units, before (d) interrogating
the meaning units in terms of the specific purpose of
this article in order to (e) generalize descriptions
reflecting the most important experiences related to
the giving of dietary advice to this group of patients.
The focus was to explore both common traits and
variation in the health workers’ narratives, searching
also for deviating cases in order to gain a richer and
more complete description of the material. Text,
analysis, and findings were discussed successively
with the other authors. While analysing the data, the
first author checked her understanding of aspects
concerning how the health workers experienced the
patients’ expectations of them in informal discussions with some of the participating health workers.
Ethics
Approval from the Medical Ethic Committee and
the Data Inspectorate was obtained. Written information on the topic of the study, anonymity,
voluntary participation, and the approval mentioned
above was sent with the invitation and was repeated
verbally prior to the interview. Written informed
consent was obtained from all health workers.
Results
Contradictory demands on the health workers
In line with the norms for good patient treatment,
the health workers initially presented themselves as
patient-centred and disagreed openly, some at the
limit of being offended, when they were confronted
with a postulation that ‘‘some health workers think
that taking a paternalistic role towards these patients
is best’’. However, they feel ‘‘what they have learned
about patient treatment’’ to be contradictory to their
experience of what the patients in general want from
them, and there were considerable variations in their
accounts of how they structure the patient encounter
and also of what they end up doing in practice.
In the following we shall elaborate on these
various aspects of role enactment that were important for the health workers. Quotations are presented
to illustrate important issues and themes, nominating the health workers HW1 to HW12. When certain
text is omitted because of irrelevance to the present
issue, this is marked by […]. Explanatory text is
enclosed by (…).
Wish to be – and meaning of – patient-centredness
All the health workers expressed a wish to be patientcentred. When asked to describe an encounter
around dietary advice, some (both GPs and dietitians) presented detailed accounts of what they do
prior to the first meeting (informing themselves
about the patient’s medical condition, life history,
language skills, and degree of literacy etc.); how they
present themselves and their working methods to the
patient; how they engage in ‘‘learn-to-know-eachother’’ activities before performing a meticulous diet
history; and how the results from the diet histories
are used to develop individually adapted dietary
advice in cooperation with the patient. Others just
stated that they ask the patient how she/he eats and
then use this information to give diet lists or other
general advice.
When asked to clarify their understanding of the
term patient-centred, the health workers seemed to
concentrate principally on two dimensions: getting
to know the individual patient and his/her cultural
background through an empathic approach (referred
to here as ‘‘the empathic approach’’); and to level out
the asymmetrical power relations between the health
worker and the patient, focusing on the encounter as
Role dilemmas in cross-cultural patient encounters
‘‘a meeting between equal partners where both
contribute with their particular expertise’’ (referred
to here as ‘‘the egalitarian approach’’). Both these
dimensions are intended to facilitate the patient’s
active participation in the encounter and thereby
also in the management of his/her diabetes.
An example is HW10, who was very explicit when
explaining these matters. She argued that an
empathic health worker must first and foremost be
willing to let the patients express their concerns and
questions:
The patient’s situation is very important for
how I shall convey information. So it is very
important for me to gain insight in the patient’s
everyday life and let her express her concerns.
‘‘How do you live? How are you? What do you
eat? Do you work? What does your husband
do?’’ The rhythm of the day. (HW10)
In addition to the empathic approach, she also
considered ‘‘a shared world view’’ as a necessary
precondition for a ‘‘good dialogue’’ which in turn is
seen as a step towards enabling the patient to take
responsibility for his/her own diabetes management.
One strategy is to demonstrate to the patient
that she/he and the health worker have something in common, thus levelling out the unequal
power relations. This is achieved through sharing
personal experiences, e.g. involving kinship relations, assuming that family ties represent a common
denominator:
One has to rely on facts, but one also has to
be a bit personal, so I say for instance: ‘‘Listen,
this is what I do in my life, what I learnt when I
was a child, and how we did it in our home’’, […]
I say that I come from a family with five children.
That means a lot, yes? ‘‘And my mummy was also
at home, while daddy worked.’’ And then, without getting private, one does get personal, and
becomes more human to them. (HW10)
The most common account during the interviews on
how to be patient-centred towards patients of
Pakistani background was that you should meet
them with knowledge of Pakistani (food) culture.
The reason given was that the patient will open up,
and thereby give room for both an empathic and an
egalitarian approach:
The patients become more talkative and you feel
that you are on their level so to speak, and that
isn’t very easy to achieve. I often notice that the
fact that I know the name of Pakistani dishes and
363
the foods they use, and that I know about the
vegetable ‘‘Karela’’, which is said to have a
positive effect on diabetes – makes them very
happy – confident. [...] I try deliberately to speak
in a way that makes them understand that I have
heard of these things before, it loosens them up,
and they talk more easily. (HW1)
It was, however, considered to be difficult to reach
this level of mutual understanding and trust. HW10
explained ‘‘the extra burden’’ of the cross-cultural
encounter by a comparison illustrating how shared
knowledge and experience with foods and dishes is
seen as a precondition to mutual understanding, and
how the cultural gap represents an impediment to
this:
To ‘‘Ola and Kari’’ (typical Norwegians) one might
say: ‘‘the blood-test shows that you have diabetes’’.
‘‘Oh? What are the consequences? What shall I do?’’
But to a woman from Pakistan: ‘‘You have
diabetes.’’ ‘‘What is diabetes?’’ And then you have
to explain. Of course you will have to explain to
‘‘Ola and Kari’’ too, but you can start on another
level! […] Like the Pakistani patient who said
that they hardly ate fish because they didn’t
know which ones they should eat. And then I
said that they could eat salmon and trout. They
had done that before, but it was too expensive.
And then I asked if they used ‘‘fish-pudding’’ or
‘‘fish-cakes’’ for dinner. And then she didn’t
know about ‘‘fish-pudding’’! Or how one uses it!
You don’t get into such situations with ‘‘Ola and
Kari’’! Everybody knows what these dishes are!
(HW10)
The patients wish for me to be paternalistic
Based on the accounts presented above, it appears
that the health workers are guided by an effort to
establish a feeling of sameness, which they consider
necessary for achieving a patient-centred approach.
They strive to build a platform of common ideas in
their effort to empower the patients, i.e. to ‘‘make
them’’ participate actively in the management of
their disease instead of just remaining passive
partners in the encounter. But there is a strong
tension between this wish to empower the patients
and a felt demand that they should take command
and be more paternalistic. The health workers
expressed a feeling that the patients expect the
hierarchic structures that they themselves try to
avoid. In fact, all but one of the health workers came
back to this dissonance, some even several times
during the interview:
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R. A. Fagerli et al.
They are used to getting dietary advice […]. What
might be strange to them is that we try to explore
what they want (and ask them to be an active
part) instead of just telling them ‘‘you should do
so and so’’! (HW4)
Pushed to the extreme, one may claim that the
Pakistani patient leaves the responsibility entirely
to you when it comes to evaluation, treatment,
and actions […]. The Norwegian patient will to a
great extent participate. The Norwegian can say:
‘‘I suspect that I might have diabetes because of
this and that’’. The Pakistani patient presents his
symptoms and: ‘‘What is wrong with me,
Doctor?’’ (HW10)
The health worker representing the exception to the
rule said that she does not think that the patients
really want a paternalistic health worker; rather
‘‘what they want is an empathic health worker who
cares for them’’.
To be – or not to be – paternalistic
The impression that the patients want them to be
paternalistic seems to frustrate most of the health
workers. In general they have objections to these
requests but there are also differences in strategies
they use to cope with these contradictory demands
in practice. During the interviews many maintained
that acting in an authoritarian manner would be
against their convictions of how to be a good health
worker. At the same time, there were pragmatic
comments about more or less deliberately adapting a
more paternalistic style under certain conditions,
while others expressed a feeling of incapability of
being paternalistic for fear of insulting the patient.
First we look at the comments reflecting resistance
to being paternalistic. Some of the health workers
explained their reluctance to be paternalistic by
pointing to effectiveness in the medical encounter,
claiming that there is no point in giving ready-made
and general advice if one seeks to achieve enduring
lifestyle changes. One health worker loudly
expressed frustration about having to adjust her role
according to the patients’ wishes:
It’s really hopeless! That I shall be forced to be
old-fashioned and just give (patients) a list of
things to eat, and not be allowed to sort of, do
what I have learned. I don’t want that! Well, it
depends. That’s clear. The 80-year-old Norwegian lady might get what she wants (a paternalistic
health worker)! But, with 30- to 40-year-old
Pakistani patients, I think it is something else!
You can’t totally accept it, at least not if you still
want to come out of it with your dignity intact!
(HW4)
Another health worker explained that she considers
it to be her moral duty to ‘‘teach the Pakistani
patients to take care of their own health and to be
less obedient towards authorities’’. After speaking
about a consultation when she ‘‘had to cut through,
and to be rather strict, maybe what one calls
authoritarian’’, she continued:
What does one gain from this in the long run?
When one works as a doctor, a fellow human
being, relationships are important, and the longterm perspectives are the most important. One
gains nothing by being the paternalistic doctor
who thumps the table and says: ‘‘Now, you must
listen to me’’! What do they learn from that? They
learn that persons with influence have power; that
they are authoritarian! They (the patients) have
no voice in their life at all! And what consequences will that have in their relationship with
their own children, for instance? And in their
experiences of the Norwegian society! I’m totally
against this. It’s awful. I think that it is a
conservative, old-fashioned, reinforcing attitude!
(HW10)
The above two quotations indicate that these health
workers hesitate to be paternalistic but still, under
pressure, may choose to act in an authoritarian
manner. More paradoxically, the statements also
show a clear authoritarian attitude underlying their
understanding of themselves as patient-centred
through their imperative to empower the patients.
The first health worker experiences a conflict
between some patients’ demands and what she has
learned about communicating with patients, and is
frustrated that she ‘‘is forced to be old-fashioned’’.
She copes with this by differentiating between
various patients according to age and ethnicity.
The second health worker indicated that despite
being principally against a paternalistic style,
because it consolidates uneven power relations, she
does in fact adapt her behaviour according to the
context. Yet, she is upset about the implications her
behaviour might have for the patients’ acculturation
process, worrying that she may indirectly teach them
that ‘‘persons with influence have power’’. This
appears in her view to be at odds both with current
ideals of Norwegian society, and with notions of
patient-centredness in medical encounters.
Second, the choice to be paternalistic can also be
more pragmatic, and was explained with reference to
Role dilemmas in cross-cultural patient encounters
experiences of ‘‘patients being too passive’’. One of the
health workers explained that when she meets a patient
who ‘‘just sits there without responding’’, she automatically changes to a more traditional style of giving
advice, just handling her knowledge over to the
patient, hoping she/he will understand her message
and ‘‘change his/her lifestyle by him/herself’’. Further
reasons for being paternalistic are when patients are so
disinterested in taking responsibility for their own
health that the health worker becomes authoritarian in
a last desperate effort to feel that she has ‘‘at least given
something to the patient’’.
A third kind of situation in which some of the
health workers (the more feminist-oriented among
them) occasionally adapt a more authoritarian role is
when confronting certain male patients. One health
worker experiences that some men lack respect for
her because she is a woman. She said that her
strategy to overcome this is to stress her professional
authority, even though she is not comfortable with it.
Another chooses ‘‘to exclude male family members
from consultations where ‘female matters’ are to be
addressed’’. However, most of the informants do
not seem to put much emphasis on such gender
issues.
In the examples above the health workers give the
impression that they are almost forced to be more
authoritarian than they prefer. But while they
consider it somewhat beneath their professional
dignity to be authoritarian, some of them also
acknowledged the advantage of this ‘‘old fashioned’’
way of giving advice:
It is surely an easier way to convey your
advice […]. And I almost think that it is more
difficult to communicate a diabetes regimen now,
because it is less defined, than before when things
were more rigid! (HW3)
One spoke frankly about how she changes her
manner of acting according to the patients’ ethnicity
and level of integration into Norwegian society,
indicating that she is deliberately more authoritarian
towards certain patients of Pakistani background
than towards others:
They expect an authoritarian attitude, so […]
instinctively I put on the white coat when I have a
Pakistani (patient), because I sort of feel this
‘‘being at the Doctor’s’’, and this respect towards
the physician I suppose is something they have
brought from their home country. It makes them
do what we tell them to […]. And again, a
Pakistani patient who speaks Norwegian fluently
365
and is of high education and so forth – then I
throw the coat aside, because then I feel it is easier
to get onto the same level. (HW5)
This health worker seems to be less occupied with
the thought of empowering the patients than others,
and her argument for being authoritarian is simply
that the patients of Pakistani background in general
expect her to be so.
Finally, a format of equality and denial of the
asymmetric power relations in the encounter may also
lead the health worker to be rather diffuse in her
communication with the patient. The wish to be
patient-centred, or the fear of not being so, sometimes
results in ‘‘a fear of being intrusive on the patient’’.
The fear increases when confronted with patients who
expose unfamiliar cultural traits, preventing the health
worker from being frank with the patient:
I feel that perhaps sometimes I get too nice, and
then I don’t achieve as much as I would lilke,
because they don’t take me seriously […]. I often
feel that it is difficult to talk about body weight
with women of 45 year and over, diagnosed with
diabetes. They are often a bit overweight, and you
know this cultural – that in their culture it is
considered an asset to be big! So, I find it difficult
to tell them that it is important to consider weight
issues. So, because it clashes with their ideals, I
often end up by saying as little as possible about
it, and give more general advice instead. (HW3)
This health worker said that she anticipates that the
weight issue will be problematic but is afraid to bring
it up. Not asking, she becomes unable to base her
advice on what is relevant for each individual patient
and is instead informed by stereotypes of what is
considered an asset within this group of patients.
Another health worker commented on the relief she
feels when being confronted with a condition that is
‘‘curable by a couple of pills’’ (and thereby
discharges her from the burdens of asking about
the patient’s background and life experiences). Fear
of confronting the patient’s ‘‘foreign culture’’, and
the risk of transgressing unspoken boundaries, may
thus prevent health workers from challenging their
presuppositions about the patient, and thereby they
are unable to base their advice on the patient’s
attitudes and life-experiences.
Discussion
This paper focuses on patient-centredness in the
encounter concerning dietary advice to Pakistani-born
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R. A. Fagerli et al.
patients. Questions related to role perceptions were
not specifically addressed in the interview guide for
the first interviews. However, as the health workers
saw this to be a major concern, which they were
allowed to discuss at length, contradictory demands
regarding role perception and enactment became
the main issues in the analysis presented in this
article.
Here the discussion will be centred on how
egalitarian ideals as interpreted in a Norwegian
context may influence the health workers’ rationales
for being patient-centred, but similar discrepancies
between the ‘‘ideal and practice’’ among GPs have
also been described for other patient groups and
situations, for example in Edlund’s study on longterm sick leave in Sweden [21].
The interviews also revealed many other aspects
that the health workers found challenging in this
type of encounter, such as language barriers,
patients’ lack of basic knowledge of how the body
functions, and the problem of allocating enough
time for these patients. These are touched on in
some of the quotations from the interviews, but a
lengthy analysis and discussion would be outside the
scope of this paper. These issues have been
discussed in other research projects [13,14,16].
The credibility and validity of the data is ensured
in that (a) the successive transcription of each
interview and preliminary analysis of data allowed
different aspects to be further explored in subsequent interviews, (b) the first author has presented
and discussed the data on which the analysis in this
article is based, as well as her findings, with the other
authors, and (c) respondent validation is performed
through informal discussions regarding the most
important findings with some of the health workers
taking part in the study during the analysis process.
Dimensions of patient-centredness versus paternalism
According to the health workers’ own accounts, a
patient-centred health worker is able to give advice
that is based on, and reflect an understanding of, the
patient’s attitude and lifestyle. However, the term
patient-centred also involves two different dimensions: the ‘‘empathic approach’’ emphasizing the
health worker’s skill in empathic communication,
and; the ‘‘egalitarian approach’’ characterized by
efforts to establish an egalitarian platform as
opposed to an authoritarian style. This is illustrated
in Table I.
The columns A and B represent the authoritarian
dimension versus the egalitarian dimension, and the
rows 1 and 2 represent whether or not patient
attitudes and lifestyle are incorporated in the advice.
The combination of the egalitarian and empathic
approaches (Table I, B2) represents the ideal of
patient-centredness. There is a true dialogue
between the health worker and the already ‘‘empowered’’ patient, as the concept would be defined by
the health workers. Yet, as we have seen, true
dialogue requires the active participation of both
parties. When patients are more passive, the health
worker must resort to other forms of interaction.
None of the health workers said that they
base their advice on prefabricated standardized
Norwegian diet lists, as one would expect a
‘‘classical’’ paternalist to do (Table I, A1). However, this does not imply that their approach is
patient-centred in the sense that the health worker
engages the patient in a dialogue and learns about
his/her life in order to develop strategies for diabetes
management. As seen in Table I we have identified
two alternative strategies that are not ‘‘really’’
patient-centred according to the definitions outlined
in the introduction, even though the health workers
themselves speak of them as such.
First, some health workers revealed that they are
so afraid of insulting the patient that they have
difficulties in acquiring good patient histories. They
are afraid to address issues they believe might be
sensitive. When not being able to take the patient’s
background and lifestyle into account their advice
becomes vague and deviates from their ideal of being
patient-centred (Table I, B1). Issues regarding
sociocultural phenomena such as literacy and the
level of integration to Norwegian society, as well as
issues related to obesity and body weight, which are
Table I. Dimensions of patient-centredness/paternalism when giving dietary advice.
A Authoritarian
1
Not incorporating patient attitude and
lifestyle in advice
‘‘Gives Norwegian diet lists’
2
Incorporating patient attitude and
lifestyle in advice
‘‘Gives diet lists on the basis of dietary
history’’
B Egalitarian
‘‘Becomes vague and diffuse for fear of
troubling the patient or for fear of acting in
an authoritarian manner’’
‘‘Engages the patient in true dialogue.
Advice is developed in cooperation with
patient’’
Role dilemmas in cross-cultural patient encounters
very sensitive in Norwegian culture, were regarded
as potentially inappropriate to address.
Second, even among health workers who incorporate patient lifestyle and background in their advice,
we find examples of paternalism, in the sense that
the health worker ‘‘makes decisions and gives clear
instructions for management based on an empathic
approach’’ (Table I, A2). This may be compared
with the findings in a representative survey among
Norwegian physicians reported by Falkum & Førde
[22]. In that study paternalists were divided into two
groups: the classical paternalists who tend to decide
for the patient without spending much time on
information and dialogue, and the modern paternalists, who also tend to decide for the patient but
who acknowledge the importance of knowledge
and understanding in order to achieve patient compliance, and who try to persuade the patient that his/
her clinical judgement is right.
In Falkum & Førdes’s study [22] more male than
female physicians were categorized as modern
paternalists but there were no differences concerning
the classical paternalists. According to the literature
male physicians tend to engage less in communication that can be considered patient-centred than do
their female colleagues [23], and they have also been
shown to be less concerned about preventive
medicine than their female colleagues [24,25]. If
this also applies to the men invited to participate in
this study, male GPs may have been less interested
in discussing such issues with a researcher. In turn
this may also have influenced their decision not to
allocate time for the interview. This may have
allowed us less background from which to analyse
paternalism than would have been the case with
male participants.
Cultural mechanisms influencing role enactment
Different social and cultural mechanisms may also
influence the health workers’ enactment of their
roles. The professional ethics of Norwegian health
workers are based on the concepts of patientcentredness and empowerment [26,27], and there
is a view of paternalism as old-fashioned and
substandard [27]. Furthermore, Norwegian society
has been described as a society with a strong
egalitarian ethos [11,28]. This is reflected in political
ideology (welfare) and political practice (consensus),
in governmental institutions (schools, healthcare,
and the welfare state) as well as in the private sphere
[11]. According to Gullestad [28], the Norwegian
version of ‘‘egalitarian individualism’’ implies,
among other things, a special emphasis on similarity,
or ‘‘sameness’’, as a prerequisite when establishing
367
informal social relations such as friendship. While
professional arenas may be characterized by hierarchy, friendships are based on equality. As equality
tends to be interpreted in terms of sameness,
informal social encounters often involve a marked
emphasis on common traits and shared beliefs, while
dissonances and differences are thoughtfully undercommunicated in the conversation. This often leads
to a social pattern of interaction marked by
consensus and the avoidance of open confrontation
and conflict.
The medical encounter is traditionally characterized
by asymmetrical power relations between the health
worker and the patient, yet currently there is a general
tendency among medical practitioners in the Western
world to renounce this asymmetry [29]. However, the
social articulation of a more symmetrical medical
encounter is likely to be shaped by local cultural
interpretations of what it means to be equal.
In the Norwegian case it seems as though the
health workers, in their articulation of patientcentredness, draw on a repertoire of social conduct
that characterizes friendship in the private sphere. In
their accounts of how to ‘‘build a common understanding of the world in order to be able to engage in
dialogue’’ it seems as though their efforts to
renounce asymmetry also involve an effort to achieve
sameness by ‘‘erasing’’ the social and cultural
differences. This tendency may be particularly
pronounced in cross-cultural medical encounters.
In these situations, the perceived differences involve
not only the hierarchy inherent in the health worker–
patient encounter but also differences due to
divergent cultural backgrounds. In their effort to
achieve sameness across these social (hierarchic) and
cultural barriers, some health workers become
diffuse and vague rather than frankly confronting
patients’ behaviour on sensitive issues such as
obesity and body weight. This may also explain the
frustration conveyed by health workers concerning
their experience of patients wanting them to be more
authoritarian than they feel comfortable with.
Another and more extreme consequence of this
egalitarian ethos is expressed through a strong moral
imperative shown by some of the health workers to
educate the patients ‘‘to be less obedient towards
authorities’’. At its most extreme this may prevail at
the expense of compliance, and might be a consequence of the recent focus on empowerment and
patient autonomy. The Norwegian egalitarian ethos
validates this perspective and may indirectly serve to
confirm the moral superiority of patient-centred role
enactment.
Finally, the ideological dimension of an egalitarian
ethos may also serve to confirm and to define the
368
R. A. Fagerli et al.
educative role of the health worker. Clearly, some
health workers, and perhaps especially those with a
holistic approach to healthcare, do not restrict their
role as educators to topics that belong strictly to the
medical profession. As indicated above, some even
evaluate their own conduct in light of what they
implicitly convey about Norwegian society. When
HW10 chooses not to be authoritarian because if she
was, ‘‘the patients (would) learn that persons with
influence have power’’, she refuses to admit her own
power as a GP, and implicitly also that of the
medical profession. Through such denial, which is
also demonstrated in other studies among professionals in Norway [11] she may, paradoxically,
undermine the egalitarian ideals that she in fact
strives to live up to, by becoming clearly authoritarian in what she sees as her effort to empower the
patient. This is because a denial of existing power
structures may restrict the opportunities for resistance from below.
patients’ autonomy and active participation in
disease management are discussed if ‘‘patientcentredness’’ is to be empowering instead of coercive
[30]. Our findings indicate that the training of health
workers could still benefit greatly from a greater
emphasis on the ability to overcome cultural communication barriers, aimed at making health workers
more sensitive towards the patient’s position and
expectations and also to be able to include critical
reflections on their own cultural background and
predispositions.
Concluding remarks
References
We have seen that concepts of patient-centredness
and empowerment are important in the accounts of
how one wish to meet the patient, and that the
health workers feel frustrated when they find that
their patients expect a more authoritarian style.
As outlined in the introduction, patient-centredness and empowerment are results of a historical and
continuous process of cultural change in Western
countries, based on ideals of equality and individual
autonomy. Patients of Pakistani background do not
always share these ideals. Moreover, many of them
find themselves at the lower end of the socioeconomic hierarchy in Norwegian society [18].
Paradoxically, the dilemma experienced from such
contradictory demands leads, as we have seen, some
health workers, despite their view of themselves as
patient-centred, to be rather authoritarian in their
effort to educate patients to take responsibility for
their own health. If this is the case more broadly, it
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Hanssen [30] points out that patients have the
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exercise in the medical encounter and this may vary
from culture to culture and from person to person.
Cultural issues such as tradition and authority need
to be addressed when ethical issues concerning
Acknowledgements
The authors are indebted to the health workers, who
gave a deep insight into their feelings and experiences concerning their work and working situation.
The study was funded by the Norwegian Research
Council, and additional grants were also received
from the Norwegian Diabetes Association.
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Marianne Lien
