Hospital Practices and Urban Pluralism: Correlating a Pediatric Practice with the Diversity of Its Setting
The main objective of this study is to identify and document, within a pan-Canadian perspective, the elements that go into making a hospital clinical practice linked to the diversity of its setting. We postulate that: (a) prognosis and treatment at a biological level are improved by taking into consideration the social and cultural dimensions of the individual and his/her family; b) a set of standards and values (ethical, medical and biomedical) pervades clinical practice and the standards and values themselves lie within a social and cultural environment; c) the quality of a therapeutic relationship (caregiver-care receiver) is consistent with the quality of insertion of the migrant into local society. With a particular interest in the bioethical issues of pediatric practice in a pluralistic setting, we intend: (1) to circumscribe the therapeutic approaches preferred by physicians, nurses and other participating healthcare professionals and the decisional processes and mechanisms within multidisciplinary teams; (2) to examine the caregiver/care receiver/family relationship and the diversity of the meaning systems encountered in clinical spaces; (3) to investigate with the clinicians the critical events encountered within the framework of their daily institutional practice. As phase I of the study (CIHR 2005-2008) has circumscribed these issues for the CHUSJ, especially for intensive care and the hematology department, phase II will focus on comparative elements of the study (Toronto Sick Kids and BC Children’s Hospital aspects) as well as on additional data gathered from nurses and other professionals associated with these sites at the CHUSJ.
Contemporary clinical practice is conducted within a complex setting where issues related to ethnic diversity form an integral part of intervention in a hospital setting. Canadian urban centers reflect this increasingly diverse Canadian mosaic (27% of Montrealers, 49% of Torontonians and 46% of Vancouverites are of immigrant origin). These metropolitan areas are also sites for technological and knowledge-based investment due to the universities and affiliated hospital centers located in these centers such as the CHUSJ (a tertiary care pediatric university hospital center), the Hospital for Sick Children (Sick Kids) and BC Children’s Hospital. As “windows on the city,” these hospitals are permeated by a set of phenomena including the transformation of their clienteles and the development of clinical situations associated with the growth of complex chronic pathologies and the advance of medical knowledge and technological resources.
The biomedical model, with its focus on a biological view of the individual, largely dominates the medical setting. A lot of attention is paid to the biological body and organic disorders, often to the detriment of a more inclusive approach where room is made for social and cultural dimensions. These dimensions, in turn, are part of social relations that have been (re)constructed through migration, settlement arrangements in local society, family structures and individual resources (social, symbolic). Clinical space is also a relational social space, where norms, values as well as professional, social and cultural models intertwine. User families, already distressed by their child’s hospital admission, face numerous challenges such as complex decision-making in often critical situations, understanding the issues associated with the proposed treatment plans and compliance. Furthermore, in a pluralistic context, the clinicians and patients’ reference systems are not necessarily shared. The quality of the caregiver/care receiver/family relationship is, however, one of the key components of treatment compliance and, more generally, the therapeutic trajectory.
The main population under study is made up of physicians, nurses and other healthcare professionals associated with the multidisciplinary services offered by the hemato-oncology and intensive care departments of the three hospitals concerned. The second more restricted population is made up of user families who have a connection with these same departments. The preferred methodological approach is qualitative and anthropological in inspiration (observations, interviews, case studies) using analysis software (N’Vivo) to enter and handle the data (same as in Phase I). The expected results include: 1) a comparative identification of conditions under which a pluralistic clinical practice emerges, one that is permeated by social, cultural, normative and value dimensions that can inspire pediatricians at the healthcare facilities concerned and other similar Canadian institutions; 2) an examination of the intra and inter-institutional dynamics (associated with the structure of the services and the promotion of multidisciplinarity) and the linking of these structures with documented caregiver/patient relations; 3) documentation of the course of clinical situations and ethical issues within a pan-Canadian context that is at the same time intra- and inter-institutional as well as intra- and inter-site in nature (while taking into consideration historical, socio-cultural and economic specificities); 4) the development of an original corpus for the purpose of teaching pediatric residents and students across Canada about urban pluralism.