Cultural transition of international medical graduate residents into family practice in Canada.

OBJECTIVE: To identify the perceived strengths that international medical graduate (IMG) family medicine residents possess and the challenges they are perceived to encounter in integrating into Canadian family practice. METHODS: This was a qualitative, exploratory study employing focus groups and interviews with 27 participants - 10 family physicians, 13 health care professionals, and 4 family medicine residents. Focus group/interview questions addressed the strengths that IMGs possess and the challenges they face in becoming culturally competent within the Canadian medico-cultural context. Qualitative data were audiotaped, transcribed, and analyzed thematically. RESULTS: Participants identified that IMG residents brought multiple strengths to Canadian practice including strong clinical knowledge and experience, high education level, the richness of varied cultural perspectives, and positive personal strengths. At the same time, IMG residents appeared to experience challenges in the areas of: (1) communication skills (language nuances, unfamiliar accents, speech volume/tone, eye contact, directness of communication); (2) clinical practice (uncommon diagnoses, lack of familiarity with care of the opposite sex and mental health conditions); (3) learning challenges (limited knowledge of Canada's health care system, patient-centered care and ethical principles, unfamiliarity with self-directed learning, unease with receiving feedback); (4) cultural differences (gender roles, gender equality, personal space, boundary issues; and (5) personal struggles. CONCLUSIONS: Residency programs must recognize the challenges that can occur during the cultural transition to Canadian family practice and incorporate medico-cultural education into the curriculum. IMG residents also need to be aware of cultural differences and be open to different perspectives and new learning.

Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study.

BACKGROUND: Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting. METHOD: Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis. RESULTS: Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs. CONCLUSIONS: In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.