Abstract
This article contributes to the growing body of literature on the methods and techniques that might be used to help ensure the cultural integrity and rigor of research that has a cross-cultural dimension. Drawing upon our experiences while conducting a study investigating patient safety concerns in Bhutan, we will reflect on how the study was conceptualized and framed around the elements of the Bhutanese traditional cultural values; how the researchers were positioned; and how the intercultural perceptions, representations, languages, and attitudes influenced the fieldwork processes. It is anticipated that the approach described in this article will help qualitative researchers to understand how important it is to recognize and be responsive to the cultural and linguistic nuances of given research settings to achieve cultural integrity.
What Is Already Known?
In qualitative research, ensuring rigor and trustworthiness is essential to ensuring the credible and meaningful application of the findings.
Researchers are required to meet the conventional criteria of credibility, fittingness, auditability, confirmability, and triangulation in qualitative research.
Cultural integrity cannot be achieved without adapting and applying research in a culturally meaningful way and without an in-depth knowledge and understanding of the sociocultural and political dynamics of a particular research setting.
What This Paper Adds?
How cross-cultural research can be framed according to the traditional cultural values of a particular research setting to achieve cultural integrity.
An illustrative example of how cultural integrity was achieved by giving due attention to the principles of cultural relevance, contextuality, appropriateness, mutual respect, and flexibility.
Introduction
Qualitative researchers are increasingly engaged in conducting studies that pose particular challenges in terms of ensuring that both the conduct of the studies in question and their findings are culturally appropriate and meaningful. Ensuring the rigor and trustworthiness of any study is essential to ensuring the credible and meaningful application of its findings. In the case of studies that have a cross-cultural dimension, however, extra vigilance is required. This is because the rigor and trustworthiness of a qualitative study investigating an issue that has a cross-cultural dimension cannot be achieved without adapting and applying research methods in a culturally meaningful way—without in-depth knowledge and understanding of the sociocultural and political dynamics of a particular research setting. In contexts where researchers lack in-depth knowledge and understanding of the sociocultural and political dynamics of the research setting, there is a risk of inadvertently imposing their beliefs, values, and patterns of behavior upon the cultural settings and participants in which the study is being conducted. This, in turn, can result in invalid research data being collected and “wrong” findings being made (Papadopoulos & Lees, 2002).
It is also important for the qualitative researchers to know how to situate and position themselves in the research setting. It is contended that the self-representations and positionality of researchers can evoke stereotypes that influence the feelings and opinions of the respondents. Thus, the self-representation or intersection of identities and positionalities of researchers has the potential to significantly affect the faithfulness of the information provided by the participants (Mullings, 1999; Subedi, 2006, 2007). It is also contended that how individuals represent themselves can make a difference to whether or not requests for interviews will be granted (Mullings, 1999). Hence, it is crucial for researchers to know how to position themselves in culturally appropriate (more fluid account of identities) way to enable them to collect valid, meaningful, diverse, and in-depth data. As discussed below, it has been argued that the essentialist (rather than fluid) notion of “insider and outsider” positionality of the researcher is problematic and cannot be solved by matching the cultural and racial identity of researchers and participants (Fletcher, 2010, 2014; Pang, 2016; Sparkes, 2002). The fundamental inquiry that follows the researchers’ positionality includes who can be “knower” (Pang, 2016; Sparkes, 2002) and what are the associations between “self and other” and “self as other” (Fletcher, 2014; Pang, 2016). Because this study related to the lead author’s cultural background, his personal experiences, perspectives, and values influenced the research questions, the setting, and his commitment to work toward a safe health-care system; the lead author/researcher was situated as a knower. Further, since the lead author resigned from his position as a nurse in Bhutan to undertake this study, he regressed his identity to “other.”
In addition, ability of a researcher to understand and speak the local language is considered important to taking a culturally nuanced approach, which in turn will determine the credibility of the researcher in the eyes of participants and the data obtained (Chen & Boore, 2010). Language, apart from being a tool or technical means for conveying concepts, is an essential part of conceptualization, incorporating values and beliefs that carry particular cultural, social, and political meanings that cannot be captured through the process of translation (Temple & Edwards, 2002). An inability to understand and speak the language of participants can be a threat to the accuracy of cross-cultural, cross-language qualitative research. This is because concepts that may be expressed in one language or have currency in a given culture do not always exist in another language or culture and thus cannot be meaningfully translated from one language to another (Tsai et al., 2004).
As argued by some authors, it is challenging for a researcher lacking cultural competence to accurately capture and portray participants’ responses. Without appropriate cultural knowledge, researchers risk misinterpreting or misrepresenting the data (Arriaza, Nedjat-Haiem, Lee, & Martin, 2015). According to Arriaza, Nedjat-Haiem, Lee, and Martin (2015) and Tillman (2002), “outsider” researchers’ lack of familiarity with the particular research setting can emerge as a personal challenge. Even if involving cultural mediators, ambassadors, or advocates, it can be challenging to translate participants’ responses accurately because certain words or concepts cannot always be translated into local dialects. Thus, it has been argued that there is no benefit in relying on cultural mediators, ambassadors, or advocates because there is a high risk of distorting participants’ responses (Chiumento, Rahman, Machin, & Frith, 2017; Sutrisno, Nguyen, & Tangen, 2014; Tillman, 2002).
It is generally expected that when conducting qualitative studies, researchers will meet the conventional criteria of credibility, fittingness, auditability, confirmability, and triangulation (Patton, 2015). While essential, these criteria have not always been sufficient to ensure or achieve the cultural integrity and credibility of a study (Im, Page, Lin, Tsai, & Cheng, 2004; Liamputtong, 2010a, 2010b). Significantly, within dominant narratives of research, discussion regarding cultural integrity is rarely recognized as a significant topic of discussion. By the term cultural integrity, Lapan, Quartaroli, and Riemer (2012) refer to researchers establishing a level of cultural trust by respecting or behaving in a manner consistent with participants’ cultural values. Since too often researchers do not examine the relationship between methodology and culture, it remains questionable whether studies conducted by researchers who lack cultural knowledge and understanding of the nuances of particular cultural contexts and the cultural worldviews of participants meet standards of cultural integrity. One reason for this is that the criteria applied in one setting may not be able to be meaningfully applied to another setting where the culture is different, at least not without adaptation. Most importantly, the researcher’s inability to develop a culturally nuanced approach—which is always challenging in the absence of understanding local sociocultural and political values—stands as a threat to achieving cultural integrity.
A key aim of this article is to provide an in-depth description of an approach that was taken to ensure the cultural integrity of a study conducted in the cultural context of Bhutan. The original study, the first of its kind to be conducted in Bhutan, investigated patient safety issues and concerns in the health-care system of the Royal Kingdom of Bhutan (Pelzang, 2016). A total of 94 participants were recruited and interviewed from across the Bhutanese health-care system and included participants from Bhutan’s tertiary education system and the Ministry of Health. Reflexive or field notes were maintained throughout this study to question personal biases, obtain a greater account of sociopolitical matters, and identify problems of the dichotomous insider–outsider dynamic present when conducting research. The accounts of each step of the process were recorded in the form of a field journal to ensure that the process of the study was clearly documented in a logical and traceable manner (McBrien, 2008; Schwandt, 1996). The notes included details of the researcher’s observations, thoughts, and feelings in the context of conducting the study.
In the discussion to follow, attention is given to describing how the study’s overall approach was framed around core Bhutanese traditional cultural values to achieve cultural integrity by giving due attention to the following principles: cultural relevance, contextuality, appropriateness, mutual respect, and flexibility (Im et al., 2004). The discussion begins with a description of the motivation for and conceptualization of the study. A description follows of how the accuracy and credibility of the interview translation and data analysis was maintained. The discussion also highlights the cultural positioning of the researchers and the barriers and enablers faced during data collection phase.
Conceptualization of the Study
Based upon the lead author’s experiences and observations during his many years working in the Bhutanese health-care system as a nurse, the study was conceptualized to explore, from the perspective of health professionals, the patient safety issues and concerns in Bhutan’s health-care system; and the influence Bhutanese traditional cultural values may have had on hospital practices. The lead author was born, educated, and has spent his working life in the Royal Kingdom of Bhutan. During this period, he gained firsthand experience of the shortfalls in Bhutan’s health-care system and began to question how the quality of patient care could be improved—a questioning that later led him to “discover” the global patient safety movement and ultimately inspired the conceptualization of this study. While working in Bhutan’s hospital system, he experienced and had the opportunity to directly observe the hierarchical system that operates. Of particular note was the observation that positions of authority in the hospital system were always dominated by physicians, who made all key high-level strategic decisions within the health-care system. Observing this and other processes characteristic of Bhutan’s hospital system, the lead researcher wanted to understand more about the factors which may have contributed to the shortfalls he had observed in providing quality care to patients. In discussion with his mentoring coinvestigator, he was particularly interested to find out what, if any, influence Bhutanese traditional cultural values had on the hospital practices he had observed during his years as a nurse. It is in this context that the opportunity to undertake a study to explore patient safety concerns and contributing factors was contemplated. He was particularly interested in having the opportunity not only to explore patient safety concerns in Bhutan but also to establish a basis upon which culturally adapted solutions to the concerns identified could be developed.
Cultural Integrity of the Study
As outlined above, the cultural integrity of this study was maintained by giving due attention to the following principles: cultural relevance, contextuality, appropriateness, mutual respect, and flexibility (Im et al., 2004).
Cultural Relevance
Im, Page, Lin, Tsai, and Cheng (2004) contend that, before commencing a study and beginning the data collection stage, the cultural relevance of the study being proposed must first be evaluated. “Cultural relevance” in this instance refers to “whether the research question can serve a specific cultural group’s issues and interests in improving their lives” (Im et al., 2004, p. 894). The cultural relevance of this study derives from its key aims to identify patient safety concerns in the cultural context of Bhutan, to improve understanding of the processes contributing to the patient safety issues and concerns identified, and to develop a basis upon which culturally adapted solutions can be found to help redress the concerns identified.
In an attempt to ensure the cultural relevance of this study, two carefully considered processes were followed. First, the research proposal itself was shaped and developed on the basis of the lead author’s cultural knowledge, acquired through a formal examination of the literature on Bhutanese culture as well as his own lived experience of being a Bhutanese person and nurse. This knowledge also informed his decision to include questions that related specifically to Bhutanese cultural values and the influences (both positive and negative) these might have had on participants’ knowledge, beliefs, values, and attitudes concerning patient safety in Bhutan’s hospitals.
Second, although a conventional patient safety framework was used to set the parameters of the study, the Bhutanese culture and context were placed at the center of the inquiry. Accordingly, the research and interview questions and the study’s overall approach were carefully framed around the profile of core Bhutanese traditional cultural values, namely, Le Judre, Tha Damtshig, and Driglam Namzha. For example, “How does the Bhutanese traditional (core) cultural value concepts of Le Judre, Tha Damtshig, Driglam Namzha impact/influence the patient safety processes and practices in Bhutan’s healthcare system?” (Pelzang, Johnstone, & Hutchinson, 2017). This enabled a culturally nuanced approach to be taken.
Le Judre refers to the infallible law of virtuous actions, which emphasizes good action. Tha Damtshig, in turn, refers to a principle of virtuous being, which emphasizes a wide range of referents including honesty, fidelity, moral integrity, moral rectitude, reciprocal affection, and gratitude, and Driglam Namzha is a system of ordered and cultural behavior which emphasizes good actions and morality such as showing respect, being obedient, disciplined, loyal, honest, just, dutiful, responsible, and respectful of and dedicated to seniors and elders (Phuntsho, 2004). These core values also guided the researcher’s approach when contacting and interviewing participants to obtain their perspectives on patient safety issues and concerns as viewed through a Bhutanese-oriented cultural lens/worldview.
Contextuality
“Contextuality” concerns the “sensitivity to structural conditions that contribute to participants’ responses and to the interpretations of situations informed by experiences, by validation of perceptions, and by a careful review of existing knowledge” (Im et al., 2004, p. 894). This is achieved when the researcher has the requisite knowledge and understanding of the research setting to access samples and collect more sensitive and accurate information.
As stated above, a highly refined system of etiquette called Driglam Namzha that prescribes respect for authority and how to speak with and approach people with authority exists in Bhutan. For instance, when a Bhutanese person approaches a person with higher authority, they need to initially approach them personally in their office. Contacting them by telephone or e-mail in the first instance is not allowed and is considered to be unethical and disrespectful. With this in mind, the participants in this study were recruited in a manner that was consistent with this value in Bhutanese culture. Participants such as managers in the Ministry of Health were recruited by approaching them personally and providing them with a plain language statement explaining the objectives and methods of the study. The lead author’s in-depth knowledge and understanding of Driglam Namzha enabled him to approach participants in a respectful manner.
Finally, in keeping with the requirements of the Research Ethics Board of Health, Bhutan, and to ensure that the research was conducted ethically (taking into account cultural integrity), permission to access the hospitals and their staff was obtained by providing a plain language statement and consent form to the key people in the selected hospitals. The lead researcher’s requisite knowledge and understanding of the Bhutanese traditional cultural values helped the researchers to successfully access participants and collect the data necessary for this study.
Appropriateness
Appropriateness, which refers to “whether the study uses appropriate communication styles, conceptualizations, and translation process” (Im et al., 2004, p. 894), involves the use of language congruent with that of the participants and making careful translations. Language, apart from being a tool or technical means for conveying concepts, is considered to be an essential part of conceptualization, incorporating values and beliefs that carry accumulated and particular cultural, social, and political meanings that cannot be articulated through the process of translation (Temple & Edwards, 2002). Translation can be a source of threat to the accuracy of cross-cultural, cross-language qualitative research. As noted earlier, this is because concepts that may be expressed in one language or have currency in a given culture cannot always be meaningfully translated into another language and, in some cases, may not exist in another language or culture at all (Tsai et al., 2004). It is also argued that the epistemological difficulties in identifying similarities and differences can occur when different cultures and languages are used (Chen & Boore, 2010). Thus, as argued by Chen and Boore (2010), it is considered important for the researcher and translators to be fluent in both source language and target language and to be knowledgeable about both cultures.
While the use of the local languages is generally encouraged in cross-cultural studies (Im et al., 2004; Papadopoulos & Lees, 2002), most interviews in this study were conducted in English by a bilingual researcher (researcher RP). Only 3 of 94 participants chose to speak in Tshangla (an eastern Bhutanese dialect which is also the lead author’s mother tongue). The reason most interviews were conducted in English was the majority of participants chose English as their preferred language for the purposes of being interviewed. There is a 3-fold explanation for this preference: First, English is the language of instruction in Bhutanese schools and training institutes; health-care professionals are also taught in English in their professional training programs. Second, English is an official language in Bhutan and is used in Bhutanese offices/institutions (e.g., English is the main language used in office communications). Third, native languages in Bhutan do not have set terms for most English words (e.g., Bhutanese native languages do not have a clear term for “safety”) and thus cannot be translated to English or vice versa. Although English was used as the language for interviews, participants were nonetheless able to express their perspectives on patient safety and also to comment on how traditional cultural values might either impede or enhance change in regard to improving patient safety in Bhutan’s hospitals.
All interview audio-recordings were transcribed verbatim by the lead author. Being bilingual, he was able to bring a culturally nuanced approach to transcription and to capture words and concepts used by participants that could not be readily translated into English. Data were subsequently analyzed using a Bhutanese cultural frame, with every effort made to ensure the renditions and interpretations made were done faithfully. The cultural metaphors used by participants were also carefully considered during the transcription and data analysis stages of the study. As a point of clarification, of the three interviews that were not conducted in English, transcription of the interviews was not possible. This is because the language used, Tshangla, is only a spoken language—that is, there is no written script for this language. This meant that a direct translation of these interviews into English had to be made before they could be transcribed. Also, there is no capacity to corroborate the translations made for reasons of confidentiality. This process may have allowed some inaccuracies to occur in the transcriptions. Even so, confidence in the translations was warranted since the views expressed by the participants were consistent with interviews conducted in English. To redress the risk of mistranslation, in addition to the data analysis steps, the accuracy and credibility of the interview translation and data analysis were ensured using the following strategy: translating the Tshangla narrative into English text by using a bilingual translator (lead author). By being a truly bilingual person with a related cultural background, the adequacy of the translations was ensured (Chen & Boore, 2010); comparison of translated transcripts with other transcripts (transcriptions of English interviews) was done to gain conceptual equivalence and credibility, and thematic and content analyses were carried out by the lead author who is knowledgeable about the Bhutanese culture. An external outsider (coauthor) assessed a critical mass of randomly selected interviews to triangulate and strengthen the credibility of the findings from a patient safety framework and cultural competency perspective, and both researchers discussed and refined themes as these emerged during data analysis and until the most credible interpretation of the data was reached.
Mutual Respect
“Mutual respect,” which involves respecting and mutually esteeming the cultures of both researcher and participants alike, is achieved when researchers are cognizant of power differentials (i.e., between themselves and the research participants recruited to their studies); respect the views, beliefs, and values of research participants; and work to overcome traditional boundaries that separate researchers from participants (Im et al., 2004). In keeping with the view of mutual respect, as stated above, the sample of participants in this study was carefully recruited in a manner that was consistent with the core values of Bhutanese culture. Participants were given the opportunity to refuse to participate in or to withdraw from the study at any time. Participants also had an opportunity to choose a preferred time and place for their interviews. Further, the process of minimizing the risk to participants (privacy and confidentiality) was carefully planned and maintained.
Finally, based on the Bhutanese concepts of Le Judre, Tha Damtshig, and Thuenpa Puenzhi, all interviews were conducted with profound respect, with attention given to empathic listening to and understanding the participants. The Thuenpa Puenzhi, which is also known as the Four Harmonious Friends is a parable that depicts the virtues of Buddhist morals—the importance of mutual respect and teamwork (Pelzang et al., 2017). As a further measure of respect, an executive summary of the findings of this study was distributed to participants and was also provided to the Ministry of Health.
Flexibility
“Flexibility” is described by Im et al. (2004, p. 894) as referring to whether “the researcher was flexible in usage of languages and time for data collection.” For this study, as described above, participants were invited to select the language in which they preferred their interviews to be conducted. Moreover, the interviews were conducted in a place that suited the participants and according to their own time and availability.
Flexibility is also taken to mean whether the participants felt comfortable and were able to answer the question(s) put to them by the researcher. For this, all participants had the option of declining questions they felt unable to answer or uncomfortable about answering and the option to withdraw from the study. Significantly, no participants declined to answer any of the interview questions and no one withdrew from the study.
Cultural Positioning of the Researchers
The study was led by (researcher RP) a Bhutanese national. His position and status in this research was primarily that of an indigenous insider and an indigenous outsider (Banks, 1998; Subedi, 2006; see definitions in Table 1). The researcher’s status as an indigenous insider was derived from his being born, raised, and educated in Bhutan; from living in Bhutan for most of his life; and working as a nurse in the Bhutanese health-care system. His status as an indigenous outsider derived from his privileged position as researcher and student in Australia. It is also linked to the fact that, in order to undertake this study, he resigned from his position as a nurse in the Bhutanese health-care system. Most appropriately, the researcher (RP) was situated as what Subedi (2006) describes as “halfie.” This positionality of the researcher allowed him to collect data with full insight and understanding (of the social life and beliefs of the participants) and more aptly without detachment, contributing to cultural integrity and rigor (Merton, 1972).
Definition of Indigenous Outsider and Indigenous Insider by Banks (1998).
Barriers and Enablers Faced During Data Collection Phase
Despite the researcher (lead author) using culturally appropriate processes to access participants, sharing the same racial, ethnic, and cultural background with the participants, data collection was not unproblematic. Even as the indigenous insider and indigenous outsider researcher—whom Subedi calls “halfies”—he faced several challenges. For example, as a halfie, he failed to prove to or convince some participants of his identity as a “legitimate researcher.” As Subedi (2006) contends, such a situation can be daunting due to a lack of prescribed methods of research to which researchers can appeal for guidance.
During this study, one notable challenge faced by the researcher involved the recruitment of participants. Being a nurse researcher, and given the particularly patriarchal relationships that have traditionally existed between doctors and nurses in Bhutan, attempts to recruit and interview participants, especially from the doctor and health assistant/clinical officer categories, were frequently met with distrust and rejection, with very few willing to participate. Most doctors were reluctant to participate in the study citing lack of time or lack of knowledge of the subject area as the main reasons. Some refused to participate, making comments like “What is this for?” Others simply cancelled their scheduled interview at the very last minute, even though the dates and times had been agreed upon days or weeks in advance. Then, there were some for whom the researcher had to wait several hours for them to arrive. For these reasons, the requisite number of participants from these groups (doctors and health assistants/clinical officers) could not be recruited, notwithstanding it was the prerogative of prospective participants’ not to agree to participate in the study.
Although the researcher’s status as an indigenous outsider enabled him to overcome traditional boundaries that in the past have separated nurses from doctors and managers, his legitimacy as a researcher was at stake at certain points during the fieldwork. His indigenous outsider status became evident on at least two occasions: first, when he was not allowed to access a consenting participant in one clinical site from where recruitment was occurring (i.e., he was denied entry by the person in charge of the unit to access the potential participant). The attitude of the person in charge suggested that she saw him as a “total outsider.” As a consequence, he felt unsupported and rejected. On a second occasion, during the initial stages of the study, the manager of an institution from where participants were to be recruited refused to sign the organizational consent to access participants. On this occasion, the researcher believed he had been viewed by the managers/participants as “no longer part of the medical community” and as having “no right to gain access to the research settings or participants” (see also Banks, 1998). The exact reasons for such hesitation in allowing him to access potential participants, however, are not known. What the researcher does recall though is that he was not welcomed or made to feel like an insider. Instead he was treated with suspicion, amplifying his awareness of the power that gatekeepers have to withhold any access to information. In keeping with the observations made by Mullings (1999), he was consistently and symbolically reminded of his status as merely a “seeker of information,” wholly dependent upon the gatekeepers for information and subsequent access to participants. Despite being challenging, this experience was valuable because it enabled him to gain insight into how negotiating access to participants can be a complicated process and one that ought to be carefully considered at the planning stage of a study—whether qualitative or quantitative in design (Subedi, 2007).
Another challenge faced by the researcher was getting participants to sign the consent form—the main reason being their concern they would be punished by their manager for participating in the study, which manager would come to know through the consent form. Despite his clear explanation about the study and processes (including privacy, confidentiality, and the security of the data), most participants were reluctant to sign the consent form. The researcher had to explain to participants that it was a university formality and the forms would remain in the safety of the university (not in the Ministry of Health, Bhutan). Despite their initial reservations, all participants accepted this explanation and signed the consent form. This situation was a potent reminder of how institutional procedures, such as requiring participants to sign consent forms, can disrupt participant–researcher trust and relationships (Subedi, 2007).
Related to the above was the additional challenge of obtaining audio-recordings of the interviews, which was essential to ensuring the accuracy of the narrative data collection (Subedi, 2007). Participants became suspicious of the researcher’s motives when he explained that the interviews would be audio-recorded. This was particularly evident when participants asked “if it was necessary to record the interview.” On one occasion, a participant frantically indicated she may not speak if the interview was recorded. This highlighted that the request by researchers to audio-record interviews may present a barrier to obtaining accurate and in-depth information about the subject since participants may simply provide limited information. Thus, as Tillman (2006) noted, even while his status as an indigenous insider afforded him same-race and cultural affiliation, his research privilege was nonetheless challenged by some participants who were conscious of his previous professional position (as a nurse) and who may have been suspicious of his motives. He also learned that participant resistance to having their interviews audio-recorded should not be seen in isolation but placed in context. As Subedi (2007) noted, participants may, in fact, have legitimate concerns about their data being misused or, more simply, just “not like” having their interviews recorded. The challenges we experienced are consistent with challenges faced by other researchers (Arriaza et al., 2015; Karwalajtys et al., 2010; Lu & Gatua, 2014; Mullings, 1999; Ojeda, Flores, Meza, & Morales, 2011; Pang, 2016).
There were, however, also benefits to being a halfie. The researcher’s status as an indigenous insider invoked support among some managers and allowed him to negotiate initial entry into the research settings. This was particularly evident with the many nurses who came forward to participate in the study. Nurses treated him as a member of “their group.” On many occasions, during their conversations, nurses (including ward managers) would tell him that “nurses need to support fellow nurse researchers” and “they are encouraging each other to participate in the study.” Other participants (nurses and nonnurses alike) possibly felt obliged to participate in this study because of their preexisting relationship. On one occasion, one of the nonnurse participants clarified his decision to participate in the study by stating after the interview “I did participate in this interview because we know each other for so long as a friend.” He went on to say that “he wouldn’t have participated in the study if we were not known to each other.” This familiarity perhaps helps explain why participants in this study were so candid in sharing their experiences of patient safety concerns and their views on how Bhutanese traditional cultural values effect patient safety practices in the Bhutanese health-care system. It is possible, because of being an indigenous insider, the researcher was not perceived as a threat to them. Thus, because he was perceived as belonging to the group being studied, he had an advantage that “outsiders” might not have had in terms of gaining knowledge from participants. This positioning enabled him to collect highly sensitive and possibly more accurate information than had he been an outsider (Merton, 1972; Mullings, 1999; Papadopoulos & Lees, 2002).
Adding to his status as an indigenous insider was being a doctoral nurse candidate. This appeared to confer recognition of his social status having increased. He was perceived as one of the “elites” and what Im et al. (2004, p. 897) call an “authority figure” in the health-care system. It seemed to him that many of the participants believed that upon the completion of this study, the researcher (researcher RP) would be in a position to bring about much needed change in the Bhutanese health-care system. This was particularly evident in interviews with the nurse participants, many of whom shared concerns about the hierarchical system and its effects on health-care practices and patient safety. Participants’ perspectives surfaced quite often during interviews and conversations, with some of the nurses explicitly expressing the view that perhaps our research could assist in making patient safety issues more prominent in the Bhutanese health-care system. It was evident that this was a key reason why many of the nurse participants came forward to participate in this study. These experiences resonates with the findings of other researchers (Mullings, 1999; Pang, 2016).
Implications
Our reflections on methods to promote cultural integrity highlight their relevance, and indeed their necessity, to achieve research rigor. Undertaking research in a setting in which a collectivistic culture exists, where participants possess a strong sense of the in-group sociopolitical dynamic, requires careful consideration of the research methods. For example, in Bhutanese health-care organizations, being part of a hierarchically nested system (Pelzang et al., 2017), it was challenging to achieve research rigor even though we applied culturally appropriate strategies incorporating participants’ cultural values. Nonetheless, rigor may be achieved using the following strategies.
Firstly, in order to generate valid and reliable data, both in macro and mezzo research, it is imperative for researchers to have a thorough understanding and appreciation of cultural values (Campbell, 2014; Wright, Wahoush, Ballantyne, Gabel, & Jack, 2016). This entails adoption of a specific epistemology which determines the research design and/or methodology and using culturally appropriate data collection methods with in-depth understanding of cultural values and sociopolitical dynamics.
Second, forming a collaborative interdisciplinary research team and building interprofessional partnerships are paramount. Linking with leaders representing the population of interest is critical to the success of such studies because this will become the central “node” for interaction with potential participants (Karwalajtys et al., 2010). Collaborative efforts with leaders help in developing innovative and contextually appropriate strategies to access and enroll participants from diverse groups. In particular, involving leaders and explaining the significance of the impact of cultural values (tussle of power relationship) in research may help ease difficulty of recruiting participants (Duneier, 2004).
Third, fundamental to the success of research is gaining the trust and respect of participants (Fletcher, 2014). The main challenge for our study was participants being unwilling to share information and/or sign the consent form. Attempting to integrate by adopting certain mannerisms and ways of behaving that are common among potential participants may aid researchers in being accepted and, in turn, recruitment (Fletcher, 2014; Karwalajtys et al., 2010). To achieve this, the researcher needs to plan for sufficient time to develop trusting relationships with the people with whom research is being conducted.
Finally, strategies to protect the privacy and confidentiality of participants and techniques for obtaining consent are important (Wright et al., 2016). As seen above, obtaining written informed consent can be complicated by differing concerns and expectations across different participant groups. Researchers need to understand and be sympathetic to this context. Where participants are unfamiliar with research and in-depth interview methods, extra time is required for discussing the process to ensure they are fully informed before providing consent (Karwalajtys et al., 2010). Additionally, participants need to be reassured about the use of appropriate measures to ensure their anonymity during dissemination of study findings.
Conclusion
The approach to cultural integrity outlined in this article was built on the five evaluation criteria for rigor in cross-cultural research informed by Im et al. (2004). The approach taken in the study which informed this article affirms that the strategies proposed by Im et al. (2004) offer an explicit, practically based approach for researchers and enables application of the principles of cultural integrity as an inclusive method for research.
Maintaining cultural integrity of qualitative research is challenging in countries where the national culture has a significant influence on shaping and informing the models of organizational functioning. To improve cultural integrity in any research (qualitative or quantitative) researchers require at least a working knowledge of the sociocultural and political dynamics of the particular research settings or countries in which they are working. Most importantly, researchers engaged in research that has a cross-cultural dimension ought to explain what they did, how they did it, and why they did it, with respect to sociocultural and political dimensions, in order to ensure the study has cultural credibility. The conventional notion of credibility can be useful, provided it is adapted and applied in a culturally meaningful way. In this article, a description has been provided of how a study investigating patient safety concerns in the cultural context of Bhutan was conceptualized, the steps taken to achieve cultural integrity, how the researchers were positioned, and the culturally relevant barriers and enablers faced by the researchers during the study. To this end, attention was given to describing how the study’s overall approach was framed around the concept of core Bhutanese traditional cultural values.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.