“Achieve the best while rushing against time”: A grounded theory study on caring for low-income immigrant cancer patients at end of life

Abstract

Background:

Between 2000 and 2020, Europe experienced an annual net arrival of approximately 1.6 million immigrants per year. While having lower mortality rates, in the setting of severe diseases, immigrants bear a greater cancer-related burden due to linguistic and cultural barriers and socio-economic conditions. Professionals face a two-fold task: managing clinical conditions while considering the social, economic, cultural, and spiritual sphere of patients and their families. In this regard, little is known about the care provision to low-income immigrant cancer patients in real contexts.

Aim:

To investigate the perspective of professionals, family members, and stakeholders on the caring process of low-income immigrant cancer patients at the end of life.

Design:

A Constructivist Grounded Theory study.

Setting/participants:

The study, conducted at a Hospital in Northern Italy, involved 27 participants among health professionals, family caregivers, and other stakeholders who had recently accompanied immigrant cancer patients in their terminal phase of illness.

Results:

Findings evidenced that professionals feel they were not adequately trained to cope with immigrant cancer patients, nonetheless, they were highly committed in providing the best care they could, rushing against the (short) time the patients have left. Analyses evidenced four main categories: “providing and receiving hospitality,” “understanding each other,” “addressing diversity,” and “around the patient,” which we conceptualized under the core category “Achieve the best while rushing against time.”

Conclusions:

The model reveals the activation of empathic and compassionate behavior by professionals. It evidences the need for empowering professionals with cultural competencies by employing interpreters and specific training programs.

Keywords

Immigrants neoplasms palliative care end-of-life care cultural competency grounded theory

What is already known about the topic?

The increase of migratory flows from Africa and the Middle East to Europe triggers the intensification of immigrants’ health-related needs.

Despite the lower disease-related mortality rate of immigrants, immigrant cancer patients bear a greater burden of disease due to linguistic and cultural barriers and socio-economic conditions, especially for those coming from low-income families.

Within a multicultural milieu, caring for immigrant cancer patients requires an intercultural approach that should be studied in real contexts.

What this paper adds

Healthcare professionals and interpreters feel they are not adequately trained to cope with low-income immigrant cancer patients’ care.

Even if professionals try to “achieve the best while rushing against time”, they don’t have means for adopting a cultural-sensitive approach to care.

Professionals’ compassionate and supportive behavior toward patients can supply other shortcomings to support the care process, especially when network resources are activated.

Implications for practice, theory, or policy

Our explicative model evidences training needs on cultural competencies.

Caring for low-income immigrant cancer patients’ end-of-life care can be a teachable moment for a range of professionals (especially palliative care specialists, interpreters, social workers).

A cross-cultural/intercultural understanding of palliative care should shape low-income immigrant cancer patients’ assistance.

Background

The complex dynamic political and economic situations in areas such as East Europe, Africa, and the Middle East have triggered a stark increase in immigration flow toward Europe.¹ Between 2000 and 2020, the region experienced an annual net arrival of approximately 1.6 million immigrants per year. In 2018 2.4 million immigrants entered the EU-27 from non-EU-27 countries. As of January 1st, 2019, of all the EU-27 inhabitants, 4.9% (21.8 million people) were non-EU-27 citizens.² In this context, Italy ranks at the 4th place among European immigration destinations.² In the majority of cases, immigrants arrive from war-struck and low-income countries and remain in economically precarious conditions for many years after their arrival in Europe.³

From a health perspective, immigrants feature lower disease-related mortality rates compared to the local populations,^3,4 yet bear a greater burden of disease⁵ due to linguistic and cultural barriers and socio-economic conditions, which greatly affect their quality of life, especially in the setting of severe diseases.⁶ Professionals taking care for low-income immigrant cancer patients face the twofold task of managing clinical conditions on one hand while considering the social, economic, cultural, and spiritual sphere of both patients and their families.^7,8 In fact, as meanings across ethnic groups differ, management of end-of-life issues^9,10 cannot be guaranteed outside an intercultural approach,¹¹ paying special attention to the multicultural milieu, effective diagnosis communication, involvement of the family in the care process, and attention to religious beliefs and existential suffering.^7,8,12,13

While literature on the needs of immigrant cancer patients at the end of life has recently increased,^8,14–19 little is known about the care provision to low-income immigrant cancer patients as a negotiated process among stakeholders in real contexts. The aim of this study was to investigate the shaping of such negotiated process as influenced by the perspectives of professionals, family members, and key-informants.

Methods

Methodological approach

The research question was: “What is the process of caring for low-income immigrant cancer patients like from the stakeholders’ perspective?” Accordingly, we opted for Charmaz’s constructivist grounded theory method,²⁰ which is a broad-ranging interpretative research approach used in the social sciences to define social and psychological processes.²⁰ The constructivist stance of the method refers primarily to how scientific knowledge is understood: an intersubjective construct influenced by participants, researchers, and the way they collect data.²⁰ By following this specific constructivist approach, we intended to explore in-depth the meaning attributed to phenomena (signified) and the (contextual and social) aspects negotiated by the informants. Constructivist grounded theory allowed developing an explicative model that can explain which factors influence immigrant cancer patients’ care. Reporting of the study followed the consolidated criteria for reporting qualitative research checklist.²¹

Settings

The primary setting of this research was the Cancer Research Hospital of Reggio Emilia (Italy) which is embedded in a General Hospital located in the Local Health Authority of Reggio Emilia Province (whose catchment area counts more than 530,000 inhabitants). The Cancer Centre has 200 beds and provides diagnostic, therapeutic, rehabilitation, supportive, and palliative care for cancer patients. It performs basic, clinical, and translational research. In addition, we involved the two hospices of Reggio Emilia province.

Recruitment

Eligibility criteria were being 18 years or older, able to provide consent and participate in data collection in Italian or English, having lived the experience of caring for a low-income immigrant cancer patient as healthcare professional (nurse, doctor, interpreter, social worker) or a family member (including loved-ones and friends). The principal investigator (S.S.) contacted potential participants by telephone or by e-mail (for family members) after at least 3 months from the patient’s death and shared the study information sheet. She then invited them to an interview in a place of their choice.

Sampling

The study carried out an initial sampling, followed by a further theoretical sampling.²⁰ The initial sampling was performed on a purposive basis (i.e., driven by the purpose/aim of the study, hence family members, interpreters, nurses, a palliative specialist and a healthcare worker as key-informants); the second round of sampling was guided by emerging analysis/coding to verify, saturate, and expand theoretical categories emerging from the previous sampling, in agreement with Charmaz’ constructivist grounded theory approach.²⁰ Specifically, the focused coding highlighted which participant categories needed to be implemented for (i) further comparisons (constant comparison among additional family members, interpreters, nurses, palliative specialists, healthcare workers) and (ii) saturating some emerging categories (i.e. “understanding each other,” “addressing diversity,” and “around the patient”). Hence, it extended the sample to include different professionals who emerged as having a role in the care process (oncologists, physicians, psychologists, social workers, immigrant association members, charity directors, and funeral operators).

Data collection

Researchers collected data by means of semi-structured open-ended interviews. We defined two interview guides (according to participants’ type as shown in Table 1) As suggested by Charmaz,²⁰ researchers pre-planned a light-structured interview guide with open-ended questions to permit the interviewer to concentrate of what the participants were saying as well as the participants to provide rich description of their experience (intensive interview). Researchers defined specific foci (caring experience, perceived care priorities, and immigration-related issues) without following any prior theoretical framework. As we developed the grounded theory study, our theoretical sampling led us to also collect data by means of a revised version of the initial interview guide, posing focused questions related to emerging categories (particularly those we named “addressing diversity” and “around the patient”). We tried to avoid factual questions and indicated a series of prompts. All the researchers received a training in qualitative interviewing within a constructivist approach. They were also advised to follow the informants’ interests and thoughts by posing probing open-ended questions which allowed flexibility for both participants and interviewers.²⁰ Interviews were conducted in Italian from May 2016 to January 2017 by two researchers (interviewer and observer), audio-recorded and then transcribed verbatim immediately after by the interviewer. All the authors conducted the interviews alternatively.

Table 1.

Interview guide.

Participants/exemplifying questions	Opening questions	Caring experience	Perceived priorities	Immigration-related issues
Professionals and stakeholders	Could you please tell me what the patient’s situation was?	What was it like for you to assist the patient in the last days of life?	In your opinion, what was important for the patient? And his/her caregivers?	How is the reception toward an immigrant patient?How do you feel about treating an immigrant patient?
	Could you please tell me what you are/were doing for the patient?	Could you tell me how you accompanied the patient to death?
		Could you tell me how you accompanied the patient to death?		What do you feel when caring for an immigrant patient?
Family members/loved ones/friends	What happened around your loved-one, in the last days of his/her life?	How did you feel at that moment? How did those days go?	What was important to you at that time?	What had your loved-one brought here in Italy?
		How did you feel at that moment? How did those days go?		How long had he been in Italy?
	What did you think you had to do?	I would like you to tell me how you felt in those moments.		Could please tell me your thoughts about the hospital and care you and your loved-one received?

Data analysis

The initial coding was carried out on the first two interviews, analyzed using the inductive and constant comparison method by two researchers. Then, open coding included six further interviews, while contextually data collection was analyzed.²⁰ By means of open coding, we identified 24 categories, then narrowed to 14 categories with focused coding. Based on these, we then elaborated a provisional model (theoretical coding). After further 19 interviews no new data emerged so the identified categories were saturated, through group discussion and audit trails, and allowed the definition of the explicative model, with four main categories and one core category.

Rigor and reflexivity

Two experts in qualitative methodology (L.G., S.D.L.) trained four researchers (S.S. a palliative physician, R.C. a physiotherapist, F.F. a neurophysiology technician, F.S. an oncology nurse) during a course in Qualitative Research held in 2015–2016 at the Hospital of Reggio Emilia.²² Participants were not met by the researchers before the interview except for two participants, co-workers of the principal investigator. Researchers applied strategies for ensuring rigor and validity,²³ starting from the methodological appropriateness of research question and used method. Every single step of the data collection and analysis was conducted by at least two researchers. The team worked collaboratively, along with the supervision of the experts. All the authors discussed the results of the various levels of coding.

In order to assess grounded theory validity, credibility, originality, resonance and usefulness are the suggested criteria.²⁰ Credibility was obtained by collecting adequate data to substantiate the model. Besides, the core category and subcategories were recurrent across all the cases. Originality was reached by using the participants’ words as much as possible during coding as well as defining categories. As to resonance, saturation achieved in our analysis permitted to have a comprehensive picture of the experience within a specific hospital setting. Finally, we valued usefulness of this study as it can offer consistent interpretation of the process of caring for immigrant cancer patients.

Ethical considerations

The study was approved by the Provincial Ethics Committee of Reggio Emilia (In-House Prot. Number 2016/0014485). All participants received an oral and written information about the study objectives, in Italian and in English, if requested. They expressed in written form their consent to participate and authorize the sensitive data processing. No interpreters were needed to assure participants’ understanding.

Study population

Twenty-seven participants were interviewed (interviews’ mean duration: 29′). No interviews were repeated. Initial sampling involved: a family member (widow), two interpreters, two nurses, a palliative specialist, and a healthcare worker. Thus, during the theoretical sampling, we interviewed four additional family members (a widow, two daughters, and a brother), an interpreter, two nurses, two palliative specialists, and a health worker. Two contacted family members dropped the study because they were still experiencing intense psychological suffering.

Participants’ demographic profile is as follows: 20 females and 7 males, with a mean age of 48.3 years (range: 31–68); 18 were Italian citizens (all the professionals, the charity Director, and the funeral operators); an interpreter, a family member, and the immigrant association member were Albanian, a family member was from Romania, another from Chile, an interpreter from Ukraine, an interpreter and two family members were Arabic. All the participants with non-Italian cultural background came from self-defined low-income families; they were resident in Italy for at least 5 years. It is noteworthy to mention that “interpreters” in Italy are not merely “translators” but more properly “cultural mediators,” who have knowledge of both cultures (the immigrant’s native culture and that of the adoptive community) and are trained to using their knowledge to adapt contents to establish respectful communication between the parties involved.

The locations of practice for health professionals included: day-hospital ward of the Reggio Emilia Hospital, and the two provincial hospices.

Results

“Achieve the best while rushing against time”

The study was carried out in a context of free public healthcare system. Participants tried to realize a care process for immigrant cancer patients by implementing their naive skills and competencies. They concentrated their “best” in the short time left to cancer patients at the end of life, trying to alleviate patients’ suffering, without taking into account any cultural understanding. This “best” did not include specific intercultural competencies nor a shared path among healthcare professionals, family members, interpreters, social workers and the other stakeholders. This was thus conceptualized as “Achieve the best while rushing against time.” Within this core category, we identified four sub-categories (Table 2): “providing and receiving hospitality,” “understanding each other,” “addressing diversity,” and “around the patient,” Figure 1 visualizes the explicative model we constructed.

Table 2.

Categories and sub-categories.

Main categories	Subcategories
Providing and receiving hospitality	Welcoming
	Trust in local health services
	Health tourism
Understanding each other	Need for communication
	Filtered communication
	Burden of spokesperson
	Acknowledging the importance of culture
Addressing diversity	Cultural minimization
	Paternalism and prejudice
	Being pushed to do more
	Diversity claim
Around the patient	Support
	Improvisation/confusion
	Bridging

Providing and receiving hospitality

In general, the positive perception of immigrants and professionals of a welcoming region also extended to the region’s healthcare system. Trust toward the healthcare system was a common feature across all the interviews we conducted.

Healthcare worker:

“There is a common culture of hospitality, to the extent that many, even if they are not residents, come here to be cured.”

Family member:

“He [her brother] wanted the treatment in Italy because he had brothers here and they trusted the healthcare services.”

Our data revealed that participants with immigrant background shared by word-of-mouth information about the possibility of keeping in hospital end-of-life rituals or religious habits. This eventuality was also accepted and allowed by some healthcare professionals within their wards and funeral agencies nearby.

Interpreter:

“Many choose Reggio Emilia, because of the ritual of Islamic washing in the hospital, the contact with the mosque. . . and the funeral agency that contacts the mosque for the religious rituals.”

For many participants with the immigrant background, accessing oncological care services meant consenting to the loved ones with cancer to feel secure by having quality end-of-life treatments and palliative care assistance.

Interpreter:

“They [immigrants from Ukraine] come here. . . because, in Ukraine, the treatment at the end of life is not the same as yours. It is much more difficult, and death is so painful.”

This category also includes what we named “health tourism.” Interviewed professionals (especially nurses, oncologists, social workers, and interpreters) reported that the healthcare service where they worked was felt like the destination of many immigrant cancer patients leaving their countries to receive appropriate treatments. Conversely, the family members confirmed that they were confident that they would have received the most appropriate care for their loved ones.

Understanding each other

The caring process for low-income cancer immigrant patients involves the category related to communication and mutual understanding. It emerged that language was a barrier to a shared understanding of care needs. Health professionals stated how communicating with patients about sensitive issues as worsening of clinical conditions, prognosis, objectives and side effects of cancer treatments without the aid of an interpreter, was both a challenging and an upsetting task. Most patients assisted spoke Italian, more or less fluently, and all doctor-patient communications were in Italian. According to health professionals, patients appeared to understand communication although they could not exclude that some linguistic nuances about medical facts (diagnosis, severeness, prognosis, risks factors) could have been lost.

They also reported that they had their messages to the patients readapted by family members attempting to protect their loved ones from bad news. Professionals reported they felt inadequate for dealing with during such complex relational situations. Moreover, professionals described they doubted the fidelity of the translation performed by family members considering their intervention an improper filter.

Oncologist:

“In the phase in which there were important things to communicate, it was the daughter who was the interpreter; but in fact, I did not understand what she said to her mother. I suspect that she did not tell things as they were.”

In turn, family members experienced acting as translators with a sense of discomfort and inadequacy. From our analysis, a sort of “spokesperson burden” emerged since the discussed issues were emotional and intimate, and the cultural subtexts of the communication involved were difficult to translate or to make clear in another language.

Family member:

“I did not translate everything of what the doctors said. I was the translator, but it was not easy to say certain things to my dad.”

Also, routine communication with immigrant cancer patients and their family was a challenging task for healthcare professionals. The participants working in hospices and the hospital narrated their lack of preparation in terms of communicative skills and cultural understanding.

Nurse:

“I do not feel well trained to handle an immigrant. You never know how much you can say, how much you can joke.”

Many professionals misunderstood the function of culture in expressing suffering, care needs. They gave to “cultural mediation” the meaning of mere “translation” into another language. Contrarily, interpreters affirmed that having clear the difference between mediation and translation is crucial for allowing mutual understanding during the caring process.

Interpreter:

“It is not just a matter of doing a literal translation: when you translate, you transmit an emotion. Translation takes on the role of reference for the patient and his/her family.”

Interpreters asserted that this misinterpretation could explain why they were often called into a situation on short notice and with no preparation.

Interpreter:

“We [interpreters] arrive at the patients’ side without knowing them, their story, if they are religious. If the interpreters were activated earlier, they would know the person better.”

An exception regarded the palliative specialists who acknowledged the role of semantics, language and the nuances of meanings in end-of-life care for immigrant cancer patients.

Palliative specialist:

“We [palliative physicians] talk about very delicate topics. I don’t just need the patient to give me a ‘Yes’ or ‘No’ answer to the pain. The words, the nuances of the words are particularly important.”

Addressing diversity

According to participants, the caring process was paced by many issues (language, religion, beliefs, habits and traditions), which influenced the way the relationship between professionals and family members was perceived.

Some professionals (especially oncologists, nurses, health workers) tended to consider cultural differences not relevant (cultural minimization). Other professionals agreed that lack of consideration toward cultural differences in the care relationship could lead to seeing the patients “all alike.” In this respect, the risk regarded thinking about care needs as universally pertinent instead of considering that culture shapes disease perception and personal preferences.

Healthcare worker:

“I do not know if it is a defect or merit, I consider them like us. . . I did not experience any issues since they didn’t have particular ‘customs’ in receiving care.”

Nurse:

“Whether they are Roma or Chinese, anything you can think outside the hospital, I focus on the health problem. . . they had habits like ours.”

However, all the professionals agreed that cultural differences were not generally taken into consideration, and for healthcare being provided, patients’ cultural differences were often ignored.

This phenomenon related to a paternalistic and prejudicial attitude toward cultural diversity. The low-income immigrant patients and their families were often labelled as “fragile” persons, with no personal resources and “lost” in a foreign world.

Nurse:

“I am always a little more careful with them. I see them more and more ‘weak’ in this situation.”

Oncologist:

“Immigrant patients have little social support, so they have no one to rely on, they are alone. . . even when they have family members here, they are always people in need who must be followed by a service.”

The common culture of hospitality all the participants referred about, along with perceiving low-income cancer patients and their families significantly disadvantaged in many aspects of life, concurred in making professionals feel coerced “to do more,” in terms of commitment and emotional involvement.

Healthcare worker:

“I’ve the urge to do something more to help them. . . I give a special eye on them because they are vulnerable, and they totally need our resources and attention.”

In opposition to how professionals perceived and acted, family members and participants with the immigrant background claimed their diversity and the right to be considered in their differences. They often wanted to make clear the meanings that “being ill,” “being healthy,” or feeling pain had in their native country.

Immigrants’ association member:

“In Albanian popular culture, disease is a kind of punishment, so who becomes sick, perceives feelings of shame and sorrow.”

All our participants with immigrant background reported that having cancer was felt like a defeat, something the family could barely accept. They stated that the motivations underneath the loved ones’ immigration considered job-seeking and getting better living conditions. In this sense, cancer was a “dream-breaker.”

Interpreter:

“Thinking of dying when you are young, outside your country is exceptionally hard. . . psychologically. Immigrating to die is unacceptable. . . Who immigrates must be healthy, young, cannot get sick. There is the fear of losing the job and then the documents, and the residence permit. . . For this they often skip the health checks.”

Around the patient

This category conceptualizes the effort family members, immigrants’ associations, supported by their communities, put in surrounding the patients. From our analysis, it emerged how evidencing issues in professionals’ modalities of addressing cultural differences and interpersonal communication, did not mean lacking attention or dedication. Equally, participants with immigrant background confirmed that they were committed to helping the best they could and providing economic, bureaucratic as well as emotive support for low-income immigrant cancer patients: the community gathers “around the patient.”

Immigrants’ association member:

“I do not think the economic factor is influent. If one wants to go home, they find the money: family is essential, it is a ‘holy bond’.”

An interpreter explained that patients and their families need help to face practical elements of the end of life. They referred in particular to bureaucracy, bequests, banking, economic decisions, but also last important wishes like the desired burial place and country.

Interpreter:

“If a person can count on the support on at least the things you can organize ahead of time, like selling the car, for example, it is better.”

All the family members reported that their loved ones felt a “bureaucratic burden,” especially for managing the expenses related to healthcare (drugs, auxiliaries), the residence permit or, if this was the patient’s wish, the many documents to go back home before passing. A family member admitted:

Family member:

“Nobody, nobody at all, helped me. . . They sent me from one office to another. I was angry.”

We found that there was confusion among participants with the immigrant background in being oriented within the last things to do for their loved one, as well as among professionals who felt uncertainty or being too busy to help.

Professionals felt they were not informed or prepared to help patients and their families in meeting organizational needs. Many reported that they provided both patients and relatives with unclear and inaccurate information.

Nurse:

“I don’t know. . . We just gave an indication like ‘Try that office’, in other cases we tried to find out ourselves a way to get solutions. But who knows? Information is here and there.”

Doctors admitted they felt unable to support relatives in corpses’ repatriation procedures when this was a patients’ and families’ desire.

Oncologist:

“We already have many problems to deal with. And we cannot deal with repatriating the corpses.”

On the other hand, social workers, funeral operators, and interpreters felt more prepared and informed.

Funeral operator:

“There is a path to follow, with permits for cremation and the ashes or corpse repatriation. We must prepare the right documentation. There is much bureaucracy around repatriation.”

Participants described what we conceptualized as “bridging strategy” for the patients. Gathering around the patients means helping them and their families both before and after the decease. In the latter case, “bridging” signifies preparing all the necessary to organize repatriation. In this context, associations, charities, co-operatives played a critical support role.

Nurse:

“For these things. . . To fulfil their loved one’s wishes, they [patient’s community members] always find money. . . I do not know how.”

Interpreter:

“The Albanian community has arranged for the plane ticket to bring her husband to Italy.”

“Being the bridge” was the role our participants with immigrant background wanted to take after loved ones’ death. This role included activities directed to the patients (realizing, if possible, the patients’ wishes about the burial place) and, also, to the family and the community members who could feel they have “closed a cycle.”

Family member:

“My sister had said that she wanted to go home, no matter what. . . I knew this, so my other sister and I decided to bring her back to Romania after her death.”

Discussion

Main findings

The present study allowed us to conceptualize a model that describes the process of assisting a low-income cancer patient, from the multiple perspective of professionals, family members and other stakeholders. The core category “Achieve the best while rushing against time” evidences the lack of a formalized and structured path performed in the contingency of the short time available. All the participants (both healthcare professionals and interpreters) tried to do their best in terms of professionalism, co-partnership, and compassion but yet felt inadequate and unprepared for facing the complexity of care and type of information to be passed to the patient. Such perception of being inadequate was common but took on different nuances based on the person’s role (“understanding each other”). This was closely linked to the person’s cultural competences—defined as the set of knowledge, comprehension skills and abilities—which allow the professionals to assist consistently across different patient needs and cultural backgrounds.¹¹

Our findings have evidenced the meaningful role of the interpreter/cultural mediator. In fact, dealing with “death is difficult in any language”²⁴ and the dealing outcome can be largely affected by the way information is provided and received. A systematic review on how professional medical interpreters influence the delivery of palliative care services to non-native speaker patients²⁵ shows that not employing professional interpreters lead patients and families to an inadequate understanding about diagnosis and prognosis. Moreover, half of the studies included in the review concluded that professional interpreters were not used adequately. This was confirmed by findings from our grounded theory which evidenced the interpreter/cultural mediator as key in facilitating a cross-cultural approach²⁶ (“understanding each other”) and providing proper intercultural cancer care²⁷ (“addressing diversity”). Family members would have appreciated a stronger role of interpreters/cultural mediators to alleviate their “spokesperson burden.” Taken together, the findings suggest opening the doctor-patient interactions to well-trained interpreters and creating a triadic care relationship where the role of culture is acknowledged and becomes a teachable moment for all the actors involved.

The emphatic, engaged, and compassionate attitude of the professionals involved acted as facilitating factor toward intercultural cancer care. As shown elsewhere,^28,29 this “situational compassion” (that is the “compassion emerging through interactions within a given situation”), promotes the urge “pushed to do more.” This attitude appears to be appreciated by immigrant cancer patients³⁰ and is a pre-requisite for a culture-sensitive care in oncology and palliative care.⁸

The category “giving and receiving hospitality” we find to be quite suitable for the research setting of this study (Northern Italy), historically characterized by a strong political commitment to promote social advancement for all citizens—immigrants as well—and by attention to preserving a free public health system for all.^31,32 Therefore, we expect our findings not overlap with those from other geopolitical settings. Certainly, the role of the political and social environment as well as the local community dynamics^33,34 are essential elements in comprehending the needs of low-income immigrant cancer patients and the best way to fulfil those needs (“around the patient”).

Strengths and limitations

This is the first study, to the best of our knowledge to describe a multi-stakeholder analysis of the process of assisting a low-income cancer patient. Among the strengths of this study, we may include the rigor of the methodological approach, which allowed us to gather rich interview data. The study population involves different key-informants with diversified roles and responsibilities in the process of caring for low-income immigrant cancer patients. Nonetheless, the findings lack the patients’ perspective. However, this was beyond the scope of the present study. The research setting was a cancer research hospital in a western country providing free access to oncological and palliative care services for all the residents, regardless of their nationality or citizenship. So, key-informants in a different setting might vary and engage in caring processes that are dissimilar to that we have conceptualized. Nevertheless, our model could explain caring processes within free public health systems and a supportive and benevolent social environment.

As to methodological limitations, we should note that no transcripts were sent to participants. We supported member checking by organizing a public meeting to return the results of the study and discuss them with stakeholders and participants. All the participants were invited and provided with the possibility to interact with researchers. Only eight participants could attend. Nonetheless, the received feedbacks were taken into account in writing the findings.

Implications

It is known that patient outcome and morale largely depend on the perception patients have of their relationships with their loved ones,³⁵ professionals’ attitude, and communication quality.^36,37 These aspects are more relevant at the end of life and immigration settings, which both represent two peculiar aspects of care delivery, according to a cross-cultural/intercultural approach.²⁶

While palliative specialists are well-trained on end-of-life care, they lack formal training on intercultural issues in health caring,³⁸ suggesting the need for curricular courses to mold sensitivity.

Our study highlights how caring for low-income immigrant cancer patients’ end-of-life care can be a “teachable moment” for a range of professionals (especially palliative care specialists, interpreters, social workers). Acquiring cultural competencies can provide professionals with the tools they need to approach immigrant cancer patients and their families,³⁹ recognizing the uniqueness of each patient and facilitating professionals’ self-awareness, sensitivity, and open attitude toward any end-of-life issue.^6,39

Likewise, specific in-hospital training by palliative specialists could be planned for official interpreters for them to grasp the nuances of palliative care. As suggested by Butow et al.,⁴⁰ interpreters could be invited to interact with the multi-disciplinary team, as with the end-of-life care team. It has been highlighted that pre-meetings between clinicians and interpreters are important to discuss topics and terminology to be used during goals of care discussions.²⁵

Moreover, healthcare professionals should be better informed about the resources of all the services available in and outside of the hospital and be invited to actively collaborate with the third sector (e.g. immigrant associations).

Finally, our findings stimulate further research for creating a theoretical explanation for the decision-making process related to death place and burial for low-income immigrant cancer patients and for expanding the present grounded theory by including the voice of patients.

Conclusion

“Achieve the best while rushing against time” is the core category that explains how professionals, family members and other stakeholders take care of a low-income cancer immigrant patient. We found that all the participants felt the pressure of the passing time to try, at their best, to help the patients. Within a setting felt as welcoming and inspiring trust, we conceptualized how professionals address cultural differences (minimizing them, assuming a paternalistic posture and still committed to “do more”) and, reversely, how familiars and interpreters claim their cultural identity. Understanding each other includes several communication-related issues: filtered communication and burden of the spokesperson. The role of interpreters was also defined and the need to increase their palliative skills detected. Support for the patients was not lacking, even when carried out in an improvised manner.

Footnotes

Acknowledgements

The authors would like to acknowledge the participants for having dedicated their time to us for collecting their precious stories. We thank Dr. Massimo Costantini of the Scientific Directorate for the opportunity given to carry out a qualitative research course and the confidence granted in the conduction of the study. We also thank Mrs Manuella Walker (Pisa, Italy), medical writer, for the editing service. We would like to also thank the patients, to whom this research is dedicated.

Authors contribution

All authors made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of data.

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.

Ethical approval

Ethical approval of the study was granted by Ethic Committee of Arcispedale Santa Maria Nuova under the number in-house prot. n. 2016/0014485.

Informed consent

All participants signed an informed consent form documenting willingness to participate to interviews and to have said interviews’ audio recorded.

ORCID iDs

Simona Sacchi

Luca Ghirotto

Data management and sharing

All data sets (in Italian) on which the conclusions of the paper rely are available on request to the corresponding author.

References

McAuliffe

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