Healing relationships between patients from visible minority groups and their clinicians in palliative care: Protocol for an interpretive description study

Methodology

This study will adopt interpretive description as a qualitative approach to studying healing relationships from the perspective of patients from visible minority groups.^27,28 This methodology generates a comprehensive interpretation of experiential clinical phenomena,^27,28 such as healing in the context of serious illness. We will employ this methodology to capture and interpret patterns within the personal and subjective experience of healing as well as potentially relevant variations that may emerge across patient narratives.^27,28 The reporting of this protocol conforms to the Observational and Qualitative Study Protocol Reporting Checklist (Supplemental Material 1). ²⁹

Sample and recruitment

Adopting a purposive sampling approach, we will recruit eligible patients through three institutions offering palliative care services in Canada. Key informants are those who (1) identify as being part of a visible minority group according to The Employment Equity Act, ³⁰ (2) have had at least two outpatient palliative care visits at McGill University Health Centre in Québec or who have seen palliative care clinicians affiliated with Bruyère Health Research Institute or Inner City Health Associates in Ontario, (3) are at least 18 years old, and (4) speak English or French. Recruitment flyers will either be posted in waiting rooms of outpatients’ clinics or distributed by clinicians to their patients and/or other clinicians who may see eligible patients. We anticipate including 10–15 participants in this study.

Data collection

We will conduct 45–60 minute semi-structured in-depth interviews with participants at their preferred location (virtually by Zoom or in-person if in Montréal). Participants will be able to choose if they prefer having a caregiver with them during their interview. We developed an interview guide to ask participants about their experience of relationships with their palliative care providers and what healing means and feels like to them in the context of these relationships (Supplemental Material 2).

Data analysis

We will transcribe audio-recorded interviews and analyze these using a hybrid deductive-inductive approach to thematic analysis.^31,32 We created a “theory-driven” coding scheme ³³ using our interview guide, which reflects our knowledge based on current literature within palliative care.^{18,23,34–48} We will apply principles of hybrid thematic analysis ³¹ and constant comparative analysis to continuously update our codebook based on new insights from the data.^27,49,50

Before initial coding of the data, we will ensure in-depth familiarization with the interview transcripts to prioritize theorizing and contextualizing over sorting of the data. ²⁸ Our analysis will reflect the contextual nature of the data by continuously moving “in and out of the detail.”^27,28 We will iteratively discuss coding schemes to enable ongoing and flexible reconstruction of themes and to critically draw broader connections between data segments. ⁵¹ After initial coding, we will first identify broad characteristics that participants find significant and meaningful for their relationships. We will then discuss similarities and differences in the data to characterize healing in the context of these relationships. ²⁸ We will examine groups of data comprising similar characteristics and consider alternative ways of broadening conceptual linkages between them, as suggested by the methodological framework. ²⁷ We will identify themes within the latent content of the data to construct a meaningful and coherent interpretive account of patients’ experiential knowledge. ²⁷ Iterations of these themes will be continuously reviewed and discussed by members of our research team to ensure an accurate and holistic representation of the data.

We will adopt strategies informed by interpretive description for ensuring rigor.^27,51 In addition to regular debriefing meetings during data collection and analysis, we will create reflexive memos at each stage of analysis to document our analytic decisions and reasoning processes.^51,52 We will also use these ongoing memos to ensure our analysis is grounded within the data.^27,28

Summary

This study aims to explore the qualities of healing clinician–patient relationships from the perspective of patients from racialized groups who are seen in the context of serious illness care. Specifically, we will invite patients from visible minority groups to share their experience of clinical relationships in outpatient palliative care. We will describe healing from their perspective and the role of clinician–patient relationships in healing. We will document the relational elements of care that foster meaningful connections and that support patients’ journey toward healing.

Implications

By identifying patient-informed elements of clinical encounters that foster healing, our study has the potential to improve the quality of clinical relationships and care for all patients affected by serious illness. This study may drive evidence for training programs centered on fostering relationship-building behaviors that patients facing multiple vulnerabilities value and that promote their sense of healing. This study may also inform future participatory research activities to co-create meaningful strategies that help clinicians build healing relationships with their patients. The findings of this study can lead to initiatives that improve clinical relationships, which may address inequities in palliative care and other clinical settings. Finally, this study may contribute to our theoretical understanding of relationship formation in the setting of sociocultural vulnerability, with attendant impact on further research in patient–provider communication.

Limitations

The study data should be interpreted in light of anticipated limitations. Race and ethnicity (from which visible minority status derives) are among many intersecting factors that impact access to and quality of healthcare. Our focus on visible minorities as the salient factor in our interviews risks failing to capture other aspects of identity, and other potential sources of marginalization, that may more significantly impact people’s experiences and relationships with clinicians. However, research into the experience of patients from visible minority groups remains in its nascency in Canada despite its significant ethno-racial diversity. The proposed sample size of our study may not support the identification of relationship qualities that reflect the experiences of all visible minority groups. Given the scope of this study and the challenges of recruiting participants, we determined that a smaller sample size would promote the feasibility of completing this study and help us produce contextual knowledge that could be pertinent for future research. To ensure that we include a diverse range of visible minority groups, we will concurrently collect and analyze interview data. Ultimately, our findings will be hypothesis-generating.