Cultural Diversity - Institute of Medical Illustrators...IMI National Guideline – Cultural Diversity Lead Author – Pip Stiff Date Created – November 2004 Last Review Date –

IMI NATIONAL GUIDELINES:

IMI National Guidelines

A Guide to Good Practice

Cultural Diversity

These guidelines have been developed by the Institute of Medical Illustrators,

in consultation with specialist advisors. They should be considered a guide to good practice, providing a baseline for auditable standards.

If necessary, adaptations may be made to take your local conditions into account.

© Institute of Medical Illustrators 2020. All rights reserved. Unauthorised copying, distribution or commercial exploitation is prohibited and will constitute an infringement of copyright.

Reproduction permission granted for personal and educational use, and for the development of Medical

Illustration departmental guidance, subject to acknowledgement of the source material.

IMI National Guideline – Cultural Diversity Lead Author – Pip Stiff

Date Created – November 2004 Last Review Date – November 2020

Review Due – November 2023 Version – V2

2

Contents

Introduction ………………………………………………………………………………………………….3

Section 1. Attitude and understanding...………………...………………………………………………..3

Section 2. Working with others…………………………………………………………………..………...5

2.1 Formal and informal interpreters………………………………………………………………………6

Section 3. Communication ….……………………………………………………………………………..7

3.1 Verbal language……………………………………………..………………………………………….7

3.1.1 Addressing a patient……………………………………………..………………………..……..8

3.2 Body language……………………………………………………………………………………….….9

3.2.1 Eye contact …………..……………. ……………………….………………….………………10

Section 4 - Photographic session ………………………………………….…………………………….11

4.1 Prior to session ………………………………………………………………………………………..12

4.2 During session ………………………………………………………………………………………...13

Summary ……………………………………………………………………………………...……………13

References………………………………………………………………………………………………….15

Acknowledgements…..……………………………………………………………………………………17




3

Introduction

Multiculturalism and diversity can affect the practise of clinical photography, in that capturing of a

patient's appearance may involve the patient acting in a way outside their usual habits. The most

common example of this is photographing an area covered for cultural or religious reasons.

However, other sensitive actions could include the act of having their photograph taken at all, or

being alone with someone of the opposite sex. It is important to be aware how patients present

themselves, as clothing and other accessories can potentially make you aware of a person’s

cultural background, which will allow you to adjust your behaviour/language/service appropriately.

It is important to acknowledge that this is a balance; one where the photographer must be aware

of differences and act accordingly, whilst ensuring that actions taken are not discriminatory or

imbalanced. Ultimately the photographer will be required to draw upon their interpersonal skills

and moral values to ensure they act lawfully and respectfully with patients (Hordern, 2016).

This document seeks to help the photographer identify best practice and interaction during a

clinical photography session, this is not an exhaustive list, nor is any completeness implied, given

that nationally thousands of patients are photographed. Therefore, our concern should be to

positively contribute to the patients' journey whilst attending our hospitals.

Section 1. Attitude and understanding These guidelines are primarily the actions to be taken by clinical photographers in the

performance of their duties through positive attitudes and effective communication. The goal is not

merely to obtain good quality images at any cost, but rather to respond to our patients positively

and professionally. In doing so the total experience of the clinical photography session is

enhanced and quality images are produced.

"We do not see things as they are, but as we are"

Immanuel Kant (1724 - 1804)




4

Attitude is an important factor when working across cultures and affects how we communicate

verbally and non-verbally. Working effectively across cultures can initially be hard work, because it

can reveal our subconscious prejudices that have developed because of our own background.

Take for instance, your attitude to anyone who supports a rival football team. You may

demonstrate prejudice towards them despite having a mutual appreciation for the same sport. Any

pre-existing attitude can be a barrier to effective communication, which risks any interaction

between a photographer and patient being stilted and awkward and is likely to cause offence.

Therefore, the photographer must first understand their own values and beliefs; only then can an

individual begin to understand and address their potential prejudices against others (Leininger,

2002).

Any treatment within a hospital (including clinical photography) must be impartial, non-

discriminatory and inclusive (General Medical Council, 2013). To achieve this, we must all seek

the virtues of sensitivity, self-awareness, compassion, tolerance and impartiality. We have an

obligation to our patients to improve our attitudes towards those of different racial & cultural

backgrounds, whether this be through self-guided learning (for instance, researching issues

affecting BAME members), hospital appointed Equality & Diversity sessions or through

discussions with your patients.

When engaging with patients, the photographer should ensure the protected characteristics are

considered and respected at all times (age, gender reassignment, being married or in a civil

partnership, being pregnant, disability, race including colour, nationality, ethnic or national origin,

religion or belief, sex or sexual orientation) (Equality Act, 2010). However, the photographer must

also understand intersectionality and how this may affect the beliefs and personal experiences of

individuals’. Intersectionality refers to the overlap of factors in an individual’s life that affect them

simultaneously such as class, income, education, immigration status, indigeneity, and geography

(Collins and Bilge, 2020). These are not mutually exclusive of each other; a patient may

experience prejudice based on any protected characteristics and additional factors. If we are to

positively influence a patient’s experience, it is imperative to acknowledge that health disparities

do exist, and in order to provide the best service to the patient there can no longer be the practice

https://www.gov.uk/working-when-pregnant-your-rights

https://www.gov.uk/definition-of-disability-under-equality-act-2010




5

to ‘treat everyone the same’ as this simply ignores multiculturalism and the needs of the most

vulnerable in society (Mkandawire-Valhmu, L., 2018).

Wherever face and head coverings are worn they can be signs of modesty, personal preference

(such as the need to cover hair loss) or religious observance. For instance, in Islam, some women

cover their faces; whereas in Orthodox Judaism men cover their heads, and many orthodox

Jewish women keep their heads covered with a scarf, snood or a wig. In Sikhism, Sikh men may

also cover their heads. For strict Muslims a facial photograph is akin to idolatry, the idea similar to

the prohibition of making images of God. However, other anatomical areas must also be included

when considering modesty and the potential cultural background of the patient.

Whilst photographing the head and face may require a sensitive approach from the photographer,

it is important to note that within a particular cultural grouping there are subgroups and this can

result in variations on the approach towards the use of coverings or other customs (Rittle, 2015).

Therefore, clinical photographers must have cultural awareness and interpersonal skills that can

accommodate the range of interactions that occur in multicultural healthcare. This ensures that all

patients are treated with the same respect, dignity and willingness to meet their needs while

obtaining the best quality documentation of the patient’s condition (Hordern, 2016).

Section 2. Working with others

Clinical photography can involve working in partnership with many individuals in order to attain the

required images and provide the best care to the patient. This can include working closely with

clinical and non-clinical members of staff, as well as the patient’s carers, relatives or friends. In

order to acknowledge and accommodate differences in beliefs and customs, photographers

should actively seek to understand them (Rittle, 2015). This is also relevant to the photographer’s

actions when they are not with the individual; for instance respecting their absence due to prayer

or religious events (Whittington Hospital NHS Trust 2009). Clinical photographers must ensure

their behaviour towards both patients and fellow colleagues is free from discrimination or prejudice

(Northumbria Healthcare 2012, Equality Act 2006).

Often a patient is accompanied by someone close to them during photography. It is important to

acknowledge and work alongside these individuals whether staff or relatives, as they often have




6

invaluable knowledge of the patient, such as their cultural or religious beliefs (Henley and Schott

2003). The individual can help advise your session or in distressing situations, comfort the patient.

In some cultures, community elders or family members make decisions and may speak on behalf

of the patient being photographed, in this scenario it can be difficult for the photographer to gain

suitable consent from the patient whilst respecting these customs and others attending (Henley

and Schott 2003). Where possible it is advised to discuss consent with both patient and family

member in order to attempt to gain mutual agreement (Ekmekci and Arda, 2017).

2.1 Formal and informal interpreters

Prior to the photographic session, the photographer should ensure that the patient fully

understands and consents (General Medical Council, 2011). It is best practice to use a

professional interpreter for all important conversations where the patient does not speak English

well or at all (Henley & Schott 2003). The photographer should explain to the interpreter what is

going to happen during the session so that they can better explain to the patient and to ensure the

interpreter is prepared. If a professional interpreter is not available or the patient prefers a specific

individual such as a family member (informal interpreter) this must be respected.

In order to make the photographic session as successful as possible, the photographer should:

Pay attention to the informal interpreter and their understanding of English, ask them if they

are able to do as you require, or consider whether it could be better demonstrated by

yourself, directly to the patient

Establish who the interpreter is and their relationship to the patient as this may affect the

patient’s willingness to do or say certain things

Be calm and patient with both the interpreter and the patient

Acknowledge the session is likely to take longer, do not rush

Never accept a child as a suitable interpreter

(General Medical Council, 2008. Henley and Schott 2003)




7

Section 3. Communication

Communicating effectively and respectfully with patients is greatly important not only for the

smooth running of the photographic session but also for the patient’s overall experience.

Communication begins from the moment the patient enters the department or you enter their

cubicle. Be aware of your body language and facial expressions as well as your choice of words

and tone of voice.

Photographers should ensure they consider that a patient may have a disability which requires

alternative communication methods and be aware of how and where to request services, such as

British Sign Language interpreters. Refer to the patients Disability Passport (if they have one) as

this will give relevant information of their needs and personal preferences, including

communication requirements. Photographers must consider that not all disabilities are visible, and

each person will have different requirements.

3.1 Verbal Language

In the 2011 England and Wales Census, 92.3% of the population considered English (or Welsh in

Wales) to be their first language, with a much lower proportion in London. 7.7% reported their first

language as ‘Other’ – Polish being highest. The highest proportion of people who responded could

not speak English well or at all were in London and the West Midlands (Office of National

Statistics, 2011).

The clinical photographer should be aware that how they read a patient’s language or behaviour

may be different to how it was intended by the patient. For example, Chinese, Vietnamese and

Thai languages use tone to completely change the meaning of a word, friendliness is shown in

other ways. As British-English speakers are used to hearing tone to portray emotion, they may

consider the tones or volume they hear to be brusque or angry, though the patient is not (Henley &

Schott 2003). Having an understanding of different cultural mannerisms and behaviours will

enable the photographer to read a patient more accurately and adjust their own actions

accordingly.




8

To communicate effectively with patients that struggle speaking or understanding English, the

clinical photographer should:

Speak plain English, slowly and clearly, avoiding jargon or slang

Not speak louder than normal

Check the patient understands, by using active listening skills instead of relying on positive

responses only

Avoid using closed questions - do not rely on short or positive responses alone to check the

patient understands. For example, a patient may respond positively to the question "has the

doctor explained what will happen with your photographs?" but their response to the

question "what has the doctor explained to you about these photographs?" may reveal gaps

in their understanding.

Be aware that people can often understand more of a language than they can speak. Do

not say or discuss anything you would not want the patient to hear.

Use positive and encouraging language

Where possible face the patient whilst you are speaking, with your mouth clearly visible

Do not assume that ‘Yes’ means the individual understands

(Rittle, 2015., Henley and Schott 2003)

3.1.1 Addressing a patient

When addressing a patient do not assume that the British or Western naming system is universal,

whereby the last name is the primary identifying point. For some cultures, different naming

systems are used which do not follow the British system and care is required to avoid unintended

offence.

Addressing all patients by their full name is best or it may be acceptable to ask the patient ‘What

would you like me to call you?’ This includes pronouns for those that may be transgender or non-

binary.

Not everyone can be accurately identified by either 'Mr' or 'Mrs' plus their last name, because

names such as Singh, Kaur, Begum or Miah are titles and prefixing the name with either Mr, Mrs




9

or Miss is meaningless. In the British naming system the surname is the identifier in health records

followed by first name and middle name. The order of the name indicates its use in the British

system - personal name first and surname last. Middles names are of less significance and a

person can be addressed by their title and surname. However, naming systems in other cultures

can be very different such as; the personal name not always coming first, the title may come after

the name or the surname may come first.

For example: Kushwant Singh and his wife Daljeet Kaur attend the department, he is never

addressed as Mr Kaur nor is his wife addressed as Mrs Singh, though Mrs Kaur may be

acceptable. Further examples illustrate this:

Jahanara Bibi (use full name)

Dilvinder Kaur (use full name)

Lew (Leff) Sapieha (Mr Sapieha)

Mohammed Yunus Miah (use full name, or first two names together)

Cheung-Ng Wai-Yung (use Mrs Ng or full name)

Shahida Begum Ditta (use full name or first two names, not Mrs Ditta)

(Henley & Schott 2003)

3.2 Body language Body language can communicate several messages such as your mood, culture and whether you

are paying attention. This can become more complex where people of different cultures portray

these in alternative ways, as well as differences due to personality. Whilst the clinical

photographer should act with professionalism, it must be acknowledged that each individual

photographer’s personal background will inevitably have a bearing on what behaviour they deem

to be professional and how the patient interprets this behaviour. As mentioned previously, there

are subcultures within all cultures and this will affect the approach each photographer takes with a

patient. It is therefore important to be aware of your personal beliefs and possible prejudices and

how this may translate into your body language and actions that the patient will see and ultimately

be affected by. After identifying these beliefs and behaviours they can be addressed and replaced

with behaviour which is sensitive to potential cultural differences (Lange, 2016).




10

Within clinical photography the use of body movements to help demonstrate and give instructions

to the patient can save time and confusion. However, the photographer must ensure they are

doing so in a non-offensive manner. Where there is a verbal language barrier, patients will be

looking to the photographers’ body language even more as a means to understanding what is

being asked of them (de Rezende et al, 2015).

Photographers should be aware of a patient’s reactions when using gesturing. If a patient appears

offended, consider if you may have caused this through specific movements. For instance, curling

the index finger in Europe and American is a gesture used to beckon someone however, in

Chinese, Philippine, Malaysian and Singaporean cultures this is considered extremely impolite

(Virtual Speech 2017). In Thai culture it is considered rude to point the soles of your feet at

another or to touch the head of another person (Virtual Speech 2017, Henley and Schott 2003).

The act of shaking hands with someone of the opposite sex can be considered immodest in some

cultures and in some Islamic culture it is also seen as rude to offer something with the left hand

(ACAS 2011).

Other considerations to make with regard to body language and actions:

Ensure you do not encroach on the patient’s personal space or do this for the shortest

possible time

Do not touch the patient unnecessarily. For example, an overfamiliar tap on the shoulder

Where touching the patient is unavoidable, explain your intentions before doing so

If touching the patient, be conscious of the way you do so

Consider how the patient may interpret or be affected by your actions

Stay alert to the patient’s reactions and stop if they appear offended or upset

(de Rezende et al, 2015., Henley and Schott, 2003., Rittle, 2015)

3.2.1 Eye contact

The degree of acceptable eye contact varies from culture to culture. In some cultures, eye contact

is important and too little can be seen as disrespectful. However, in other cultures such as South

Asian and Indo-Chinese cultures too much eye contact can be seen as aggressive and in Hispanic




11

culture lowering the eyes is a form of respect (Henley and Schott 2003). In some cultures, making

eye contact with the opposite sex is seen as flirtatious and men may avoid eye contact with

women as a form of respect (Henley and Schott 2003). Photographers understand that all patients

will act differently to situations but particular behaviours such as eye contact may be overlooked.

Considering a patient’s cultural background will help the photographer recognise why a patient

may make a lot of or no eye contact which may help put both photographer and patient at ease

(Maier-Lorentz. 2008. Understanding Transcultural Nursing 2005).

Section 4: Photographic procedure

During your time with a patient, it is helpful to draw upon your knowledge of different cultures.

However, it is also prudent to neither make assumptions about a patient's culture, nor make

assumptions about the patient based on their culture. Each patient has a unique makeup of

groups with whom they identify, not just ethnic or religious, but also socio-economic, age-based,

gender-based, and with a myriad of sub-cultures therein. The patient cannot be stereotyped

according to any one of these (Nirta and Roh, 2019; Holland and Hogg, 2010). Nor is a patient's

culture fixed, but changes according to the environment or situation (Holland and Hogg, 2010).

The most apparent characteristics which speak of a patient’s culture - gender, attire, skin colour,

language and accent - are open to misinterpretation. The cultural differences to which healthcare

professionals are trained to be most acutely sensitive - ethnicity, religion, sexual orientation - may

not be the most important to the patient during the photography session.

"Patient–provider communication is a vital part of health care regardless of the cultural

backgrounds of those involved. However, culture does add another dimension to an often already

difficult communication situation." (Ulrey and Amason, 2001).

Thus, the best general practice during a session is to draw upon your understanding of different

cultures, to maintain cultural sensitivity, but to use these only to inform a more effective

communication with the patient. Your judgement of a patient's understanding, capacity, comfort

and consent should always derive from your communication with them, and not your cultural

assumptions. These guidelines should therefore apply to any patient the photographer sees.




12

4.1 Prior to the session

This is the photographer's opportunity to make sure the patient understands the procedure about

to take place and to establish informed consent. Cultural differences between the patient and

photographer can create barriers to achieving this, as the likelihood of being misunderstood

increases (Crawford, Candlin and Roger, 2015). While both patient and photographer "are

responsible for the communication that takes place", the photographer is "especially responsible

for accurate communication because they are expected to use their training and competence to

develop positive relationships" (Ulrey and Amason, 2001).

The clinical photographer should ensure that their role is made clear to the patient to avoid

confusion. Due to some cultural traditions, assumptions may be made regarding the job role or

level of authority of staff based on age or gender (Henley and Schott 2003). Whilst gaining

consent the photographer must ensure the patient understands as far as possible what will take

place during the photographic session, particularly in the case of removing of clothing so as not to

cause the patient unnecessary stress. Use encouraging and reassuring language with the patient

but be mindful never to coerce the patient into giving consent or undergoing a procedure if they

decline or appear unhappy.

A photographic session can be uncomfortable for all patients, regardless of culture. A major

feature of clinical photography is the need to expose parts of the body. It is rare for any patient to

be entirely comfortable with undressing for photographs. It is advised for all intimate photography

that a chaperone is present (IMI Chaperone Policy 2019, (General Medical Council) (GMC), 2013).

What is considered intimate can be perceived differently by photographer and patient, particularly

for those with strict modesty beliefs such as for Hindu and Muslim women. Therefore, it may be

advisable to offer a chaperone where the removal of any clothing is necessary during photography

(American Medical Association, 2007. IMI, 2019. ACAS, 2011). If at all possible, a patient should

be photographed by a person of the same sex as this may limit the distress and discomfort for the

patient. (Holland and Hogg, 2010)




13

4.2 During the session

Effective and culturally sensitive communication must continue throughout the photography

session.

Refer to body parts by their common names but avoid informal terms

When instructing a patient to adopt a posture, demonstrate the posture yourself and use

movement cues

Give instructions one at a time and in the right order

Explain what you are doing

Look out for non-verbal signs - body language and facial expressions - of discomfort. Be

aware that such signs may differ greatly between individuals and be culturally informed.

Check with the patient that they are ok and happy to continue

Be prepared to stop the session if the patient is unhappy.

Where possible use pictures or examples to demonstrate

Allow time, don’t rush or be impatient

Maintain patient modesty wherever possible

(Henley and Schott, 2003. Rittle, 2015)

Summary

The clinical photographer's remit is not merely the production of quality images. The

photographer's interactions with a patient will colour the patient's overall healthcare experience

and may have long-lasting repercussions. It is a legal requirement that all patients and colleagues

are treated without discrimination. Yet it is also a requirement that we are sensitive to a person's

values and beliefs, and make reasonable adjustments to accommodate them.

We achieve this balance by first acknowledging our own values and beliefs. We use these to

inform us of the prejudices and biases we may bring with us, particularly when communicating

across cultural boundaries. These may be as crude as believing members of a certain race,

gender or sexual orientation will think or act in a certain way, or as subtle as assuming a particular




14

tone of voice denotes a particular attitude. Following this by better informing ourselves about other

cultures, we can then attempt to bridge the divides.

Armed with this background understanding, we are able to adjust our own behaviour. However, it

is impossible to always strike the perfect balance or be completely informed. Thus also being

mindful of the practical steps highlighted in the sections above, which can be applied to the

photographer's interactions with all patients, which will help mitigate the misunderstandings or

miscommunications that could lead to complaint, or lapse in care, dignity and professional

standards.




15

References

ACAS. 2010. Religion or belief and the workplace. A guide for employers and employees (October

2020).

Collins, P.H. and Bilge, S., 2020. Intersectionality. John Wiley & Sons.

Crawford, T., Candlin, S. and Roger, P. (2015). New perspectives on understanding cultural

diversity in nurse-patient communication. Collegian; 24-1; pp. 63-69

de Rezende, R.D.C., de Oliveira, R.M.P., de Araújo, S.T.C., Guimarães, T.C.F., do Espírito Santo,

F.H. and Porto, I.S., 2015. Body language in health care: a contribution to nursing

communication. Revista brasileira de enfermagem, 68(3), pp.430-436.

Ekmekci, P.E. and Arda, B., 2017. Interculturalism and informed consent: Respecting cultural

differences without breaching human rights. Cultura, 14(2), pp.159-172.

Equality Act. 2010.

General Medical Council., 2002. Making and using visual and audio recordings of patients (May

2002). The Journal of audiovisual media in medicine, 25(4), p.165.

General Medical Council., 2008. Making decisions about investigations and treatments (June

2008). Consent. Part 2: Consent: patients and doctors making decisions together.

General Medical Council., 2013. Good Medical Practice (April 2013). Working with doctors

Working with patients. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-

for-doctors/good-medical-practice [Accessed August 2020]

Henley, A. and Schott, J., 2003. Culture, religion and patient care in a multi-ethnic society: A

handbook for professionals.

Holland, K. and Hogg, C. (2010). Cultural Awareness in Nursing and Health Care. 2nd ed. Great

Britain: Edward Arnold, pp. 4, 51

Hordern, J., 2016. Religion and culture. Medicine, 44(10), pp.589-592.




16

Institute of Medical Illustrators. Confidentiality and consent. 2020. Available from:

www.imi.org.uk/account/national-guidelines [Accessed August 2020].

Institute of Medical Illustrators. Chaperone Guidelines. 2019. Available from:

www.imi.org.uk/account/national-guidelines [Accessed August 2020].

Lange, C., 2016. Nursing and the importance of body language. Nursing2019, 46(4), pp.48-49.

Leininger, M., 2002. Culture care theory: A major contribution to advance transcultural nursing

knowledge and practices. Journal of transcultural nursing, 13(3), pp.189-192.

Maier-Lorentz, M.M., 2008. Transcultural nursing: Its importance in nursing practice. Journal of

cultural diversity, 15(1), pp.37-43.

Mkandawire-Valhmu, L., 2018. Cultural safety, healthcare and vulnerable populations: A critical

theoretical perspective. Routledge.

Nirta, L. and Roh, H. (2019). Cultural diversity should be taught: a reply to UK medical students’

view on interacting with multicultural patients. Korean J Med Educ 2019 Jun; 31(2): pp. 173-176.

Northumbria Healthcare NHS Foundation Trust., Religious Observance. 2012. Available from:

[https://madeinheene.hee.nhs.uk/Portals/14/Religious%20Observance%20%20v4.pdf[Accessed

August 2020]

Office for National Statistics. 2011 Census: English Language Skills (England and Wales).

(February 2018) Available from: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-

by-ethnicity/demographics/english-language-skills/latest#data-sources [Accessed July 2020]

Rittle, C., 2015. Multicultural nursing: providing better employee care. Workplace health &

safety, 63(12), pp.532-538.

Understanding Transcultural Nursing., Nursing2005: January 2005 - Volume 35 - Issue – pp.14-

23.

Ulrey, K. L. and Amason, P. Intercultural Communication Between Patients and Health Care

Providers: An Exploration of Intercultural Communication Effectiveness, Cultural Sensitivity,

Stress, and Anxiety. Health Communication, 13(4), pp. 449–463




17

Acknowledgements

Thanks to Oyebanji Adewumi, Associate Director Inclusion at the Barts Health Inclusion Team for

advice and guidance.

Acknowledgement to Ian Berle for his work on the first version of these guidelines.

Lead author

Pip Stiff, Senior Medical Photographer, Barts Health NHS Trust, Royal London Hospital, London.

Working group

Arezoo Alford, Specialist Senior Medical Photographer, Guy’s and St Thomas’ NHS Foundation

Trust, London.

Nicholas Gray, Medical Photographer, University Hospital of North Durham, Durham.

Documents

Cultural Diversity - Institute of Medical Illustrators...IMI National Guideline – Cultural Diversity Lead Author – Pip Stiff Date Created – November 2004 Last Review Date –