Jones Mexican-Americans' Perceptions of Culturally Competent Care:"

If one of the most important goals of any health care provider is providing the best quality of care possible for one's patients, then the health care researcher is no less responsible for ensuring their work is of the best possible integrity. To insure this, the health care researcher must follow stringent protocols in gathering and presenting their information, as well as in extrapolating meaning from that information. Indeed, it is of significant consequence if published mainstream research is competently preformed in all of its aspects. Not only does this insure researcher, institution, and publication credibility, but it insures that the actual "field" application of the conclusions drawn from research work are beneficial to patient care.

One of the best ways to evaluate the credibility of any work of research literature is to investigate several key questions pertaining to the methods and information utilized in its investigation, composition, and communication. Specifically, it is useful to ask questions concerning data analysis, credibility, audibility, fittingness, confirmability, as well as the conclusion and discussion reached by the researcher/s. Applying these questions to the article, "Mexican-Americans' Perceptions of Culturally Competent Care," by Maria R. Warda, leads one to draw some interesting conclusions.

In her research article, Maria R. Warda seeks to answer the question of just what makes up "culturally competent care" as it relates to Mexican-Americans. Toward this goal, Warda advances the idea that there are four main areas of cultural care that relate to the Mexican-American community, and how well they are served by health care professionals. These are "family, spirituality, communication, and health beliefs and practices" (Warda, 2000, p. 203). Specifically, in consideration of these four areas of cultural care, Warda's research seeks to answer just what traits, beliefs, and practices making up the four areas exert the most influence on the health care of Mexican-Americans.

In collecting data for her research, it is important to ascertain the type of data obtained. For example, in this instance, one must ask whether the data collected is focused on human experience. This is specifically important in Warda's article due to the culturally-based material in question. Indeed, culture is best (some would say, only) described through experiential observation -- either related by the subject, or by an outside observer. Of course, it is important to consider that this kind of data is subject to personal interpretation and observation -- however, such is the nature of cultural study. Regardless, in asking this question regarding Warda's research, one must clearly conclude that she does use human experiential data. Specifically, Warda uses focus group interviews of individual patients, "...used to explore the subjective perceptions of Mexican-Americans regarding the indicators of culturally competent care (203)." Further, she specifically employs the method of group interaction in order to obtain higher quality experiential data than could be gleaned from individual interviews (206). However, in considering the question of whether Warda included an adequate pool of participants necessary for sufficient data saturation is questionable.

Of course, in conducting research, one must ensure that to the best of one's ability, one has gathered enough of a data pool to include all desirable information relevant to the research question at hand. In Warda's case, she included the experiences of four focus groups consisting of twenty-two Mexican-Americans (206). Of these individuals five members were registered nurses, were equally representative of gender overall, as well as age (over 18). In addition, the participants were required to have received health care within the past year, or were currently receiving care (206). Finally, participants varied with regard to levels of health (206).

In consideration of the above participant pool and requirements, one must consider whether it is reasonable to assume that data saturation was present in the study. Although the author does specifically state that data saturation was not a goal, due the predetermined "number and format of the focus groups" (208), there is an implied belief that data saturation is taken into account in the design of the study. After all, if the data was not believed to be sufficient to provide a credible answer to the research question, why undertake the research at all?

Unfortunately, the presence of sufficient data saturation is highly doubtful in this instance. Not only is the study pool relatively small, with only twenty-two participants, but the varied levels of health (the distribution is never specified), age, and cultural sub-characteristics are never taken...

After all, a patient with an ingrown toenail is likely to display very different behaviors and beliefs, even culturally, as well as be in possession of very different personal health care experience histories than a terminally ill patient. Further, age is also a factor, even culturally. What is a dominant characteristic culturally for one generation may no longer be in force two generations removed. Finally, the fact that the study defined the research pool as "individuals of Mexican descent either born in Mexico or the United States" (204) indicates a possible laxity in the composition of the pool. After all, an individual born and raised in the United States is likely to be heavily influenced by the dominant culture of the nation, and is perhaps better identified as a member of a sub-culture of American raised Mexican-Americans. This issue is never addressed. In short, all of these factors combined leave serious doubt as to whether the observations gathered are representative of the data required and available to answer the research question.
In performing the analysis of the data gathered in her focus groups, Warda describes the strategy used to analyze the information. In specific, Warda describes her analysis technique on page 208:

Although grounded theory techniques were used to organize and describe

The Mexican-Americans' experience with the health care system, this study did not follow all the steps of grounded theory methodology. Written memos from the focus groups were reviewed immediately, and the interview guide was modified accordingly. In this study, the coding, categorization, and conceptualization of the data were done after the completion of all focus groups.

Data saturation was not a goal, because the number and format of the focus groups had been initially determined. The goal was to use rich, culturally relevant data from the focus groups to develop a theoretical framework that describes the participants' perceptions of culturally competent care. (208)

In addition, she describes in detail the coding procedures used to categorize the data gathered as well, including axial coding, open coding, and theoretical coding based on an analytical process of grounded theory (although full grounded theory methodology was not used), In addition, she employed the expertise of a Hispanic nurse practitioner (trained in qualitative methodology) to confirm the data analysis (209).

With this in mind, one must then ask if Warda remained true to the data in her interpretation of meaning. Of course, given the lack of data saturation (even implied by the very existence of the study), one must come to the table with significant reservations regarding Warda's extraction of meaning from the information gathered. However, if one were to put these reservations aside, Warda does do an acceptable job of drawing conclusions from the experiences of her participants, and as such, is true to the data gathered (such as it is). Indeed, this is especially true in her conclusions based on the "stories" of the participants, the need for personalismo based on confidence, trust, and a sense of personal friendship (212), all logical components of her conclusion that health care providers must understand the specific cultural characteristics that must be provided in order to deliver quality health care to Mexican-Americans.

Of course, if one wishes to consider that Warda's conclusions remained true to the data, one must also imagine that she fully understood the procedures used to analyze the data. Here, Warda demonstrated sound knowledge, in spite of her other shortcomings in the article. For example, not only did she fully explain the process of the coding and analysis of the data (208), but she also sought to confirm the analysis via a third party versed in qualitative methodology (209). Although one might imagine that this step could possibly indicate a lack of knowledge or confidence in the researcher's ability to apply the correct analysis procedure, even if this were the case, her decision to include the Hispanic nurse buoys the credibility of the project.

In considering the credibility of the data gathered, it is clear that Warda went to some length in assuring that the responses of the participants be as genuine as possible. In specific, Warda implemented an intricate balance of sub-group demographics within the focus groups. For example, Warda separated the groups by sex in order to avoid potential self-editing or censorship of response due to the cultural concept of "machismo" (206), as well as separated the nurses from the lay patients due to the "intimidation factor" they might introduce (206). In short, these built in safeguards ensure that the data is a credible representation of the experiences, beliefs, and feelings of the respondents, and not projections of what they believe others want or…