Cultural safety and cultural competence: what does this mean for physiotherapists?
(Laws, regulations and rules)
Physical therapy (Practice)
Physical therapy (Research)
Therapeutics, Physiological (Laws, regulations and rules)
Therapeutics, Physiological (Practice)
Therapeutics, Physiological (Research)
Physical therapists (Training)
Physical therapists (Laws, regulations and rules)
|Publication:||Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2006 New Zealand Society of Physiotherapists ISSN: 0303-7193|
|Issue:||Date: Nov, 2006 Source Volume: 34 Source Issue: 3|
|Topic:||Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 200 Management dynamics; 310 Science & research; 280 Personnel administration Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation|
|Product:||Product Code: 8043600 Physical Therapists NAICS Code: 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists SIC Code: 8049 Offices of health practitioners, not elsewhere classified|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
|Legal:||Statute: Treaty of Waitangi, 1840|
Legislation governing physiotherapy practice within Aotearoa/New Zealand requires physiotherapists to practise in a culturally safe manner, demonstrating cultural competence. Although physiotherapists are likely to be more familiar with the notion of cultural diversity and its implications for professional practice, the concepts of cultural safety and competence extend the debate from how people are described and understood, to how health professionals understand themselves and are deemed by the receivers of that care to be safe and culturally competent. The purpose of this paper is to highlight cultural issues for physiotherapists working in New Zealand, particularly those newly arrived in Aotearoa, who are expected to demonstrate cultural safety and cultural competence in clinical practice. The authors examine how New Zealand has evolved as a bicultural society, the emergence of cultural safety, its evolvement within health care practice, and influence on cultural competence. The Maori health perspective and the physiotherapy view of health are examined with particular reference to cultural safety and cultural competence. Finally, legal issues and clinical practicalities are outlined. It is hoped that the ideas presented will increase awareness of the importance of physiotherapy work that integrates both the strengths of physical based medicine and a socio-cultural perspective of health. Main C, McCallin A, Smith N (2006): Cultural safety and cultural competence: what does this mean for physiotherapists? New Zealand Journal of Physiotherapy 34(3): 160-166.
Key Words: Cultural safety, cultural competence, professional practice, physiotherapy
Within Aotearoa/New Zealand the New Zealand Society of Physiotherapy (NZSP) Bicultural Policy, Standards of Physiotherapy Practice and physiotherapy legislation require physiotherapists to practise in a culturally safe manner (New Zealand Society of Physiotherapists Inc., 1997; New Zealand Society of Physiotherapists Inc., 2006; Physiotherapy Board of New Zealand, 2005). While physiotherapists have been educated to provide culturally sensitive care that recognises beliefs, meanings and practices specific to cultural groups (Kirkham, Smye, and Tang, 2002), the concept of cultural safety and its application to practice is less well understood. Cultural safety/kawa whakaruruhau, emerged as a significant component of nursing education within New Zealand in the 1980s (Ramsden, 1993; Kearns & Dyck, 1996; Ramsden, 2005). Cultural safety emphasised cultural awareness, cultural sensitivity, and power sharing with Maori. Power sharing within a bicultural framework was seen as an key issue in health education, as it was a means to address the longstanding inequalities within health care interactions and service delivery that had effected Maori health (Nursing Council of New Zealand, 2002).
Taeora Tinana, the Maori partner of the NZSP, representing Maori physiotherapists, adopted the framework of the Nursing Council to direct the development of cultural safety within physiotherapy and developed the NZSP Guidelines for Cultural competence in Physiotherapy Education and Practice in Aotearoa/New Zealand (2004). In practice, cultural safety is about providing a safe health care environment where there is respect and understanding between the service provider and the users of the service. It is the user of the service, the client, that determines if the service provider is giving culturally safe care or treatment. Cultural safety within physiotherapy is defined as:
"The effective delivery of physiotherapy services to a person or family from another culture, as determined by that person or family. Culture includes, but is not restricted to: age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief, and disability.
The physiotherapist delivering the physiotherapy service will have undertaken a process of reflection on his or her own cultural identity and will recognise the impact that his or her personal culture has on his or her professional practice. Cultural safety is about absence of discrimination and about behaviour that ensures that staff and patients are valued and respected and being included in decision making. Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual."
(New Zealand Society of Physiotherapists Inc., 2004.p.9).
Having a clear understanding of cultural safety is fundamental to practising in a culturally competent manner. This is even more important today because the Health Practitioners Competence Assurance (HPCA) Act (Ministry of Health, 2003) encompasses cultural safety within the concept of cultural competence. The main focus of the HPCA Act is to protect the health and safety of the public by ensuring that health practitioners are competent and fit to practise (Physiotherapy Board of New Zealand, 2003). Furthermore "cultural competence in physiotherapy practice requires the successful integration of the Treaty of Waitangi, cultural safety and Maori health" (New Zealand Society of Physiotherapists Inc., 2004). Clearly, this legislation has implications for practice, especially for international physiotherapists coming to work in this country.
NEW ZEALAND--A BICULTURAL SOCIETY
The development of biculturalism in New Zealand is historically located (Durie, 2001). Maori, the indigenous people of New Zealand/Aotearoa, first came into contact with Europeans as far back as 1769 when Lieutenant James Cook of the British Royal Navy circumnavigated New Zealand (King, 2003). This early visit had far-reaching effects on Maori health. While Maori welcomed British settlement in some respects they were particularly vulnerable to new diseases. The overall impact on Maori mortality was tremendous and the Maori population was reduced by 75% (Poole, 1991).
As a result, some Maori chiefs sought British protection offered under the Treaty of Waitangi (Poole, 1991). The Treaty, signed in 1840, was an agreement made between the Crown of the United Kingdom and the Tribal Nations of New Zealand. The Treaty has two texts, the official English version and a literal English translation of the Maori text, Te Tiriti o Waitangi. However the texts have some significantly different meanings. Under the international law of Contra Preferentum, if there are two texts, the indigenous text should be adhered to. The NZSP Bicultural policy accordingly lists the four provisions as;
"Article 1: The right of the Crown to govern, in return for
Article 2: The right of the Tribal nations of Aotearoa to exercise full authority in respect of their own affairs; and
Article 3: The right of all people to equality and equity.
Article 4: (a protocol or intent in the Maori text) The right of all people to their own religious and spiritual beliefs."
(New Zealand Society of Physiotherapists Inc., 1997, p.1)
The Treaty did not specify how the responsibilities between British sovereignty and Maori self-governance would be managed, beginning a debate that has continued ever since (Fleras and Spoonley, 1999).
Evidence that colonial rule intentionally deprived Maori of their land, their identity, and their right to self-determination is witnessed in the many acts of land confiscation and laws introduced for assimilation. Like many indigenous peoples across the world, Maori were not only "deprived of human rights and fundamental freedoms" (Reid and Cram, 2005), but were marginalised so that their access to health and social services was compromised (Reid et al., 2002). For many years, the Ministry of Health was concerned with the inequalities in the health status of Maori, which was significantly lower when compared to other populations in Aotearoa/New Zealand (Ministry of Health, 2000, 2001, 2002).
Despite various government efforts, health outcomes declined and health disparities between Maori and non-Maori health increased (Ministry of Social Development, 2002). The poor state of Maori health became a government priority in the 1980s. The Treaty was incorporated into many Acts of Parliament. Legislation integrated the three Treaty principles, partnership, participation and protection into government policy (Johnson and Wallace, 2000; Ramsden, 2005). These principles were the basis of cultural safety.
At the same time biculturalism was proposed as a strategy to honour cultural differences. Yet understanding cultural norms and values was not enough. Thus biculturalism now emphasises political action (Durie, 1998). This was necessary because, according to the bicultural worldview, there are just two cultures, Maori and "other/tauiwi". Although biculturalism is not clearly defined, it is often understood on a continuum that ranges from a cultural exchange at one end to independent or semi-dependent Maori organisation at the other end (Durie, 2003). The goals of biculturalism are to develop "cultural skills and knowledge; better awareness of the Maori position; a clearer focus on Maori issues and Maori networks; best outcomes for Maori over all activities; and joint ventures within agreed upon time-frames" (Durie, 1998, p. 102). These strategies have the potential to have a significant impact on all health care professionals working with Maori.
Although few countries escape the complexities that arise with multiculturalism, the distinctive bicultural emphasis in New Zealand challenges many residents and visitors alike. It is not so much the presence of differing beliefs and ideals that makes bicultural issues unique, but rather the progressive integration of the principles right across every part of New Zealand society.
In striking contrast to the many centuries of social development across Europe, in New Zealand there were hundreds of years of Maori development followed by colonisation and development of a European culture within just two hundred years. In a relatively short space of time some argue that colonisation subjugated the Maori population (Gordon, Shaw, and Dorling, 1999; Howden-Chapman and Kawachi, 2002). The arguments are complex. For example, although many Maori move between both worlds, if Maori are tangata whenua [the people of the land], their 'ways of being, doing and knowing are normal and accepted'. In contrast, when a Pakeha [European] majority control who and what is normal, often Maori are seen as different, difficult, or 'radical' (Reid and Cram, 2005, p. 34). Whatever the explanation, there is little doubt that Maori health is poorer, and obligations under the Treaty of Waitangi require all health professionals to integrate cultural safety into practice, in order to demonstrate cultural competence.
CULTURAL SAFETY AND COMPETENCE IN PRACTICE
In practice, even though physiotherapists may be clinically, ethically and legally competent they may compromise Maori health outcomes if they do not practise in a culturally safe manner (Haswell, 2002). The aim of cultural safety is to challenge the stereotypical images of culture that portray an indigenous minority within a "culture of poverty" (Ramsden, 1993, p. 8). In other words, Maori do not choose poverty as a way of life, but historically were driven into a culture of impoverishment, as cultural heritage was undermined. Understanding the basis of cultural safety is critical because, in order to be competent, all physiotherapists working in New Zealand are required to understand Maori models of health and how health service practices can disadvantage Maori (Ramsden, 1993).
Cultural safety is a three-stage process. The first step is cultural awareness, the second cultural sensitivity, with the third being cultural safety (New Zealand Society of Physiotherapists, 2004; Nursing Council of New Zealand, 2002). Development of cultural awareness begins with the recognition that "there are differences in the emotional, social, economic, historical and spiritual contexts in which people exist" (Haswell, 2002). In the second stage, cultural sensitivity develops, as personal and professional culture, attitudes and behaviours are examined. Sensitivity to the subjectivity of health increases (Sargent et al., 2005). Cultural safety is therefore supported with knowledge about biological variations, Maori illness causality and culture bound illnesses and interactions. Understanding is expected to reduce unintentional discriminatory practices. Skills are acquired in cultural encounters and physiotherapists learn to share power with Maori and encourage self-determination by having conversations about treatment that support Maori wellbeing (Wareham et al., 2005). So cultural safety develops (Sargent et al., 2005).
A MAORI HEALTH PERSPECTIVE
If physiotherapists are to deliver quality care to their clients, they are expected to provide culturally congruent care (Lim et al., 2004). The Maori health perspective is distinct; it is very different from a Western view, as physical, spiritual, mental and family aspects of health are integrated with identity, life principle, inherited strength and emotions. Health from a Maori perspective is different from the more simplistic biomedical model of health in which health is seen as the absence of illness (Pomare et al., 1995; Durie, 1998; White et al., 1999).
In a Maori perspective of health taha wairua/the spiritual aspect of health, is fundamental (Durie, 1998). Wairua refers to faith and understanding that is seen in person-environment interaction. Wairua recognises that tribal lands and water and access to these territories are integral to the person's identity and wellbeing. Hinengaro/mental health, is about the expression of thoughts and feelings. Mind and body are inseparable. Tinana/physical health, assumes that good physical health is essential for growth and development. The extended family/wnanau, is equally important, as the capacity to belong, to share and care are central. Whanau is a key social structure for all physical and emotional care (Pomare et al., 1995; Durie, 1998). Overall, Maori recognise the interaction of mind, body, spirit, family and the wider community. This has implications for physiotherapists who may need to work with Maori clients and families in very different ways from the usual non-Maori health perspective (New Zealand Society of Physiotherapists Inc., 2004; White et al., 1999).
PHYSIOTHERAPY HEALTH PERSPECTIVES
The biomedical model of health has been integral to the development of physiotherapy (Roberts, 1994). This model focuses on normality, where any deviation from the norm is diagnosed as either illness or a physical malfunction (Germov, 2002). Physiotherapists are familiar with the term normal, which is an objective measure derived from observation of the usual, or average, be this a physiological measurement, movement, or a pattern of behaviour (Williams, 1986). This approach to practice is very similar to the biomedical model, where any deviation from normal has a causal agent, which may be identified through measurable and objective assessment. Causal agents supposedly occur biologically and are very different from the socio-cultural understandings of causality that have affected health outcomes for many Maori.
In Western medicine the focus on external causality has resulted in a general acceptance that illness is a specific entity, independent of either culture or the nature of the individual (Sim, 1990). If a person has varying symptoms for instance, the assumption is that the illness is different. Unlike the Maori health perspective, the biomedical model emphasises the body as machine, assuming that mind and body are separate, occupying distinct locations and having specific functions (Nicholls and Larmer, 2005). Thus, the person is separate from, although influenced by their environment and culture. In essence, Western medicine treats the disease rather than the person. This model of health is conservative and "universally criticised for its ability to depersonalise health care" (Nicholls and Larmer, 2005 p. 58).
In contrast, the biopsychosocial perspective of health has proven useful for physiotherapist practice (Engel, 1977). An extension of the biomedical model, the biopsychosocial perspective recognises the biological, psychological, and social factors affecting the person, who is in constant interaction with the changing environment (Germov, 2002). Again, causality is emphasised, as is adaptation, and individual values and beliefs are respected and integrated into care. While these alternative perspectives may assist physiotherapists in their understanding of cultural safety, knowing the historical, socio-political and environmental factors that have impacted Maori health outcomes is important as well. Insights add to knowledge and ultimately cultural competence, once the importance of working to reduce health disparities for Maori is understood.
In regard to physiotherapy, the HPCA Act (Ministry of Health, 2003) provides a framework to ensure that clinicians are competent and fit to practise and a legislative means of ensuring the principles of the Treaty of Waitangi are adhered to. In response to the Act, the Physiotherapy Board of New Zealand has developed a re-certification process whereby existing practitioners must be prepared to demonstrate compliance with ten educational and competency requirements, before being re-issued with their practicing certificates. Physiotherapists who are educated abroad and wish to practise in New Zealand, or those who have been previously registered and are now returning to the work force, must also demonstrate attainment of these competencies (Physiotherapy Board of New Zealand, 2003; Physiotherapy Board of New Zealand, 2005). Similarly, in support of the Act, the NZSP has produced the Standards of Physiotherapy Practice 2006, covering the profession's expectations of all practising physiotherapists, with the focus being on patient-centred care (New Zealand Society of Physiotherapy Inc., 2006).
Specifically, in relation to cultural safety, the Board requires each physiotherapist to "analyse consumer health needs and wants" and to "communicate effectively" involving interpreting the communications of the consumer and their family (Physiotherapy Board of New Zealand, 2005). These competencies require that the physiotherapist identifies the significance of their own culture and its impact on the client's culture and adapts their practice accordingly. Unfortunately there is, as yet, no formal means of monitoring and recording the attainment of cultural safety, as perceived by the consumers of physiotherapy care.
Physiotherapists are expected to demonstrate an understanding of all laws underpinning physiotherapy. For example, the Code of Health and Disability Services Consumers' Rights 1996 (Health and Disability Commissioner, 1996) gives every consumer the right 'to be provided with services that take into account.... beliefs of Maori' (Right 1), 'freedom from discrimination' (Right 2) and the right to 'effective communication' (Right 5) (Health and Disability Services Consumers' Rights, 1996). While a later draft of the Public Health and Disability Bill in 2000 included compliance with the principles of the Treaty of Waitangi, this was opposed on the grounds that 'Maori might make claim to preferential treatment [in health]' (Durie, 2003, p. 131). That decision resulted in a change to the Bill that now recognises the Treaty of Waitangi in District Health Board restructuring. Many physiotherapists work for District Health Boards in New Zealand and as competent employees are therefore required to practise according to the principles of partnership, participation and protection.
The call for cultural safety and competence may challenge physiotherapists working in biomedically-dominated health services. The biomedical model has a long history of social control that is quite different from the social model of health that links health with the social, cultural, behavioural, and politico-economic factors that affect people's health (Germov, 2002). The biomedical view is at odds with the theme in this paper that sickness and health are intertwined with socio-cultural factors and impact on health outcomes (Cunningham and Durie, 2005).
When biological and technical aspects of health are considered in isolation from socio-cultural factors cultural misunderstanding results (Cram et al., 2003). In clinical situations, negative health experiences potentially decrease the uptake of care by Maori and thus widen the gap between Maori and non-Maori health status. Employing a cultural checklist with Maori fails to recognise the diversity of Maori experience. Instead physiotherapists must first understand their own personal and professional culture and the possible impact they may have on others (Ramsden, 1993). Consider failure to collect accurate ethnic data in physiotherapy. Such data is essential to understanding and addressing health inequalities. Culturally safe practice would first begin with an awareness that this is poor practice, followed by implementation of ethnic data collection (Ratima, 2006). If physiotherapists do not consult with their Maori clients and families about their requirements, positive outcomes may be compromised. It is emphasised that just because a client may be of a certain culture, this does not necessarily mean that the person identifies with that culture in a prescribed way. Therefore, it is vital that physiotherapists work in partnership with Maori, adopting approaches to practice that foster respectful, holistic care. "Partnership implies an association of equals" (Durie, 1998, p. 86), and usually occurs through consulting with others.
In the same way, if Maori are to participate equally in interactions with physiotherapists the Maori perspective of health must be recognised. For some Maori this may mean that the significance of wairua/spirit should not be underestimated. As already discussed family support structures are essential to nurture taha wairua. Wairua gives meaning and presence to the whole person so that good physical health is possible (Durie. 1998). By focusing only on physical symptoms, physiotherapists educated within the biomedical model may miss a significant underlving cause of ill health.
In the same way, the Maori client is protected culturally when the physiotherapist recognises that whanau may expect to participate in the care of the sick person. Decision making with whanau is often totally different from family interactions with non-Maori families. For example, whanau may choose to make decisions collectively. This means that important discussion regarding a family member with one individual only, without referring to the family decision maker, would be culturally insensitive. A culturally competent physiotherapist would find out from the extended family if there is a decision maker and who that is, in order to discuss treatment options. Similarly, some whanau expect to attend family meetings. Although whanau may not communicate openly, physiotherapists need to be aware that some cultural non-verbals that are not recognised as offensive in one culture are provocative to another, and may affect family participation in decision making. Therefore, actions such as providing extra space in the consulting room for family members go a long way to demonstrate a level of respect for members of a different culture.
Rapport is also imperative for genuine consultation. For example, while general practitioners believe that there is no difference working with Maori or non-Maori clients, the majority recognise that extra time is needed to build rapport and communicate with different family members, as well as the person who is sick (McCreanor and Nairn, 2002). This point is important for the culturally competent physiotherapist who may need to take time to establish rapport first, especially if they want to ask a client to partially disrobe for treatment (Bassett and Tango, 2002).
In many ways rapport is foundational to cultural competence that requires the demonstration of appropriate, respectful actions. For example, the concept of tapu can influence the way people, places, events and relationships are treated. Tapu is about sacredness (Durie, 1998). Things that are tapu warrant restraint and respect. Transgressions of tapu may evoke physical or mental retribution. Women in the post-partum period for instance, and mourning relatives of a deceased person, are tapu. The head is an example of a body part that is tapu. The culturally competent physiotherapist understands that a client's head should not be touched without first asking permission. Pillows used under the head should not be moved to or from the floor, or used under the feet. Some services use blue pillows for the head and white pillows for any other body support, in respect of the above.
Likewise, a culturally competent physiotherapist will appreciate the value of rongoa or Maori remedies (Cram et al., 2003). Some Maori use these traditional nearing practices in conjunction with Western medicines. Therefore, the physiotherapist will be sensitive to the value of rongoa and encourage clients wanting to use native plants for example, or perhaps consult with a Maori healer, who has a broader view of healing and wellbeing. Being culturally competent supports the Maori health perspective and demonstrates a genuine desire on the part of the physiotherapist to improve health outcomes for Maori.
Clearly, there are many ways in which physiotherapists can make various cultural interactions more sensitive and effective, thereby facilitating Maori access to care. This is consistent with the process of physiotherapy that concerns itself with the client's social and physical function and thus requires the therapist to understand the context according to the client's point of view (World Confederation for Physical Therapy, 2001). Physiotherapists committed to working in a culturally safe manner need to take into account the context of care, and make every effort to reduce barriers that may block successful communication and treatment.
In conclusion, this article presents some issues that Western trained physiotherapists might find useful. All health care professionals practising in New Zealand are required to understand the concepts of Maori health, cultural safety and the Treaty of Waitangi, in order to develop cultural competence. Cultural competence in practice is about recognising and respecting the client and their family's values and beliefs that potentially influence decision making for treatment. It requires that the physiotherapist works with the client and family, appreciating that how one cultural group understands the world may be different from the physiotherapist's perspective. The culturally competent physiotherapist recognizes how they communicate their own culture and adapts practice accordingly to support health outcome improvement for Maori. This article is by no means exhaustive of all the relevant aspects of culture that could be considered. However it is through reflective thinking and understanding of this nature that delivery of culturally safe care from culturally competent physiotherapists is assured.
The authors gratefully acknowledge input from Mike McCallin (physiotherapy), Shona Patterson (occupational therapy) and Maria Rameka, Iwi Ngapuhi Bicultural Advisor, Auckland University of Technology, who gave feedback on the cultural dimensions of the paper.
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* Since the arrival of Europeans to New Zealand, Maori health outcomes have suffered relative to non-Maori.
* Biculturalism was proposed as a strategy by government in order to reduce the inequalities of health outcomes for Maori.
* Cultural safety emphasises cultural awareness, cultural sensitivity, and power sharing with Maori and includes exploration of the differences between Maori and Western health perspectives.
* Adopting culturally safe practice will help clinicians meet legal and social obligations of providing culturally competent care. It is hoped this will reduce barriers that currently block positive outcomes for Maori health status.
* Practical approaches for the integration of cultural safety into clinical practice are discussed.
ADDRESS FOR CORRESPONDENCE
Catherine Main, 23/123 Owens Road, Epsom, Auckland. Tel: 09 638 7371. Email: firstname.lastname@example.org
Catherine Main BSc Hons (Physiotherapy), BSc Hons (Physiology)
23/123 Owens Road
Antoinette McCallin PhD, MA (Hons), RN
Auckland University of Technology
Private Bag 92006, Auckland
Naumai Smith MHSc, BA(Ed), RGON
Auckland University of Technology
Private Bag 92006, Auckland
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