Cultural safety values difference: key concepts in cultural safety include understanding your own values and beliefs and how they affect relationships with clients and the dynamics of power relationships.
|Publication:||Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2001 New Zealand Nurses' Organisation ISSN: 1173-2032|
|Issue:||Date: Feb, 2001 Source Volume: 7 Source Issue: 1|
|Product:||Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners SIC Code: 8049 Offices of health practitioners, not elsewhere classified|
CULTURAL SAFETY education encourages nurses to reflect on their
life histories in order to help them understand and accept differences
in others. Beliefs and values formed through one's background can
affect the way a nurse relates to others. Nurse educators recognise the
importance of self-awareness and reflective practice by nurses in
understanding the unequal power inherent in relationships with clients.
Cultural safety is one of the features of the Maori renaissance over the last 15 years. It has become part of standards of nursing practice. It aims to prepare the nurse to listen to the client and family, relating with respect and acceptance. Some personal reflections experienced while studying cultural safety are analysed in this viewpoint.
The first reflection is on the varied and sometimes negative reactions from colleagues and clients when I shared the topic of study with them. Most showed interest and listened thoughtfully to my impressions. However, some were indifferent that such teaching should be necessary. The latter responses were mainly from older, middle-class, European New Zealanders, predictable perhaps in a society which, until recent times, has been sheltered from much cultural diversity and conflict on a personal level. I knew in my own past I had felt affronted when discussing some cultural issues but with education and greater understanding I became better informed. The anger and guilt often experienced when facing racism stems from ignorance and reluctance to face fears and prejudices.
Are we willing, for example, as New Zealanders to listen to and accept the historical claims that Maori have been unfairly treated under successive European-dominated governments? (1,2,3,4) The evidence is clear in widely publicised health statistics that Maori need fairer representation in positions of control of their lives. (4,5) Maori have been alienated by social and health policies laid down since colonisation began in the 19th century.
Cultural safety teaching began in the 1980s in response to claims from a group of Maori nurses that patients were "... expressing dissatisfaction about how nurses provided care irrespective of particular patients' needs ..." The charge was that as health professionals "... we were not respecting the history and present circumstances of the individuals and groups we nursed." (6)
Non-Maori nurses were often failing to see beyond their own cultural views and therefore blindly making assumptions about appropriate care for clients. At this time in the history of the health care service, client satisfaction and quality issues were coming under greater scrutiny. Legislation had been passed to protect the rights of patients to quality care. (7) Health professionals and patients were voicing their concerns in an effort to improve things.
There was controversy both publicly and within nursing during the early years of cultural safety education. One commentator claims the mystery of risk for patients was because of wrong interpretations of the meaning of cultural safety. (8) It is not so much about knowledge of basic Maori culture, but of learning New Zealand history and the reasons why Maori are disadvantaged compared with the dominant population in terms of health, education, economic and occupational achievement. Knowledge of colonisation and its effects on the people and the reality of power dynamics in health care can help nurses approach clients with greater respect and openness. (8) Poorly trained tutors often brought pain and guilt for students. Many labelled the teaching as political indoctrination. Client safety is more to do with the conscious or unknowingly expressed attitudes and assumptions of nurses, which can be demeaning to others, than with the degree of hands-on nursing skills. (8)
When people are first challenged with the reality of personal and institutional racism there are normal reactions of fear, distrust and denial. A number of nurse researchers have identified a chain of normal responses in the learning of cultural safety--a poutama or staircase of knowledge, which can take many months to work through. (9) The process begins with an understanding of personal experience and knowledge, through to racism awareness, learning Treaty of Waitangi history and acceptance of cultural differences. This is followed by the development of strategies for change at institutional level. This framework, which challenges attitudes, can lead to a major shift in students' thinking.
The second valuable reflection was to look in greater depth at my own cultural background and realise that my life experience powerfully affects the way I relate with others. This concept is in contrast with the patient-centred emphasis in nursing care which was taught during my training in the 1970s. Identifying personal prejudices and stereotypes about particular groups in society was a challenge in honesty and it was interesting to connect these attitudes with past events or family practices. Our values and beliefs have a strong influence on the ways we relate to others. This has huge implications for nurses who are relating to often vulnerable patients.
Role models, family relationships and other factors such as race, gender, religion and occupation, determine for a person what is considered to be acceptable behaviour. (10) Social scientists in recent times have brought a greater focus on the power of individual human behaviour and the effect on others in a given social situation. There is often great variation in individual responses to a given situation. Individuals can powerfully affect social situations, as situations can affect individuals. The two interact so "we are both the products and the architects of our social worlds". (10) No two nurses in the same challenging care situation will behave in the same way towards a patient. Quality health care is a subjective experience for individuals.
As cultures have come together in the modern world there is inevitable conflict. One description of western, industrialised cultures as being characteristically individualistic and competitive is interesting in looking at cultural differences in society. (10) This contrasts with the characteristics of collectivity common to Maori, Asian and other third world cultures, where more value is put on the welfare of the group. The resulting effects on self concept and social relations are correspondingly different, depending on cultural heritage. This analysis is helpful when confronting challenges of cross-cultural conflict in health care leadership styles and in the nurse-patient relationship.
Looking at the historical background of the Celts, as an often colonised people, was helpful in trying to understand experiences for Maori under British rule. (11,12) Modern archaeology has revealed the Celts to be a complex, resourceful and varied group of tribal societies, which can be compared to Maori. (11) The varied Celtic groupings were similar to those within Maoridom, a feature which characteristically inhibited unity and strength when confronted with other powers. Colonisation of Celtic groups by the Romans, Vikings and Anglo-Saxons almost extinguished the culture, through mechanisms of legislation and justice. Land losses and assimilation by the dominant power caused disintegration of language and identity. (12) This can be compared with experiences for Maori under British rule from 1800 onwards.
Examining colonisation has been helpful in identifying the position of marginalised groups in society. Prominent New Zealand historian, Claudia Orange, identifies that while intentions by many early British settlers in New Zealand were usually honourable, there was also much lawlessness and disregard for others. (2)
Organised immigration to New Zealand from 1860 onwards forced Maori to change their lifestyles. Maori numbers were quickly overwhelmed. Colonial expansion beyond Europe usually meant rights of settlement through discovery. (1) Colonial settlers were sustained by a sincerely held conviction in the superiority of their own civilisation and in their right to settle in a land which appeared to them largely unoccupied and undeveloped. (1) The civilising mission of Europe meant that intellectually and morally superior attitudes by some prevailed. Domination through government law drove a wedge into traditional Maori tribal life.
There is perhaps a pervading cultural legacy among tauiwi of hegemonic pride, superiority and intolerance of others. (1) In advocating parallel development in health organisations, which embraces the principles of the Treaty of Waitangi, the uniqueness of Maori culture and the fact the best people to address Maori problems are Maori themselves has been stressed. (13) The dominant non-Maori population has a responsibility "... to neutralise the pakeha backlash and provide resources so the shift is possible." (13) The aim is to have a vision for the future and to avoid feeling threatened by the need for Maori self-determination.
There have been many accounts of cultural dominance and the resulting impact on personal self worth and identity. One commentator compares the effects of cultural imperialism to those of racism, in that the life experience and values of others are devalued as being worthless or of lesser importance. (14)
Issues of power in the health service are widely recognised and cultural safety education encourages health professionals to be aware of them. Many educators have highlighted the dominance of the medical profession within the health service as a cause of the subordination of other groups and the values they represent. (15,16) Educational theorist PauloFriere claims oppressed groups in society need to regain control over their own lives by firstly recognising the reality of oppression and then overcoming the negativity with which they have been labelled. Leadership from within the oppressed group is critical in helping the group as a whole to develop unity and pride. (16)
Recent attention to treaty principles of partnership and participation has brought a very different style of health care for people and communities. (17,18) Health professionals are now encouraged to understand cultural issues and to recognise that economic and social oppression contributes directly to poor health. Developments in tribal health policies will help ensure Maori regain control of their health concerns.
Learning about cultural safety has made me more aware of the power my words and actions have in influencing clients I communicate with. The power dynamics inherent in such interactions influence outcomes in terms of how safe a client feels and quality of communication. Looking in depth at my own background has allowed me to analyse the of sort person I am and how effectively I relate to others. Hopefully changes to my practice will include better listening skills, greater empathy and intuition, skills which affirm clients and encourage partnership in health care. Cultural safety has highlighted the connection between cultural backgound and health status among groups and individuals. Greater knowledge has helped me to better understand many problems encountered in practice, including low self esteem, violence, drug dependence and poor parenting skills.
Understanding the importance of cultural safety in health care takes time and needs ongoing reflective skills. Sound, good quality education is the key to imparting the complex concepts to be learned in cultural safety. The nurse-client interaction is dynamic and unique, subject to personal and situational variation. Self-knowledge and awareness of cultural differences will improve understanding and acceptance of others in conflicts which do occur. Many problems of the present can be better understood by learning about the past. Skills of active reflection and evaluation of practice are critical in helping nurses become safe in interacting with all clients.
(1) Mulgan, R. (1989) Maori, Pakeha and Democracy. Auckland: Oxford University Press.
(2) Orange, C. (1989) The Story of a Treaty. Wellington: Allen and Unwin.
(3) Temm, P. (1989) Settlers discard the Treaty. Race, Gender, Class. Nos 9 and 10. Christchurch: Race, Gender, Class Collective.
(4) Charman, K. (1988) Hauora: An indictment on social equity. New Zealand Nursing Journal; 81: 9, 16-18.
(5) Te Puni Kokiri. (1993) Factors Affecting Maori Health. Te Ara Ahu Whakamua (Strategic Direction for Maori Health). A discussion document. Wellington: Te Puni Kokiri.
(6) Wright, T. (1995) Understanding cultural safety. Kai Tiaki: Nursing New Zealand; 1: 6, 22-23.
(7) Burgess, M. E. (1996) A Guide to the Law for Nurses and Midwives.(2nd ed) Auckland: Longman.
(8) Saxon, K. (1995) Students support cultural safety. Kai Tiaki: Nursing New Zealand; 1: 6, 24.
(9) Wood, P. J., and Schwass, M. (1993) Cultural Safety: A Framework for changing attitudes. Nursing Praxis in New Zealand; 8: 1, 4-15.
(10) Myers, D.G. (1993). Social Psychology. (4th ed) New York: McGray-Hill.
(11) James, S. (1993) Exploring the world of the Celts. London: Thames Hudson.
(12) Duncan, A. (1992) Celtic Christianity. Dorset: Element Books Ltd.
(13) Cooney, C. (1996) Learning to Work as Partners. Kai Tiaki: Nursing New Zealand; 2: 2, 22-24.
(14) Starhawk. (1987) Truth or Dare. New York: Harper Collins.
(15) Duffy, E. (1995) Horizontal violence: A conundrum for nursing. Collegian; 2: 2, 5-17.
(16) Roberts, (1983) Oppressed group behaviour: Implications for nursing. Advances in Nursing Science; July, 21-30.
(17) Durie, M. (1988) The Treaty of Waitangi and health care. The New Zealand Medical Journal; 102, 283 285.
(18) Kearns, R. (1997) A Place for cultural safety beyond nursing education? The New Zealand Medical Journal; 110: 1037, 1-2.
--Susan Benham, RGON, works as a practice nurse in a general practice in Whakatane. The article was developed from an assignment she wrote as part of her studies for a Bachelor of Nursing.
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