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EDITORIAL July 2008
A Re-examination of Cultural Safety: A National Imperative
Perspectives about cultural safety are only recently appearing in textbooks, and now a small amount of related research activity is also beginning to emerge. The 13th Australian Nurse Educators’ Conference, held at Te Papa Tongarewa. October 2007, included a cultural safety theme that provided a rare opportunity for nurse educators to exchange relevant information. The present discussion incorporates themes presented at the conference augmented by perspectives drawn from discussions with colleagues. I also draw on my experience of teaching cultural safety as part of my professional work with both registered nurses and undergraduate nursing students. This collection of thoughts and insights is offered (in the absence of robust evidence) with the simple desire to promote debate, discussion and consequent movement in the cultural safety journey. Within New Zealand nursing considerable value is attached to the aim of offering a culturally safe service to all people. Registered Nurses [RNs] are required to demonstrate competency specific to cultural safety both initially to achieve registration, and subsequently in order to maintain a practicing certificate from the Nursing Council of New Zealand (Nursing Council). Cultural safety is “the effective nursing practice of a person or a family from another culture, as determined by that person or family”, while unsafe cultural practice is “any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual” (Nursing Council of New Zealand (NCNZ), 2005, p.4).
Inherent in the model of cultural safety used in education is the belief that efforts to describe the practices, beliefs and values of each culture should not occur as this promotes an ideology of sameness and an erroneous assumption that culture is a simplistic concept which can be captured in lists. Whereas the philosophy underpinning cultural safety has a clear focus that each person should be nursed regardful of all that makes them unique, encompassing the cultural, emotional, social, economic and political contexts in which people live. The process inherent in cultural safety education includes exploring the culture of nursing, recognising the impact that personal culture has on professional practice and the subsequent power relationship between nurse and the consumer of nursing care (NCNZ, 2005).
Ramsden, in 2002, noted that infrastructure and patient empowerment were two areas of concern in relation to the advancement of cultural safety. The absence of a national infrastructure to facilitate cultural safety education was deemed a risk as “apart from the Nursing Council guidelines on cultural safety there have been no other attempts to guide, influence or nationally support the people who are teaching in this area” (Ramsden, 2002, Chapter 10, paragraph 19). To date there is little evidence that this risk has been reduced in the intervening years. There is a direct correlation between this identified educational risk and Nursing Praxis in New Zealand Vol. 24 No. 2 2008 Page the enduring lack of a nationally congruent understanding of cultural safety. Infrastructure to support the development of cultural safety must be fostered. Publication of a collection of clinically applicable examples of both culturally safe and non-culturally safe encounters, from the perspective of both patients and nurses, is long overdue.
Ramsden’s second issue was that “In the future it must be the patient who makes the final statement about the quality of care which they receive. Creating ways in which this commentary may happen is the next step in the cultural safety journey” (Ramsden 2002, Chapter 11, paragraph 13). It continues to be difficult to know how nurses can make it safe for patients to tell them when they feel unsafe. While in total agreement that this situation needs to be changed, I contend that the next steps in the cultural safety journey are significantly more fundamental than those identified by Ramsden.
The culturally safe approach to care has not had the desired uptake by nurses practising in New Zealand. Nationally the concept of cultural safety has been poorly understood. It has endured as a predominantly ethnic application; and has been confused continually with the more traditional Transcultural nursing movement (where the articulation of cultural differences from the dominant group are exposed, learnt and used as a checklist of things to do and not do). The consequence of such an approach is perhaps best summed up in the following quotation:
No need to hear your voice when I can talk about you better than you can speak about yourself …. Only tell me about your pain. I want to know your story. And then I will tell it back to you in a new way. Tell it back to you in such a way that it becomes mine, my own. Re-writing you I write myself anew. I am still author, authority. I am still colonizer, the speaking subject and you are now the center of my talk. (hooks, 1994, p. 343).
I argue that in addition to the confusion with Transcultural nursing the current expression of cultural safety fails to comprehend the intrinsic complexities of cultural identity. The emphasis needs to move from categories of difference to individuals who have unique cultures. The inclusion of categories of cultural safety (age/generation; gender; sexual orientation; socio-economic status; ethnic origin; religious/spiritual belief, and disability) by Nursing Council (2005) has done little to advance the understanding of the concept of cultural identity. Instead these categories may endorse, albeit unwittingly, a reductionist approach to cultural identity and by default, cultural safety, as in all probability only one of the cultural categories listed above will be selected.
This reductionist focus on single cultural categories (of difference) as if they were, or ever could be, discrete, static and homogenous encourages labelling and categorisation of people. This in turn fosters stereotyping, while disregarding all other possible cultural identities of the individual person. Instead the primary focus needs to be on the bi-cultural partnership where each patient-nurse encounter is a genuine meeting of two different and unique cultures. Both parties engage in this meeting in the knowledge that they bring their own unique culture to the encounter (Ramsden, 1993).
In my experience an overwhelming majority of RNs (including nurse educators) and nursing students confuse cultural safety with the concept of ethnicity (specifically Maori), rather than seeing it as focus to promote the uniqueness of each person resulting from multiple intersecting cultural layers. Furthermore the belief that RNs would be forced to modify their own cultural identity in order to practice in a culturally safe manner has thrived in the absence of clearer understanding of the concept of cultural safety. This latter point may have contributed to the inertia evident in relation to a more inclusive implementation of cultural safety. The result of this confusion is that many now view cultural safety as a professional imposition rather than an embracing concept that would enhance the way in which nurses work in partnership with people.
In conclusion “maa te matatau, ka tau te whiringa – with awareness comes choice”. The Nursing Council Guidelines (2005) need to be deconstructed and then reconstructed with the express aim of redeveloping a meaningful way forward for culturally safe nursing education (and nursing practice as a natural extension of this education). Clarification of fundamental misunderstandings about cultural safety provides an ideal starting point for nurses to re-engage in the journey toward cultural safety for every person.
Geraldine Clear RN, MA
Associate Director of Nurse Education (Academic)
UCOL, Palmerston North
References
Hooks, b. (1994). Outlaw culture: Resisting representations. New York: Routledge
Nursing Council of New Zealand. (2005). Guidelines for cultural safety, the Treaty of
Waitangi and Maori health in nurse education and practice. Wellington: Author.
Ramsden, I. (1993). Kawa Whakaruruhau: Cultural safety in nursing education in
Aotearoa (New Zealand). Nursing Praxis in New Zealand, 8(3), 4-10.
Ramsden, I. (2002). Cultural safety and nursing education in Aotearoa and Te
Waipounamu Unpublished PhD thesis, Victoria University of Wellington, New Zealand
Retrieved on January 17, 2008, from http://culturalsafety.massey.ac.nz
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