Five principles of cultural safety

The cultural safety journey: An Australian nursing context Odette Best

You people talk about legal safety, ethical safety, safety in clinical practice and a safe knowledge base, but what about Cultural Safety?

(Ramsden, 2002, p. 1)

............................................................................................. Learning objectives This chapter will help you to understand and examine: • Your own beliefs, values and attitudes, and the influence these may have on your

work with Aboriginal and Torres Strait Islander Australians • The effects of Australian colonial nursing history on Aboriginal and Torres Strait

Islander people • Nursing practice that respects the differences of clients • The power that nursing practice can have on Aboriginal and Torres Strait Islander

people • The journey from cultural awareness to cultural safety.

............................................................................................. Key words beliefs, values and attitudes colonisation cultural safety decolonisation whiteness of nursing

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cultural safety

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Introduction This chapter explores the framework of cultural safety within nursing and midwifery practice. It discusses cultural safety from the perspectives of both nurses and clients,

with a particular focus on how cultural safety is relevant for Aboriginal and Torres Strait Islander people.

an approach to nursing practice developed in New Zealand that recognises the importance of cultural understanding and seeks to practise

The chapter begins by outlining the development of cultural safety theory by Maori registered nurse Irihapeti Ramsden. Cultural safety is placed within its historical context and is defined as a journey that involves cultural awareness- of your own culture and the culture of others.

in a way that provides a culturally safe service

colonisation

Nursing and midwifery students are encouraged to consider the potential influence of culture on their nursing and midwifery practice, and to ask questions about the 'whiteness' of the nursing profession. This chapter uses an historical approach to explore the 'whiteness' of nursing, the establishment of nursing in Australia, and its effects on Aboriginal and Torres Strait Islander peoples.

Understanding cultural safety involves considering the different ways in which cultures define health. Within Australia, the biomedical model of health dominates; however, this is a relatively new model and is not the only definition available. This chapter provides an Indigenous definition of health, and compares it with the World Health Organization's (WHO) definition.

The cultural safety journey involves moving from cultural awareness to cultural safety. This chapter explores how to cultivate cultural safety and embed it within nursing practice. The chapter concludes with five principles of cultural safety that are fundamental to nursing and midwifery practice with Aboriginal and Torres Strait Islander peoples.

Developing the theory of cultural safety Maori nurse Irihapeti Ramsden developed the nursing framework of cultural safety. In her doctoral thesis she stated 'that the dream of Cultural Safety was about helping people in nursing education, teachers and students, to become aware of their social conditioning and how it has affected them and therefore their practice' (Ramsden, 2002 , p. 2). She argued that the framework for cultural safety is designed to demystify colonial history

and prevent its effect on widespread attitudes and beliefs about indigenous peoples.

the process of taking over land for Ramsden's work in cultural safety emerged from her own journey as a Maori student nurse and nursing graduate, the colonisers' use and establishing control over the indigenous people.

Colonisation typically involves taking political control of a country, occupying it with settlers and exploiting the country's resources.

and her response to the educational process, which 'was so obviously designed for student nurses who did not , and could not share the experience of the colonisation of my land and people and history' (Ramsden, 2002. p. 2).

Chapter 3 The cultural safety journey

For Ramsden, cultural safety starts with an understanding of culture, which she defined as:

The accumulated socially acquired result of shared geography, time, ideas and human experience. Culture may or may not involve kinship, but meanings and understandings are collectively held by group members. Culture is dynamic and mobile and changes according to time, individuals and groups. (Ramsden, 2002, p. lll)

It is important to note that the concept of cultural safety does not anchor culture to ethnicity. Instead, culture is expanded to incorporate many components that can make up an individual's culture. While ethnicity can often be an important aspect of culture, it is not a sufficient definition (and may not always be the most important component).

This definition of culture also accepts that individuals may belong to multiple cultures at any one time. For example, within Australia's Aboriginal and Torres Strait Islander communities, culture can be determined by many markers in addition to physical appearance or ethnicity, such as the link to Country, or by our profession, spirituality or sexuality. ln this sense, Aboriginal and Torres Strait Islander Australians are no different from other Australians.

Ramsden noticed that her experiences as a Maori nurse and the experiences of paheha (white) nurses were in stark contrast. She found that her paheha nursing peers had little understanding of the brutal colonial and racist history of New Zealand.

The omission of the colonial history of New Zealand in the basic state education system had led to a serious deficit in the knowledge of citizens as to the cause and effect outcomes of colonialism. Without a sound knowledge base it seemed to me that those citizens who became nurses and midwives had little information of substance on which to build their practice among this seriously at risk group. (Ramsden, 2002, p. 3)

As a newly graduated nurse, Ramsden was constantly expected to look after only Maori clients and their families . She reported that, at times, she would watch inappropriate care being given to Maori patients and recognise the distress of these clients. She would add to her own client load by helping or explaining things to the client that the paheha nurse had instructed them to do. One outcome of this extra work was that Maori patients would ask to be looked after by Ramsden; the paheha nurses would shrug their shoulders, look at Ramsden and walk away (Ramsden, 2002). She explained that 'this meant dealing with such social mechanisms as personal and institutional racism in the context of a violent colonial history and coming to terms with the inherent power relations, both historical and contemporary' (Ramsden, 2002 , p. 3). The experience described by Ramsden is common among Aboriginal and Torres Strait Islander nurses in Australia (Best & Nielsen, 2005; Nielsen, 2010).

Ramsden questioned the outcomes of inappropriate nursing care for Maori. clients:

Consciously or unconsciously such power reinforced by unsafe , prejudicial demeaning attitudes and wielded inappropriately by health workers, could cause people to distrust and avoid the health services. Nurses need to understand this process and become very

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.,. Yatdjuligin CULTURAL SAFETY is an outcome ,. of nursing and midwifery education that enables safe service to be defined by those who receive the service.

CULTURAL SENSITIVITY alerts students to the legitimacy ,. of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the effect this may have on others.

CULTURAL AWARENESS is a beginning step towards understanding that there is difference. Many people undergo courses designed to sensitise them to formal ritual rather than the emotional, social, economic and political context in which people exist (Ramsden, 2002).

Figure 3.1 Ramsden's process of cultural safety in nu rsing and midw ifery practice

skilled at the interpretation of the level of distrust experienced by many Indigenous people when interacting with the health service which has its roots in the colonial administration. (Ramsden, 2002, p. 3)

Ramsden's thinking about culture therefore began to focus on the power imbalance bet ween the nurse and the client. This greatly informed her theory of cultural safety. She argued that 'cultural safety became concerned with social justice and quickly came to be about nurses, power, prejudice and attitude rather than the ethnicity or cultures of Maori or other patients'. (Ramsden, 2002, p. 5)

Ramsden defined a three-step process for developing cultural safety, and argued that work on cultural safety needs to be continuous. She proposed that nurses need to move from cultural awareness and through cultural sensitivity, before learning to practise with cultural safety. (Ramsden , 2002 , p. 117)

The Australian context: Developing cultural awareness Ramsden (2002) identified that cultural awareness is the first step on the journey to cultural safety. It is a 'beginning step towards understanding that there is a difference. Many people undergo courses designed to sensitise them to formal ritual rather than the emotional, social, economic and political context in which people exist' (p. 117).

Cultural awareness training is common in Australian health care settings. Interestingly, most cultural training focuses on learning about Aboriginal and Torres Strait Islander people. Little, if any, cultural awareness training encourages nurses to think about nursing culture - such as the 'whiteness' of nursing, the history of the

Chapter 3 The cultural safety journey

profession's growth and the history of the relationship between nurses and Indigenous Australians. Colonial practice and its effects on both nursing and Indigenous Australians are rarely discussed. As McGibbon and colleagues (2013) noted, cultural awareness training that includes 'a focus on knowledge about cultural practices of diet, dancing and dress has taken us even further away from the confronting colonialism in nursing' (p. 5).

By and large, non-Indigenous Australians have little sense of their own cultures. They often dismiss culture by saying 'I'm just Australian'. But what does that mean within the context of cultural safety? Non-Indigenous Australians do have cultures, but these cultures are rarely examined. This means that people with recognisable cultures, which are usually determined by ethnicity, are positioned as the 'other' - as being different from the norm.

An important aspect of developing cultural awareness is to remember not to accept that 'the culture of nursing is normal to patients' (Ramsden, 2002, p. 110). While Ramsden wrote from a Maori perspective, this applies equally to Aboriginal and Torres Strait Islander people in Australia - and to many other Australians. Nursing has its own culture, with its own practice and language that can seem very strange to clients.

An historical perspective of Aboriginal and Torres Strait Islander cultures further explains the cultural distance between Indigenous clients and many nurses. Prior to invasion, Aboriginal and Torres Strait Islander people practised their own approach to medicine. Health provision was dealt with according to gender and age, and health knowledge was passed down from generation to generation. Health resources depended upon what was locally available. Hospitals staffed with nurses and doctors made no sense within traditional Aboriginal health care. (For an extended discussion of the history of Aboriginal and Torres Strait Islander health practices prior to invasion, see chapters l and 2.)

Understanding our own individual beliefs, values and attitudes

beliefs, values and attitudes

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In order to begin the journey to cultural safety, as nurses we need to understand our personal perspectives and the individual beliefs, values and attitudes that we bring to nursing practice. Nurses also need to reflect on the profession's positioning within the health care system and within the wider community.

The Concise Oxford Dictionary (Pearsall , 1999) defines beliefs, values and attitudes in this way:

This then raises questions about nurses' own beliefs, values and attitudes towards Indigenous Australians. It is only recently that study of Aboriginal and Torres Strait Islander peoples and their cultures has been included in primary and secondary education. Many misconceptions continue to inform widespread beliefs, values and attitudes

• beliefs: an acceptance that something exists or is true, especially without proof; firmly held opinions or convictions.

• values: principles or standards of behaviour.

• attitudes: a settled way of t hinking or feeling.

about Indigenous Australians. These beliefs, values and attitudes are formed in early childhood and are influenced by many different mechanisms such as family, class, ethnicity, religion and schooling.

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The theory of cultural safety recognises that beliefs, values and attitudes are constructed through our social environments and will depend upon our childhood experiences. Cox and Taua (2013) argued that cultural safety is underpinned by a philosophical commitment to social constructivism that 'refers to the socially constructed nature of reality, where humans come to know the world through experience and together construct reality by negotiating meanings through communication and power relationships' (p. 321).

This approach to cultural safety makes it clear that nurses enter the profession with well-defined beliefs, values and attitudes about a whole range of issues. Accepted beliefs, values and attitudes will vary between nurses as well as between nurses and their clients. Many writers recognise that, before nurses can move towards practising cultural safety, they need to understand their own beliefs, values and attitudes, and the social structures in which they operate (Cox & Taua, 2013; Ramsden, 2002; Nielsen, 2010; Sherwood, 2010). The challenge is then for each individual nurse to understand that there are differences between people. Part of the cultural safety journey is the development of nurses' awareness of themselves and recognition that they do not necessarily know or understand the clients in their care. Nurses need to recognise how their personal beliefs, values and attitudes may influence their care of clients.

Nurses who do not receive cultural safety education may have nothing more than stereotyped, misleading myths to guide them in their attitudes towards Aboriginal and Torres Strait Islander people. Ill-informed stereotypes perpetuate because there is often little social contact between non-Indigenous Australians and Indigenous Australians, because Aboriginal and Torres Strait Islander people are either excluded from media representations or are shown in negative ways, and because Aboriginal and Torres Strait Islander people are rarely included in popular culture. The journey towards cultural safety, with its initial focus on cultural awareness, is a step towards addressing this shortfall.

Case Study 'Aboriginal woman in Bed 28 is non-compliant' When I was working as a registered nurse, I arrived for a late shift and was informed that the 'Aboriginal woman in Bed 28 is non-compliant in her care' . I was expected to do something about it, and she was allocated to my care for the shift. As I introduced myself to my patients at the beginning of the shift, I met this woman.

I found myself talking to a very distressed Aboriginal Elder who had been designated to a male registered nurse on the early shift. The nurse had been instructed by the doctor to insert a catheter. Of course, the female Elder refused the catheter. She also refused to be showered by the male nurse.

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Chapter 3 The cultural safety journey

The nurse did not try to understand why the patient refused care, but automatically labelled her as 'non-compliant'. When I asked the patient what had happened, her reply was simple: 'You know I can 't have a male do that to me'. The Elder then allowed me to insert her catheter and shower her.

I spoke to the registered nurse in charge of the shift and explained that Indigenous communities have protocols about men's and women's business. This woman was not being non-compliant; she was simply following her cultural values and beliefs. For her, it was impossible to accept that type of care from a male.

Questions for reflection • What are your own beliefs, values and attitudes about Aboriginal and Torres Strait

Islander Australians? Where did you gain them from? How were they formed? Have you ever questioned whether they are valid or true? Do you recognise any ill-informed stereotypes that you have not noticed before?

• What are some of the commonly held beliefs about Indigenous Australians? • How may these be considered stereotypes?

Who defines health? Each person's beliefs , values and attitudes contribute to her or his understanding of what is meant by 'health'. The biomedical definition of health can be quite different from the definition of health advocated by Aboriginal and Torres Strait Islander communities. One of the most widely accepted definitions of health is outlined by the WHO (1946) as 'not only the absence of infirmity and disease but also a state of physical, mental and social well-being'. This definition has not been amended since 1948.

In contrast, the National Aboriginal Health Strategy (National Aboriginal Health Strategy Working Party, 1989) states that health is:

... not just the physical well-being of the individual but the social, emotional and cultural well-being of the whole community. This is a whole of life view and it also includes the cyclical concept of life-death-life. (p. x)

Swan and Raphael (1995) extended the definition with this comment:

The Aboriginal concept of health is holistic , encompassing mental health, physical, cultural and spiritual health. The holistic concept does not refer to the whole body but is in fact steeped in harmonised inter relations which constitute cultural well-being. These inter relating factors can be categorised largely into spiritual, environmental, ideological, political, social, economic, mental and physical. Crucially, it must be understood that when the harmony of these inter relations is disrupted , Aboriginal ill health will persist. (p. 19)

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These definitions have some notable differences. From an Aboriginal and Torres Strait Islander perspective, health includes the community and the distinct interconnectedness of all elements. The Indigenous definition also outlines the continuation of health by including spirituality as the continuing cycle of 'life-death- life'. Today, we would define the traditional Aboriginal and Torres Strait Islander approach to health as 'holistic'. Prior to 1788, it was simply the norm. Every aspect of a person was regarded equally, including biological, psychological, sociological, spiritual and communal dimensions. In contrast, the WHO's definition operates from an individualist perspective. It does not reflect community nor spirituality.

It is important to note that comparing and contrasting these definitions of health is not about trying to identify which is right or wrong. Instead, it is about recognising that an Aboriginal definition of health may be different from the dominant Australian (Western) definition. Differences in defining health are valid and need to be acknowledged. The implication for nursing practice is that different clients may hold different beliefs about what health means. Different approaches to health care may be needed, to accommodate their definitions.

Questions for reflection

• What is your personal definition of health? • How have your beliefs, values and attitudes informed your definition of health?

Cultural awareness and the rise of the nursing profession in Australia This section describes the development of the nursing profession in Australia. Understanding the history of nursing is an important aspect of cultural awareness. It positions nursing within Australia's colonial history and helps to explain the colonisation of the profession (and therefore its 'whiteness'), the nursing profession's attitudes towards Aboriginal and Torres Strait Islander people and the history that underpins the longstanding suspicion of nursing held by many Aboriginal and Torres Strait Islander people.

Western approaches to nurse training in Australia began in 1838, with the first Sisters of Charity nurses arriving in Sydney: the Irish girls had arrived (Francis, 2001). Australia's nurse training was influenced by the work of Florence Nightingale, who had established a nursing school in London by 1860. In 1863, the widow of the New South Wales Chief Justice wrote to Nightingale, asking her to send trained nurses to Australia. This plea initially fell on deaf ears but, in 1864, doctors in Sydney requested of the Board of the Sydney Infirmary that it employ a small number of trained sisters from the Council of the Nightingale Fund. They argued that the 'doctors at the Sydney Infirmary were sure that nurses were the key to any effective cure' (Godden, 2006, p. 40).

Chapter 3 The cultural safety journey

Six nurses trained by Nightingale arrived in Sydney in 1868 (Francis , 2001). By the 1890s, most hospitals had become 'nurse training institutions' (Madsen, 2007, p. 14).

In the early days of the Australian colony, little was done for the health of Aboriginal and Torres Strait Islander people. They continued with their traditional approaches to health care. However, the introduction of diseases such as whooping cough and sexually transmissible infections affected Aboriginal people. These diseases were unknown prior to colonisation, and Indigenous health practices had no experience in treating them. Initially, there was little interest from the colonisers in either prevention or treatment. Many Aboriginal people described the new diseases and the decline of their health as 'white man's poisons'. When missions and reserves were established under the Acts of Parliament that were used to segregate people, entire communities were incarcerated, and traditional medical practices began to disappear. The use of traditional medicine was forbidden on the missions and reserves, as it was seen as 'witchcraft'.

Cox (2007) described the trauma and the legacy it left on the lives of many Aboriginal people by the missions and reserves. Forde (1990) described the role of nurses on missions and reserves. At Woorabinda Mission, Johnson (a visiting medical officer) stated that:

.. . the appalling conditions and high death rates of Woorabinda were in part due to the staff and is made up of three officers of the Department who are too fond of drinking, a mentally unstable Matron and a professionally negligent Medical Officer. Qohnson, cited in Forde, 1990, p. 48)

Florence Nightingale had conducted research on the health of Aboriginal Australians before her nurses started their work in Australia. Her interest in the health of Aboriginal people had begun after a meeting with Sir George Grey, 'who had discussed with her the apparent deterioration and gradual disappearance of native races after contact with white civilisation' (Seaman, 1992, p. 90). Nightingale applied to the Colonial Office for aid to carry out an enquiry 'to ascertain, if possible the precise influence which school training exercised on the health of native children' (Nightingale, 1863, p. 3). She successfully obtained funding and devised a 'simple school form' that was sent to the native schools of the colonies. She received responses from Western Australia and South Australia and presented her research in York (England) in 1864 (Nightingale, 1865).

The responses from Australia that described Aboriginal people were highly racist and showed gross ignorance. Aboriginal people were described as 'savages', 'uncivilised ' and in urgent need of being brought into a state of civilisation. In the mid-1800s, the 'civilising' of Aboriginal people involved conversion to Christian beliefs. Aboriginal spirituality was not acknowledged, and people's spiritual beliefs were not regarded as being essential to their health and identity.

Within Nightingale's writings, there is no acknowledgement of the efficacy of Aboriginal health and healing practices, such as caring for the sick, using traditional medicines, child-bearing practices, healing the injured and caring for the frail aged

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A native belonging to the institution became ill with spitting of blood; a sure mark of fatal disease, if the patient is treated in the usual way The patient begged to be allowed to go into the bush; and after days hunting of horses, he returned sufficiently recovered to resume his occupations. (Nightingale, 1865 p. 4)

Despite the widespread myth that Aboriginal people were 'savages' and 'barbaric', some non-Indigenous women highly valued Aboriginal women's knowledge of birthing and midwifery (Alford, 1986; H. Gregory, personal communication, 12 May 2009; Summers, 2000). Traditional birthing practices were widely used during this era.

Nightingale was scathing about the effects of colonisation on the health of Aboriginal Australians. She outlined what she believed were the root causes of their health decline: l. 'The introduction to the natives of intoxicating liquor 2. The use of native women as prostitutes 3. Hunger, as a result of deprivation of traditional hunting grounds 4. Attempts to 'civilise' the natives by interfering with their traditional habits and

customs 5. Poor sanitary conditions as the result of natives being brought into schools or

buildings under more confined conditions than had been their custom 6. Cruelty and ill-treatment. (Nightingale, I863, cited in Seaman, 1992) Nightingale's work is filled with the contradictory views that were common at the time. She identified alcohol as a problem, but gave little attention to the fact that alcohol was often used as payment and bribes. Nightingale believed that aspects of Aboriginal people's declining health were due to attempts to civilise Indigenous people and the interruptions to their traditional lifestyles, but she argued that there was a strong need to educate them into the Christian belief system. She identified education as essential for civilising Aboriginal people, but did not take into account the deeply entrenched educational practices of Aboriginal people, which were based on responsibility for land, the learning of languages, understanding of the seasons, migration across Country to gather resources and the practice of traditional medicine.