Despite the fact culturoI safety has
been part of nursing education
since 1993, many nurses are stni
confused by the concept. A review
of the literature brings together a
number of critical themes.
By Margaret Hughes and
Tony Farrow
T
his year, nurses will be asked to prove
their continuing competence in a number
of domain areas. Within domain one of
the Nursing Council's competencies — professional responsibility — nurses will be asked to
show they both apply the principles of the
Treaty of Waitangi to their practice and nurse
in a manner the client determines as cutturalty
safe.^
While there is a relationship between these two
areas, we believe some nurses are stilt confused about the differences and similarities
between them. This is unsurprising, given that
many nurses have not had the opportunity to
attend cultural safety workshops. This article
briefly describes the similarities and differences, and the implications these have for practice. If nurses are to be assessed on competencies, we believe opportunities must exist
for them to be exposed to education in these
areas.
major focus of cultural safety in New Zealand,
many nurses we speak to on a daily basis appear to believe the Treaty of Waitangi and how
to look after someone who identifies as Maori,
or is from a different ethnic group than themselves, is the only focus.
If we were to design a machine where we could
place all the cultural safety articles ever published and separate out all the principles and
concepts involved, the process would provide
a useful starting place for understanding cultural safety. Our journey begins with the brave
step that Maori nurses first made at hui during
the 1980s, where the poor health statistics of
Maori were identified and questions asked as
to why this was occurring.^ ^ ^ Challenging the
prevailing beliefs of the times is something
those nurses should be proud of.
Culture in nursing refers to people who differ
from you in terms of attitude, beliefs, roles
within society and "being in the world".j^ Other
factors include age, disability, gender, socioeconomic group or sexual orientation, as well
as ethnicity.^j 1213 9 7 These are pivotal to understanding cultural safety today and identify
that it is not only race or cultures that can
appear "exotic" to nurses. Ramsden stated that
cultural safety was also about being aware that
clients view nurses as "exotic".,,,,. In an
What is cultural safety?
Nurses have written profusely about the history of our cultural safety journey and there
are many classic articles which identify its concepts. This journal has published many of them.
The earliest articles identify cultural safety in
terms of Maori health and ethnicity. ^ j ^ 5 ^ 7 a
4,5,7,14
These can be considered as the starting place
anthropological sense, nurses are viewed as
in our cultural safety journey.
having a culture with specific customs, a way
In 1993 the concept was broadened out to inof communicating, a set of "tools" and dress,
clude what the architect of cultural safety, the
that mean nurses and nursing are different to
late Irihapeti Ramsden, referred to as the "catclients' accepted norms and standards.
egories of difference".^ While ethnicity in the
Another principle which might be separated out
form of indigenous Maori health must remain a
by our machine is the name cultural safety it-
KAl nAKI NURSING NEW ZEALAND > FEBRUARY 2006
self. This is problematic for some, especially
those new to its study. When people first come
across the concept and are awate of the controversy surrounding its journey, many suggest
changing the name. However, Ramsden was
adamant the name "cultural safety" must remain, as it is consistent with the requirement
that nurses are physically and emotionally safe
in their assessments and interactions with clients.^gj^^ So, too, must they be culturally
safe.-,,,. The term "safe" is also consistent
with the client stating whether they have felt
"safe" within the client-nurse interaction and
ensures the power remains with the client to
define that interaction.^^ This is clearly the
intention of domain one and is pivotal to understanding the relationship of power and
empowerment within the health system.
Ramsden also talked of the client being nursed
"regard/u//y".g This can be a difficult concept
to grasp, in part because of the strongly held
myth of an egalitarian society where everyone
is born and treated equally. Ramsden notes
that, historically, nurses, on receiving their
nursing medal, swore an allegiance to nursing
people regard/ess of their difference, including
those of race, creed or colour.^ ^^ However, this
is contrary to cultural safety, as it suggests
oneness, sameness and assimilation. Cultural
safety is about acknowledging that people are
different, and therefore valuing and respecting difference, with nursing care based on those
differences, not regardless of them. .
Cultural safety also requires nurses to be aware
of the assumptions we hold about others and
not to base nursing care on our socially and
culturally constructed assumptions.
This
is because faulty assumptions can lead to faulty
decision making and judgements, which can
in turn lead to stereotyping, labelling and
sometimes victim blaming.
Avoiding making judgements about others may
sound easy, but in fact it can be difficult be-
cause often our initial judgements happen automatically. We are so socialised into the "way
things are done around here", that our attitudes become the cultural norms. The
socialisation process and the social structures
we are schooled, raised, work within and protected by. shape the way we live. These in turn
mould our attitudes, beliefs and values. Knowing our own cultural heritage and associated
beliefs, values and attitudes is a vital component of cultural safety.
It is in fact much
more important than knowing the clients' culture. Indeed it is questionable whether it is
truly possible to know someone else's culture.
Cultural safety, therefore, is intended to
assist nurses know their own cultural backgrounds, identifying their own beliefs and attitudes. Cultural safety is also about recognising that nursing itself is a culture, with its
own implicit beliefs and attitudes. Understanding and accepting this reality can help nurses
identify when they are imposing their beliefs
on clients about "the best way" to do things.
Avoiding cuttural risk
As more concepts are extracted by our machine,
we see that cultural safety is about ensuring
we do not place clients at cultural risk. To do
this is just as dangerous as placing them at
physical, emotional or mental risk.^^ The poor
health statistics of some groups within New
Zealand society will attest to this. If clients
feel the care they are receiving is not culturally safe, they will not return to it and in some
cases their health will continue to deteriorate.
This goes some way to explaining why many
Maori under-utilise primary health services but
"over-utilise"secondary services. None of us
would return to receive care where we felt we
had been demeaned, diminished or
disempowered. This is the definition of cultural risk — the opposite of nursing people in
a culturally safe way.
Ramsden and educator Elaine Papps ask us to
he cognisant of the social, political and economic determinants of people's health, and how
health can be affected by a lack of access to
scarce, valuable resources such as employment,
education and health care., ,^ „ This is a challenge for many New Zealanders who claim that,
in our "fair" society, health and education are
available equally to all. Cuttural safety acknowledges that access is a broad concept, embracing financial access, geographical access (having the transport to get to appointments) and
culturally appropriate access (feeling safe when
using the services). There is much support for
this viewpoint in many health policy documents.^^ ^^ ^^ Cultural safety asks us to reflect
on the care we give people who may differ from
us in ability, gender, age, socio-economic status and sexual orientation, so that the values
nursing says it supports, such as empowerment,
advocacy, holism and caring, remain more than
promises and are actually present in practice.^^
What cultural safety is not
People new to the study of cultural safety often describe it as being about "commonsense"
and "just about respect". However, this understanding is flawed. Cultural safety is not about
being respectful in terms of politeness, and it
is not about commonsense. Both these values
are cultural constructs. What might be
commonsense and respectful in one culture is
not necessarily commonsense and respectful in
another.
In addition, cultural safety is not just about
ethnicity, nor is it only about Maori or our obligations under the Treaty of Waitangi. Cultural
safety, then, can never be about having a
checklist of how to look after someone.There is no one way to look after someone who
identifies as Maori or Samoan or Vietnamese.
Nor is there one way to care for a young person, or someone from a different socio-economic group, just as there is no one way to
nurse someone with a disability, or who is different from the nurse by gender or sexual orientation. It is impossible to become an authority on your own culture(s), let alone some-
one else's, and it is counter to the concept of
cultural safety, where difference within cultures, not just between them, is acknowledged
and respected.,pjp What cultural safety asks
us to do when we face a nursing situation outside our sphere of cultural experience is to
"ask". This sounds simple, but in reality it can
be difficult, especially if you are interacting
with someone from your own culture.
Knowing our obligations under the Treaty of
Waitangi as New Zealand's founding document
is the right place to start with cultural safety.
Even though we may live in an increasingly
multicultural society, our ethical and contractual obligations are with the tangata whenua
as the first people of the land.j^^^ The Treaty
underpins many pieces of legislation that govern the nursing profession. Therefore we need
to be aware of its role and the articles of its
two versions.
Becoming aware of past injustices
Mere compliance to the standards and codes
of nursing would be a very low level of ethical
and professional reasoning, as cultural safety
is also about personal ethics. Ramsden asked
nurses, upon reaching the end of their undergraduate education, to see the injustice and
social discrimination in our society and then
do something about it.^^ ,^ However, she also
reasoned that possibly only one third of graduates would be able to do this. Nurses need to
be politically aware and be able to reflect on
the effect of repeated breaches of the Treaty,
which have led to the removal of a people from
their economic and spiritual base. The results
of this injustice are poor health statistics, life
expectancy and quality of life compared to non
Maori. Recognising the legacy of our history is
essential to avoid blaming the victims of poor
health.^
Our willingness to examine these complex issues determines what sort of society we live
in, as an understanding of the issues around
the Treaty of Waitangi goes to the heart of the
political, social and economic disparities between Maori and non Maori health.
The Treaty can also be a model for effective
relationships between clients and nurses, between nurses, and between nurses and other
members of the interdisciplinary team. The
principles of partnership, participation and
protection, as identified in the 1988 Royal
'It is the client who assesses whether the care they Commission on Social Policy, are a useful
have received has been culturally safe or not.'
framework for caring for any person in a cul-
'IT IS IMPOSSIBLE TO BECOME AN AUTHORITY
turally safe way.^^
While the intentions behind ongoing assessment of competency to practise are laudable,
some nurses may be placed in the unenviable
position of having to demonstrate competency
in areas where they have not had access to
information. Students are exposed to cultural
safety throughout the three-year undergraduate programme. However, many nurses who
trained some years ago have not had this opportunity, unless they have actively sought
cultural safety education post registration.
We support the Nursing Council's expectations
that nurses practise in a culturally safe way.
However, nurses should also have the opportunity to be exposed to cultural safety education before they are measured against standards. Cultural safety is a demanding and difficult concept, as it can challenge both professional and personal beliefs and assumptions.
It is vital workshops on cultural safety are offered to nurses who have not had recent exposure to this concept. Ideally, these would be
provided by employers, in the same way as
other in-house education. However, as this is
unlikely to occur, we suggest the Nursing Council becomes responsible for holding cultural
safety workshops before assessing competency.
The intention of this article has been to pro-
Assessing the domains
How do we assess whether the care we deliver
is culturally safe nursing care? Ramsden was
quite clear that it is the client who assesses
whether the care they have received has been
culturally safe or not. It is pleasing to note
that the domains of competence specifically
stipulate this too.^ While this is consistent with
cultural safety concepts, historically it has not
been included in any of the Nursing Council's
or NZNO's codes or standards. Although nurses
have been required to function as culturally
safe nurses since 1993,^^ ^^ ^g 29 ^^^''^ ^^^ ''^^"
no assessment after registration and no measurement criteria on which to assess culturally
safe nursing care. This makes Domain One a
radical and welcome addition to the nursing
competencies. In addition, the domains clearly
tease out the two arms of cultural safety and
identify that nurses must work within the Treaty
of Waitangi and they must be culturally safe.
While the former can be assessed by demonstrating knowledge of the relationship of the
Treaty of Waitangi to culturally safe nursing
care, proving that you are culturally safe can
be more complex.
vide some practical information about what cultural safety is and what it is not, in order to
broaden the concept beyond ethnicity. In doing this we have used a selection of classic
resources available to nurses wanting to read
more about the subject. We have touched on
the important relationship between the Treaty
of Waitangi, Maori health and culturally safe
client-nurse relationships, and identified the
influence of cultures within cultures such as
age, gender, disability, socio-economic group
and sexual orientation. Ultimately this information will be useful to nurses seeking to provide evidence of cultural safety in its wider
sense as required by domain one within the
nursing competencies.^ However, this information is not enough on its own. Nurses who have
not been exposed to cultural safety education
need to have access to workshops before competency assessment occurs. Without such exposure,
many nurces may be unable to provide evidence of
competency to practise in a culturally safe way. •
Margaret Hughes, RN, BN, MBS, and Tony
Farrow, RN, BN, MHSc (Hons), are both
senior lecturers in the Christchurch Polytechnic Institute of Technology's Faculty
of Health and Sciences.
References
1) Nursing Council of New Zealand, (?005a) Competenciei fo' the registered nurse scope of practice. Wellington: Author.
2) Dyck. I. & Kearns. R. (1995) Iransfofming the relations of research: towards cjlturally safe geographies of health and illness. Health and Practice; 1: 3, 137-1A7.
3) Kearns, R. (1997) A place for cultural safety beyand nursing education. The Hen/ Zealand Medical Journal:
\W:
1037, 23-?4,
A) Ramsden, I . (1990) Kawa Whokarunihau: cultural safety in nursing education in Aoteoroa. Wellington: Ministry of Health.
%) Ramsden, L (1993) Kama Whakaruruhau: Guidelines for Nursing and Midwifery Education in Aoteoma. Wellington: Nursing Council of New Zealand,
6) Hamsden, I, (1995b) What have we learned? Kai riaki Nursing New Zealand: 1 : 10, Z.
7) Ramsden, I, (1996) The Treaty of Waitangi and Cultural safety:
Wetlington: Nursing Council of New Zealand.
The rate of the Treaty in Nursing and Midwifery Eduction Guidelines for Cultural Safety in Nursing and Midwifery Education in Aoteroa.
8) Wood, P. & Schwflss, M. (1993) Cultural Safety: A framework for changing attitudes. Nursing Praxis in New Zealand; B I : 1 , 4 - ! 5 .
9) Ramsden. I, (October 1995a) Cultural safety: Implementing the concept. New Zealand College of Midwifes Journal.
6-9,
10) Cooney, C. ( 1 9 9 i ) A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand; 9: 1, 6-11.
11) Nursing Council of New Zealand. (1996) Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. Wellington: Author,
12) Nursing Council of New Zealand. (2002) Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. Wellington: Author.
13) Nursing Council of New Zealand. (2005b) Guidelines foi Cultural Safety, the Treaty of Waitangi and Maan Health in Nursing Educatian and Practice. Wellington: Author.
14) Ramsden, I . (2000) Cultural Safety/Kawa Whakaruruhau ten years on: a personal overview. Nursing Piaxis in New Zealand; 15; 1, «-12.
15) Ramsden, I. (2005) Towards cultural safety. In Wepa, D (Ed.), Cultural Safety in New Zealand/Aoteoroa.
(pp2-20). Auckland: Pearson Education New Zealand.
16) Papps. E. (2005) Cultural safety, daring Lo be different. In Wepa, D (Ed.), Cultural Safety in New Zealand/Aotearoa.
(pp20-29), Auckland: Pearson education New Zealand.
17) Benham, S, (3001) Cultural safety values difference. Kai Tiaki Nursing in New Zealand; 17: 1 , 28-29,
18) Thompson, S. (2001) Developing a culturally safe curriculum. Kai Tiaki Nursing New Zealand; 7: 1, U - 1 7 ,
19) Papps, £. (2002) Cultural safety, what is the question? In Papps. £ (Ed,), Nursing in New Zealand, Cnticat Issues, different
perspectives, (pp, 95-107). Auckland: Pearson Education New Zealand,
20) Coup, A, (1996). Cultural safety and culturally congruent care: A comparative analysis of Irihapeti Ramsden's and Madeleine Leiningefs educational projects for practice. Nuisirjg Praxis in New Zealand;
11. 4-10.
21) Papps, E. & Ramsden, I. (1996) Cultural Safety in New Zealand: the New Zealand Experience. International
Journal for Quality in Health Care; 8: 5, 491-A97,
22) Ministry of Health, (2001) Priorities for Mkori and Pacific Heolth: Evidence from Epidemiology. Wellington: Author,
23) Ministry of Health. (200?) He Korowi
Orongo: Maori heolth strategy. Wellington: Author,
24) National Advisory Committee on National Health and Disability. (1998) The social, cultural and economic determinants
Committee.
of health in New Zealand: Action to improve health. Wellington: National Health
25) Kermode, S, 8. Brown. C, (1994) Where have all the flowers gone? Nursing's escape from the radical critique. Contemporary Nurse; 4: 1 . fl-15.
26) Royal Commission on Social Policy. (1988) The April Repart. 1-5, Wellington: Government Press.
27) NZNO, (1993a) Social Policy Statement. Wellington: Author,
28) NZNO. (1993b) Standards for Nursing Practice. Wellington: Author.
29) NZNO. (199S) Code of Ethics. Wellington: Author.
KAI TIAKI NURSING NEW ZEALAND > FEBRUARY 2006