Monday, 13 June 2011

'Cultural safety' in nursing practice

Critical refection on professional responsibilities (Cultural safety)
During the Competency Assessment Programme (CAP) course, I learned about the Treaty of Waitangi (TOW), its historical significance and its relevance to the health of the indigenous Maori population of New Zealand/Aoteoroa. From lectures and the reading that I did, I know that there is a difference in socio economic and health and outcomes between Maori and non-Maori New Zealanders.  For example, data indicates that compared to non-Maori, Maori have a lower median income, reduced life expectancy, a higher youth suicide rate, higher incidence of breast cancer in women (Kingi, 2007, Rapata-Hanning, 2010).  I learned that the burden of disease and ill-health experienced by indigenous populations happens when people have been dispossessed of land and resources by the dominant group in a society (Wilson, 2006).  This was the experience of the New Zealand Maori as a result of early British colonisation.   
As an outcome of learning about the TOW, and as a European New Zealander I am now fully aware of the injustice and social discrimination in our society and, as a health care professional, wish to do something about it.  The TOW establishes the rights of Maori and the nature of their relationship with the government.  A useful way forward is to think of the treaty as a model for effective relationships between clients and nurses, between nurses, and between nurses and other interdisciplinary teams.  The treaty principles of participation, protection and partnership are a useful framework for caring for any person in a culturally safe way (Kingi, 2007, NCNZ, n.d.).
So what is cultural safety? A great deal has been written about cultural safety in nursing.  The earliest articles identify cultural safety in terms of Maori health and ethnicity (Ramsden, 1990).  In 1993 the concept was widened to include what Ramsden (1993) referred to as ‘categories of difference’. More recent research shows that culture in nursing refers to people who differ from you in terms of attitude, belief, culture, values, roles within society, age, disability, gender, socio-economic group or sexual orientation (NCNZ, n.d.; Papps, 2005).
We can take this that 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.  Being culturally safe requires nurses to be aware of the assumptions that we hold about others and not to base nursing care on or socially and culturally based assumptions. In practice, cultural safety means being able to engage within a socio-political context of beliefs about family (whanau). It means understanding what is forbidden (tapu) in a range of health care practices from washing someone, through to physical examinations or handling biological specimens (ODHB, n.d.). 
In professional practice, the central tenant of cultural safety is that rather than the nurse determining what is culturally safe, it is the recipient of that care who decides whether they feel safe with the care that is given. This client-centred philosophy is in contrast to traditional nursing education which was founded upon the idea that all people should be treated the same rather than recognise their differences.  Today cultural safety requires that nurses provide care mindful of those things that make people unique (Hughes & Farrow, 2006).   
Having returned to clinical nursing after 26 years, I have seen the treaty principles of partnership, protection and participation applied in everyday clinical practice. In particular, I have observed that nurses no longer ‘do procedures’; rather they explain, describe, then gain the client’s consent to carry out their work.  Part of this is due to legislative changes such as the Code of Health and Disability Services Consumers’ Rights (1996), but it is also obvious that professional education and curriculum changes that encourage and facilitate an understanding of difference have had an effect.    
In my clinical practice I took care of a resident (P) with input (participation) from her daughter, niece, General Practitioner, dietician, physiotherapist, occupational therapist, other nurses, caregivers and unit manager.   On her third day in the ward P decided that she was too sore (due to bone pain from a fractured vertebra) to get out of bed each day.   She first mentioned this to her GP (who she greatly respected) and asked his permission to ‘stay in bed’.  P told us she discussed it with him first (as she said, because he had the power to authorise her to stay on bed rest) because the nurses were not listening to her and, even though she was shouting out with pain, they were insisting that she get up out of bed each day.  
Her daughter was upset to see her mother in pain but knew (from her experience as a part-time care giver) that if P stayed in bed all day, she would be more susceptible to bed sores. The physiotherapist was encouraging P to stand up and use a walking frame to manoeuvre and use the commode but she was also finding this too painful.  Through a process of discussion and explanation of the possible complications of being on total bed rest, balanced with her desire to stay in bed because it was less painful, it was agreed by all health care professionals involved in P’s care that she should stay in bed, unless she wished to get up.  This was documented in her notes and signed by the family. As a concession to personal grooming, P agreed to have one shower a week so that her hair could be washed. 
The outcome of this agreement meant that P’s care was different from that of other residents.  The discussion that was part of the decision making helped everyone involved understand what she wanted (participation).  It also showed that there was a conflict in values and professional duty of care between what nurses believed was good care (e.g., getting her out of bed each day) and what she wanted (to stay in bed).  P’s decision was based on her personal needs and preference to be comfortable.   As a team of healthcare providers we worked together (partnership) to prepare a plan of palliative nursing care that provided safe and effective nursing care (protection) and that the client was happy with (culturally safe).
Hughes, T and Farrow, T. (2006).  Preparing cultural safety assessment.  Kai Tiaki Nursing New Zealand, February, pp 12-14.
Kingi, T. R. (2007). The Treaty of Waitangi: A framework for Maori health development.  New Zealand Journal of Occupational Therapy, 54(1), pp 10.
Otago District Health Board (no date). Tikaka: Best practice guidelines.
Nursing Council of New Zealand (no date). Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing practice. Wellington: Nursing Council of New Zealand.
Papps, E. (2005).  Cultural Safety: Daring to be different.  In Wepa, D. (Ed.): Cultural safety in New Zealand/Aotearoa.  (pp 20-29).  Auckland: Pearson Education, New Zealand.
Ramsden, I. (1990). Kawa Whakarurhau: Cultural safety in nursing education in Aotearoa. Wellington: Nursing Council of New Zealand.
Rapata-Hanning, M. (2010). Professional Nursing Practice: Maori Health Focus, Lecture 6 May.
Ramsden, I. (1993) Kawa Whakarurhau: Guidelines for Nursing and Midwifery Education in Aotearoa. Wellington: Nursing Council of New Zealand.


  1. Liz this is an excellent description of the issues facing nurses and the cultural safety of patients. Your example is very poignant and illustrates the situation so well.

    The old adage that "nurse knows best" no longer cuts it that is for sure. This demonstrates the importance and significance of client-centred care and listening to the client's needs before imposing what we think is right. It has taken a long time to get to this stage in nursing and medicine - not sure about the latter even now but I have seen lots of examples where it is practised. For example, informed consent.

    The same principles apply to students don't they, and through modeling this modus operandi, the students through having their needs considered will hopefully go on to practise in a similar manner with their clients.

  2. Thanks Liz, I've come over from the UK and have had some difficulty understanding the TOW and how it applies to nursing practice. Your discription has helped alot.