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).

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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

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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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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·• Yatdjuligin and very young. One person who responded to Nightingale’s study hinted at the use of traditional medicines. Bishop Salvadore wrote:

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.

The overarching belief that Aboriginal Australians needed ‘civilising’ was evident in all of Nightingale’s work and underpinned much of her analysis. Of course, this belief was not only held by Nightingale, but was also very much part of the colonial project. Nightingale’s assumptions also influenced her decisions about which women were ‘appropriate’ to be trained as nurses. The Nightingale scheme of nurse training ’emphasized good moral character as a qualification for nursing education and to reinforce this, trainees were to be resident at the hospital under the vigilant eye of home sisters’ (Gregory & Brasil, 1993, p. viii). At this time, there was no thought of training Aboriginal nurses. One response to Nightingale, from a Mrs Camfield from Western Australia, stated:

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There is not in nature, I think, a more filthy, loathsome, revolting creature than a native women in her wild state. Every animal has something to recommend it; but a native woman is all together unlovable. (Nightingale, 1865, p. 7)

Nightingale’s research provides a backdrop for the emergence of the nursing profession in Australia. Her system of nursing was introduced into Australia as a way to improve the health of the new colonists. Nursing as a profession began to gain legitimacy, with nursing training programs introduced across the country. This training had little or no regard for Aboriginal and Torres Strait Islander people. There are no documentary records of what these early trainee nurses were being taught about Australian ‘natives’ and their ‘uncivilised ‘ ways.

The growing nursing profession gave little regard to the possibility of training Aboriginal and Torres Strait Islander nurses, because their health care was administered under the Acts of Parliament. Interestingly, an inquiry and subsequent report was undertaken in England in 1945, when the Colonial Office on Command of His Majesty presented to Parliament the Report of the Committee on the Training of Nurses for the Colonies (Colonial Office, 1945). Following a preliminary survey examining the state of nursing services in colonial territories , two subcommittees were formed to consider retrospectively: l. The training of nurses in the United Kingdom and its Dominions for service in the

colonial territories 2. The training given in the colonies to indigenous nurses.

When the Report was released, it clearly noted that:

At first the only trained nurses were those who were recruited in the United Kingdom and the Dominions or from nursing sisterhoods in Europe, but it was speedily recognized that no great extension of medical services could take place unless the greater part of the nursing staff was drawn from the local populations. (Colonial Office, 1945 , p. 3)

The first recommendation of the Colonial Office Report (1945) gave a comprehensive overview of the training needs and requirements of nurses , midwives and mental health nurses across the colonies. However, the second recommendation, the training of Indigenous nurses , was largely ignored in Australia. The overall policy environment relating to the segregation and treatment of Aboriginal and Torres Strait Islander people in principle was in conflict with the second recommendation. It is no surprise that the recommendation was ignored.

Questions for reflection

• How did Florence Nightingale’s beliefs, values and attitudes determine the status of Aboriginal Australians in the nursing profession?

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.,. Yatdjuligin Moving beyond cultural awareness to cultural sensitivity According to Ramsden (2002), cultural sensitivity is the second step in the journey towards a practice of cultural safety. She defined cultural sensitivity as ‘alerting the student to the legitimacy of difference’, that ‘begins a process of self-exploration as the powerful bearers of their own life experiences and realities and the impact this may have on others’ (Ramsden, 2002, p. 117). Developing cultural sensitivity involves recognising the culture that underpins nursing in Australia.

The Australian health care system is inherently ‘white’, and nursing is no exception. Cox and Taua (2013) stated that ‘members of the white (or mainstream) culture are inheritors of unearned, unexamined and unacknowledged privilege’ (p. 326).

As Aboriginal Professor of Indigenous Studies Moreton-Robinson (1999) explained:

Whiteness in its contemporary form in Australian society is culturally based. It controls institutions, which are extensions of white Australian culture and is governed by the values, beliefs and assumptions of that culture and its history. Australian culture is less white than it used to be, but whiteness forms the centre and is commonly referred to in public discourse as the ‘mainstream’ or ‘middle ground.’ (Moreton-Robinson, 1999, p. 28)

Puzan (2003), a white American nurse, offered some insights into experiences of nursing in the United States:

Evidence of the entrenchment of whiteness within nursing can be found not only in practice, but even more fundamentally, in the locations where the formative giving and receiving of nursing education takes place. (p. 3)

In Australia, the nursing profession is clearly entrenched within the biomedical model as the by-product of the colonisation process. As Cox & Taua (2013) argued, for many Australians this is taken by default as the most legitimate system -both socially and politically. The biomedical model historically has excluded Aboriginal and Torres Strait Islander healing and health knowledge and has created a nursing curriculum that largely ignores Indigenous content. Throughout much of colonial history, it also involved the active exclusion of Aboriginal and Torres Strait Islander people from nursing education.

Currently little research is being conducted in Australia

whiteness of nursing on the ‘whiteness of nursing’. One exception is the work of Nielsen (2010), an Aboriginal Registered Nurse who has explored Aboriginal nurses’ experiences of the cultural challenges involved in working in mainstream health care. Nielsen’s research involved interviews with Indigenous nurses to explore their experiences. She identified four major themes that influence the practice of contemporary

‘the structural and systematic white dominance of this profession which pervades all areas from colleague interactions to the provision of client care . As a predominantly Westernised system within this country, the field of health care is permeated by the social norms and expectations defined by white culture’. (Nielsen, 2010, p. 23)

Indigenous nurses: l. Discrimination 2. The whiteness of nursing

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3. Cultural clashes within nursing 4. Cultural vitality. (Nielsen, 2010, p. 12) Nielsen argued that ‘the dominance of whiteness within nursing is an ever present and saturating force and one that is keenly felt by Indigenous nurses and therefore the broader Indigenous community’ (Nielsen, 2010, p. 20).

A culturally sensitive approach means that the nurse recognises and legitimises the differences between herself/himself and the client. When caring for Aboriginal or Torres Strait Islander Australians, it is helpful to understand the history and the colonial authorities that controlled Indigenous Australians since invasion, as this may have a profound effect on the Aboriginal and Torres Strait Islander client. It is also important to understand that the nursing profession has ‘power’ and ‘whiteness’ that may affect clients. In a health care setting, nurses are typically in a position of power over clients. The Nursing Council of New Zealand (1996) stated that ‘when one group uses its position of power to impose its own values upon another a state of serious imbalance occurs. This threatens the identity, security and ease of the other cultural group creating a state of dis-ease’ (p. 8).

An historical perspective helps to understand why some Indigenous women are reluctant to visit hospitals for antenatal care; they are influenced by the recent memory of generations of children being removed from their Aboriginal mothers while they were hospitalised to give birth. Historical practices have created a great deal of distrust within Indigenous peoples with regard to the use of hospitals.

Question for reflection

Identify how the ‘whiteness of nursing’ may affect care provided to Aboriginal and Torres Strait Islander people in Austral ia.

The continuous journey towards cultural safety For Ramsden (2002), cultural safety is an ongoing journey that allows clients to define their own care:

Cultural safety is an outcome of nursing and midwifery education that enables safe service to be defined by those that receive the service and is achieved when the recipients of care deem the care to be meeting their cultural needs . (Ramsden, 2002, p. 117)

In order to practise culturally safe nursing, a nurse must undertake a process of self- reflection to explore her or his own beliefs, values and attitudes, and must consider the potential effects of these on recipients of their care. Cultural safety requires nurses and midwives to understand their own cultures and acknowledge the power imbalance inherent within nursing practice.

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.,. Yatdjuligin Ramsden (2002) stated that:

Cultural Safety has been expanded to include all people encountered by nurses who differ in any way from the nurse. Whatever the difference, whether it is gender, sexuality, social class, occupational group, generation, ethnicity or a grand combination of variables, difference is acknowledged as legitimate and the nurse is seen as having the primary responsibility to establish trust. Cultural Safety is therefore about the nurse rather than the patient. That is, the enactment of Cultural Safety is about the nurse while, for the consumer, Cultural Safety is the mechanism which allows the recipient of care to say whether or not the service is safe for them to approach and use. Safety is a subjective word deliberately chosen to give the power to the consumer. (pp. 5-6)

Within the context of Aboriginal and Torres Strait Islander health, it is essential for nurses to recognise the immense diversity within the Indigenous community. Aboriginal and Torres Strait Islander people hold a wide variety of beliefs, values and attitudes. There is just as much diversity within the Indigenous community as there is within the non-Indigenous community. Multiple cultures exist within the Indigenous community quite apart from ethnicity. For example, it is not enough to say that you can safely nurse Indigenous peoples if your values include homophobia or misogyny.

Aboriginal and Torres Strait Islander people from very remote communities, where English may be a second or third language, may not have the same beliefs about health care as Aboriginal and Torres Strait Islander people from urban communities. Culturally safe care for Indigenous people involves understanding of the self, understanding the power of the profession, recognising the biomedical system and context and looking for the diversity that exists among clients.

Five principles of cultural safety In 2005, the Nursing Council of New Zealand released a summary of the five principles of cultural safety (Nursing Council of New Zealand, 2005). In this section, these principles are applied to the Australian nursing context.

1. Reflect on your own practice Reflecting on your own practice is a critical aspect in providing culturally safe care. This reflection needs to go beyond a focus on clinical skills, to considering cultural safety and how it is enacted.

As Cox and Taua (2013, p. 329) noted, nurses need to reflect on: • Their cultural identity • Their assumptions about health, illness and people • Their personal definitions of health • Their patients’ definitions of health • Whose definitions of health are legitimised (by law and society)

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• The implications of these definitions for nursing practice • The consequences of these definitions for clients’ health care. This reflection is important for all nurses, whether they are Indigenous or non- Indigenous. Many Indigenous nurses find the reflection particularly important, because the biomedical system may challenge their own beliefs, values and attitudes.

One example comes from my own practice. While working as a registered nurse at a large urban Aboriginal Medical Service, my role as sexual health coordinator involved supporting young, at-risk Indigenous women. I faced a constant problem when taking the young women to the tertiary hospital, because the Indigenous young women would not agree to consultations with the male obstetricians and gynaecologists. I had to negotiate with hospital staff to navigate this culturally determined position of women’s business.

2. Seek to minimise power differentials The relationship between nurses and patients is power laden, and this can influence nurses’ ability to provide culturally safe care, particularly for Aboriginal and Torres Strait Islander people. Taylor and Guerin (2010) noted that the power imbalance may be intentional or unintentional; they argued that nurses need to consider how they might shift the power balance within the practice setting (p. 15). An example of this power imbalance is use of the term ‘non-compliant’, to describe when patients do not follow a nurse’s instruction. A term like non-compliant emphasises the power that nurses have over clients and gives no analysis of the ways in which the health system may create problems for clients and may cause ‘compliance’ to be problematic.

Nurses who practise with cultural safety are mindful about actively minimising the power differential between themselves and their patients. Many Aboriginal and Torres Strait Islander Australians have previously experienced culturally unsafe care in hospital, and this will influence their current expectations of care. They may feel that their beliefs, values and attitudes will be ignored or not taken into account. In addition, many Indigenous Australians use a combination of Western and traditional medicines to promote their health. One way for nurses to minimise power differentials is to accept the efficacy of combined therapies for some Indigenous peoples. This may be as simple as recognising the value of traditional medicines such as tea tree oil and eucalyptus oil, which have been used for thousands of years to treat infections and respiratory distress. Remaining focused on how to acknowledge Indigenous practices is a very powerful way of minimising power imbalance.

3. Engage in discourse with the client Culturally safe practice requires true engagement with clients. It involves seeking to understand their unique needs, beliefs, understandings and preferred ways of doing things (Taylor & Guerin, 2010, p. 15).

Historically, patient engagement has not been successfully achieved for Aboriginal and Torres Strait Islander people. Poor management can be magnified by the medical

M}W

•a• Yatdjuligin jargon and acronyms used by nurses, whose language may be difficult to understand for people without health-care training. Culturally safe practice that truly engages with clients will involve using language that patients can easily understand.

Nurses’ lack of engagement with Indigenous clients has been noted by both nurses and their clients. In 1977, Samisoni, a Fijian-trained nurse, conducted research into the experiences of Indigenous clients at public hospitals in Brisbane and stated that ‘amongst the comments that were offered, the most emotionally disturbing referred to the rudeness and abrupt manner which they were subjected to by nursing staff’ (Samisoni, 1977, p. 46).

Blackman (2009), an Aboriginal Registered Nurse, identifies four important factors in engaging with Indigenous patients: l. The nurse’s readiness to practise in a way that is culturally safe 2. The nurse’s ability to listen and communicate appropriately 3. The nurse’s knowledge of the local Aboriginal health systems 4. The nurse’s level of acceptance by the local Aboriginal community (Blackman, 2009,

p. 213).

4. Undertake a process of decolonisation Many indigenous peoples around the world have experienced colonisation, which has been overwhelmingly detrimental to their health. Evidence of this exists today in the

decolonisation different life expectancies between Indigenous and non- Indigenous people. The New Zealand Council of Nursing’s approach to cultural safety recommends a conscious process of decolonisation. Taylor and Guerin (2010) identified

the process of ending colonisation and challenging its continuing effects, to allow self-determination for indigenous peoples. It involves appreciating the value of traditional practices and reclaiming them when appropriate.

that ‘it is this element … that separates cultural safety from all other approaches, acknowledging the key role of a colonising history in contemporary health outcomes for Indigenous peoples’ (p. 15).

In 1960, the United Nations established an entity devoted exclusively to the issue of decolonisation. With hopes of speeding the progress of decolonisation, the General Assembly adopted the Declaration on the Granting of Independence to Colonial Countries and Peoples (known as the Declaration on Decolonization). The Declaration states that all people have a right to self-determination, and proclaims that colonialism should be brought to a speedy and unconditional end (United Nations, 1960). Aboriginal and Torres Strait Islander Australians have experienced significant moves toward self- determination in recent years , in particular through the establishment of the Aboriginal Medical Services. However, there is still much work to be done for Indigenous health to improve.

The recent Northern Territory Intervention is an example of how far from true decolonisation Australia remains. The Intervention began in 2007 and saw The Racial Discrimination Act 1975 (Cth) being suspended to allow for the Intervention legislation to be passed. In 2009, the United Nations investigated the Northern Territory Intervention

Chapter 3 The cultural safety journey

(also called the Emergency Response, or NTER) and gave a damning report. It stated that:

The NTER, however, has an overtly interventionist architecture , with measures that undermine Indigenous self-determination, limit control over poverty, inhibit cultural integrity and restrict individual autonomy (Anaya, 2010, p. 4)

The process of decolonisation remains difficult within Australia while we have racially based legislation applying only to Aboriginal and Torres Strait Islander people.

The process of decolonisation is not something that needs attention by Aboriginal and Torres Strait Islander people alone (Cox & Taua, 2013; Sherwood, 2010). For decolonisation to be truly effective, it needs to become an approach that has widespread acceptance throughout Australia. Within the context of this book, it means that decolonisation is an important process for nurses. McGibbon and colleagues (2013) stated that ‘working towards decolonising nursing includes a commitment to exposing colonising ideologies, values and structures embedded in nursing curricula, teaching methodologies and professional development’ (p. 8). This requires a personal commitment from each individual nurse , as engaging in the process of decolonising can be both difficult and confronting.

Decolonisation involves reflecting on the colonial history that determined how Aboriginal and Torres Strait Islander people were identified, positioned and treated under decades of Acts of Parliament. It involves teaching this history and recognising its continuing effects on Indigenous communities across Australia. Through understanding this history, non-Indigenous Australians will be able to ‘decolonise’ themselves of the dominant myths about Aboriginal and Torres Strait Islander people.

In their discussion about decolonisation, Aboriginal nurses Edwards and Sherwood (2006) suggested that their work was ‘written to inform the nursing workforce within urban, rural and remote regions of Australia about the critical importance of de-colonising all aspects of the health service delivery related to Aboriginal health’ (p. 178). They argued that the harsh and unrelenting legacies of colonisation are ‘the critical issues that underlie the lack of improvement in Aboriginal health ‘ (p. 178).

Edwards and Sherwood (2006) proposed a process of decolonisation in order to shift the health paradigm:

De-colonising processes require all individuals [including Indigenous Australians] to explore their own assumptions and beliefs so that they can be open to other ways of knowing, being and doing. We believe that Australian nurses must undergo a process of decolonisation in order that Aboriginal people’s pain, worry, anguish and torments are heard , recognised and accepted, so that there may be an improvement in the health and wellbeing of Aboriginal people. To do this, non-Indigenous Australian nurses need to be receptive to and respectful of the voices of Aboriginal society, without expecting that as a people we must constantly justify and argue our basic rights. It is only when this happens that we can all come together as a healthy nation free of guilt , blame, and separation. (p. 178)

•a:• Yatdjuligin 5. Ensure that you do not diminish, demean or disempower others through your actions This final principle may seem self-explanatory, but it can sometimes be difficult for nurses to fulfil. This principle involves active self-reflection, which requires a degree of self-awareness, an understanding of one’s own beliefs, values and attitudes and, most importantly, a willingness to critique practices and systems. Nurses are frequently ‘time poor’, and this can make the final principle particularly difficult to navigate. In order not to diminish, demean or disempower clients it is very important for nurses to understand their own beliefs, values and attitudes and how they do or can affect other people.

An obvious example is the question of whether a nurse has power in determining who is Aboriginal. For example, as a young student nurse I was constantly challenged about my Aboriginality due to being urban-born and raised. I was not considered a ‘real Aborigine’ due to not living in the outback, where the ‘real ones’ live. I was often asked , ‘But you’re only part Aborigine aren’t you7 ‘

The Australian Indigenous community is eclectic- just like the broader Australian population. Overwhelmingly in the Aboriginal community, Aboriginality is not determined by skin colour. The underlying common myth that the darker a person’s skin colour the more Aboriginal she or he is does not typically apply within Indigenous communities. This means that comments from nurses, such as ‘Oh, but you don’t look Aboriginal ‘ or ‘but you are only part Aboriginal’ are demeaning for many Aboriginal people.

Blood-quantum classifications for Aboriginal people were imposed by colonisers. New South Wales legislated for Aboriginality as early as 1839, while Tasmania legislated as late as 1912 (Parliament of Australia, 2002). During these eras, Aboriginality was determined by skin colour, and identification as ‘full-blood ‘, ‘half-caste’, ‘quadroon’ or ‘octoroon’ was common. This non-Indigenous approach to defining Aboriginality was particularly apparent when missions and reserves were established. It is critical that nurses understand that Aboriginal people do not determine Aboriginality by skin colour; using language relating to skin colour or suggesting blood quantum is highly offensive.

Case stud My experience as a patient While I was working as a Nursing Director, I was admitted to a large tertiary hospital as a patient. I was diagnosed with a double ear infection, which required hospitalisation for intensive intravenous (IV) antibiotic treatment and pain management. I had a cannula inserted to receive IV antibiotics in the Emergency Department and was administered Fentanyl subcutaneously. I was prescribed Endone for pain relief. When I was admitted to hospital, I was not asked whether I identified as Aboriginal. I was also not asked about my occupation. continued •

Chapter 3 The cultural safety journey

Four hours after being admitted to the ward, my pain began to escalate. I requested Endone from the Registered Nurse (who had not introduced himself at the beginning of his shift). He looked at my medication chart and went to get the pain relief. He returned and offered me two Panadeine. I questioned him about what medication I was being offered, and he explained that ‘these are Panadeine’ . I stated that doctor in the Emergency Department had written me up to receive Endone. The nurse replied that ‘we don’t give End one out willy nilly and Panadeine should hold your pain ‘ . My pain soon escalated severely, and I became highly agitated . The nurse avoided me.

Shortly after this encounter, the Aboriginal hospital liaison officer arrived . I asked how she knew that I had been admitted, and she explained, ‘You identified within the Emergency Department and the box had been ticked’ .

I rang a friend who worked at the hospital as an anaesthetist. In my highly distressed state, I asked him to come and see me. Simon (the anaesthetist) took my chart and read through my notes to ascertain my clinical history and reason for admission. He then took my chart to the nurses’ station and asked why I was not receiving adequate pain relief, as written up. Within a few moments the nurse appeared with a dose of Endone. The Registered Nurse in charge of the shift also arrived, and apologised for the error. I then asked not be looked after for the rest of the shift by my designated nurse.

Questions for reflection Reflect on the five principles that underpin cultural safety. 1. Reflect on your own practice.

• Considering the practice of the Registered Nurse in the above scenario, what areas of his practice should he reflect upon and why?

• What potentially were the beliefs, values and attitudes that influenced his culturally unsafe nursing practice?

2. Seek to minimise the power differentials. • Describe one example of how the nurse used power differentials in his care giving. • Describe an example of how the nurse could have minimised power differentials.

3. Engage in discourse with the client. • Describe the discourse in which the nurse should have engaged .

4. Undertake a process of decolonisation. • Describe the lack of understanding about decolonisation demonstrated by the

nurse. 5. Ensure that you do not diminish, demean or disempower others through your actions.

• Name the actions of the nurse that were diminishing, demeaning and disempowering.

Reflecting on your answers to these questions, think about where you would place the care provided by this nurse along the defined journey of cultural safety.

Mi}M

W4eM

l

Yatdjuligin

Conclusion The links between this book’s title and the discussion about cultural safety in this chapter are particularly pertinent. Yatdiuligin- ‘talking in a good way’- involves putting all the pieces together and discussing them in a context that translates to ‘learning in a good way’ . This process can be confronting and may cause discomfort. If the information is confronting or challenging, Yatdiuligin sets the scene to enable the reader to receive it in a good way (Best, 2011 ). For example, a person about to be told information that she or he may find challenging and may cause anxiety (such as the history of the Acts of Parliament, or the history of some of the ill- informed beliefs, values and attitudes about Indigenous Australians), could look to Yatdiuligin to help manage the anxiety. It is about hearing the information in a ‘good way’ while intrinsically trusting one’s teachers.

This concept links to the person’s commitment to becoming a culturally safe nurse. This journey is about exploring things that the nurse does not know, through showing, talking and mimicking (much in the way that nursing is taught) . The journey towards cultural safety should bring together disparate threads and contextualise the knowledge. Undoubtedly, it can be very confronting; all new knowledge can be confronting for the learner. Through the journey of cultural safety, nurses will be able to improve their practice with all clients and truly bring positive benefits to Aboriginal and Torres Strait Islander people in the pursuit of good health .

This chapter has focused on the concept of cultural safety from the perspective of Aboriginal and Torres Strait Islander Australians. Through a discussion about the history of nursing and the power of the nursing profession, this chapter encourages today’s nurses to undertake their own journey towards cultural safety. Nurses need to understand the history of health care for Aboriginal and Torres Strait Islander people and appreciate the legacy that remains from the colonial systems. Through examining their own systems of beliefs, value and attitudes, nurses will be able to journey through cultural awareness and cultural sensitivity and work towards culturally safe practices. Nurses are in a unique position to promote health for Aboriginal and Torres Strait Islander people, particularly if they practise nursing through a conscious reflection on cultural safety and decolonisation.

Nurses are engaged in culturally safe practice when their care is determined as safe by the recipients of that care. The capacity for reflective practice becomes second-nature for nurses who are culturally safe practitioners.

The essential elements of cultural safety include: 1. Reflect on your own practice. 2. Seek to minimise power differentials. 3. Engage in discourse with the client. 4. Undertake a process of decolonisation. 5. Ensure that you do not diminish, demean or disempower others through

your actions.

Ill

Learning activities 1. Define where you would position yourself

on the cultural safety journey. 2. Identify what you need to do to progress

along the cultural safety journey. 3. Outline the significance of teaching

cultural safety in the Australian health care

Further reading

Chapter 3 The cultural safety journey

education setting for Aboriginal and Torres Strait Islander Australians.

4. Identify the importance of enacting the five underlying principles of cultural safety, and outline how you would begin this process.

Cox, L. & Taua, C. (2013) . Socio-cultural considerations and nursing practice. In J. Crisp, C. Taylor, C. Douglas & G. Rebeiro (eds), Fundamentals of Nursing, 4th edn, pp. 320-40. Sydney: Elsevier.

Forsyth, S. (2007). Telling stories: Nurses, politics and Aboriginal Australians, c. 1900-1980. Contemporary Nurse, 24(1), 33-44.

Happel!, B., Cowin, L., Roper, C. , Lakeman, R. & Cox, L. (2013) . Cultural safety. In B. Happel!, L. Cowin, C. Roper, R. Lakeman & L. Cox, L. (eds) , Introducing Mental Health Nursing: A Service User-oriented Approach, 2nd edn , pp. 347-64) . Sydney: Allen & Unwin.

Happel!, B., Cowin, L., Roper, C., Lakeman, R. & Cox, L. (2013) . Sociological understandings of mental health and Indigenous social and emotional well-being. In B. Happel!, L. Cowin, C. Roper, R. Lakeman & L. Cox (eds), Introducing Mental Health Nursing: A Service User- oriented Approach, 2nd edn, pp. 183-212). Sydney: Allen & Unwin.

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