How can mental health nurses prove they are culturally safe? How can mental health nurses, who sometimes have to nurse people who do not believe they need care, demonstrate they practise in a culturally safe way? Two nurses provide some suggestions.

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Historically, nurses have been required to be culturally safe in their practice. (1,2) But now all registered nurses (RNs) must show competency within their scope of practice, including evidence of competence in culturally safe practice. (3) At first, this requirement may appear challenging for nurses working in mental health, given that practice in this area sometimes requires nursing people against their will, or where personal freedoms are temporarily restricted. While mental health practice does have some unique challenges, good mental health nursing practice actually exemplifies cultural safety. Likewise, cultural safety supports the articulation of good mental health nursing practice, and the description of good mental health nursing practice will likely meet the requirements of an audit of culturally safe practice. Some mental health nurses have expressed concern that in any audit they cannot articulate the true complexities of mental health nursing. However, we suggest good mental health nursing practice embraces cultural safety.

Nurses can now be audited on their ability to provide culturally safe practice. (4) Providing care which is culturally safe in its broadest context, and which is relevant and meaningful, is consistent with the benefits of belonging to a profession. However, demonstrating culturally safe practice in mental health may be challenging for some nurses.

Cultural safety is about understanding that those who use health services may differ from individual nurses in many ways, including age, gender, socio-economic group, disability, sexual orientation, religion, immigrant status and ethnicity. (4) The concept of cultural safety is also premised on the belief that nursing has a culture, one that is likely to have different belief systems from clients/patients. A culturally safe nurse will recognise that his/her own and others beliefs are culturally and socially constructed by sociallisation processes, such as family, friends and educational institutions. A culturally safe nurse also comprehends that people are shaped by their history, including the socio-economic environment in which they were raised. As well as recognising these differences, culturally safe nursing requires nurses to nurse regardful of these differences. (5)

The concept of cultural safety is also based on the notion that nurses have power in their relationship with clients. The culturally safe nurse will be aware that it is the nurse's role to ensure power is not used "over" those who use health services, but rather "for" them. Power used well will help people feet safe using health services to help them get well. Thus there are many similarities between cultural safety and the values within the recovery competencies, which all mental health workers are required to use in their practice. (6) It is also consistent with the Health and Disability Code of Consumer Rights. (7)

Cultural safety in mental health nursing

Cultural safety is as relevant to mental health nursing as it is to other areas of practice, where people are able to make informed health choices. However, there are times in mental health when nurses are required to nurse people who do not want intervention. These times include working with people who, on occasions, are unable to make informed choices, due to their acute symptoms. Nurses can also be involved in compulsory assessment and treatment, which is at odds with the wishes of the the mental health service user. Sometimes, professional judgements need to be made which affect the personal freedoms many of us take for granted.

On the surface, nursing someone against their will appears contrary to the concepts of cultural safety, as it requires "power over" the person. However, the ethical justification for nursing someone against their will (and using "power over") is that the person is temporarily unable to make an informed choice about their health care. Interventions, including nursing interventions, are aimed at improving the person's mental status so they can again make an informed choice in the future. "Power over", then, can be justified temporarily and is, in fact, "power for" the person.

Providing culturally safe practice is also challenging when some people, for instance, may experience psychosis, have a different view of their own state of wellness, or present with challenging behaviours. The following exemplar is not untypical in an acute mental health unit: Ben*, 24, arrived in the acute services in the early hours of the morning in the company of the police. He was unkempt and had been living under a bridge for the last two nights because he had become increasingly frightened of his neighbours, whom he now believed "were terrorists". Ben was well known to the services and one of the challenges for the nursing staff was to search his belongings on arrival, as he usually covered everything (extremely well) in tin foil "to stop radiation waves". As Ben's admission continued, he became increasingly fearful and suspicious and needed a low stimulus environment, as he was misinterpreting the intentions of those around him, as well as the reinstatement of the medications he had stopped three weeks prior to his admission. Ben identified as European but differed to the nursing and medical staff by age, gender, disability and socio-economic group.

(* The person's name and other details have been changed to protect confidentiality.)

Ben's situation is one commonly faced by nurses working in mental health. While it is true that service users can be psychotic, have challenging behaviours and are sometimes "insightless", there are still "moments in time" when opportunities to work in partnership with them can be taken. (5)

Nurses need to demonstrate the application of cultural safety concepts to practice. This, firstly, requires an understanding of the concepts, and the knowledge and skills to make an assessment of the situation and prioritise cultural safety interventions alongside nursing interventions. While there is not, and never can be, a "checklist for cultural safety practice", (5) we can look to the concepts within cultural safety to guide our interventions with Ben (see Box 1). For example, we can use the Treaty of Waitangi principles of partnership, participation and protection as a framework for cultural safety practice. These three principles are intended to work alongside each other and could be likened to a see-saw arrangement, in that when Ben becomes more well, protection can be lessened, and participation and partnership increased. This framework can be used for all clients, including, but not exclusive to, Maori. This is consistent with the intention and spirit of the Treaty of Waitangi as a partnership arrangement for two different cultures. (5)

Box 1

A CULTURAL SAFETY TOOL KIT

The Treaty of Waitangi principles of partnership, participation and
protection Power over/to and with

Not accepting the status qua but challenging societal assumptions

Not demeaning, disempowering and diminishing others' choices

Respecting difference and nursing in a way that is regardful of it

Not assuming you know best but asking the client what they need in
order to get well

Not making judgements about others' lifestyle because it differs from
yours, as this stereotypes and results in victim blaming

Empowering others, advocating and having an holistic approach

Recognising the influence of social, economic and political
determinants of health

Knowing your own journey, what you believe in and how this may be
different to others

Accepting that your way of knowing may not be the only correct way

Recognising that nursing is a culture which makes it different to the
consumers

Recognising that language and communication are used to subtly
construct the reality of and for the client, eg "discontinuance"
as opposed to "non compliant"

Safety first but recognising that cultural safety is just as important
as physical, mental, gender and emotional safety

Reflecting on your practice

Empowering the client

Working in partnership ensures "power over" relationships are minimised, and "power to", "power for" and empowerment of the person is supported. Partnership does not have to be interpreted as an equal relationship, as those invalved might each bring differing strengths and skills at different times. It can also mean cooperation, (8) where the nurse and Ben eventually work together. Partnership may mean that the principle of protection is invoked, whereby Ben, who is temporarily unable to make decisions about his health care because of his mental status, is still given quality treatment.

Nurses must support the principle of service user participation, even when those people need treatment against their will This will include involving Ben in the design of his treatment plan. Even though Ben may consider he does not need treatment, supporting the right of clients to be heard is vital. There are also less obvious situations and opportunities where Ben can be asked his preferences, and where the nurse should not assume they know best. (5) These can include negotiation, small choices and the communication skills included in calming in "calming and restraint" procedures. We have seen multiple instances of this occurring in practice, whereby skilled mental health nurses actively listen to the desires of those being treated against their will. Such practices are examples of partnership, protection and participation and, therefore, culturally safe practice, and can be used as exemplars in demonstrating such practice in any Nursing Council audit.

The challenge for some nurses may be in providing written evidence of their skilled practice. We suggest an exemplar which links what might appear to be everyday practice with the concepts within cultural safety.

Cultural safety does not override physical safety; rather it is about the care of people, "regardful" of their difference, not regardless of it. (4,9) It is about advocating, and being able to reflect on the professional choices we make. Cultural safety is one of the many "safeties" we must have. Working in mental health, nurses will use their advanced assessment skills to determine which cultural safety concepts will be included. We have provided a tool kit where the concepts within cultural safety can be drawn on, depending on each unique situation.

The demonstration of culturally safe practice is a regulatory requirement and mental health nurses need to be able to articulate how they provide such care. We suggest that the Treaty of Waitangi framework of partnership, participation and protection within an exemplar format and the "mix and match" use of the cultural safety terms, can help nurses consider culturally safe practice, even in challenging situations.

Many skilled mental health nurses already practise in a culturally safe way. The application of this framework to describe such practice will allow these nurses, if they are audited by Nursing Council, to demonstrate culturally safe nursing.

References

1) NZNO. (1993) Standards for nursing practice. Wellington: Author.

2) Nursing Council of New Zealand. (2001) Code of Conduct. Wellington: Author

3) Nursing Council of New Zealand. (2005a) Competencies for the registered nurse scope of practice. Wellington: Author.

4) Nursing Council of New Zealand. (2005b) Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing education and practice. Wellington: Author.

5) Ramsden, I. (1996) The Treaty of Waitangi and cultural safety: The role of the Treaty in nursing and midwifery education guidelines for cultural safety in nursing and midwifery education in Aotearoa. Wellington: Nursing Council of New Zealand.

6) Mental Health Commission. (2001) Recovery competencies for New Zealand mental health workers. Wellington: Author.

7) Health and Disability Services Commission. (2004) Health and disability code of consumer rights. Wellington: Author

8) Stack, D. (2004) Bullshit, backlash and bleeding hearts. Wellington: Penguin.

9 Papps, E. (2005) Cultural safety, daring to be different. In Wepa, D (Ed.), Cultural Safety in New Zealand/Aotearoa. (pp20-29). Auckland: Pearson Education New Zealand.

Margaret Hughes, RN, BN, PGDip Health Systems Man., MBS, PGCert (nursing) Cert.Adlt. Tchg, was a senior lecturer at CPIT when she co-wrote this article. She now works as a rescource writer at Careerforce.

Tony Farrow, RN, BN, DipHealth (Mental Health Nursing), MHSc, GradCert Higher Ed, is a principal lecturer at the Christchurch Polytechnic Institute of Technology (CPIT).