Learning how to be culturally safe: one nurse found that her nursing education did nothing to help her practise in a way that was culturally safe. What really helped was education about the principles of the Treaty of Waitangi and New Zealand's colonial history. Here she shares her journey to becoming a nurse who is culturally safe.

The pioneer of cultural safety (otherwise known as Kawa Whakaruruhau) in this country is Irihapeti Ramsden. Sadly, this wonderful nursing leader died in April, 2003. The concept of cultural safety is broad, rather abstract, and sometimes misunderstood by both nurses and members of the public. (1,2) Indeed, sections of the media have, in the past, contributed to this misunderstanding by their negative and inaccurate portrayal of the concept. (3)

Maori academic Ranginui Walker explains the term Kawa Whakaruruhau as meaning a nurturing protocol, (2) which is in itself a beautiful and appropriate concept for nursing. I believe the best definition of cultural safety can be found in Irihapeti Ramsden's thesis, where she describes it as being centered on the nurse and the power the nursing role has over the patient. (1)

Culturally safe practice by definition includes the nurse being aware of her/his power and sharing it with the patient, eg by developing a trusting relationship with the patient and their family, and involving them actively in decision making about their care. (1)

Cultural safely within my employer's clinical career pathway (CCP) guidelines requires a partnership approach on behalf of the nurse, where the nurse establishes and promotes a sense of equality with the patient. This is not an easy task, as the nurse is in the position of authority and has the health care knowledge and understands the hospital system the patient has entered. This sets the patient at an obvious disadvantage from the outset. This article aims to explore the meaning and relevance of cultural safety in New Zealand nursing today, using the insight provided by Ramsden's work and examples from my nursing journey.

Cultural safety arose from a Maori perspective on the health system and its failure to deliver adequate and accessible care to Maori, evidenced by the negative health statistics evident for Maori in this country. (1,4,5)

The Nursing Council first introduced the concept of cultural safety into the nursing and midwifery education curriculum in 1990, the year I graduated as a comprehensive nurse. Thus the Nursing Council, in conjunction with Irihapeti Ramsden, has been instrumental in integrating cultural safety into nursing. (1) Paradoxically, the Nursing Council's recommendations for cultural safety education differ in one important distinction from Ramsden's. The Council's guidelines for this subject dearly state that, in order to reduce the confusion surrounding cultural safety, it "needs to be separated from the Treaty of Waitangi and Maori Health issues". (6)

In contrast, Ramsden states: "The key to the application of cultural safety in New Zealand is the Treaty of Waitangi." (1) Both parties agree, however, on the measurement of cultural safety being provided by the recipient of nursing care: the patient. (1,6) In other words, the patient determines whether or not they have received culturally safe nursing care.

Culture in the nursing context is defined by the Nursing Council as referring to the common beliefs and behaviours of groups of people. (6) Culture can thus be recognised as including differences in not only ethnicity but also such factors as sexual orientation, age and gender. (1,6)

Ramsden goes further to define culture as a very complex phenomena with meanings and understandings commonly held by the cultural group. (1) It is also important for the nurse to recognise her/his own cultural reality, including personal attitudes and beliefs, and the impact this has on their practice and the way they perceive and relate to their patients. (1,2) Nursing is a culture in itself, and, as Ramsden recognised, subcultures exist within the hospital environment. (1) Each ward I've worked in has had its own unique, dynamic culture, with some aspects changing with leadership and staff changes. Some outdated or inefficient practices can be difficult to change in a ward setting.

Nursing culture in New Zealand, with all its history and ingrained practices, and peopled with diverse individuals, has proven a difficult environment in which to introduce a change or development in thinking, such as cultural safety. Ramsden revealed this difficulty in her thesis. (1)

Culturally safe nursing practice involves recognising people's differences and respecting them. Importantly, it involves not treating everyone the same, as this approach denies people's diversity and individuality. (1) Assuming we are all the same is a simplistic and condescending way of thinking. It allows us to ignore or overlook our differences and, indeed, our individual personalities. It also does not promote acceptance or respect, which are integral components of nursing. Culturally safe practice involves being aware of and casting off the stereotypes about people perpetuated in our society, particularly by sections of the media.

My nursing practice has not, until recently, involved an awareness of cultural safety. I will explain why. My nursing journey began as a student at Northland Polytechnic in 1987. My introduction to Maori studies during this course involved a Maori tutor, apparently untrained as a teacher, attempting to teach us aspects of Maori culture and usually reverting to singing Maori songs.

I recall feeling confused and frustrated about exactly what I was supposed to have learned that would help my nursing practice. Ramsden comments on this early period of cultural awareness in nursing education. Thinking at the time was concerned with teaching aspects of Maori culture, in order to produce nurses who would, presumably, practise in a culturally safe manner towards Maori. (1)

The marae visit

I remember the marae visit, which has been identified as still a relevant part of nursing education today. (4) Waiting for almost two hours at the marae for the Maori elders to arrive was, from my impatient Pakeha point of view, a waste of time and seemed inconsiderate. Today, however, I can recognise the privilege of being allowed to stay on the marae, and I remember the generous hospitality. Being crammed in like sardines to sleep on mattresses on the floor was a new experience and I can't say I enjoyed it. It was too different from my "culture", so to speak. On reflection, my nursing training did not give me the skills to practise in a culturally safe manner.

The Nursing Council introduced cultural safety into the nursing education in 1990, as I was moving into nursing practice. It has taken years to integrate cultural safety into the nursing education system to the point where it is now better understood by both nurse educators and students alike.

Failure to understand

Ramsden describes the upheaval caused by people's failure to understand and accept the concept, and the continuing media pressure and political influence brought to bear on its introduction. (1) Despite this pressure, the Nursing Council, together with Ramsden, continued in their commitment to cultural safety as an integral part of nursing education. My discussions with current nursing students and nurses who have graduated within the last few years reveal they have knowledge of the concept, congruent with Ramsden's writings. One researcher, however, notes that research on student nurses shows a "lack of understanding of the concept". (7)

I missed out on the benefits of cultural safety education during my nursing education. Hopefully, I have made up that deficit by reading the literature and also by completing the CCP at my workplace.

I began collecting material for the CCP six years ago, as it involves gathering a large amount of evidence of practice and the presentation of this in a portfolio. As I had been nursing since 1990, I decided to apply for expert level on the CCP. I was stunned when I failed, mostly in the practice domain of cultural safety. I had thought cultural safety involved treating everybody the same, with dignity and respect. It was only after discussion with a clinical nurse educator that I became aware of partnership, participation and protection--"the three Ps"--associated with the cultural safety. I was ignorant of how the Treaty of Waitangi, from which these principles arise, related to nursing practice. (6) To be fair, there was really no education on the Treaty during my school days and my nursing education had not included this important part of our country's history. I believe this highlights the failure of New Zealand's education system to teach the history of its own country. Both Ramsden and Walker discuss the political forces associated with this country's education system. (1,2)

It wasn't until 2003, when I attended a two-day Treaty of Waitangi workshop at my workplace, that I began to truly learn the history of New Zealand. The effects of colonisation on the indigenous people of this country had never before been so graphically presented to me and in way that was difficult to deny. It was a shocking experience to learn of the legislation passed by the British colonisers which deliberately deprived Maori of their land and their rights, thus leading to economic and cultural deprivation. The process of assimilation, whereby even educational policies promoted the Maori being assimilated into the British culture, was also new me.

Members of the workshop gave personal examples of racism, which were also a shock to me, in this age of supposed tolerance and enlightenment. The facts illustrated the dominance of the colonisers in establishing a majority by force of numbers, and by a pervasive and continuing powerful cultural dominance, whereby Maori have had many aspects of their rich culture and heritage suppressed.

The Nursing Council's guidelines on cultural safety in nursing and midwifery education and practice recommend separating the concept from the Treaty of Waitangi and Maori health issues. (6) But I think cultural safety, both in tertiary education and in clinical settings, needs to be taught in conjunction with treaty education and the effects of colonisation on Maori. It needs to be taught in a way that clearly identifies the links between all three subjects. The Council's guidelines also mention the links between the three. (6)

Cultural safety failed to have an impact on my thinking and consequently on my nursing practice, until I had been educated about the reality of this country's short yet dramatic colonial history, which is inseparable from Treaty of Waitangi.

Through this education I was able to finally have some insight and consequently more compassion for the indigenous people of this country and their suffering. It also enabled me, finally, to have some understanding, as a Pakeha, of the ways in which I, as a bearer of my own culture, view other cultural groups in this country. I can now recognise the effects of my own social conditioning and critically analyse the attitudes and ingrained stereotypes I hold as a result. How, as a nurse in New Zealand caring for many Maori patients, could I possibly practise in an effective and culturally safe way without knowing about the Treaty, our colonial history and their effects on Maori?

I am not alone in this conclusion. For example, Roberts asserted that all overseas nurses coming to New Zealand should do Treaty of Waitangi workshops and cultural safety education and assessments before practising here. (8) She speaks from her own experience of nursing Maori people and the difference cultural safety training made to the effectiveness of her care. Roberts also mentions the importance of New Zealand nurses being educated in our country's heritage and ways. It is important to note that not all people who appear to be Maori identify as Maori. (1) An important component of cultural safety is recognising people are so diverse and it can never be assumed that because they look or behave in a certain way, they belong to a certain group, either ethnic or otherwise. This highlights the pitfalls associated with stereotyping people. Another observation Ramsden makes is how the diversity of people's upbringings contributes to the differences found within the "same" cultural groups. (1)

Transcultural nursing 

Thus it is fair to conclude that no amount of education on "aspects" of a particular culture or cultures can prepare nurses to practise in a culturally safe manner. This is the downfall of transcultural nursing. (1)

Transcultural nursing differs from cultural safety in several significant ways. It promotes studying aspects of a particular culture in order for nurses to care for people outside their own culture, and consequently reinforces stereotypes. It also assumes nurses and their associated culture are accepted as a normal experience by the recipients of care. Cultural safety assumes the opposite, ie that nurses and nursing culture is "exotic" or strange to people. (1,9) If one has ever been a patient, one can relate to this feeling of strangeness--I know I can.

It is relevant to note that the pakeha health system can present as a greater cultural risk to Maori than to Pakeha. (1)

The three principles of partnership, participation and protection illustrate the incorporation of cultural safety into practice simply yet effectively. The nurse establishes a partnership with the patient and their family; she or he encourages active participation from the patient and family in decisions regarding health care; and the nurse also protects the patient's rights, including confidentiality and access to health information. While knowledge of the treaty principles and historical education is important in understanding cultural safety, it needs to be stressed that the concept is all encompassing and able to be applied to all cultures. "It is not about Maori culture per se, but the delivery of effective health care to all consumers as equals." (2)

On my second attempt at gaining CCP, after much thought and writing practice exemplars, I was awarded certification at expert level. Reading Irihapeti Ramsden's thesis, however, was my real education in the meaning of cultural safety. I feel I now have a far better understanding of this approach to life and to nursing.

HOW CULTURAL SAFETY CHANGED MY PRACTICE

Learning about cultural safety, the Treaty of Waitangi and the impact of colonisation on Maori challenged and changed some of my deeply held attitudes, beliefs and ingrained stereotypes. Thus my nursing practice has also changed. An example of this change was apparent to me recently when I nursed Mrs Jones (not her real name). She came into the day surgery unit for an elective procedure, accompanied by her seven children. Mrs Jones, who was heavily pregnant, apologised for the fact she hadn't been able to get a babysitter. Before my newfound understanding of cultural safety, I probably would have felt impatient with Mrs Jones, thinking to myself "surely she could have found someone to mind the children". Mrs Jones and her family would inevitably have felt that impatience, either through my body language or through my conversation. My attitude would have affected my approach--I may have not been as welcoming--and I would not have established an effective rapport with Mrs Jones.

Accepting and respectful

I came to the situation with a more open mind and had an accepting and respectful approach. I realised the priority was not convenience for the system and for nurses but to make Mrs Jones and her children as comfortable and welcome as possible. Previously, I would have been quietly judgemental about the fact a woman had seven children, with world overpopulation a real threat to our planet. But it is not for me to judge others based on my opinion and I now realise many factors are involved in determining family size. I went through the preoperative checklist with this hard-working mum, who was cheerful and did not show any signs of the stressful time she must have had bringing her children a long distance to get to hospital by 7.30am. She was interested in how many children I had and their ages. Through this communication we were able to establish a common ground, yet also acknowledge our differences, eg in ethnicity and family size. Before my cultural safety education, I had a strong desire to "pigeon hole" people and yet that is impossible to do with individuals. Cultural safety has made me a kinder and more compassionate nurse, with a curiosity about people's lives replacing the desire to "categorise" people according to my prejudices and belief system. And for that I am very grateful.

REFERENCES

(1) Ramsden, I. (2002) http://culturalsafety.massey.ac.nz/

(2) Walker, R. (1996) Nga Papa a Ranginuihe Walker Papers. Auckland: Penguin Books Ltd.

(3) Spence, D. (2001) The evolving meaning of 'culture' in New Zealand Nursing. Nursing Proxis in New Zealand; 17: 3, 51.

(4) Hughes, H. (2003) A cultural safety journey. Kai Tiaki Nursing New Zealand; 9: 11, 22.

(5) Manchester, A. (2003) Addressing the health gaps between Maori and non-Maori. Kai Tiaki Nursing New Zealand; 9: 10, 13.

(6) Nursing Council of New Zealand. (2002) Guidelines for Cultural Safety, the Treaty of Waitangi, end Maori Health in Nursing and Midwifery Education and Practice. Wellington: Author.

(7) Warren, S. (2003) How students understand cultural safety. Kai field Nursing New Zealand; 9: 5, 26.

(8) O'Connor, T. (2004) The role of overseas nurses in our health system. Kai Tiaki Nursing New Zealand; 10: 2, 14.

(9) Jeffs, L. (2001) Teaching cultural safety the culturally safe way. Nursing Proxis in New Zealand; 17: 3, 43.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in November last year.

Sandra Meyst, RN, BHSc (Nursing), was working in Whangarei Base Hospital's surgical admissions unit when she wrote this article. She resigned from her position earlier this year to begin studying for a visual arts degree at Northland Polytechnic.