Preparing for cultural safety assessment: despite the fact cultural safety has been part of nursing education since 1993, many nurses are still confused by the concept. A review of the literature brings together a number of critical themes.

This year, nurses will be asked to prove their continuing competence in a number of domain areas. Within domain one of the Nursing Council's competencies--professional responsibility--nurses will be asked to show they both apply the principles of the Treaty of Waitangi to their practice and nurse in a manner the client determines as culturally safe. (1)

While there is a relationship between these two areas, we believe some nurses are still confused about the differences and similarities between them. This is unsurprising, given that many nurses have not had the opportunity to attend cultural safety workshops. This article briefly describes the similarities and differences, and the implications these have for practice. If nurses are to be assessed on competencies, we believe opportunities must exist for them to be exposed to education in these areas.

What is cultural safety?

Nurses have written profusely about the history of our cultural safety journey and there are many classic articles which identify its concepts. This journal has published many of them. The earliest articles identify cultural safety in terms of Maori health and ethnicity. (2,3,4,5,6,7,8) These can be considered as the starting place in our cultural safety journey.

In 1993 the concept was broadened out to include what the architect of cultural safety, the late Irihapeti Ramsden, referred to as the "categories of difference". (5) White ethnicity in the form of indigenous Maori health must remain a major focus of cultural safety in New Zealand, many nurses we speak to on a daily basis appear to believe the Treaty of Waitangi and how to look after someone who identifies as Maori, or is from a different ethnic group than themselves, is the only focus.

If we were to design a machine where we could place all the cultural safety articles ever published and separate out all the principles and concepts involved, the process would provide a useful starting place for understanding cultural safety. Our journey begins with the brave step that Maori nurses first made at hui during the 1980s, where the poor health statistics of Maori were identified and questions asked as to why this was occurring. (4,7,9) Challenging the prevailing beliefs of the times is something those nurses should be proud of.

Culture in nursing refers to people who differ from you in terms of attitude, beliefs, roles within society and "being in the world". (10) Other factors include age, disability, gender, socioeconomic group or sexual orientation, as well as ethnicity. (11,12,13,9,7) These are pivotal to understanding cultural safety today and identify that it is not only race or cultures that can appear "exotic" to nurses. Ramsden stated that cultural safety was also about being aware that clients view nurses as "exotic". (4,6,7,14) In an anthropological sense, nurses are viewed as having a culture with specific customs, a way of communicating, a set of "tools" and dress, that mean nurses and nursing are different to clients' accepted norms and standards.

Another principle which might be separated out by our machine is the name cultural safety it self. This is problematic for some, especially those new to its study. When people first come across the concept and are aware of the controversy surrounding its journey, many suggest changing the name. However, Ramsden was adamant the name "cultural safety" must remain, as it is consistent with the requirement that nurses are physically and emotionally safe in their assessments and interactions with clients. (5,9,7,15) So, too, must they be culturally safe. (8,12,13) The term "safe" is also consistent with the client stating whether they have felt "safe" within the client-nurse interaction and ensures the power remains with the client to define that interaction. (16) This is clearly the intention of domain one and is pivotal to understanding the relationship of power and empowerment within the health system.

Ramsden also talked of the client being nursed "regardfully". (9) This can be a difficult concept to grasp, in part because of the strongly held myth of an egalitarian society where everyone is born and treated equally. Ramsden notes that, historically, nurses, on receiving their nursing medal, swore an allegiance to nursing people regardless of their difference, including those of race, creed or colour. (7,15) However, this is contrary to cultural safety, as it suggests oneness, sameness and assimilation. Cultural safety is about acknowledging that people are different, and therefore valuing and respecting difference, with nursing care based on those differences, not regardless of them. (17,10)

Cultural safety also requires nurses to be aware of the assumptions we hold about others and not to base nursing care on our socially and culturally constructed assumptions***17,7,1s This is because faulty assumptions can lead to faulty decision making and judgements, which can in turn lead to stereotyping, labelling and sometimes victim blaming. (18)

Avoiding making judgements about others may sound easy, but in fact it can be difficult because often our initial judgements happen automatically. We are so socialised into the "way things are done around here", that our attitudes become the cultural norms. (19) The socialisation process and the social structures we are schooled, raised, work within and protected by, shape the way we live. These in turn mould our attitudes, beliefs and values. Knowing our own cultural heritage and associated beliefs, values and attitudes is a vital component of cultural safety. (19,7) It is in fact much more important than knowing the clients' culture. Indeed it is questionable whether it is truly possible to know someone else's culture.

(10,20) Cultural safety, therefore, is intended to assist nurses know their own cultural backgrounds, identifying their own beliefs and attitudes. Cultural safety is also about recognising that nursing itself is a culture, with its own implicit beliefs and attitudes. Understanding and accepting this reality can help nurses identify when they are imposing their beliefs on clients about "the best way" to do things.

Avoiding cultural risk

As more concepts are extracted by our machine, we see that cultural safety is about ensuring we do not place clients at cultural risk. To do this is just as dangerous as placing them at physical emotional or mental risk. (13) The poor health statistics of some groups within New Zealand society will attest to this. If clients feel the care they are receiving is not culturally safe, they will not return to it and in some cases their health will continue to deteriorate. This goes some way to explaining why many Maori under-utilise primary health services but "over-utilise"secondary services. None of us would return to receive care where we felt we had been demeaned, diminished or disempowered. This is the definition of cultural risk--the opposite of nursing people in a culturally safe way. (8)

Ramsden and educator Elaine Papps ask us to be cognisant of the social political and economic determinants of people's health, and how health can be affected by a lack of access to scarce, valuable resources such as employment, education and health care. (4,15,21) This is a challenge for many New Zealanders who claim that, in our "fair" society, health and education are available equally to all. Guttural safety acknowledges that access is a broad concept, embracing financial access, geographical access (having the transport to get to appointments) and culturally appropriate access (feeling safe when using the services). There is much support for this viewpoint in many health policy documents. (22,23,24) Cultural safety asks us to reflect on the care we give people who may differ from us in ability, gender, age, socio-economic status and sexual orientation, so that the values nursing says it supports, such as empowerment, advocacy, holism and caring, remain more than promises and are actually present in practice. (25)

What cultural safety is not

People new to the study of cultural safety often describe it as being about "commonsense" and "just about respect". However, this understanding is flawed. Cultural safety is not about being respectful in terms of politeness, and it is not about commonsense. Both these values are cultural constructs. What might be commonsense and respectful in one culture is not necessarily commonsense and respectful in another.

In addition, cultural safety is not just about ethnicity, nor is it only about Maori or our obligations under the Treaty of Waitangi. Cultural safety, then, can never be about having a checklist of how to took after someone. (7,15) There is no one way to look after someone who identifies as Maori or Samoan or Vietnamese. Nor is there one way to care for a young person, or someone from a different socio-economic group, just as there is no one way to nurse someone with a disability, or who is different from the nurse by gender or sexual orientation. It is impossible to become an authority on your own culture(s), let alone some one else's, and it is counter to the concept of cultural safety, where difference within cultures, not just between them, is acknowledged and respected. (10,20) What cultural safety asks us to do when we face a nursing situation outside our sphere of cultural experience is to "ask". This sounds simple, but in reality it can be difficult, especially if you are interacting with someone from your own culture. Knowing our obligations under the Treaty of Waitangi as New Zealand's founding document is the right place to start with cultural safety. Even though we may live in an increasingly multicultural society, our ethical and contractual obligations are with the tangata whenua as the first people of the land. (10,4) The Treaty underpins many pieces of legislation that govern the nursing profession. Therefore we need to be aware of its role and the articles of its two versions.

Becoming aware of past injustices

Mere compliance to the standards and codes of nursing would be a very low level of ethical and professional reasoning, as cultural safety is also about personal ethics. Ramsden asked nurses, upon reaching the end of their undergraduate education, to see the injustice and social discrimination in our society and then do something about it. (5,9,15) However, she also reasoned that possibly only one third of graduates would be able to do this. Nurses need to he politically aware and be able to reflect on the effect of repeated breaches of the Treaty, which have led to the removal of a people from their economic and spiritual base. The results of this injustice are poor health statistics, life expectancy and quality of life compared to non Maori. Recognising the legacy of our history is essential to avoid blaming the victims of poor health. (9)

Our willingness to examine these complex issues determines what sort of society we live in, as an understanding of the issues around the Treaty of Waitangi goes to the heart of the political, social and economic disparities between Maori and non Maori health.

The Treaty can also be a model for effective relationships between clients and nurses, between nurses, and between nurses and other members of the interdisciplinary team. The principles of partnership, participation and protection, as identified in the 1988 Royal Commission on Social Policy, are a useful framework for caring for any person in a culturally safe way. (26)

Assessing the domains

How do we assess whether the care we deliver is culturally safe nursing care? Ramsden was quite clear that it is the client who assesses whether the care they have received has been culturally safe or not. (7,9) It is pleasing to note that the domains of competence specifically stipulate this too.(1) White this is consistent with cultural safety concepts, historically it has not been included in any of the Nursing Council's or NZNO's codes or standards. Although nurses have been required to function as culturally safe nurses since 1993,(11,27,28,29) there has been no assessment after registration and no measurement criteria on which to assess culturally safe nursing care. This makes Domain One a radical and welcome addition to the nursing competencies. In addition, the domains clearly tease out the two arms of cultural safety and identify that nurses must work within the Treaty of Waitangi and they must be culturally safe. While the former can be assessed by demonstrating knowledge of the relationship of the Treaty of Waitangi to culturally safe nursing care, proving that you are culturally safe can be more complex.

While the intentions behind ongoing assessment of competency to practise are laudable, some nurses may be placed in the unenviable position of having to demonstrate competency in areas where they have not had access to information. Students are exposed to cultural safety throughout the three-year undergraduate programme. However, many nurses who trained some years ago have not had this opportunity, unless they have actively sought cultural safety education post registration. We support the Nursing Council's expectations that nurses practise in a culturally safe way. However, nurses should also have the opportunity to be exposed to cultural safety education before they are measured against standards. Cultural safety is a demanding and difficult concept, as it can challenge both professional and personal beliefs and assumptions. It is vital workshops on cultural safety are offered to nurses who have not had recent exposure to this concept. Ideally, these would be provided by employers, in the same way as other in-house education. However, as this is unlikely to occur, we suggest the Nursing Council becomes responsible for holding cultural safety workshops before assessing competency. The intention of this article has been to provide some practical information about what cultural safety is and what it is not, in order to broaden the concept beyond ethnicity. In doing this we have used a selection of classic resources available to nurses wanting to read more about the subject. We have touched on the important relationship between the Treaty of Waitangi, Maori health and culturally safe client-nurse relationships, and identified the influence of cultures within cultures such as age, gender, disability, socio-economic group and sexual orientation. Ultimately this information will be useful to nurses seeking to provide evidence of cultural safety in its wider sense as required by domain one within the nursing competencies. (1) However, this information is not enough on its own. Nurses who have not been exposed to cultural safety education need to have access to workshops before competency assessment occurs. Without such exposure, many nurses may be unable to provide evidence of competency to practise in a culturally safe way.

References

(1) Nursing Council of New Zeatand. (2005a) Camptencies for the registered nurse scope of practice. Wellington: Author.

(2) Dyck, I. & Kearns, R. (1995) Transforming the relations of research: towards culturally safe geographies of health and illness. Health und Practice; 1: 3, 137-147.

(3) Kearns, R. (1997) A place for cultural safety beyond nursing education. The New Zealand Medical Journal; 110: 1037, 23-24.

(4) Ramsden, I. (1990) Kawa Whakaruruhau: cultural safety in nursing education in Aotearoa. Wellington: Ministry of Health.

(5) Ramsden, I. (1993) Kawa Whakaruruhau: Guidelines Nursing und Midwifery Education in Aotearoa. Wellington: Nursing Council of New Zealand.

(6) Ramsden, I. (1995) What have we Learned? Kai Tiaki Nursing New Zealand; 1: 10, 2.

(7) 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 und Midwifery Education in Aoteroa. Wellington: Nursing Council of New Zealand.

(8) Wood, P. & Schwass, M. (1993) Cultural Safety: A framework for changing attitudes. Nursing Praxis in New Zealand; 81: 1, 4-15.

(9) Ramsden, I. (October 1995a) Cultural safety: Implementing the concept. New Zealand College of Midwives Journal, 6-9.

(10) Cooney, C. (1994) A comparative analysis or transcultural nursing and cultural safety. Nursing Praxis in New Zealand; 9: 1, 6-11.

(11) Nursing Council of New Zealand. (1996) guidelines for Cultural Safety, the Treaty of Waitangi und Moon Health in Nursing Education und Practice. Wellington: Author.

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

(13) Nursing Council of New Zealand. (2005b) Guidelines Cultural Salary, the Treaty of Waitangi and Maori Health in Nursing Education und Practice. Wellington: Author.

(14) Ramsden, I. (2000) Cultural Safety/Kawa Whakaruruhau ten years on: a personal overview. Nursing Praxis in New Zealand: 15: 1, 4-12.

(15) Ramsden, I. (2005) Towards cultural safety. In Wepa, D (Ed.), Cultural Safety in New Zealand/Aotearoa. (pp2-20). Auckland: Pearson Education New Zealand.

(16) 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.

(17) Benham, S. (2001) Cultural safety values difference. Kai Tiaki Nursing in New Zeeland; 17: 1, 28-29.

(18) Thompson, S. (2001) Developing a culturally safe curriculum. Kai Tioki Nursing New Zealand; 7: 1, 14-17.

(19) Papps, E. (2002) Cultural safety, what is the question? In Papps, E (Ed.), Nursing in New Zealand, Critical Issues, different perspectives. (pp. 95-107). Auckland: Pearson Education New Zealand.

(20) Coup, A. (1996). Cultural safety and culturally congruent care: A comparative analysis of Irihapeti Ramsden's and Madeleine Leininger's educational projects for practice. Nursing Praxis in New Zealand; 11, 4-10.

(21) Papps, E. & Ramsden, I. (1996) Cultural Safety in New Zealand: the New Zealand Experience. International Journal for Quality in Health Care: 8: 5, 491-497.

(22) Ministry of Health. (2001) Priorities for Maori und Pacific Health: Evidence from Epidemiology. Wellington: Author.

(23) Ministry of Health. (2002) He Korowui Orange: Maori health strategy. Wellington: Author.

(24) National Advisory Committee on National Health and Disability. (1998) The social, cultural und economic determinants of health in New Zealand: Action to improve health. Wellington: National Health Committee.

(25) Kermode, S. & Brown, C. (1904) Where have all the flowers gone? Nursing's escape from the radical critique. Contemporary Nurse; 4: 1, 8-15.

(26) Royal Commission on Social Policy. (1088) The April Report, 1-5. Wellington: Government Press.

(27) NZNO. (1993a) Social Policy Statement. Wellington: Author.

(28) NZNO. (1993b) Standards for Nursing Practice. Wellington: Author.

(29) NZNO. (1995) Code of Ethics. Wellington: Author.

Margaret Hughes, RN, BN, MBS, and Tony Farrow, RN, BN, MHSc (Hons), are both senior lecturers in the Christchurch Polytechnic Institute of Technology's Faculty of Health and Sciences.