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Making the links between cultural safety and let's get real: a values-based programme, developed by Te Pou o Te Whakaaro Nui, for use with clients who have mental health and/or addiction issues, has similarities to cultural safety and could be used across the health care system.


The education programme for enrolled nurses (ENs) is now a national diploma, at level 5 on the New Zealand Qualifications Authority (NZQA) framework. It is delivered over 18 months in nine institutes of technology around the country. The new programme was developed to prepare ENs for their extended scope of practice. Around 1300 ENs are now practising in the extended scope of practice. This means ENs can now work in acute and mental health areas, they no longer have to work only with stable and predictable service users and clients, and they are able to work across the lifespan. (1) This article looks at the Let's Get Real skills. (2) and the cultural safety skills and knowledge needed to work, not just in mental health, but in all areas of health care.

In 2010 and 2011 we had the privilege of working alongside EN students studying for the diploma at Christchurch Polytechnic Institute of Technology (CPIT). Last year, 28 EN students graduated from CPIT. With the change in the scope of practice and NZQA level, these EN students are able to work in acute and mental health areas of nursing.

Part of our role includes teaching cultural safety in nursing, and mental health for ENs. In 2011 we introduced the Let's Get Real skills into both the theory and clinical courses. Te Pou, the Ministry of Health-funded body responsible for mental health workforce development, research and information dissemination, has rolled out the Real Skills framework. This describes the essential knowledge, skills and attitudes required to be an effective worker in the mental health and addictions area. The ultimate aim is to improve the experience of people seeking mental health and addictions support. (2) This aim is consistent with health care professionals who work in mental health and also fits well with the philosophy of best practice nursing that the EN mental health course in the school of nursing at CPIT is based on. What has become apparent as we have designed the teaching sessions is the many similarities between cultural safety in nursing and the Let's Get Real skills.

What we found in 2011 was that EN students were keen to learn about mental health and were open to embracing the concepts required to care for someone with a mental health concern, whether that was in a medical or surgical ward, in mental health inpatient areas or in the community.

Let's Get Real is based on five values and 11 attitudes that run throughout the seven real skills. The five values are respect, human rights, service, community and relationships. The 11 attitudes required for working in mental health and addictions are being compassionate and caring, genuine, honest, non judgemental, open-minded and optimistic, patient, professional, resilient, supportive and understanding. The values and attitudes are represented in the seven real skills that make up Let's Get Real. (2)

These seven real skills are:

* Working with service users using a partnership approach, focusing on the service users' strengths, supporting recovery and working with others in a meaningful and genuine way.

* Working with Maori and their whanau to achieve maximum individual or collective wellbeing and strength. This is defined as whanau ora.

* Working alongside whanau so they are supported to participate in the recovery of service users and have access to all information, education and support.

* Recognising that service users and their whanau are part of a wider community and that a service user will return to live in a community.

* Challenging stigma and discrimination, challenging the language used to define others, the labels we use to describe others who differ from us, and the way the media report incidents involving service users can shape how service users are treated in the community. Challenging and dealing with stigma and discrimination supports service users to be included in the community and valued.

* That service users and their whanau need to be supported using the codes of practice, standards of nursing, codes of ethics, legislation and regulation available in New Zealand. Recognising that the law, codes and policy have evolved over time in response to New Zealand requirements and recognising that people are entitled to this protection.

* People working in mental health and addictions services are encouraged to reflect on the care and support they give the service user, and work as an effective team member to support the person's recovery.

Working in partnership

Similarly, cultural safety in nursing is about working in partnership, supporting people to participate in their own health care, and protecting their rights to good care. This is described as working with Tiriti o Waitangi principles of partnership, participation and protection. Protection is specifically highlighted, in terms of protecting the person's rights, their beliefs and values.

Cultural safety asks nurses to ensure the service user identifies if the health care has been culturally appropriate or not, and to make sure the health care provided has not demeaned, diminished or disempowered the person. This is important so the person is not placed at cultural risk.3 Cultural safety also asks the nurse to reflect on the care and support they give and how they can improve it. Cultural safety is all about challenging the status quo and challenging the stigma and discrimination found in the community. Cultural safety asks the nurse to find out what is important to the service user, to understand that to many people family includes the extended family (whanau) and that, in most cultures, health is more than merely being free of illness. Cultural safety is not just about being from another ethnicity or race, but it can be if that is what is important to the service user. (3)

We feel there are many similarities between Let's Get Real and cultural safety and that Let's Get Real would be useful, not just in mental health and addictions workplaces, but across the whole health care system, where ever there is the potential for cross cultural communication of any sort. Cross cultural miscommunication might happen when people of different ages, genders, socioeconomic backgrounds or ethnicities start to communicate with each other and talk past each other. This is illustrated by the scenario (right), which is a true story, although the names and places have been changed to maintain confidentiality. As the scenario demonstrates, when some one being nursed is different to those doing the nursing, the potential for judgemental, disrespectful or cultually unsafe care is present. The tenets of cultural safety and the values and attitudes manifest in Let's Get Real skills provide clear guidance on how to avoid such unsafe care.

Cultural safety in nursing (3,4) and the Let's Get Real skills both use Tiriti o Waitangi principles to guide health care interactions. Although cultural safety specifically highlights protection as a Tiriti o Waitangi principle when nursing others, this is implicit in the Let's Get Real skills, values and attitudes. Cultural safety and the Let's Get Real skills also highlight the need to deal with stigma, discrimination and the effects of stereotyping, prejudice and bias. Cultural safety is person- and whanau-centred, as is Let's Get Real. Cultural safety asks whose interests are being served by something being done this particular way or the system being organised a certain way. Let's Get Real asks health care professionals and others working in mental health and addictions, to reflect on the care and support they give, in order to improve the service they deliver.

Clients are the experts on their care Let's Get Real and cultural safety in nursing are similar in that neither try to be an expert on a person's culture. Clearly the architects of both realised the only person who can be an expert in their care is the person themselves. Both cultural safety and Let's Get Real identify the important role that codes of ethics, standards of practice, policy and procedures, guidelines and the law play in health care delivery. Both concepts aim to work with these important documents because both are based on the concept that service users are entitled to have their rights protected.

Both concepts are important in all New Zealand's health services, not just mental health, and could be useful concepts for nurses working in medical, surgical, paediatric, aged care or primary care areas. Mental health service users do use medical and surgical health services, they have children who sometimes require health services, and, with our growing ageing population, they will be and are in our aged-care health. Let's Get Real seems to complement cultural safety. However, there is a reason cultural safety is a paramount competency associated with the EN and registered nurse scopes of practice and competencies in delivering quality nursing care. (1,5) That is because the genesis of cultural safety was based on the experience of Maori pain and inequity. But, subsequently, the driving force and guiding hand behind cultural safety, Irihapeti Ramsden, broadened its application to include all categories of difference, as reflected in the Nursing Council's guidelines on cultural safety. (6)



Although cultural safety and Let's Get Real use different language and terminology to discuss the concepts wihin them, eg cultural safety talks about caring regardfully, not making assumptions and judgements, the categories of difference and not placing people at cultural risk,3 there are many shared meanings as well. These include using the Tiriti o Waitangi principles to provide services, being respectful of difference, reflecting on the way you interact with others, the importance of being whanau -focused and person-centred. The values and attitudes that support the Let's Get Real skills also have shared meaning with cultural safety (2,7) and together provide a framework that supports ENs to work well with service users in any area of the health system.


(1) Nursing Council of New Zealand. (2010) Competencies for the enrolled nurse scope of practice. Wellington: The Author.

(2) Te Pou o Te Whakaaro Nui. (2009) let's Get Real Overview. Wellington: The Author.

(3) Hughes, M. & Farrow, T. (2006) Preparing for cultural safety assessment. Kai Tiaki Nursing New Zealand; 11: I, pp12-14.

(4) McEldowney, R., Puckey, T. & Richardson, F. (2005) Cultural safety, daring to be different. In Wepa, D (Ed.), Cultural Safety in New Zealand/ Aotearoa. (ppl02-121). Auckland: Pearson Education New Zealand.

(5) Nursing Council of New Zealand. (2009) Competencies for registered nurses, Retrieved 17/04/2012.

(6) Nursing Council of New Zealand. (2005, amended 2011) Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. Retrieved 17/04/2012.

(7) Hughes, M. & Farrow T. (2007) How can mental health nurses prove they are culturally safe? Kai Tiaki Nursing New Zealand: 13: 8. pp 18-19.


Miriam had been admitted for investigations for a cholecsystectomy at the beat hospital. She was in a lot of pain, as anyone who has had this complaint knows. She felt miserable. Miriam was an unusual looking woman in her late 30s, although she looked much older, mainly due to the life she had lived so far.

When she asked for something for the pain, there seemed to be some reluctance from the nursing staff. Miriam could not work out what was going on at first. She knew the staff were disapproving of her, although she could not articulate how she knew this. Maybe it was in their unspoken words, their facial expressions and body language, but she just could not pin down why she was not allowed anything for the pain. She was alone and miserable. Most of Miriam's whanau lived in the North Island, although she had lost contact with many of them due to her life choices.

Due to a series of seemingly unconnected but related events, Miriam was a service user of the Community Alcohol and Drug Services (CADS). Miriam lived with an addiction to valium (originally prescribed by a GP) and past misuse of opiates. She freely admitted she had made some bad choices in her life but she was currently turning things around for herself and her daughter.

What Miriam didn't know was that, when she asked for pain relief there were informal meetings being held in the office and a decision was made that she was probably "drug seeking". An assumption had been made, due mainly to Miriam's personal appearance and disclosure that she was a service user of the CADS, that Miriam was seeking drugs and she probably wasn't in pain at all. This appeared to be a "multidisciplinary" decision. In reality, it was discrimination, based on stereotyping and stigma.

At no time did the health care professionals ring CADS to seek clarification and, if they had, they would have been told by the case manager that Miriam actually needed more pain relief medication, not less. No other or alternative pain relief measures were suggested or trialled for Miriam. At one point, one of the nurses handed over in report that Miriam should be watched closely because she was pretty sure her daughter had brought her in some drugs at visiting time because "she seemed very restless after her daughter had left".

Miriam's stay in hospital was unpleasant to say the least, and she suffered. It was only when she herself rang her case manager at CADS to intervene and act as an advocate that she received adequate pain relief.

The label given to Miriam of "drug seeker" meant her bells were left unanswered, no information was shared or supplied to her or her daughter, or accessed from other health services involved in her care. She was not cared for using any kind of partnership model, and stigma and discrimination were evident in her treatment".


Had Miriam been nursed according to the ethos and tenets of cultural safety and the five values, 11 attitudes and seven get real skills outlined in Let's Get Real, her experience would have been very different.

A nurse working from a cultural safety framework would know that their own way of doing and being in the world is not necessarily the only or correct way of living. They would not use power over others and they would not stereotype, victim blame or make judgements about others based on assumptions. In short, nurses would have advocated, not assumed.

Similarly, nurses using the Let's Get Real skills framework would use a recovery approach and instill hope for the future, be open-minded to others' experiences, honest with themselves and with Miriam and their colleagues, genuine, compassionate and caring.

Margaret Hughes

Margaret Hughes, RN, BN, MBS, Cert Adult Tchng, PGCert (Nsng), works in the enrolled nurse and registered nurse programmes at Christchurch Polytechnic Institute of Technology (CPIT).

Lisa McKay, RN, BN, MA (mental health), PGDip (Nsng), is the academic manager in the school of nursing at CPIT.
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Title Annotation:EDUCATION
Author:Hughes, Margaret; McKay, Lisa
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:May 1, 2012
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