Cultural safety initially arose from considering the health care experiences of Māori.
Over time the concept has evolved to address needs related to access and use of health care services for all patients or clients. The term ‘cultural safety’ shares some links with other ideas related to culture and nursing such as transcultural care, cultural competence or culture specific care but is sometimes narrowly interpreted as addressing specific cultural or ethnic needs of clients.
A Māori term for cultural safety kawa whakaruruhau can be translated as protection from potentially harmful or troublesome elements and relates more to the actions and activities of nurses, nursing and health professionals rather than focusing on ethnicity.
New Zealand nurse and nurse educator Irihapeti Ramsden (Te Awe Awe o Rangitane, Tikao o Ngaitahu) maintained that cultural safety was not about the patient but about the nurse’s behaviour and attitude toward patients and their ability or otherwise to create a trusting relationship.
In my recently completed PhD study I looked at cultural safety in nursing education and practice in Aotearoa New Zealand. I found that culturally safe care is consistent with caring qualities inherent in any nursing philosophy. Cultural safety and nursing acknowledge a connection between the nurse and the person experiencing illness, stress or lifechanging health situations. Both aspire to the maintenance and sustanance of health and both value the idea that the quality of the relationship can influence health care processes and outcomes. Another feature of cultural safety takes into account the worldview and life experience of the person receiving care and supports a moral idea of protecting and maintaining human dignity.
Culturally safe care adds another dimension to these shared characteristics by highlighting the role that power, difference and identity have in shaping health care interactions.
I analysed narratives of cultural safety from 16 registered nurses to gain a deeper understanding of how they interpreted cultural safety and how they applied the concept in their everyday nursing practice. The focus of cultural safety has tended to be on the culture of the individual nurse and has not always taken into account structural factors.
Participant stories showed that the settings in which the participants worked, and the values and beliefs guiding practices in each setting, determined the degree to which culturally safe care was able to be integrated with their everyday nursing.
To gain a better understanding of this, I explored the relationship between the nurse’s attempts to apply cultural safety knowledge in the context of their practice settings. I did this because I wanted to find out what kind of nursing situations and events enabled or constrained their efforts to work in a culturally safe way.
Cultural safety, like many other aspects of nursing, is taught to people with different backgrounds, experiences, values and beliefs which influence their understanding of cultural safety. These differences can affect the level of uptake of cultural safety knowledge and the nurse’s intent to work in a consciously culturally safe way in practice.
The nurse’s stories around cultural safety identified many meanings of cultural safety including for example: ‘being a good listener’, ‘knowing your own values and how they might affect what you are doing’, ‘respecting another person, feeling right about what I am doing- like a pair of comfortablyfitting shoes, if the shoes are too tight it usually means I am not doing something right’, ‘cultural safety is about carrying and catching people’s stories, coming from a place of unknowing to a place of knowing (a person)’.
As registered nurses, participants found that it was not always possible to work in a culturally safe way. The following excerpts from their narratives illustrate how their care was constrained by the prevailing values and beliefs guiding and structuring the delivery of care in different health settings.
For example Louise who works in an aged care unit said ‘culturally safe nursing is about a partnership between the nurse and the patient and the things that can come in between which prevent you from giving quality care and can undermine what you do’. Shewas referring to being unable to meet a client’s request for a bath in the evening. rather than the morning, because of the demand to follow the unit’s daily routines.
Patricia works in a day surgery unit and reports constraints on her ability to work in a culturally safe way include ‘having too many people, coming to stay, when we’re processing people like widgets on a conveyor belt. …tomorrow I may be able to do more, whereas today we’re just processing widgets’.
Jill works in an acute specialist surgical unit and talks about how the environment might be for people unfamiliar with a hospital setting ‘…but it would be worse for people of other cultures because [the unit] is a mainstream Pākēhā, male-dominated set- up and I mean, I don’t mind hospitals too much because, you know, that’s part of my culture and I understand a wee bit more, but I think it is frightening for people who do not understand the system. I think they [hospitals] actually promote unsafe practice, just the way they are set up, the physical set-up’.
These examples give an insight into how some of the participants identified structural constraints when trying to work in a culturally safe way. While there were other stories told of how these constraints were overcome, space prevents me from identifying these.
The purpose of these examples is to show that culturally safe nursing is not the sole responsibility of the individual nurse and can be influenced by the structure of the particular setting. My study identified how resources available to nurses in any setting can open up or close down possibilities to create conditions for culturally safe care.
So what is cultural safety and why does it matter in 2011?
One function of cultural safety knowledge is to enable the nurse to provide effective and safe care that meets a person’s health care needs in a way that maintains the patient’s personal, social and cultural identity. Identity can be considered as a resource that a person draws on to maintain their wellbeing and social connectedness during times of illness and stress.
Cultural safety provides a structure which can guide or assist a nurse to provide and manage care in a way that protects and sustains a person’s identity and wellbeing.
Cultural safety matters in 2011 because it offers a way for reminding us of the importance of relationship and intent in health care and provides a useful framework for analysing and understanding health care when working within networks of power in everyday practice.
As health care becomes more complex and diversified it is important that people using health services are able to feel valued, listened to and respected and that their sense of self, identity and wellbeing are maintained as they negotiate complex health settings.
In my research ‘culture’ in ‘cultural safety’ can be seen in relation to the culture of nursing and the culture of the setting within which nursing takes place.
Fran Richardson is a senior lecturer at Whitireia Community Polytechnic
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