Values, beliefs and attitudes

Values are the standards by which people judge their own and other people’s actions. Values are commonly used to denote worth or goodness. All value and belief systems are linked to culture because they are based on cultural factors and the meaning that individuals ascribe to these.

Values are also about how an individual has learnt to think things ought to be or people ought to behave, especially in terms of qualities such as honesty, integrity and openness which, when people are asked what their values are, tend to be the values they rate as most important to them.

Beliefs are the assumptions made about yourself, about others in the world and about how you expect things to be and how you think things really are. Beliefs tend to be deep set and an individual’s values stem from their own beliefs.

Attitudes are the established ways of responding to people and situations that have been learned, based on the beliefs, values and assumptions held; the ways in which a person reacts to a situation and their related behaviour can reflect their attitudes. However, individuals can exhibit behaviours in ways that do not necessarily reflect their beliefs and values. An example of this might be a football supporter swearing, arguing vociferously and haranguing the umpire; then it is revealed that this person is a professor of ethics at a prestigious university.

There are differences between beliefs, values and attitude; however, they are all linked. An individual’s beliefs and values can have an impact on their attitudes and behaviours. However, they can use emotional intelligence to have a positive attitude and adjust their behaviour in particular situations (Jones & Creedy 2008; Ranzijn et al 2008; Talbot & Verrinder 2010; Taylor & Guerin 2010).

Culture often influences a person’s daily life in ways they are usually unaware of. Thus culture is hidden and taken for granted, so when the individual comes across a person or situation that does not mirror these invisible cultural values and beliefs, they judge them and almost always assume that it is the other person or situation which has the problem. This is known as ethnocentrism.

Ethnocentrism

Matsumoto and Juang (2004) state that:

However, ethnocentrism can lead to stereotyping and prejudice about anything perceived as ‘strange or different’. The extreme form of this is xenophobia—a morbid fear of foreigners. Much of the current public and Federal Government reaction to refugees arriving by boat could be described as being perilously close to xenophobic. These types of reactions are usually based on the belief that the values and practices of your own culture are superior and of greater worth than those of another culture (Weller 1991).

Such reactions are a common response, particularly from people who have not been exposed to people or groups different from their own (Hooghe 2008). Fortunately in Australia, as a multicultural society, most people have been exposed to many different groups and so should, in theory, be more tolerant than people in other societies who live in more homogenous societies. However, ethnocentrism is alive and well in Australia and is closely linked to the power and authority of the dominant group—which we examine in more detail later in the chapter.

What a person thinks of other societies and cultures has an impact on their personal and professional self. It is worth keeping in mind that ethnocentrism was one of the key components of European colonisation of Australia and of New Zealand, thus setting the tone for dealings with Indigenous inhabitants. This has also played out in various ways with the subsequent waves of immigration.

Reflecting on your personal values, beliefs and attitudes can go a long way to genuinely contributing to a more tolerant and fairer society.

In contrast to ethnocentrism, cultural relativism involves attempting to understand a culture from its own standards, or the position that there is no universal standard by which to measure cultures. Therefore, all cultures are equally valid and must be understood in their own terms and are deserving of respect. Of course this is often difficult to do when a cultural behaviour seems to be inexplicable and appears to cause distress, disease or death.

A powerful example of this is the practice in some traditional African groups of placing cow dung or soil on the stump of the fresh umbilical cord of the newborn. This practice has high potential to introduce tetanus to the infant, which results in almost certain death if the mother has not been immunised. So while cultural relativism asks a health professional not to judge this group’s cultural practice, it may be felt that neither can the practice be condoned. An ethical response is for the health professional to make the knowledge about the problems with such a practice available to the group and hope the change of behaviour comes from within, rather than from being forced upon them.

A danger associated with learning about and defining other cultures is the assumption that people can be categorised, rather than individualised, by virtue of ethnicity and culture. People cannot be put into little culturally specific boxes or labelled by virtue of culture and race. It should not be assumed that the criteria for a certain cultural group are true for every person who belongs to that group. While culture is viewed as composed of shared values, ideas and beliefs, those within a cultural group may differ widely in their individual take on things. One culture begins to overlap with another and it can be seen that cultural groups are not well defined, bounded entities.

When generalising, the individual takes a specific idea and extrapolates to a broader group of circumstances; whereas stereotyping is more about attributing certain characteristics to a group, based on some common factor the group has (or is perceived to have). Making assumptions to predict behaviours in individuals or groups who are different from ourself can lead to stereotyping or to generalising. Though a stereotype and a generalisation may appear similar, they function quite differently. Galanti (1991) describes both terms as follows: a generalisation is a beginning point; it indicates common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual; and a stereotype is an end point; no attempt is made to learn whether the individual in question fits the statement. Stereotyping does not tend to allow for individual differences within cultures and commonly victimises groups by blaming their cultures for perceived and negatively valued practices. For example, some health practitioners believe the reasons many Australian Indigenous families suffer poor hygiene is the result of the traditional mobility of Indigenous groups, when in fact, it has more to do with overcrowding, non-functional health hardware and lack of appropriate housing infrastructure.

Prejudice

Prejudice is the process of making a judgment about an individual or group of individuals on the basis of their social, physical or cultural characteristics. Such judgments are usually negative, but prejudice can also be exercised to give undue favour and advantage to members of particular groups. Prejudice is also usually about forming a negative judgment about someone based on a stereotype rather than on actual evidence. It is the formation of a judgment without any direct or actual experience. When a person is unaware or incapable of understanding behaviour from the other person’s cultural perspective they are more likely to become prejudiced or behave in a prejudiced manner. According to Hollinsworth (1998:48):

All human beings carry around erroneous or unsubstantiated beliefs about the world (or at least others in it). In most cases, however, when confronted with new information or experiences which contradict or question such errors, an individual can change their mind without too much difficulty or trauma. Prejudices are usually highly resistant to amendment, unlike many overgeneralisations. An example might be: ‘everyone seems to drink beer in Darwin pretty much all of the time’ (based on little or no evidence) = overgeneralisation; ‘people in Darwin are all “yobbos” as they only drink beer’ = prejudice.

For additional discussion on race and ethnicity see Paniagua (2004).

Allport (1954) saw prejudice as closely connected with ethnocentrism, defined as preference for one’s own group and its values and culture. We have to be mindful of not only focusing on extreme behaviours but also of identifying ordinary or everyday racism. Therefore we need to concentrate on social and historical factors which have given rise to specific ideologies and institutions that construct and support environments of everyday racism, which differs from the presumed ignorance or insanity of seemingly isolated and random acts. While human beings are genetically the same, the term race is used to convey superficial physical characteristics such as skin colour or facial features. Given that there is known to be more genetic variation within races than between them, the term race is socially, rather than biologically constructed (Price & Cortis 2000).

Ethnicity is often used to refer to the group one belongs to as a result of a mix of cultural factors that can include language, diet, religion and ancestry (Bhopal 2001). Race and ethnicity are often still used synonymously. Others distinguish race as being primarily physical, culture as sociological and ethnicity as psychological (Narayanasamy 1999). Social scientists tend to reject the term race as a verifiable entity or useful way to categorise people, because it has historically been associated with notions of different levels of intellectual development, and social evolutionism that portrayed some groups of people as ‘less evolved’ than other, generally European, peoples. Ideas such as social evolutionism have since been proven to be entirely fallacious. Today other terms, such as ethnicity, are used to describe difference; these terms tend to give more emphasis to cultural and social differences. However, human proclivity to want to group people is rarely value neutral and is therefore difficult to disassociate from hierarchical presentations. While ethnicity and race are related concepts, the concept of ethnicity is rooted more in the idea of social grouping, marked especially by shared nationality, tribal affiliation, shared genealogy or kinship and descent, religious identification, language use or specific cultural and traditional origins, whereas race is rooted in the idea of a biological classification.

In 1950, in the UNESCO statement ‘The Race Question’, signed by internationally renowned scholars including Ashley Montagu, Claude Lévi-Strauss, Gunnar Myrdal and Julian Huxley, it was proposed to ‘drop the term “race” altogether and speak of “ethnic groups”’. That suggestion has largely been taken up; current terminology includes ‘ethnically diverse groups’.

Myths and stereotypes are a key component of racism:

Note that between 40% and 79% of Indigenous Australians have self-reported racism as part of their everyday lives (Paradies et al 2008).

At an individual and interpersonal level racism often amounts to:

Labelling of Indigenous Australians includes stereotypes relating to dark skin, despair, levels of alcohol consumption, laziness, levels of intelligence, ability to work and care for children and levels of criminality. These are all part of the myths and stereotypes that perpetuate racism in Australia.

Culture is also dynamic; it is constantly changing. Outside influences that could precipitate major changes in a culture are often interpreted and adapted to accommodate them into the ways of doing things within that particular culture (MacLachlan 1997). Flexibility of behaviour and looseness of structure are essential for the generation of new culture and modification of old ways. Most Australians and New Zealanders appreciate the fashion culture that evolved in the nineteenth century when non-Indigenous women complied with the expectations of the day and wore corsets, bustles and neck-to-toe coverings. Yet many women of today disapprove of or pity Muslim women who choose similarly modest clothing.

That is primarily because culture is so much a part of who an individual is deemed to be that it is difficult to see, much like the fish that can’t see the water that surrounds its world. And so an individual judges the world and all that is in it by their own culturally informed values.

World view

World view is a concept that lies behind the way we understand culture; it refers to the fact that people or groups of people perceive and relate to the world in different ways. World view is also tied to the concept of different ways of knowing and forming knowledge. These will influence understandings about all aspects of life, including health: how we experience health and illness, what it means to be well, what we do when we get sick, who we talk to and how we understand the cause/s of our conditions.

The Māori scholar Te Ahukaramu Charles Royal offers a useful way to understand the world view of Indigenous peoples when he writes:

Many Australians are mindful that Indigenous peoples were the first Australians and certainly most New Zealanders are aware of the rightful place of the Māori in Aotearoa history. Most people are aware of the devastating impact the colonisation process has had on these groups; we touch on this briefly in this chapter and it is linked to the discussion in Chapter 9. It bears repeating that, like all groups in Australia, there is huge diversity within Indigenous peoples. Some groups still retain strong traditional ties after having first come into contact with non-Indigenous Australians as late as the 1950s or even the early 1970s, as is the case of some Arnhem Land and Central Australian communities. However, there are also many Indigenous families who have been exposed to western cultural systems for over 200 years and these individuals and groups will vary in their access to and incorporation of western values and beliefs. So, as we try to appreciate the different world views of all groups, we must do so only as a beginning point.

World views and contested knowledges

World view is also tied to the concept of different knowledge systems. As well as there being different ways of perceiving the world, there are also different ways of ‘knowing’ about the world, which will influence understandings of all aspects of life, including health. For example, Marika-Mununggiritj (1995), a Yolŋu educator and Elder, illustrates how she sees the difference between the Yolŋu view of knowledge and a western view of knowledge, using the idea of metaphor. She says that:

Negotiating between different knowledge systems is central to understanding about working in a variety of cultural contexts—wanting, and being expected, to achieve successful outcomes in what can often be difficult circumstances.

When different knowledge systems are discussed, the term ‘contested’ can be used to describe the way in which different world views and knowledges in a sense strive for legitimacy. For example, contestation is ‘the process of challenging or questioning something that is assumed to be given. Contestation often reveals the contingency of things that are assumed to be universal truths’ (Wohling 2009).

What this means is that if an individual knows only one way of seeing the world, or one way of understanding it, they will take this to be the ‘true’ way of seeing the world—it becomes their reality. However, the problem is that they may be more likely to disregard others’ world views, or to not see them as legitimate ways of knowing about the world. Contested knowledges are therefore about an individual being challenged to look at their ways of knowing and consider other possible ways of knowing and thinking.

In doing so, a person is likely to become increasingly aware of how their usual ways of doing things are dependent upon the historical, social and cultural context in which they have grown up and now operate within. It is about challenging their own world view and developing the language to articulate understanding of the ramifications of these challenges. Through the process of negotiating different knowledge systems, the individual is opened up to considering the value and the legitimacy of other knowledge systems (Wohling 2009). This is why throughout this chapter ‘knowledges’ rather than just ‘knowledge’ are referred to.

Assumptions about truths embedded within knowledge systems create a deeply contested area. For example, knowledge is interpretive; that is, it is part of human endeavour to create meaning and reality within given environments. Knowledge is also contingent, which means that it is situational and relative only to particular circumstances. All knowledge is also political, in that it is constructed by relationships of power based on domination and subordination. This is a different view of knowledge to the objectivist, scientific view of knowledge, which is dominant in western society and particularly in areas such as health.

Indigenous knowledges

In Australia and other colonised countries, the presence of different world views and the contingent and contested nature of knowledges are nowhere more poignantly reflected than through Indigenous cultures. One of the perceived clashes between western scientific knowledge and some Indigenous knowledges, for example, is that concepts of neutrality and objectivity within western scientific research are located within a cultural model that generally fails to acknowledge Indigenous perspectives. That is, western scientific knowledge has long been held up as the ultimate truth and every other form of knowledge is measured against this yardstick. However, as can be seen below, Indigenous knowledges are legitimate in their own right and this concept needs to be recognised when working in cross-cultural contexts.

For example, one of the features of Yolŋu theory of knowledge, and the theory of knowledge of Indigenous peoples throughout Australia, is the notion that ‘knowledge belongs to people’. It is not an abstract or universal thing. It is tied to people and to places and to history, and is held by right, as is land, history, ceremony and language. By contrast, an objectivist view tends to present knowledge as an abstraction, separated from people. Western science has tended to base itself within an objectivist theory of knowledge. This differs from the way many Indigenous people view knowledge making. Indigenous knowledges have their own sets of beliefs and protocols about the generation of knowledge and truth claims. These may differ between groups of Indigenous people. However, the tendency is for these knowledges to exist within a more constructivist theory of knowledge, seeing knowledge not as abstract, but something that is generated by people, is localised and is collective.

These concepts of knowledge and world view are very important to understand, as they are fundamental to what can be understood about culture.

It is also important to remember that it is not just other cultures whose world views need to be recognised. As MacLachlan (1997) said, individuals need to ‘think through’ their own culture, which means being aware of their own world views and understandings to help explain why people think and act the way they do. In doing so, it may be understood that an individual’s way of experiencing the world is just one way, rather than the ‘only’ or the ‘right’ way.

World views and Indigenous health

Once an individual attempts to appreciate differences in world views it is much easier to understand why it is natural for Indigenous peoples to see health in a much broader context. First, a brief review of some current concepts of health.

When thinking or talking about health, people often assume that a shared meaning of the concept exists. On closer examination it becomes apparent that the term ‘health’ not only has more than one definition, but its meaning will differ between individuals, both within and across different cultures, and this difference has important implications for health systems and services.

Baum (2002) explains:

So, how can the concept of ‘health’ be defined? Spector (1996) notes that this question is often answered by referring to the World Health Organization (WHO) definition: ‘A state of complete physical, mental and social well-being and not merely the absence of disease’ (WHO 1946 in Spector 1996).

This definition of health moves away from the idea that health is purely the ‘absence of disease’, as it was once defined. Grbich (1999) explains that defining health as the absence of disease contributes to a view that sees the body as functioning separately from the mind. Therefore, in this view, the mind is not perceived as playing a role in the development and healing of illness, and the impacts of social and physical environments are also ignored.

The WHO definition goes some way to addressing these concerns. However, it too has been criticised for reasons such as its use of the term ‘complete’, which does not allow for the multidimensional nature of health. That is, people can be healthy in one aspect of their lives while being ill in others (MacLachlan 1997). This point is linked to another criticism: that it defines an ideal state to which we all can or want to aspire, therefore ignoring issues of poverty and power which prevent many from pursuing this ideal (Grbich 1999).

Spector (1996) provides other definitions of health, making the point that health is an elusive concept, in some ways defying definition. However, she argues that health practitioners all enter their profession with their own culturally based concept of health. That is, our view of health, while it is likely to be informed by accepted definitions, will be shaped in part by our cultural background and world view. This applies to both health professionals as well as people in the general community who access and interact with health systems and services.

In many western countries such as Australia, the dominant health systems operate using a biomedical model of health (Grbich 1999; MacLachlan 1997). According to Grbich (1999), when a health practitioner is using the biomedical approach, the body is essentially viewed as a machine with a set of interrelated parts. The malfunctioning or ‘sick’ part is isolated, causes are sought and treatment is instigated. This biomedical model is derived from a typically western scientific framework of knowledge and understanding, based on objectivity and scientific rationalism, which breaks something down into its smallest components for analysis, rather than sees something as a whole. As health practitioners it is therefore necessary to question both your own and the dominant understandings of health and their origins, to begin to understand how health can differ across cultures.

Health for many Indigenous people is a matter of determining all aspects of their life—including control over their physical environment—of dignity, of community self-esteem and of justice. It also relates to relationships to land and connections with the spiritual world (Grbich 1999). It is not merely the provision of doctors, hospitals, medicines or the absence of disease and incapacity. Health is a multidimensional concept that embraces all aspects of living and stresses the importance of survival in harmony with the environment.

The National Strategic Framework for Aboriginal and Torres Strait Islander Health (2003) describes health as:

This definition shows that for many Indigenous peoples, health does not focus on the individual, as is usually the case in western societies. Rather, an individual’s health is tied up with the health of the community, which is also inseparable from the health of their country.

Commonly held Indigenous beliefs propose that when factors that influence social wellbeing and harmony within groups are maintained, people are healthy. However, when social, emotional and cultural wellbeing is disrupted, ill health results. Indigenous spirituality was and still is essentially land centred. While this broad definition of health is emphasised by Indigenous people in different ways, they believe that health cannot be disassociated from self-determination, land rights and cultural vitality; and it cannot be neatly divided into mental and physical aspects (NATSIHC 2003).

Identity

There are strong connections between culture, identity and health, although these may not at first seem obvious. However, the student will need to think about the extent to which identity and health might be linked, given the different kinds of definitions of health that exist. For example, for many Indigenous peoples, both in Australia and in other countries, identity is tied up inextricably with land and kinship.

Many Indigenous cultures identify themselves through the land, or ‘country’. Country is the source of peoples’ beliefs and knowledge systems and is reflected in art, music, dance and ceremony. Indigenous cultures continue to be inseparable from country. The connection between people and the land is not only reflected in cultural strength, but is also evident in the lifestyle and social structure of people, no matter where they are physically located. Thus, to be removed from country (in both a physical and spiritual sense) is to take away those elements that sustain a person spiritually and mentally, which ultimately impacts on the person’s ability to sustain themself physically.

For further reference, Brian McCoy (2006) offers an anthropologist’s perspective on the ownership of health beliefs and Taylor and Guerin (2010) offer an overview of Indigenous health and the links with cultural practice.

Implications of cultural diversity for practice

People with different experiences and values are likely to have different ways when making assessments, especially about the perceived worth of something. They might have different ideas about what is important, and what is not important. They might have different ideas about what criteria to use when making a judgment, and what evidence to include or not to include. There are also often differences between the various stakeholders or participants in the process or service delivery. Their differences are often a result of where they stand in relation to the healthcare and their responsibilities.

When making a cultural assessment, unless there is a balance in the understandings, efforts to do things in a culturally appropriate manner will be relatively meaningless and possibly harmful. Different skills accompany different knowledge and broad understandings to provide a balanced framework for assessment. This is unlikely to occur if the assessment is focused solely on outcomes and does not include participants.

Some consideration of the factors and processes of prioritising complex decision making with regard to clinical assessment is also required. Health service providers can work with clients and their families in a number of ways while being sensitive to the wishes and not taking over the role of caring from the family (Taylor & Guerin 2010). It is vital that clients and their families feel supported and that clear, concise and non-jargon language is used in order to facilitate maximum comprehension and understanding of information received and given (Lowell et al 2005).

Education about the whole healthcare process is also essential as the client and family may be unfamiliar with disease physiology, progression, symptoms, treatment options and side effects. It is a common human response to be fearful of the unknown, therefore the more information and resources people have with regard to things like pain management, administration of medication and access and use of aids and equipment, the more straightforward the process of decision making should be.

When dealing with people from culturally diverse backgrounds, it is crucial to ask who provides care and who is responsible for making decisions within the client and family context. For example, for most Indigenous peoples, this means taking into consideration the kinship and family structure and what determines acceptable social behaviour (O’Faircheallaigh 1999).

When communicating in any healthcare context in general, and in a culturally diverse context specifically, it is critical to consider the following essential components of culturally safe and effective work practice:

Values, beliefs and attitudes of professions

The nurse should keep in mind the different cultures of the various professions that the health professional interacts with and/or belongs to. They should think about what unites professionals and what differences they may have. This will help develop understanding of their own and other professionals’ cultures.

When students begin their training in any of the professions they are acculturated in the values, beliefs and understandings of that particular profession. These values are outlined in the relevant codes of ethics which provide people with a valuable tool for reflecting on their professional culture.

Nurses should make sure they are familiar with and refer to their own code of ethics and those of any other profession they come into contact with. Some of these are listed at the end of this chapter.

Nursing in contemporary Australia

Clinical Interest Box 8.1 is a snapshot of the culture of the nursing profession, which is the largest contingent of the health workforce in most western countries.

Professionals want what is best for their clients. To achieve this, rather than trying to change the world view of other professionals, they should accept their differences and work together to improve services for their clients.

Multidisciplinary teams: a cultural challenge?

Structures of teams differ considerably. Some are vertical, profession-specific structures, as often seen in urban hospitals, where there is a hierarchical line of authority descending from the person in charge to the most junior team member. Community health teams generally have a more horizontal structure, with most or all of the team members at a similar level of responsibility and authority. The leadership of the team may rotate among the members, depending on circumstances.

A vertical structure tends to place the decision making within the hands of one or two at the top. In horizontal structures, decisions are often reached by consensus. This process enhances the involvement of the community and of all the team members.

Primary healthcare management is geared towards consensus. One person might be designated manager and coordinator and be paid accordingly but still share the functions of management in such a way that all team members, employees and community are empowered. The type of management necessary for this approach to healthcare will necessarily be different from the management that works in the traditional top-down, medical model of healthcare (Johnson 1996).

Lupton (2003) describes how health professionals and patients are socialised into authoritative, hierarchical professional roles. ‘Both patients and doctors (and other health professionals) have expectations and needs … which at times demand that the doctor take an authoritative stance’.

The hierarchical nature of health training and urban practice predisposes professionals to authoritative and an often autocratic stance. This can contribute to a professional culture that differs from the more egalitarian power-sharing processes used in community health teamwork. Most health professionals have to unlearn these patterns of past behaviour to be able to participate effectively in teamwork. One hallmark of people having made the transition from a hierarchical structure in a hospital to the more horizontal structure of a community health team is a team member’s willingness to take up tasks usually assigned to lower status professional groups.

Community health teams tend to be multidisciplinary, involving health workers, doctors, nurses, community welfare, allied and other professional groups, as well as administrative and management staff. They require each member to have specific areas of expertise as well as advanced generalist skills and the capacity to support and complement each other.

Overlapping of roles is unavoidable due to the nature of the work of most community health teams and the extended role of most community health practitioners. This is commonly a source of conflict in teams whose members originate from traditional practice backgrounds of urban hospitals and private practice and are more familiar and comfortable with the models of clear boundaries between professional roles, responsibilities and authority (Glass 2010).

From a positive perspective, multidisciplinary teams with overlapping roles reduce professional barriers and barriers between individuals and increase the team’s capacity to deal effectively with the demands on the service, while using individual expertise as appropriate. Individual team members need to expand their professional identity by incorporating the values and goals of the team. In the process of doing this there are some compromises with the level of professional autonomy exercised, when compared to non-team environments. The gains in working in multifunctional teams can be substantial. Such work helps the team member gain insight and skills in other professional disciplines, provide better care, as well as contributing to using the individual’s expertise more effectively through the support of the team (Glass 2010).

However, if team members look upon themselves as representatives of their profession or discipline, instead of as team members, this will inhibit team synergy (that is, the output of the whole team is greater than the sum of the individual parts); if team members merely represent the interests of their profession, the team becomes competitive rather than collaborative (see Clinical Interest Box 8.2).

Introduction

Some of the difficulties individuals experience in accessing mainstream services are primarily the result of differing and often competing world views, language barriers and misunderstandings. Major factors that influence access and equity in a service are the appropriateness of the service to all its users and the previous experiences of the client, both within wider society and within the service itself.

Being different; being the other

It is not hard to see how difficult it can be for some members of minority and culturally diverse groups to access mainstream services. Most of you will by now have recognised that biases and prejudices exist within all people, in the workplace and in the broader society.

Many individuals are able to identify times where they felt uncomfortable or unsafe in situations (in work, social or service environments). This discomfort will often occur in situations where the individual is not in the same category as the other members, whether it be their gender, sexuality, ethnicity, class, income or profession which makes them different. On some of these occasions there will be nothing overt in the behaviour or environment of the group that can be identified, only this sense of unease for the individual. At other times that person may feel this discomfort more strongly and that they are, in fact, discriminated against.

In some cases individuals can choose when to declare their ‘differentness’. For example, they can decide not to tell the GP that they use recreational drugs (for fear of being labelled a ‘drug user’); they might not tell their next-door neighbour that they are homosexual (for fear of being judged or subjected to homophobia); they might not tell their workmates that they are a devout Christian (for fear of being discriminated against for their religious beliefs) or a teenager might not tell their midwife that they have had three abortions (for fear of being judged as promiscuous or stupid). These people still suffer marginalisation and discrimination from mainstream (or other minority) groups but it is less constant because physically they can ‘blend in with the crowd’.

People who look physically different from the mainstream group cannot hide their identity or choose not to disclose it. Every day they come in contact with mainstream groups or belief systems and are made aware of their difference. These experiences, many of which begin in childhood, will contribute strongly to the identity and sense of self held by these marginalised individuals and groups. Their experiences will interact and be simultaneously influenced by cultural differences and family and world view (Kruske 2007).

Before exploring the experiences of users of health and human services it is useful to try to gain an understanding of experiences of prejudice and racism. These experiences have a profound effect on who a person is and how they access mainstream institutions that are staffed predominately by, and designed to service, members of the dominant group.

Interactions with the dominant medical system

In Australia and New Zealand it is commonly held that the dominant medical system is derived from western world views and understandings of health and the body, and is also the result of western scientific rationalist thinking. It is not surprising, then, that significant issues arise when a person of a different world view or cultural background interacts with such a system. This then impacts on how a patient or client accesses a system, how they are diagnosed and how they are treated. As can also be seen, culture can be looked at from a number of perspectives when talking about interactions with the dominant medical system. One of the most powerful examples for exploring the issues that arise from such culturally different interactions comes from Indigenous experiences with a non-Indigenous medical system. Many Indigenous peoples report difficulties with and, as a result in many cases, avoidance of mainstream medical services (Lowell et al 2001).

Physical environment for healing

In an old but, sadly, still relevant study, on the need for cross-cultural awareness training at the Royal Darwin Hospital (RDH), Curry (1990) described some of the cross-cultural difficulties experienced by Indigenous people at RDH. He explained that many people were intimidated by the sheer size of the building, within which it was easy to become disorientated. Limited access to fresh air and outdoors areas were two other concerns reported. In the study, the author described how RDH was compared with the ‘old hospital’, a tropical-style building which felt more familiar. Factors such as these, combined with the fact that people are away from home, can contribute to a fear of and uneasiness about treatment in hospital.

Family

As discussed, health for Indigenous people is intertwined with the whole community in which they live. As such, family is integral to the healing process and families often wish to be with the person who is sick, whether that is during the consultation process, or during a hospital stay. As Grogan (1996) explains, separation from family can cause anxiety for individuals, even to the extent that it affects recovery from illness. A sense of isolation is often experienced when in hospital and such a feeling is possibly universal. However, in western culture we are taught to understand that isolation from family and friends is part of the process of being ill and therefore we supposedly accept that our time in hospital requires us to heal alone. Such a cultural view is in direct opposition to that held by many Indigenous peoples, particularly people from remote communities where distances between hospital and community also prevent access to elements of healing such as bush medicines and traditional healers.

Surgery

In many Indigenous cultures, surgery is often equated with sorcery and requires deep trust of the doctor by the patient to allow so much power over their body and bodily products such as blood (Reid 1983). Body and spirit are bound in an intimate relationship that has both physical as well as spiritual dimensions and blood is still a topic of great cultural sensitivity throughout much of Indigenous Australia. Because of the restricted nature of the associated knowledge, there needs to be some circumspection in relation to discussion about blood. Care should be taken, particularly in cross-gender contexts and in mainstream health services, such as surgery, where healthcare requires direct involvement in the management of blood.

Thus, many Indigenous peoples see the non-Indigenous medical and health systems at odds with their beliefs of health and healing. The unfortunate result of such a situation is the avoidance of, or at least passive resistance to, accessing health and medical services, unless in cases of emergency or through lack of choice.

Compliance

Most non-Indigenous health professionals tend to approach the issue of Indigenous attitudes to, and utilisation of, health services as a matter of compliance or non-compliance. As Humphery and colleagues (2001) explain, compliance is used to describe the extent to which a patient is ‘following doctor’s orders’, with regard to aspects of their treatment such as medication, for example.

According to Humphery and colleagues (2001), compliance is a peculiarly western biomedical construct. As practitioners in cross-cultural contexts, it is important to be aware of this issue. That is, non-compliance should not necessarily be seen as a problem, specific to a particular culture. Rather, the reasons behind so-called compliance and non-compliance need to be reassessed in light of the appropriateness of aspects of the dominant medical system for people from culturally diverse backgrounds. As the authors conclude:

Over thirty years ago Aboriginal Community Controlled Health Services (ACCHSs) were established throughout Australia in response to Indigenous perceptions (and a growing body of statistical evidence and literature) that their healthcare needs were not being effectively met by mainstream health services.

The ACCHS model is based on a primary healthcare approach or holistic healthcare framework, integrating illness care with disease prevention, intersectoral collaboration and advocacy for social justice. From their community base, ACCHSs have been at the forefront in terms of innovation in Indigenous health. This has been through processes like the application of the primary healthcare model in Australia, the development of the Aboriginal health worker as a profession, provision of health promotion and counselling programs and participation in community-generated research (see Clinical Interest Box 8.3) (RACGP 2007).

A comprehensive primary healthcare approach appeals to Indigenous community-controlled health organisations because they see it as being concerned with a development process by which people improve both their lives and their lifestyles. This is opposed to the more selective form of primary healthcare which is concerned with medical interventions aimed at improving the health of the largest number of individuals at the lowest cost.

The most important point here is that the overall approach adopted by community-controlled organisations is about managing the input and outcomes of health improvements and developing a realistic timeframe for achieving sustainable results. Primary healthcare can be seen as being part of a self-determination and community development framework. The main challenge to long and slow processes that lead to sustained improvements in people’s lives is that we live in a political and economic climate of short-term expediency, not one that promotes long-term change.

It’s all about you/me/them/us

Attitudes of the service provider and the relationship that is formed between practitioner and client can often be the lynchpin in successful service delivery.

Though overt racism has become increasingly socially unacceptable, racism still exists and many Australians still believe that racism is a significant and widespread problem. Much more pervasive than blatant overt racism is the subtle covert kind. It is difficult for those who do not experience this form of racism to see it, but it has a major impact on those who do experience it, and many do—on a daily basis. As Mellor and colleagues (2001) contend, subtle racism occurs in the context of everyday living, such as shopping, using public transport and eating in restaurants. This list can surely be added to, with issues such as accessing mainstream services, be it health, welfare, education and justice systems. The perpetrators and victims of subtle or covert racism have different perceptions and understandings of racist interactions, due largely to ambiguities and denial or ignorance of prejudice on the part of the perpetrators (Mellor et al 2001).

Understanding their own prejudices and taking responsibility for how these feelings can affect service delivery is one of the most significant things that an individual can do to improve services for individuals and groups who are marginalised from the system. Most people do not intend to be racist in their attitudes but every time they assign a negative feeling towards someone based on their culture, language, behaviour or beliefs, this is racism.

Establishing similarities, while respecting difference

Working with groups or clients who are different from yourself does not require an overemphasis on the differences—such an emphasis could in fact impede the development of relationship between the provider and the client.

Working in partnership and looking for strengths

There is increasing recognition in health services of the ineffectiveness of providing services that do not take into account the social, cultural and environmental influences of the client. Furthermore, many have argued that the biomedical approach of the health industry is too focused on pathology. The biomedical model of healthcare entails a reliance on, and trust in, expert systems (Giddens 1990) and hence is also called the ‘expert’ model. Disease is viewed as an organic condition—the causes of disease or illness can be found within the body or biology and will respond to a medical intervention. In this approach the practitioner, as the expert, determines the health needs of the clients and offers advice, education and other strategies to address these needs. The expert model assumes domination and control of the health interaction by the professional (Elkan et al 2000).

This model has been increasingly challenged, as it fails to recognise or respect the centrality of the client’s role in determining their own health. It also fails to address problems that relate to the cultural, social, historical and environmental influences of health and wellbeing. In an area as complex as Indigenous health, the expert model fails to recognise the multiple layers of complexity that influence this population’s health and wellbeing.

Being the partner

An alternative approach lies in the partnership model. Working in partnership requires us to transfer the focus of professional attention away from problems, deficits and weaknesses and towards the strengths or power of the client or community. This orientates the professional towards developing a collaborative and equal partnership with clients, focusing on building individual, family and community assets (De Jong & Miller 1995). A major premise of the partnership model is that all clients have strengths and capabilities and are more likely to respond to interventions that build on these rather than on those that identify weaknesses and deficits (Darbyshire & Jackson 2004; Dunst et al 2002; Unger & Nelson 1990).

Another important component of the partnership model is that, rather than the expertise lying with the professional, there is an increasing emphasis on the expertise of the client. The assumption is that, with support, they will discover their own way, rather than learning to adopt some ‘right way’ defined by a clinician (Barnes & Freude-Lagevardi 2003). Family-centred partnership involves professionals and family members working together in ‘pursuit of a common goal’ and is ‘based on shared decision making, shared responsibility, mutual trust and mutual respect’ (Dunst 2000).

An important feature of the partnership model is to develop rather than threaten the client’s self-esteem. Working in a strengths-based or partnership model does not deny the expertise of the professional; it merely identifies the complementary expertise of the client (Davis et al 2002). The partnership model is particularly important when working with marginalised groups, such as Indigenous peoples, who are historically mistrustful of ‘experts’ or authority figures (Unger & Nelson 1990). An important component of the principle of empowerment, embedded within the partnership model, occurs when the professional believes in the client’s ability to understand, learn and manage situations (Dunst & Trivette 1996).

The aim of partnership models that focus on strengths is to increase participants’ capabilities and feelings of self-worth (Barnes & Freude-Lagevardi 2003; Darbyshire & Jackson 2004), rather than perceptions of themselves as ‘incompetent and dysfunctional’ (Alison et al 2003). Medicine, by its very nature, supports the notion that only medical practitioners can diagnose, treat and cure. This creates dependence that is often unconsciously reinforced by practitioners. It is essential that services based on a partnership model build skills and capacity rather than create dependency (Kemp et al 2004).

Empowerment

Empowerment has been described as ‘recognising, promoting and enhancing people’s ability to meet their own needs, solve their own problems, and mobilise the necessary resources in order to feel in control of their own lives’ (Gibson 1991). Adopting this model can be difficult for professionals who work within ‘the hierarchical, paternalistic organisations that resist power redistribution between the different levels of responsibility’ (Houston & Cowley 2002).

The extent to which professionals can empower others has received some attention in the literature. Wallerstein and Bernstein (1994) and others (Houston & Cowley 2002) question whether one privileged group can empower others from its position of dominance or whether people have to take power and empower themselves. Mowforth (1999) further challenges the concept of partnership by arguing that the relationship between client and professional can never be equal because one person is sharing vulnerability, and also because of professionalism and the assumed boundaries that constrain the professional’s own behaviour.

Others caution that professionals may have a heavy sense of their own authority which is incompatible with programs that respect clients as experts of their own lives. Shared decision making between professionals and clients is important and it may be the personal qualities and attitudes of the staff that influence program success, more than the particular type of training staff members receive or the roles they play (Barnes & Freude-Lagevardi 2003).

However, all health professionals can examine their own communication style and biases, for their own prejudices and judgements impact greatly on their ability to work in partnership. If health professionals believe that their clients are unable or unwilling to take control of their own lives, long-term health gains will be difficult to achieve. Working in partnership requires health professionals to assist individuals to develop, secure and use resources that will promote or foster a sense of control and self-efficacy (Gibson 1991; Rodwell 1996).

Cultural safety and what that means for work practice

The experience of working as a health professional in culturally diverse health service contexts is an interesting and often challenging process. There are differences and commonalities between and within different cultures. People who live or work within a culture other than their own need to recognise that their own beliefs and behaviours (i.e. culture) will have an impact upon their treatment and care of, or service provision to, their clientele. This idea will be explored further through the concept of cultural safety.

Cultural safety is a term that has gained considerable recognition in sections of the health arena. Much of the literature on cultural safety relates essentially to the nursing field, but others are now beginning to relate it to other disciplines. Even within the nursing field, the definition has been somewhat refined. Many authors have turned their attention towards defining and explaining cultural safety and its implications for practice. A few of these definitions are provided below.

Papps and Ramsden (1996) define cultural safety as:

Williams (1999) builds on this and defines cultural safety as:

In summary, cultural safety means an environment that is spiritually, socially and emotionally safe, as well as physically safe, for people. By contrast, unsafe cultural practice is any action that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual or group.

Why is it important to have a culturally safe work environment? As has been previously mentioned, mainstream health service delivery for Indigenous peoples is often considered to be inappropriate and ineffective. Similar issues exist within other cultural groups, as touched on elsewhere in this chapter.

Cultural safety is really to do with how to create and maintain contexts in which participants can access and experience what they need from the health service without in any way compromising their identity.

The health professional’s role

A health professional’s effectiveness is an individual issue and depends largely on the way they interact with each client. This does not mean that they should ignore or deny the systemic issues that place limitations on how much change they can make. However, it is accepted that people are naturally drawn towards others who are similar to themselves, and that it is easier to communicate with someone from one’s own cultural group or subgroup. Conversely, health professionals cannot ignore their duty of care to provide high quality services to all people, and this requires practitioners to be mindful of their values, beliefs and experiences.

The importance of addressing ethnocentrism and prejudice of individuals, professions and services cannot be emphasised enough. There are many aspects of society and mainstream services that we cannot change as individuals but the attitudes of a non-judgmental, caring and empathetic practitioner can make a significant impact on the experience of a client.