Culture shock

Culture shock refers to feelings of anxiety, isolation, loss, confusion and powerlessness experienced by some people when they enter unfamiliar cultural contexts (Eckermann and others, 2010). Such shock becomes particularly acute, according to Brink and Saunders (1976, cited in Eckermann and others, 2010:124), when minority groups come into contact with the healthcare system because they are often disadvantaged in terms of the language, culture, rules and regulations of this system. This reality affects all those who are hospitalised to some extent, but imagine what it means to someone who comes from a group negatively targeted by the very people who are now responsible for their care, or for a person who does not share the language or sociocultural conventions taken for granted by the majority. It can be argued that culture shock might affect many people whenever they are in a position of seeking help from mainstream systems, including the healthcare system. Thus those who are part of a minority group experience significant stress, in a hospital or any other institution, which is related to differences in communication, attitudes and beliefs as well as differences in customs and routines. Such stress will invariably affect the individual’s capacity and willingness to engage with the priorities and treatments of healthcare systems.

As discussed above when considering health definitions and constructions, healthcare professionals have a special language based on their discipline(s); they even cultivate a particular form of shorthand. These spoken and written forms of communication facilitate understanding between healthcare professionals, yet they are mostly foreign to outsiders. Similarly, the routines, technology, customs and rituals of a hospital are largely developed to make the institution work as efficiently as possible, yet they may seriously stress and disempower clients. If these stressors are coupled with isolation, unfamiliar attitudes and beliefs, some clients are seriously disadvantaged. We can appreciate the impact of these dynamics for some populations when we consider that Indigenous people in Australia, for example, are hospitalised two to five times more frequently than other Australians (Eckermann and others, 2010).

Access to interpreters, liaison officers and Indigenous/Māri health workers helps nurses gain some valuable insights into recognising culture shock and helping others cope with it. Health workers and liaison officers (be they Indigenous or of other origin) are always in the minority within mainstream institutions. They are continually supporting clients who are experiencing culture shock as well as dealing with their own stressors. Further, they find themselves in situations in which they are expected to be experts on every issue related to their own group(s) while having to cope with the constant pressure of operating in demanding cross-cultural environments characterised by various languages, health priorities and behaviours, social positions and cultural constructions. Working in partnership and power sharing with staff in these positions is critical.

If nurses are to develop skills appropriate to working with the diversity between us and our clients and colleagues, we need to keep in mind the way differences within and between groups can be evaluated, such as through the concepts of class, culture and ethnicity that we introduced you to above. Eckermann and others (2010) have argued that personal perceptions of differences depend on a number of additional complex and interrelated factors such as ethnocentrism, power, our history of contact with other groups, our approach to explaining difference, and our philosophy, values and beliefs. We examine some of these issues below.

Culture clash and culture conflict

According to McConnochie (1973, cited in Eckermann and others, 2010:3), culture clash is based on whether we recognise others as human beings and on whether people perceive that they might share compatible values and beliefs. McConnochie goes on to claim that people are naturally suspicious of difference—it is our view that people learn to be suspicious of difference just as they learn other aspects of culture. Culture conflict ensues when people do not find cultural commonalities (language, goals, principles, philosophies), but for our purposes here it is especially relevant that it occurs when one group assumes power over another and attempts to control them and enforce their beliefs, values and cultural practices on a subordinate group (Eckermann and others, 2010). This is of course the situation of Indigenous people in the face of the practices of mainstream culture.

Ethnocentrism is the belief that our own cultural group (or those we identify with in a given context) is not only essentially different from but also superior to others (Eckermann and others, 2010), and results in what can be called ‘othering’. In othering, anyone perceived as different to the self (the other) is seen as inferior, suspicious, strange, exotic and unable to be understood or considered not worth the effort of trying. For example, residents may see strangers in a small town as ‘other’ (often referred to in Australia by the derogatory term ‘blow-ins’). Australian- or New-Zealand-born citizens might see those born overseas as ‘foreigners’, or the privileged may see the poor as ‘not one of us’ but ‘other’. ‘Otherness’, then, can be assigned to various cultural aspects such as class, sexual orientation, religious or spiritual beliefs, ethnic origin, migrant experience, gender, age and disability.

In nurse education there is an emphasis on the differences that nurses will encounter between themselves and their clients. However, it is equally as important to emphasise that the healthcare workforce is also extremely diverse along all the dimensions of the broad definition of culture used in cultural safety, i.e. in terms of cultural identity, ethnicity, class, ability/disability, gender and sexual orientation and in terms of beliefs, values, attitudes and related behaviours. Nurses may thus assign otherness to doctors (and vice versa) or to nursing colleagues and clients, leading to further problems for achieving cultural safety in the workplace. When ethnocentrism is mixed with power, then a powerful profession or system such as the ealthcare system (which believes it is the best or knows what is best) is able to suppress the less powerful, with dire consequences for healthcare.

Above we discussed how an unnuanced notion of worldviews (where those who identify with the same culture are thought to share systems of beliefs) is problematic due to the highly variable ways that individuals express and embrace their culture and due to the different lifeworlds in which life’s circumstances unfold. The result of such systematised models of culture is the production of stereotypes, where everyone who shares a cultural identity is assumed to actually be the same (in terms of worldviews, lifeworlds and related behaviour). Although stereotypes can be both positive and negative, these over-generalisations always deprive the ‘object’ of individuality. As a result, in applying stereotypes we develop misguided ‘mindsets’ and attitudes (whether these are positive or negative) towards people, which can be dangerous in healthcare settings.

A real-life example concerns a woman who is Aboriginal and has always lived in urban areas. She was horrified when it was suggested that her family might be interested in ‘traditional birthing methods’. The mistake was the stereotype assuming that all Aboriginal people are the same and, therefore, that the traditional birthing models, long struggled for by some Indigenous women in remote Central Australia, would also be welcome by those in urban South-East Queensland. Another example is a man who identified his ethnicity on an admission questionnaire as Māri and was then visited by the Māri health worker. He had not requested this visit and had never previously had any particular contact with Māri health services. He told the nurse that he would have preferred to have been asked first.

Prejudices (literally prejudgments) are the sometimes positive but more usually negative attitudes people develop around the stereotypes they have about people who they see as essentially different to themselves. Personal racism in the form of put-downs, ‘jokes’, violent acts and so on (one of three levels of racism, the others being systemic/institutional and scientific racism) is one form of prejudice. These attitudes are usually based on myths, rumours or over-generalisation from specific experiences. Just like other aspects of culture, prejudices and racism are learned during childhood socialisation, so that often the prejudices of parents or societies are passed on to successive generations. In our experience, people often defend their prejudices and justify them by linking them to their values and beliefs. For example, following a process of reflection on a role-play where one of the authors played the part of a beggar, someone admitted that they ‘had no time for’ (held deep prejudices against) people on the streets that tried to beg from them and that they perceived as homeless. They went on to defend the prejudice by explaining that they were brought up to work hard and to take care of themselves—no one had given them any hand-outs, and besides they reckoned that people become homeless because they are drug addicts or lazy or both.

Here there was no empathy or openness towards the myriad of possible stories about why a person might end up begging on the street; instead there were several entrenched stereotypes about homeless people and beggars that informed their prejudice. Because prejudices are part of the way of looking at the world (worldview), people invest a good deal of their emotions in them and are quite resistant to change. However, as discussed above, people have agency and are able to challenge prejudices that their families, professions or society may have tried to socialise into them. For nurses, the practice of developing awareness of prejudices is crucial for nursing care, as prejudices lead to discrimination.

Discrimination is the acting-out of prejudice, the act of speaking or acting against those who are perceived as different from ‘us’. The progression from ethnocentrism to stereotyping to prejudice to discrimination originates in tendencies and encouragement to be proud of our culture, who we belong to and who we are. Pride in one’s cultural identity and group is not necessarily harmful. However, when prejudice and ethnocentrism become a corollary of this kind of cultural pride, it can inform the development of an insidious cycle of prejudice (Figure 17-3) which has important implications for communication between people from diverse cultural realities. It is easy to get caught in the cycle of prejudice, especially in a multicultural society with a colonial history. If people are unfamiliar with the varied cultural backgrounds of others, it is easy to make faulty assumptions and to treat people according to entrenched social stereotypes. As indicated above, this effect is perpetuated if those around (family, friends, colleagues) and especially the media convey a certain image of another group. As Allen (2006:66) observes, ‘One of the difficulties of multiculturalism is not recognizing the relations of dominance within which cultural difference is constructed.’

FIGURE 17-3 Cycle of prejudice.

From Eckermann and others 2010 Binang goonj: bridging cultures in Aboriginal health. Sydney, Elsevier, p. 157.

Racial discrimination is a problem of long standing for indigenous people internationally, as positive images and stories of individuals and their communities only rarely appear in the mass media. In Australia, although there is some evidence of change with the release of films such as Bran Nue Dae (2010), a dedicated Indigenous pay-television channel (NITV) and greater exposure of popular musicians, successful athletes, academics and so on, there is the struggle against a negative focus that constantly invokes and embraces stereotypes. One only has to think of policies and processes such as the NTNER discussed earlier to appreciate how deeply entrenched stereotypes justify the application of punitive practices to highly diverse people that again render all guilty and irresponsible (Brown and Brown, 2007).

Power

Within the complex interaction of ethnocentrism, stereotypes, prejudice and discrimination, power becomes an extremely important issue. In anthropological theory, power is an extremely complex concept with an interesting genealogy. One way of understanding power comes from the work of the sociologist Max Weber (Bendix, 1996), who identified three kinds of power evident within society: political, economic and social power.

An essential feature of power is that those who dominate in imbalanced power relations work hard to maintain their position. A major means of achieving this is to set up society so that those who have limited access to power and self-determination are subjected to systemic bias, defined by Savitch (1975:8, cited in Eckermann, 2010:46) thus: ‘Systemic bias can be defined as the prerequisites necessary for access to the political system and effective performance in it … That is, the more pressure a group can muster, the better able it is to shift policies towards its objectives. Essential prerequisites for such participation are organisational and communication skills which in turn require money, commitment of personnel, a trained staff, propaganda apparatus, and the like.’

The system itself, controlled by those who already hold dominant positions in power relationships, maintains the powerful because those not ‘in the know’ may not understand the rules, regulations, norms and values or do not possess the resources that provide access to the system. Let us look at ‘health’. To ‘access’ or influence this system, one must first understand it; to understand it, one must have some knowledge of it and have been successful in it; to be successful in it, one must generally have come from a part of society that has traditionally been influential in developing and controlling the system. As Taylor and Guerin (2010) demonstrate, systemic racism or institutional racism are terms used to describe the disadvantage of minorities in their attempts to engage and access systems of institutions and the ways in which the dominant system doesn’t give the same advantage to other groups. They give the example of anti-smoking programs that were designed by dominant groups. The example reveals the operation of power, as being a program designed by the dominant group it operates for the dominant group, leading to the decrease of smoking rates among dominant groups but not among various other populations in Australia.

Systemic bias, then, effectively excludes some sections of society from accessing and participating in decision making. This not only leads to entrenched patterns of domination and dependence, but it also may result in structural violence. Structural violence can take three forms (Eckermann and others, 2010):

These forms of violence can be measurable over time. For example, if life expectancy continues to show significant variation, as it does between Indigenous/Māri peoples and other Australians and New Zealanders, we can say with certainty that members of these groups are experiencing structural violence. In Australia at the national level for 2005–07, life expectancy at birth for Aboriginal and Torres Strait Islander males was estimated to be 67.2 years, 11.5 years less than life expectancy at birth for non-Indigenous males (78.7 years). Life expectancy at birth for Aboriginal and Torres Strait Islander females was estimated to be 72.9 years, 9.7 years less than life expectancy at birth for non-Indigenous females (82.6 years) (ABS, 2010b). In New Zealand/Aotearoa, 2002 statistics show that life expectancy for Māri males and females born in 2010 are 7.8 and 7.1 years respectively below that of other New Zealanders (Statistics New Zealand, 2011b).

Similarly, if sections of society are exposed to chronic poverty, then it can be argued that they are experiencing structural violence—violence inherent in the social system which limits their physical as well as their psychological life chances. It is, therefore, important to understand the pressures that poverty exerts on individuals and their families/communities. It is also important to understand the underlying structures that create and maintain poverty.

Consequently, groups in Australia and New Zealand/Aotearoa experience what Galtung called cultural violence, which resides in the ‘symbolic sphere of our existence’ (Galtung, 1990:291). These symbolic spheres dominate mainstream beliefs, values and attitudes inherent in religion, ideology, science and art. They are inherent in institutions such as education and health and in the assumptions about the way things are or the way they ought to be. Because cultural violence is part of everyday life, it is hard to identify. Examples of cultural violence include stereotyping and discrimination against specific cultural groups, the imposition of the dominant culture’s value systems and destruction of cultural heritage artefacts such as language and customs. There is, then, a close relationship between cultural violence, structural violence and systemic bias which, it can be seen, are all forms of racism. Indeed, Galtung (1990) believes that cultural violence underlies all other forms of violence in society and that colonial societies generally may be categorised as violent cultures.

Models of care

Whereas in transcultural nursing the nurse considers the client as different or exotic, culturally safe nurses consider in what ways they and the culture of clinical nursing might seem ‘exotic’ to clients. Self-awareness is therefore critical. Personal self-reflection requires nurses to bring to consciousness their own historical, cultural, social and personal context; their own beliefs, attitudes and values; and their own personal biases and cultural assumptions about others. Nurses then need to consider how all of these dimensions may affect the nursing care they provide to those they consider different to themselves and to those they might assume to be the same as themselves.

A common misunderstanding in discussions on the impact of nurses’ cultures on nursing care and the need for cultural safety is the notion of ‘treating everyone the same’. The authors have often heard nursing students exclaim ‘But I treat everyone the same’, or ‘Why should they get different treatment to anyone else?’ While nurses should treat everyone with the same level of positive regard and respect, these remarks reveal that the students have confused notions of equity and equality by suggesting that these terms mean ‘sameness’. In fact, everyone is not the same: each person is unique and has unique needs. A deeper problem with such ways of thinking is that they also suggest everyone has the same advantage, so they deny inequality.

In contrast to functionalist views that conceive culture as fixed and bounded wholes where members share systematised beliefs and conceive members of a culture as the same, culturally safe care means that each person receives care and treatment according to their individual needs. Importantly, through Ramsden’s work, the emphasis changed from the nurse’s assessment of practice in terms of the client’s needs to the client’s assessment of the service/level of care. Further, cultural safety is concerned with the transfer of power between healthcare providers and those receiving the service (Eckermann and others, 2010). Thus, Ramsden (2002) points out nurses need to become aware of the level of distrust that will mark their interactions with indigenous clients and clients from minority groups. Such distrust is based on a history of oppression (see Cox, 2007; Forsyth, 2007). As we have seen, the process of colonisation has typically been associated with structural and cultural violence against indigenous people. Any nurse who can understand their own culture and the theory of power relations can be culturally safe in any context, and those actions which reinforce respect, responsibility and the legitimacy of difference are likely to support cultural safety (Ramsden, 2002).

Although cultural safety was conceptualised by a Māri nurse and originated in a post-colonial context, the beauty of it is that it is applicable to any encounter whatsoever. Overall, Ramsden’s (2002) concept and principles of cultural safety are relevant to all people because the interaction between a nurse and a client is always a bicultural relationship whether differences between individuals are expressed by gender, sexuality, social class, occupational group, generation, ethnicity or a grand combination of variables. The underpinning tenet, then, of cultural safety is that each person should receive care that takes account of their unique identities and experiences. Cultural safety is a holistic concept, so to achieve such care all aspects of that person must be considered (Ramsden, 2002).

There is no doubt that there has been a growth in awareness of multicultural issues in the nursing profession. As a result, a plethora of cultural awareness orientation programs have been implemented to increase cultural sensitivity and understanding between people from different cultures. Nevertheless, many still have not realised that cultural safety respects a person’s cultural values and preserves their wellbeing regardful of differences (Ramsden, 2002). This approach is very different from providing culturally sensitive care regardless of differences.

Ramsden (2002) illustrates that cultural safety reaches beyond cultural awareness and sensitivity (Figure 17-4). The progression clearly highlights that the terms ‘cultural awareness’ and ‘cultural sensitivity’ are not interchangeable with ‘cultural safety’; they are separate concepts (Ramsden, 2002). All need to be achieved for nurses to be in a position to negotiate culturally appropriate and safe care with clients. The core principles and concepts of the New Zealand/Aotearoa model of cultural safety in nursing and midwifery have been endorsed by the Congress of Aboriginal and Torres Strait Islander Nurses (1998), and the theory of cultural safety is reflected in some nursing curricula in Australia. Further, it has helped shape the National Remote Area Nurse Competencies which many remote area nurses throughout Australia, who work in partnership with Aboriginal and Torres Strait Islander health workers, developed (Centre for Research in Aboriginal and Multicultural Studies (CRAMS), 2001). In relation to cultural safety, CRAMS stated (2001:2): ‘For us in Australia, reaching this higher order in nursing means placing more emphasis on awareness raising about ourselves and our society and implementing strategies which flow from this more sensitive position.’ In 2007 the Australian Nursing and Midwifery Council (ANMC) released a position statement entitled Inclusion of Aboriginal and Torres Strait Islander Peoples’ health and cultural issues in courses leading to registration or enrolment that was based on cultural safety (ANMC, 2007).

FIGURE 17-4 The process of achieving cultural safety in nursing and midwifery practice.

From Nursing Council of New Zealand (NCNZ) 2011 Guidelines for cultural safety, the Treaty of Waitangi and Māri health in nursing education and practice. Wellington, NCNZ, p. 5. Online. Available at www.nursingcouncil.org.nz/download/97/cultural-safety11.pdf 19 May 2012.

Competence defined

Both transcultural nursing and cultural safety have generated much debate about dealing with the complex interaction between cultures (nursing, medical, hospital, nurses’ personal cultures, clients’ cultures) and health that occurs during healthcare encounters. These debates have encouraged dialogue about how to transform the philosophies underlying caring for people who are culturally different from the nurse (that is, to some degree, everybody). In this section we consider this process and the range of competencies necessary to ensure that nurses provide high-quality, evidence-based and culturally safe care in whatever context of practice they are working.

Cultural competence, as Taylor and Guerin (2010) point out, has been the subject of some critique due to the challenges involved in assuming that a practitioner can reach an endpoint and ‘be’ competent. These authors describe how notions of cultural competence have been expanded in Australian social sciences to include many elements of cultural safety, especially those concerning the implications of colonial history, notions of power (and disempowerment and empowerment), and the consideration of how one’s own culture affects the provision of care (Taylor and Guerin, 2010:17). The Australian National review of nursing education: multicultural nursing education cites a number of definitions of cultural competence derived from a range of sources (Eisenbruch, 2000:4). The one that comes closest to our intent here is (Maureen Fitzgerald, 1999, University of Sydney; cited in Eisenbruch, 2000:4): ‘the ability to identify and challenge one’s own cultural assumptions, the ability to see the world through culturally different lenses, to analyse and respond to the “cultural scene” and “social dramas” in ways that are culturally and psychologically meaningful, for client and professional alike, and the ability to turn such thinking into praxis, providing meaningful, satisfying and competent care.’

The influence of culture on nursing practice is generally raised in relation to the rapidly changing and diversified demography of nations. Following Ramsden (1993, 2002), we argue that all healthcare professionals are required to be culturally safe because whenever they are interacting with a client they are entering a bicultural relationship (i.e. your culture meets the culture of your client); even if you and your client share a cultural identity, your values, health beliefs and practices will not necessarily be the same. Remember that from the perspective of cultural safety, nurses’ care is effective, appropriate, positive and empowering only if the clients, their families and communities assess it as such.

Reflecting on self

Ramsden (2002) and many other writers agree that the first step towards culturally safe care is exploration of nurses’ own attitudes and beliefs, the social, cultural and professional structures into which they have been socialised, and the influences these have on the relationships they form with people when they are in the dominant position in the power relationship. Ramsden (2002) acknowledges that, as a member of a minority group operating in mainstream society, ‘Unless I understood myself very well as the bearer of culturally derived attitudes such as internalised racism and social class, I could very well become the oppressor of Māri and others who were less powerful than myself.’ There are particular challenges for members of the dominant white culture in New Zealand/Aotearoa and Australia when writing about or researching the areas of culture and health. The process of unpicking their own culturally constructed attitudes to ensure the work does not add to the oppression of others is not easy. The endeavour has to be based on sincere dialogue, consultation, negotiation, monitoring and evaluation by those most likely to be affected by the results of the work.

Cultural safety is not about attempts to ‘learn’ cultures, which tends to lead to ‘recipe’ thinking and assumptions about particular cultural ways of being. Further, as we’ve noted above, nurses working in Australia and New Zealand/Aotearoa will encounter many different cultures in their work; learning all of these presents an insurmountable task.

Durie (2001) stresses the point that a healthcare practitioner does not actually need knowledge of another’s culture; however, they do need to understand the cultural and social context of the client and how that may be affecting their health. In taking account of all of these aspects the healthcare relationship results in the best possible outcome for the person.

Professional nursing regulation and cultural issues

The Nursing Council of New Zealand regulates nursing practice (NCNZ, 2007), specifying four domains of practice for registered nurses: professional responsibility, management of nursing care, interpersonal relationships, and interprofessional healthcare and quality improvement. Within each of these four domains are sets of indicators against which competency is determined, and the requirements of culturally safe and competent practice are encompassed within all the domains and their associated indicators. More specifically, Competency 1.5 states (NCNZ, 2007:13) ‘Practises nursing in a manner that the client determines as being culturally safe’, with the following indicators:

In Australia, the requirements for professional registration are not nearly so clear-cut. Many of the elements of the definitions discussed above are reflected in the Code of ethics for nurses in Australia and the Code of professional conduct for nurses in Australia (Australian Nursing and Midwifery Council, 2008a, 2008b). Thus, nurses are expected to respect individual needs, values, culture and vulnerability. With regard to issues of culture, the ANMC’s National competency standards for the registered nurse state that ‘The registered nurse recognises that ethnicity, culture, gender, spiritual values, sexuality, age, disability and economic and social factors have an impact on an individual’s responses to, and beliefs about, health and illness, and plans and modifies nursing care appropriately’ (ANMC, 2006:2). It can immediately be seen that this range of issues closely mirrors those that are outlined in the definition of culture used in cultural safety with which this chapter began. It is also of note that the standards refer to the individual, rather than homogenising people by suggesting that they can receive appropriate care based on a group identity.

We’ve already discussed understanding the influence of culture shock and power imbalances and the need for reflecting on self, one’s own culture and profession, and on attitudes and beliefs about ‘the other’. Finally we turn to a number of skills concerned with communication, trust and negotiating knowledge and outcomes that nurses’ need, to be able to provide culturally safe and competent care.

Communication skills

This textbook provides a dedicated chapter on communication skills. Here we briefly overview some issues of relevance to cultural diversity. A common language is obviously a basic component of effective communication, but in healthcare it is far from a given (see Clinical example). As this scenario demonstrates, language is a significant cultural issue as it conveys meaning; consequently, communication is culturally defined, so both verbal and non-verbal communication can be primary stressors in cross-cultural communication.

The importance of interpreters is increasingly about more than mere language translation—there can also be elements of cultural brokerage in their work, as shown in the following example.

A Polish woman in her 80s was admitted to a mental health facility. She had a depressed mood on admission but was not suffering from clinical depression. The woman was not fluent in English; she could only answer simple questions. She did say that she was sad, and she cried a lot. Sometimes she raised her hands in the air and wailed. Being in hospital was also distressing for her, so this was making her more tearful.

A young worker from the community sector (she worked in an NGO, a non-government organisation) decided that the woman should not live by herself and that it was too much to do visits every couple of days to check on her welfare and do her shopping. The mental heath staff did not use an interpreter to properly assess the woman, but proceeded on collateral information from the community worker only. Nobody clarified with the woman when her husband had actually passed away, and it was assumed from the discussion with the community worker that the husband had died years before. In fact, the woman’s husband had passed away just two weeks earlier.

Due to the NGO making an application to the public trustee, all of the woman’s finances were taken into the care of the public trustee, who also interviewed her without an interpreter. There was a decision taken by those concerned that she would have to go into care.

The woman’s daughter, who had returned to Poland about 20 years earlier, came back to Australia when she heard that her mother was going to go into a home and would have her finances managed by others. Subsequent work with the daughter, mental health services and an interpreter established that the woman was not mentally incapacitated in any way and could manage her finances with no problem. They filed an application to get her finances back into her own care.

It took many months (which were very distressing to the client and her family) to get the decision reversed. A natural grieving process for her husband had led to this chain of events, due to nurses’ cultural assumptions and the failure to use interpreters at every step.

Personal communication, Kerry Kennedy, 12 December 2011, reproduced with permission.

THE POWER OF ATTITUDE

A Māori mother of three, two of whom were at school, reported to the Review Team that she had decided to take the baby to the medical centre and inquire about immunisation. She escorted the older children to school and carried the baby on to the centre, without an appointment. Dressed casually, she entered the centre and approached the nurse at the reception area. At first the nurse ignored the mother until she had completed her current task, then before the young woman spoke, the nurse turned to her with an expression of impatience and distraction.

The mother said that she felt so uncomfortable that she shrank away, excused herself and left. There was no exchange of words, yet the interaction had been so powerful that it completely blocked access to health service. The young woman said that she felt shy and ambivalent, and did not feel able to assert herself in the medical centre and in the presence of the nurse who was exhibiting behaviour which the mother felt was an unspoken commentary on her baby, her casual appearance, her social class and her being Māri. Whether the nurse had intended to convey a negative message was not the issue; her professionalism should not have permitted her to behave in a way that could have been interpreted as obstructive to contact by the mother seeking her assistance.

Lessons to be learnt from this example:

NOTES

ONLINE RESOURCES

Australian Critical Race and Whiteness Studies Association, www.acrawsa.org.au

Australian Institute of Aboriginal and Torres Strait Islander Studies, www.aiatsis.gov.au

Culture Matters, http://culturematters.org.nz/about

Department of Immigration and Citizenship, http://www.immi.gov.au

Human Rights and Equal Opportunity Commission:

Indigenous Health InfoNet, www.healthinfonet.ecu.edu.au

Indigenous Law Resources, Royal Commission into Aboriginal Deaths in Custody, www.austlii.edu.au/au/other/IndigLRes/rciadic

Koori Mail, online newspaper, www.koorimail.com

National Aboriginal Community Controlled Health Organisation, www.naccho.org

National Indigenous Times, online newspaper, www.nit.com.au

National Museum Australia; exhibition on the true story of the Irish in Australia, www.nma.gov.au/exhibitions/irish_in_australia

Northern Land Council, Land and Sea Rights, www.nlc.org.au/html/land_native_wik.html

Prime Minister Paul Keating’s Redfern speech, 1992, www.antar.org.au/issues_and_campaigns/self-determination/paul_keating_redfern_speech

Prime Minister Kevin Rudd, Apology to Australia’s Indigenous Peoples, 13 February 2008, www.fahcsia.gov.au/sa/indigenous/progserv/engagement/Pages/national_apology.aspx

Queensland Health; ‘community’ profiles, www.health.qld.gov.au/multicultural/health_workers/multicltrl.comm.asp

Roll Back the Intervention, http://rollbacktheintervention.wordpress.com

Stop the Intervention, http://stoptheintervention.org

Waitangi Tribunal, www.waitangi-tribunal.govt.nz/treaty