AUSTRALIA: COLONISATION AND THE CURRENT POPULATION CONTEXT

Given the history of colonisation in the Australian context, the population is comprised of First Nations peoples, descendants of European settlement and migrants. Before discussing more fully how culture and healthcare interact it is important for nurses planning to work in Australia to understand the context of their work in terms of the populations they will be serving. This is true for both international and domestic nurses. In the author’s experience the former often have little understanding of Australian populations and their histories and the latter have variable levels of historical knowledge and a mix of attitudes towards various population groups. Some people carry entrenched and unexamined attitudes towards Indigenous Australians, mainstream³ Australians or migrants. This may in part be due to their lack of experience and exposure to Indigenous Australians, or to their lack of knowledge about Indigenous history, as reflected in this comment from a student: ‘I was surprised to see the number of students that had never had any interaction with Indigenous Australians or travelled outside their birth city. It was good to see them able to discuss their own culture and learn of the suffering still inflicted on Indigenous persons. I later saw it as a relevant topic to those students.’

Most people, however, are well aware that Australia is now a multicultural society, but what is perhaps less well known is that before the British began the colonisation of Australia in 1788 some 500 Indigenous language groups had lived here for up to 80 000 years (Colbung, 1988; Crisp and Taylor, 2005: 123). Further they were not the aimless wandering nomads so often depicted but lived in ‘well-defined socioeconomic, political, land-owning units’ as Crisp and Taylor note. From the perspective of Indigenous people then, the more than 200 years since colonisation is but a moment in their overall history. This point is important because it explains why it is that Indigenous Australians consider themselves to be First Nations or Status People; that is, they have specific and enduring rights in Australia.

Some people find it difficult to understand why it is that historical issues are so fresh in peoples’ minds because they see colonisation as happening over 200 years ago. However colonisation is an ongoing process rather than a single event and it continues to be played out in government approaches to Indigenous people.⁴ Unlike the New Zealand situation (see below), the colonisation of Australia was enacted under the legal fiction of terra nullius (empty land), which left the way free for the newcomers to take possession of the land and morally justify the impact on Indigenous peoples. Many Indigenous people lost their lives through massacres, starvation, neglect and introduced diseases.

Further, it was said of the Australian Indigenous cultures and the incoming colonisers that it would be hard to find such differing understandings of the world and humans’ place in it. Country for Indigenous people was and is the source of their identity and the basis of their cosmological understandings of the universe; for the newcomers it was merely a resource to be exploited. The current crisis in Indigenous health that we see today is profoundly related to dispossession and removal from kin and country and related traditions including language and ceremonial (religious) life, which often reduced Indigenous people to the status of fringe dwellers in their own land during the nineteenth century. In addition, many were unable to hunt or gather traditional foods and instead were forced to live on poor quality rations such as white flour and sugar, and substances such as tea, tobacco and alcohol were introduced.

The twentieth century brought complex legislative frameworks in all states and territories that attempted to control every aspect of the lives of Indigenous people, first under the banner of ‘protection’ since the authorities assumed that Aboriginal people would ‘die out’. As in New Zealand, the authorities were concerned about increasing numbers of those they conceived of as ‘mixed-race’⁵ children and they set about developing policy and practice to remove ‘fair-skinned’ children from their Aboriginal parents and kinship groups: those are now generally known in Australia as ‘the stolen generations’. When the state came to terms with the fact of continued Aboriginal existence the policy changed to assimilation in which the goal was to train the stolen generations, and Indigenous people more generally, to live like whites. In these complex processes families were fragmented by institutionalisation on government or mission reserves and reformatory schools and by marginalisation from the workforce, education and health services (see Human Rights and Equal Opportunity Commission, 1996, 1997; Kidd, 1997; Reynolds, 1982; Rintoul, 1993). Indeed health services were involved in some of these processes. The result is that since health services are largely run by governments, attending them is often resisted as the experiences are bound up in fear and a lack of trust towards health services (see Cox, 2007; Forsyth, 2007). Historical processes, such as deeming petty misdemeanours a crime under the special laws on missions and reserves, also saw the widespread criminalisation of Indigenous populations that we still see today in the overrepresentation of Indigenous people at all levels of the criminal justice system (Cuneen, 2001).

Although in the late 1970s the special laws in the states and territories for Indigenous Australians began to be changed, the ideal of true self-determination is difficult to achieve without a treaty or proper political representation. Space does not permit us to discuss Native Title and Land Rights here and the ongoing struggles for people to be recognised in these processes, given the many different contexts in which they live. Students are referred to Ritter (2009) for further information on these topics. The federal government finally made a national apology to Indigenous Australians in 2008; however, adequate concrete compensation has never been realised.

It is also important to understand that Aboriginality or Indigenous identity is not about skin colour but is about relationships. Because of the lack of trust between mainstream health services and Indigenous Australians the latter began to set up their own primary healthcare services from the 1970s. These are known as Aboriginal Medical Services and their peak body, the National Aboriginal Community Controlled Health Organisation (NACCHO), supports the nationally accepted means of determining Aboriginality. The means of determining has three parts and all are needed for Aboriginality to be recognised: descent (the individual can prove that a parent is of Aboriginal or Torres Strait Islander descent); self-identification (the individual identifies as an Aboriginal or Torres Strait Islander); and community recognition (the individual is accepted as such by the Aboriginal or Torres Strait Islander community) (NACCHO, 2007).

The estimated resident Indigenous population of Australia as at 30 June 2006 was 517 000 people, or 2.5% of the total Australian population. Like many colonised peoples Australian Indigenous people still experience widespread poverty, have lower life expectancy and poor health and they are more likely to be unemployed, experience housing problems and have poorer educational outcomes than the rest of the population. Of the states and territories, NSW had the largest population of Indigenous Australians (152 700 people), followed by Queensland (144 900 people). The Australian Capital Territory had the smallest population of Indigenous Australians (4300 people), while Indigenous Australians comprised 30% of the population of the Northern Territory (Australian Bureau of Statistics (ABS), 2006a). An issue that many Indigenous and mainstream Australians have in common is religion, as 73% of Indigenous Australians who answered the question about religion in the census were of a Christian denomination (ABS, 2006c).

Another important factor is that more than one in five Australians were born overseas which means that you, your colleagues and your clients will come from a range of ethnic and cultural backgrounds. According to the 2006 Census, the proportion of the population born overseas has not changed since 1996 and is 22% of the total population. The overseas-born population increased in number between 1996 and 2006 by 13%, from around 3.9 million to 4.4 million. The two largest overseas-born groups consisted of those born in England (19% of all overseas born) and New Zealand (9%). China overtook Italy as the third largest birthplace group (each country accounting for around 5% of all overseas born). Around 2.1 million of Australia’s overseas-born population is European. Of particular note for nursing is that a number of Australia’s recent arrivals were born in countries recently affected by war and political unrest. Over 73% (or around 14 000) of Australian residents born in Sudan arrived in 2001 or later. Likewise, a high proportion of the populations born in Zimbabwe (48% or 10 000 people), Afghanistan (45% or 7000), and Iraq (34% or 11 000) arrived in 2001 or later. Since 1996, the groups which increased the most in number were those born in New Zealand (by around 98 000), China (96 000) and India (70 000) (ABS, 2006b).

Since communication is central to nursing care it is important that you understand the diversity in this area too. The ABS reports that there are over 60 languages spoken by Aboriginal people and Torres Strait Islanders and an additional 200 languages other than English spoken in the Australian community. The 2006 census found that 11% of all Indigenous Australians spoke an Indigenous language at home, and in the Northern Territory 54% of Indigenous people spoke an Indigenous language at home. Sixteen per cent of the total Australian population did not speak English at home. There were also important variations in English proficiency amongst those who spoke another language, based on their age and their place of birth. The ABS estimates that 84% of all people younger than 25 years who spoke another language at home spoke English well or very well, compared with 60% of those aged 65 years and over. People born in Australia who spoke a language other than English at home could generally speak English well (ABS, 2008).

AOTEAROA: COLONISATION AND THE CURRENT POPULATION CONTEXT

Most people living in New Zealand know something of the history of the land, in as much as Māori settled Aotearoa from the Pacific over 1000 years before European explorers started arriving. Pre-European contact saw Māori as a people deeply connected to the land and natural world around them (Consedine and Consedine, 2001: 80). Their societal life structures were based on kinship and tribal affiliations, laws were based on custom. When the British began their antipodean colonising they initially opted for the larger continent of Australia and it was the sealers and whalers who set up temporary residence in New Zealand. Eventually settlers arrived and by the early 1800s the population of Europeans was believed to be around 2000. Numbers of Māori at that time were estimated to be around 125 000 (Waitangi Tribunal, 2010).

In 1838 the British sought to annex New Zealand due to numerous unscrupulous purchases of Māori land and the lawlessness that had arisen among the people. On 6 February 1840 a treaty was drafted (the Treaty of Waitangi) and signed by the English and approximately 45 Māori Rangatira (chiefs). In addition, a Māori text of the treaty (Te Tiriti O Waitangi) was taken to northern parts of the country and copies were sent to other areas of the land to obtain additional Māori signatures. In signing the treaty, the chiefs are believed to have yielded their sovereignty to the Queen of England in exchange for the Queen’s protection and the granting to Māori the same citizenship rights, privileges and duties enjoyed by the citizens of England. The treaty also guaranteed Māori possession of their land; however, with a stipulation they could sell their land only to the Crown. The treaty was to recognise New Zealand at that time as one nation but two people: the Indigenous Māori people, and the non-Māori, mainly European settlers and their descendants.

Initial reading of the treaty seemed to promise benefits for both sides, but when more and more settlers arrived they wanted to buy land. If Māori did not wish to sell conflict would eventuate. Many lost their lives in the wars that erupted. But it was not only the wars that eroded the Māori population, it was also the diseases introduced by the Europeans to which Māori had little or no natural immunity. Loss of land also saw many living in poor conditions in makeshift camps with poor sanitation. By 1900, the Māori population had dropped to an estimated 45 000 (Consedine and Consedine, 2001: 99) and Māori were seen by the settlers to be a ‘disappearing race’. Their tikanga (general behaviour guidelines for daily life and interaction in Māori culture, commonly based on experience and learning that has been handed down through generations) was also being eroded. This wearing down of the fabric of Māori life has continued until today.

The intent and provisions of the Treaty of Waitangi were largely ignored until the 1970s, when legislation was introduced requiring statutory bodies and government to undertake their responsibilities in a manner consistent with the founding promises of the treaty. In 1975 the Waitangi Tribunal (see www.waitangi-tribunal.govt.nz/) was established to consider claims by Māori against the Crown regarding breaches of principles of the treaty and to make recommendations to the government to provide recompense. Since 1985 the tribunal has been able to consider acts and omissions by the Crown dating back to 1840. This has provided Māori with an important means to have their grievances against the actions of past governments investigated. Aside from these actions and grievances, attention and awareness is now also on the aforementioned health and social disparities and there is a focus on improving the health and social status of Māori while recognising and respecting all aspects of cultural being.

The legacy from those early years is a society with ‘major ethnic and cultural disparities in health status and most other markers of Indigenous wellbeing’ (Kearns, Moewaka-Barnes and McCreanor, 2009: 124). Aside from the loss of land Māori experienced loss of their language and their cultural way of being. They are over-represented in nearly all negative social and health statistics; for example, unemployment, poverty, housing, income, education, youth suicide rates and general health and wellbeing. Kearns et al (2009: 124) suggest that the processes of colonisation such as that which Māori experienced resulted in the ‘denigration, marginalisation and alienation’ of the very essence of their culture. Consedine and Consedine (2001: 218) suggest that as a result of this colonisation

While the majority of early settlers were British, since that period people have arrived from Europe as well as Asia. In the second half of last century following the world wars a significant migration of people from the Pacific began (Khawaja, Boddington and Didham, 2007). The population of Pacific peoples grew quite rapidly during the late 1960s and early 1970s and caused a great deal of racial tension at times with both Māori and non-Māori groups. An important aspect of reducing this tension and ultimately accepting Pacific groups was the formation of partnerships with various community groups and activities as well as an increase in intermarriage. By the late 1990s a large proportion of Pacific people were born in New Zealand and increasingly their children were also of Māori and other ethnic descent. The other major population group to appear was Asian. Arrival of Asian groups actually predates the Pacific groups although in much smaller numbers. Many arrived in the late nineteenth century during gold rush days. Later in the twentieth century the number of different Asian groups increased dramatically and at the 2006 census they had exceeded the Pacific groups in population numbers. Much more recently, refugees and other settlers from Africa and the Middle East have arrived.

The diverse generations born and arriving in New Zealand since the first colonial settlers have afforded opportunities for miscegenation (a very old term referring to the process by which children are born to parents who were assumed to be of different ‘races’) of New Zealand’s population groups (Khawaja et al, 2007). As suggested earlier, although colonial thinking was that Māori would eventually disappear or be absorbed into the European population, this assumption has been discredited. However, it is this thinking that firmly influenced the collection of official statistics for much of the twentieth century. Khawaja et al (2007: 5) refer to the routine assignment of ‘ethnic grouping on the basis of ancestry (degree of blood), with little or no regard to lifestyle, culture or beliefs’.

The census of 2006 (Ministry of Social Development, 2009) revealed a population of almost 3 million (77%) European, just over half a million Māori (14%), with the remainder being Asian (9.2%), Pacific (6.9%) and other (0.9%) respectively. The apparent anomaly in these figures is caused by people identifying with more than one ethnic group (Ministry of Social Development, 2009). Because people can identify with more than one ethnicity, the total number of ethnic responses may be greater than the number of people. Consequently understanding ethnicity is important, and having a mutual understanding of this might be even more important. This is, however, not so simple and later in this chapter we explore the ideology of ethnicity.

Suffice to say in summary that Indigenous groups have their own structural, institutional and interpersonal philosophies and practices from which they operate. Nonetheless, colonised societies such as Aotearoa and Australia develop to fit the lifestyle, values, priorities and beliefs of the incoming dominant cultures and so the culture of the colonisers becomes the norm in society’s main institutions such as health, education, welfare, corrections, the media and so on. It is this kind of sometimes hidden but always present cultural dominance and unexamined privilege that the practice of cultural safety, discussed below, seeks to overcome. For example, in Australia the National Health and Hospitals Reform Commission (NHHRC) (2008: 211) noted that ‘Generally, the health system delivers services in a way that is better suited to the needs of the broader population rather than the particular needs of Aboriginal and Torres Strait Islander people’.

DEFINITIONS OF CULTURE, ETHNICITY, RACE AND HEALTH

Before we can begin to consider cultural assessment issues we need to be clear about what we mean by the various terms used in this context. The common terms used include: culture, ethnicity, race and health. While there are numerous definitions of these terms we have taken a constructivist view, referring to the notion that humans create ideas about culture, ethnicity, race and health. That is, such concepts do not just appear from nature but are constructed by humans to serve certain purposes at certain times.

CULTURAL SAFETY

Early nursing understandings in New Zealand (late nineteenth to early twentieth century) and Australia saw culture as a racialised term (the racialised other), used mostly to refer to the visible difference between the original inhabitants and settlers. Nurses were considered to be the ‘humanitarian bearers of civilised health care’ for the natives who were in need of civilising to the perceived dominant culture (Spence, 2001: 52). As the century went on, nursing interest in culture generally declined although some nurses chose to explore it further in university studies in the social sciences and anthropology.

As indicated in the introduction to this chapter, in the 1970s awareness re-emerged regarding the relationships between nurses and patients and the term culture once again developed meaning (Spence, 2001). A new ideology, ‘transcultural nursing’, authored by Madeleine Leininger, was developed. Nurses were to learn the healthcare needs of specific minority ethnic groups. In transcultural nursing perceived cultural differences are learnt and used as a checklist of things to do and not do. In transcultural nursing the nurse undertakes study to learn the specifics of other cultures (mostly within an ethnic sense) and then is deemed to know what individuals from the culture need. The consequence of such an approach is perhaps best summed up in the following quotation:

The key point in this quote is that the unique experience of the client becomes that of the nurse and the client is expected to behave in a particular way because they belong to a particular group. Because the nurse has studied this group they assume they can determine what the person needs. This model was not fully embraced in New Zealand or Australia, although one of the authors of this text can recall her nursing student days when she was directed to visit various cultural (religious) sites to interview key leaders and ask them what their particular beliefs were around healthcare practices. She then had to write a report describing particular health preferences for these groups. An assumption made then was that they would now know how to nurse a person from that group if they come into hospital. However, we do not accept this argument. In this text we focus on holism: students are taught to assess and respond to the biological, psychological and social needs of clients. The transition to culturally safe nursing from this point seems much simpler.

The Australian Nursing and Midwifery Council defines cultural safety as:

In the model of ‘cultural safety’ we promote the position that efforts to describe the practices, beliefs and values of each culture should not occur, as this promotes an ideology of sameness and an erroneous assumption that culture is a simplistic concept which can be captured in lists of things to remember and do. It is this checklist mentality that is intrinsic to transcultural nursing. If this concept was valid think about yourself being the recipient of nursing care. What do you need the nurse to know about you? Will that be the same as the person next door who may come from the same ethnic group as you? What if there are two Vietnamese people in hospital and one happens to also identify as gay? Are their needs the same because they both identify as Vietnamese? We stress that each person is an individual with many unique ways of being. Therefore the underpinning philosophy of cultural safety is that each person should be nursed ‘regardful of all that makes them unique’, encompassing the cultural, emotional, social, economic and political contexts in which they live (Ramsden, 1993; 2002).

Cultural safety is a term initially unique to New Zealand and nursing education. The pioneer of the concept is Irihapeti Ramsden. The concept of kawa whakaruruhau (cultural safety) arose out of a nursing education leadership hui held in Christchurch, New Zealand in 1989 in response to recruitment and retention issues of Māori nurses. The National Health and Hospitals Reform Commission guidelines were initially written by Ramsden in 1991 and further developed by a council committee and Ramsden. By 1992 the Nursing Council of New Zealand (NCNZ) had adopted the following definition of cultural safety:

Cultural safety relates to the experience of the recipient of a healthcare service. It provides consumers of heathcare services with the power to comment on practices and contribute to the achievement of positive health outcomes and experiences. By this process the meaning and experience of their illness is validated rather than challenged by biomedical understandings. In doing this they also then have the ability to provide feedback on any negative experiences. The process inherent in cultural safety education includes exploring the culture of nursing, recognising the impact that personal culture has on professional practice and the subsequent power relationship between nurses and the consumers of nursing care (NCNZ, 2005). Cultural safety then ‘… contends that people are so diverse that teaching simple ritual and custom stereotypes and rigidifies ideas of culture and does not allow for human diversity (nurse or patient), nor does it take into account historical effects and socioeconomic status’ (Ramsden, 1996, cited in Ramsden 2002: 110). Ramsden (2002: 109) explained that:

Ramsden talks here about the nurse as a bearer of culture. She maintains that nurses must understand their own culture in order to fully respond to the culture of others.

Cultural safety education

The purpose of cultural safety in nursing education extends beyond the description of practices, beliefs and values of ethnic groups. As we now know, confining learning to rituals, customs and practices of a group can be misleading and does not address the complexity of human behaviours and social realities. The assumption that cultures are simplistic in nature can lead to a checklist approach by service providers, which negates diversity and individual consideration. Cultural safety education is focused on the knowledge and understanding of the individual nurse rather than on attempts to learn accessible aspects of different groups. A nurse who can understand their own culture and the theory of power relations can be culturally safe in any context (Box 4.4 and Fig 4.2).

Figure 4.2 The process towards achieving cultural safety in nursing practice.

(Ramsden, 1992)

According to Ramsden, cultural awareness is the beginning step in the process of learning cultural safety, which involves understanding difference, while cultural sensitivity is an intermediate step during which self-exploration by the student begins. Cultural safety is an outcome of learning that enables a safe, appropriate and acceptable service, defined by those who receive it. Cultural safety is underpinned by communication, recognition of the diversity in worldviews (both within and between cultural groups) and the impact of colonisation and ongoing marginalisation on minority groups.

CULTURAL COMPETENCE AND CULTURAL SAFETY

As we indicated at the beginning of this chapter, there are many terms and approaches used to describe what is often called being ‘culturally competent’. There are countless ways by which this can be achieved and here we’ve focused on the approach of cultural safety. In addition, there are many definitions of cultural competence that combine aspects of cultural safety and transcultural nursing, the argument being that nurses need cultural self-awareness and knowledge about the health beliefs and practices of various cultures (for example, see Munoz and Luckmann, 2005: 47–49; Hines-Martin and Pack, 2009: 159–160). The concept of cultural self-awareness fits well with the concept of cultural safety as ‘cultural safety does not ask nurses to discover the cultural dimensions of any culture apart from their own’ (Dowd et al, 2005: 9, cited in Eckermann et al 2006: 166). Likewise, Fitzgerald’s definition (1999, cited in DETYA, 2001) says that cultural competence is ‘the ability to identify and challenge one’s cultural assumptions’.

Many students come to courses on culture expecting to learn all about other cultures. One of the authors recalls a student who, after doing a course on cultural safety, complained, ‘I don’t even know what that headdress that Muslims wear is called!’ This of course brings us to the very crux of the matter: there are as many names for the headdress as there are cultural and linguistic groups who wear it. With so many different cultures and so much variation within culture it is actually quite impossible to expect students to learn about the diverse cultures that they’ll encounter in their work. As Warren (2009) argues, generalising approaches to cultural competence conceptualises cultures as bounded wholes that exist out there to be learned, rather than appreciating culture as a broad, dynamic relational concept as used in cultural safety.

Becoming culturally safe is not a one-lesson program but rather a lifetime journey of study and learning. There are several discrete areas in which you must have knowledge:

Nursing students will notice that more and more institutions are mandating that those who practise must take cultural issues into account when providing healthcare and we turn to these requirements in Australia and New Zealand after first considering some crucial aspects of nursing care.

COMMUNICATION

There are many forms of illegal discrimination based on ethnicity, colour or national origin that frequently limit the opportunities of people to gain equal access to healthcare services. It is said that ‘language barriers have a deleterious effect on health care, patients are less likely to have a usual source of health care, and have an increased risk of non adherence to medication regimens’ (Flores, 2006). The Australian and New Zealand healthcare systems assume strong English proficiency in healthcare encounters. However, for people who do not speak English or for whom it is a second or third language, seeking care in healthcare settings such as hospitals, nursing homes, clinics, day care centres and mental health centres, language is a considerable barrier. As we saw in the section on population statistics, for each context there is tremendous diversity in people’s English language proficiency.

Those who are limited in their ability to speak, read, write and understand the English language encounter countless language barriers that can result in limiting their access to critical public health, hospital and other medical and social services to which they are legally entitled. Many health and social service programs provide information about their services in English only. When persons whose first language is not English seek healthcare at hospitals or medical clinics, they are frequently faced with receptionists, nurses and doctors who speak English only. These language barriers severely limit the ability to gain access to these services and to participate in programs. In addition, the language barrier often results in the denial of medical care or social services, delays in the receipt of such care and services or the provision of care and services on the basis of inaccurate or incomplete information. For example, with regard to medication, if a person who has a minimal understanding of English is not given clear understandable instructions regarding their medication, adherence to or incorrect dosage may be a problem. Services denied, delayed or provided under such circumstances could have serious consequences for both clients and providers of healthcare.

Chapter 6 describes in more detail how to communicate with people who do not understand English, how to interact with interpreters and what services are available when no interpreter is available. It is vital that interpreters be present who not only serve to verbally translate the conversation but who are also able to assist you with asking the assessment questions above.

Family means different things to different people and it is very difficult to provide one definition of family. One of the biggest mistakes made in healthcare happens when the concept of family is considered from a mainstream understanding only or from rigid takes on Indigenous traditional kinship structures. In contemporary mainstream society, the concept of a nuclear family (mum, dad and children) remains the most powerful normative preference. There are occasions when clients’ circumstances differ from this ideal, when the people they designate as their family are not regarded as family at all by health services and, at times, are considered deviant.

As Dench et al indicate (2007: 75) it is crucial to think about how a client’s family functions with regard to healthcare decisions and hospital visiting preferences. This is especially important for Indigenous clients who may designate next-of-kin and family relatedness in ways that are unfamiliar to nurses whose knowledge base is grounded in the assumptions made by the cultures of medicine and nursing. These nurses focus their care decisions on individuals and, for them, the idea of bounded nuclear families is entrenched. Consider the following scenario:

We encourage you to think very differently about family to encompass such circumstances. We know that in Australia and New Zealand families are diverse, so it is important we understand how to ensure family is considered in an individual’s healthcare, according to the context described by that individual. Think about who you include when you talk about your family. You might live with people you regard as family even though they are not blood relatives. Who can correctly say who a client’s next-of-kin is? It might be the birth family or those who raised the person or perhaps the family they have created with a partner. There are numerous possibilities. How will you support homosexual relationships and struggles to have partners accepted as spouses and next-of-kin? How about those situations in which children have two mothers or two fathers? Think about people with longstanding disabilities estranged from their families many years ago when institutionalised. There are times when the person with a disability want staff members contacted because they are their significant others, rather than their birth families.

Making assumptions in this area of nursing care can bring significant distress for your clients. As nurses you must be aware that your cultural assumptions are just that—they are not universal ways of being and you need to be alert for different ways of understanding the world and social institutions such as the family. In sum, the concept of family and who is important and who can make decisions within a family can be decided only by individuals in the context of their particular family or in the face of their inability to do so by members of the family itself.

CULTURAL IDENTITY

Our identities as cultural beings are not only based on being born into a particular cultural milieu but are strongly related to our experiences as we go through life. Just as all members of a single family are not exactly the same and in fact may hold quite different beliefs and values to their parents and siblings, those who identify as belonging to a particular culture do not experience or express that cultural identity in the same way. In line with the broad definition of culture used in cultural safety, aspects of a person’s cultural identity are influenced by their ethnicity, their gender, their ability or disability, their education and their status within society as members of either dominant or minority groups. In addition, many people socialised in cultures in which traditional healthcare resources are used, such as in some Indigenous communities, may prefer to use this type of care even when residing in a mainstream cultural setting with mainstream healthcare resources available. It is therefore not possible to teach you the cultures, religions and ethnicities that shape a person’s world view as this will be unique to each individual. However, it is important that you understand that differences exist and are legitimate.

CAUSES OF ILLNESS AND DISEASE

Disease causation may be viewed in three major ways: from a biomedical or scientific, a naturalistic or holistic or a magico-religious perspective.

CULTURAL EXPRESSION OF ILLNESS

AUSTRALIAN NURSING STANDARDS

In 2010 Australia moved to a national registration system under the newly formed Nursing and Midwifery Board of Australia under the Australian Health Practitioner Registration Agency (AHPRA). The standards for Registered Nurses set by the Australian Nursing and Midwifery Council (ANMC) in 2008 have been adopted by AHPRA. According to the council’s standards a registered nurse provides evidence-based nursing care to people of all ages and cultural groups including individuals, families and communities (ANMC, 2008: 2). Of particular relevance is the following (ANMC, 2008: 12) in section 9.5 of their standards. A registered nurse:

For the full 2008 Registered Nurse Competency Standards go to: http://www.nursingmidwiferyboard.gov.au/en/Codes-and-Guidelines.aspx

In 2003 the ANMC released a position statement for the inclusion of Aboriginal and Torres Strait Islander peoples’ health and cultural issues in courses leading to registration or enrolment and these were updated in 2007 (Box 4.5).

NEW ZEALAND GUIDELINES FOR CULTURAL SAFETY

Registered nurses (RNs) are required to demonstrate competency specific to cultural safety to achieve initial registration, and subsequently in order to maintain a practising certificate from the NCNZ (Nursing Council). The following principles (Box 4.6) underpin cultural safety education (NCNZ, 2009).

The NCNZ (2009: 8) also stipulates the expected outcome of nursing education in New Zealand; that registered nurses are to ‘practise in a culturally safe manner, as defined by the recipients of their care’. They require that student nurses will:

CONCLUSION: CULTURALLY SAFE NURSING

There are several steps that you must climb on the journey to cultural safety. The integration of this knowledge into day-to-day practice will take time because many practitioners in the healthcare system are hesitant to adopt new ideas. Cultural safety does not come instantly, certainly not after reading a chapter or several chapters or books on this specialised area. It is complex and multifaceted, and many facets change over time.

You are now learning the contemporary scientific meanings of health and illness. But such knowledge is just one part of nursing care because you must confront your own biases, preconceptions and prejudices about specific ethnic, religious, sexual or socioeconomic groups and explore your family’s background and traditional beliefs and practices. The first step in understanding the healthcare needs of others is to understand yourself on the basis of cultural values, beliefs, attitudes and practices that are relevant to health and illness. The second step is to identify the meaning of health to the other person, remembering that concepts are derived, in part, from cultural meanings and definitions of health. Considerable research has been conducted into the definitions of health that may be held by various groups, as noted in the Indigenous definitions of health above.

Third, you must understand the culture of the healthcare delivery system, how it works, what it does, the meanings of various procedures and the costs and consequences to the clients and to you as a nurse. Fourth, you must be knowledgeable about the social backgrounds of your clients—the meanings of immigration, racism, socioeconomic status, ageing and so forth. Fifth, you must be aware if English is not understood, and be aware of the resources available to help with interpreting.

This chapter is about developing a deep understanding that each client and nurse has their own reality, that these multiple realities are socially constructed and that they are informed by, but not reducible to, culture. A central aim of this chapter was to change the way you see yourself and the world around you so you can impact positively on the power relations between nurses and clients and between clients and health services. Further we aimed to establish an appreciation that there is as much within culture variation as between culture variation. Health contexts such as hospitals and the health professions such as nursing and medicine also have their own cultures. Your challenge is to work within these systems without diminishing, demeaning or disempowering any individual (see Box 4.11).

The bibliography includes various books and selected websites to link you to introductory material related to this content. Remember what is connected to cultural safety: culture, ethnicity, religion, socialisation, population diversity, immigration, religion, demographic change, globalisation, health and illness, modern and traditional beliefs and practices, sociopolitical issues, education, sanitation, housing and infrastructure.

The reflections of eminent medical anthropologist Professor Arthur Kleinman arose from his own experience of caring for his wife of 40 years who developed a debilitating neurological disorder. He sums up perfectly the enduring need for self-awareness in caring professions such as nursing: