Cultural Safety And Its Application In Contemporary Nursing

11 November 2018

Nursing practice demands for accountability to the patient, to the profession and the employer and the first time the term cultural safety was used was in 1988 in New Zealand and was born out of the experiences of the indigenous people of the country. The definition of cultural safety is the effective nursing practice of a person or family from another culture which is often determined by that person or family. The Code of Health and Disability Services Consumers Rights provides patients with the legal rights for the care they receive from health care providers, and provides a mechanism for patients who are dissatisfied with the health care provided to make complaints.
Cultural safety specifically borders on respect to patient rights to be treated with respect; no discrimination or coercion in decision making; to be listened to, understood and receive information in ways to ensure understanding, including provision of an interpreter; to be given choices for possible treatment; to give informed consent; and the right to complain. Nurses are expected to practice by these rights and also applying their nursing knowledge and experience when catering for the needs of patients and their family and meet the requirements for continuing competence, including culturally safe practice within the scope of competent clinical and cultural care.
Culture includes the following even though not restricted to, gender; sexual orientation; age or generation; socioeconomic status and occupation; religious or spiritual beliefs; ethnic origin or migrant experience; and disability. The nurse/midwife delivering the nursing/ midwifery service will need to have undertaken a process of reflection on his/her cultural identity and in the right position to recognize the impact that his/her professional practice is affected by his/her personal culture and always remembering that unsafe cultural practice comprises any action which diminishes, demeans the cultural identity and wellbeing of an individual.
Cultural safety, a conceptual framework designed to guide health care delivery identified as safe by the person receiving that care and aim towards enlightening nurses on the need for a change in attitude and educating them about health care relationships with clients, improve their understanding of the ever growing diversity in culture between New Zealand society at large and nursing basically because majority of the people benefiting from and delivering health services today in New Zealand come from ethnic backgrounds that is diverse and people bring this difference with them into health care services and expected this to be recognised.
ISSUES AFFECTING THE DELIVERY OF PROFESSIONAL NURSING CARE
Various issues affecting the delivery of professional nursing are include but not limited to the following: (1) Failure of the nurses to acknowledge and respect the attitude, beliefs and practices of patients whom they are to care for: the patient has the right just like any other patient to be attended to and given appropriate healthcare service but because this young man is currently serving a term of home detention for sexual abuse offences, the nurses rather prefer to exercise their right to refuse to nurse him and even forgetting that this patient has a diagnosis of haemophilia, and has been admitted to the ward for a Factor Eight transfusion which is very important to his wellbeing. Since patient expectations of nurses are examined based on the establishment of nurse-patient relationships and effective communication, as well as exploration of patient autonomy as a social construct, this power exercised by the nurses is therefore against the call for equality in health care delivery.
(2) Lack of preparation on the nurse’s path to understand the diversity within their own cultural reality and the impact of that on any person who differs in any way from themselves: This can be supported by the notion of trans-cultural care which emerged in the 1950s in the United States as a form of care which focuses on the values and beliefs of diverse cultures and how this knowledge is used to provide culturally specific care to patients from particular cultures. This requires nurses to have knowledge of the specific cultural values and beliefs of a wide range of racially and ethnically diverse populations in order to provide culturally congruent care. This was lacking on the path of the nurses and impacted their delivery of healthcare service because the man has characteristics that make him different from them.
(3) Failure of the nurses to apply social science concepts that underpin the practice of health care: According to Jeffs (2001) suggestions, different strategies for cultural safety education have been introduced over the years leading to a range of outcomes which aren’t consistent with cultural safety principles and this could have played a role in the response of the nurses in this scenario. It is generally expected where culture is viewed from the dominant perspective rather than in terms of power, that cultural safety may be substituted for a course on Maori health, instead of seeing both as essential and when this coexist with the removal of relevance of ethnicity by placing one form of oppression in competition with others, this may maintain the status quo by a process of ‘divide and rule’ to focus on the nursing culture rather than the nurse as the culture bearer and over time, the nurse does examine self culturally in practice rather than nursing as a culture in practice which will help to tackle this inequality.
THE CORRECT PROFESSIONAL NURSING RESPONSES
The correct professional nursing responses should be based on the various principles of practice that exist in cultural safety and in general four principles exist towards aiding the correct professional response from nurses. The first one aims to improve health status and well-being of New Zealanders; on the other hand, the second one improves the delivery of health services. The third and forth principle focuses on the differences among the people who are being treated and accepting those differences and understanding the power of health services and how health care impacts individuals and families. It is expected that nurses should be aware and understand that cultural safety aims to improve the health status and wellbeing of New Zealanders and applies to all relationships by placing emphasis on health gains and positive health and wellbeing outcomes accompanied by nurses been able to acknowledge the beliefs and practices of those who differ from them. If this is possible then nurses will be able at all time to fulfil their basic role which is caring for the needs of patients irrespective of the scenario the patient or nurses find him or herself.
Beyond this all, cultural safety aims to enhance the delivery of health services through a culturally safe workforce by identifying the power relationship between the service provider and the people who use the service. By this, the nurses which are the health care provider in this case, accepts and works alongside others after undergoing a careful process of institutional and personal analysis of power relationships which empowering the users of the service to be able to express degrees of perceived risk or safety and they knowing that irrespective of their socioeconomic status they will be duly care for. Also, more has to be done towards preparing health care providers to understand the diversity within their own cultural reality and to apply their knowledge of social science concepts that underpin the practice of health care to everyone and understanding that health care practice is more than carrying out tasks but rather is about relating and responding effectively to people with diverse needs and strengths in a way that the people who use the service can define as safe.
Finally, nurses should be aware that cultural safety has a close focus on understanding the impact of the health care provided as a bearer of his/her own culture, history, attitudes and life experiences and the response other people make to these factors therefore they should also improve themselves in this direction and challenge one another to examine their practice carefully.Nurses should be prepared and understand the role that they play as health care providers towards resolving any tension between the culture of the health care institution and the people using the services and be at all time willing to understanding that such power imbalances can be examined, negotiated and changed to provide equitable, effective, efficient and acceptable service delivery.
THE NEED FOR CHANGE IN WORKPLACE CULTURE
Over the years, the long-term value of the concept of cultural safety as a tool for cultural regeneration is hard to assess and depends on the integrity of the processes that underlie the concept of cultural safety. Most cultural safety research has been completed in New Zealand, but the statistical evidence of the benefits of cultural safety is lacking, and other evidence is largely qualitative and anecdotal. Irihapeti Ramsden, the architect of cultural safety, stated that cultural safety training is too skewed toward Maori studies in many nursing courses and a number of controversies during the mid 1990s affected the concept of cultural safety in New Zealand and critics claimed that nursing students were afraid to speak out about the excesses of cultural safety on their nursing degrees, presumably for concerns about failing their course after not meeting cultural safety requirements.
Critics have claimed that cultural safety is based on airy-fairy quasi-psychological subjects which have resulted in an abandonment of rigorous and theoretical task-based nursing. Public opposition to cultural safety during the 1990s led to a Parliamentary Select Committee inquiry into its teaching, whilst a simultaneous review was carried out by the New Zealand Nursing Council and after the review the New Zealand Nursing Council revised the guidelines for cultural safety in Nursing and Midwifery Education to placate public concern that cultural safety privileged Maori. In general, cultural safety has been criticized for lacking a clear and comprehensive practice framework that is easily translated by, and responsive to, both culturally diverse health care providers and equally diverse health care recipients, therefore the need for change in workplace culture.
I suggest that the following changes: (1) A universal approach to health care should be the dominant approach and should assume the same service for all; (2) There should be a balance of power relationships in the practices of health care so that everybody receives an effective service; and (3) There is a need to challenge health care providers to examine their practice carefully, recognising the power relationship in health care institutions.
A Universal Approach to Health Care
The solution to this disparity is a universal approach to health care should be the dominant approach and assumes the same service for all. This approach does not take individual or cultural needs into account and consequently tends to put the focus of deprivation and disparity onto individual or cultural difference. A universal approach ignores structural barriers to service and ignores the culture and inherent values of the health care service which may impact on care.
It is notable to say that in New Zealand, as in other nations, huge changes have occurred throughout the socio-cultural development of a rapidly growing multicultural society. Such changes demand a greater awareness and responsiveness towards the cultural differences between each individual and/or groups of individuals, and especially the shared beliefs and practices of various minorities social, ethnic, religious and gender groups in society, such as young people, elderly people, and those who are mentally ill or disabled. However, the values, ideals and basic rights of such groups have often been overlooked, ignored or minimized because, as is common in western or postcolonial countries, any arguments from a cultural or ethically relativist perspective are often overridden to favour those of the more prevalent views of western ethnocentrism and moral universality. This phenomenon continues to fuel a persistent and convoluted debate in nursing, especially within the teaching and practices associated with nursing ethics.
For nurses, the problem of operating within a system that tends to promote rights-based and/or principles-/rules-based ethics in the face of a rapidly changing social environment remains a considerable challenge. For instance, problems may arise when nurses attempt to match notions of desirable ‘universal’ moral principles, such as autonomy and justice, with the largely relativistic ‘cultural norms’ of different patients under the auspices of the dominant culture of medicine. This difficulty is perhaps compounded rather than alleviated by nursing attempts to attach universalistic notions of shared values or practices derived from the multicultural or trans-cultural concepts in nursing care. Yet, irrespective of the dominance of prevailing ideologies within health care, and continuing debates about the overall purpose and direction of nursing ethics, there will always remain a requirement for nurses to respond ethically to the socio-cultural needs of their patients, and perhaps especially to the specific needs of patients who belong to aboriginal, minority or marginalized groups.
This therefore call for a universal approach that would value collectivist ways of autonomous decision making as well as individualistic ways, appreciate alternative viewpoints regarding issues pertaining to health care delivery.
FACTORS THAT DEMONSTRATE MY PRACTICE IS CULTURALLY COMPETENT AND PERSON-CENTRED.
PROMOTES SOCIAL JUSTICE AND EMPOWERMENT
The concept of social justice is often used to imply that there is a fair and equitable distribution of benefits and burdens in a society. Such a view of justice depends largely on the notion of the distributive paradigm of justice; that is, justice as a personal right based on the practice of individual freedoms within the usual societal limits. This type of interpretation, so common perhaps in the neoliberal societies of previously colonized western nations (such as New Zealand, Australia and Canada) is not an interpretation that is commonly experienced within indigenous or other culturally affiliated minorities. In these settings, social justice implies that, within the different social, economic and political contexts in which people exist, ‘difference’ should be treated with ‘difference’; that is, according to the different cultural needs of the recipient of nursing care rather than nurses’ need to maintain their own ‘nursing’ culture, or the culture of medicine, or any other arguably predominant culture. Such imbalances require not only awareness and sensitivity on the part of nurses; they require attention to social justice using empowering practices.
MAINTAINANCE OF INDIVIDUAL/COLLECTIVE CULTURAL AUTONOMY AND IDENTITY
The concept of autonomy is broadly seen as the capacity of individuals to shape the conditions under which they live. It implies an individual’s, or a group of individuals’ ability to plan, pursue, participate in and evaluate their own choices in social life. The term may therefore be used to refer to the self-determination of one individual or culturally affiliated group of individuals within collective bodies such as minority groups and indigenous peoples. Cultural autonomy strongly relates to cultural knowledge and identity, which in turn dwells within the traditions, language and practices of a given cultural group. The upkeep of these traditions and practices is therefore of importance in every culturally affiliated group, but especially so for indigenous cultures (such as Maori) who still retain cultural memories of past colonial experiences that often saw them denied such basic autonomous rights, the subsequent demise of their language and knowledge, and, most devastatingly, their loss of identity and prestige.
This problem has occurred in several indigenous societies around the world, and remains an issue that should be of moral concern to nurses everywhere. It is generally well known that in traditional societies, collective cultural membership matters more than individual membership and much importance is placed upon shared decision making. In such ways, cultural knowledge is shared and identity maintained. In other societies, especially neo-liberal ones, the individual is regarded as a fully autonomous being and great store is placed on the legal maintenance of individual rights and freedoms, privileges and protections.It follows, then, that for members of dominant ‘cultural’ groups (e.g. the middle and higher socioeconomic classes), health care institutions such as hospitals (where the main values and practices remain firmly focused around dominant social cultures that include medicine) offer at least some cultural similarities and opportunities to maintain individual identity and status. In the case of less dominant cultural minorities, this possibility is usually far less likely. They may be at least doubly disadvantaged in that they could easily lose any cultural authority, power and influence that they may otherwise possess, and they may lose control over their own cultural practices because of the nature of their illness and an inability to respond in ways more familiar to them. When this occurs, the greatest threat to the (cultural) safety of individuals is a danger to their identity. Hence, for those receiving nursing care, the maintenance of cultural identity always requires the consideration of a significant degree of either individual or collective autonomy, as every instance of choice denied to one may be regarded as an instance of control imposed on all.
PROMOTES TRUST AND RESPECT
Trust is a desirable and necessary ethical element of any relationship between nurses and patients, families or communities. Undoubtedly, the maintenance of trust itself is a vital social phenomenon in all traditional societies, being developed not by promises or expectations but by the observable actions of others. These actions include factors such as an ability to meet others face to face, to look, listen and speak at appropriate times, and to be generous with both time and self. Subsequently, it may be argued that this particular requirement is obtained only through nurses’ closer attention to their own attitudes and responses within the entire social environment. This crucial difference means that nurses need to accept that they are bearers of a culture that may be exhibited through the use of professional power, and that it is not necessarily enough to know and be sensitive towards the needs of others; they must act on these needs ethically within a relationship of mutual respect and trust. It follows that to work as nurses within indigenous and other socially diverse groups requires them to place themselves in a position based on trust, and to strive continuously to maintain that trust as, without it, ethical nursing practice cannot take place.

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