FORTALEZAS DEL ESTUDIO

This section draws on two international studies to identify the tensions and complexities involved in transferring cultural safety from the indigenous bicultural context of New Zealand to international multicultural nursing contexts. I have focused on one Canadian study (Anderson et al., 2003) and two Australian authors (Johnstone & Kanitsaki, 2007). Others authors in Andersen et al. have provided a suite of articles contributing to theorising cultural safety in a multicultural context (Brown & Varcoe, 2006, 2009; Brown & Smye, 2002). Unfortunately due tospace restrictions it is not possible to permit a broad critique of this body of literature.

The study by Anderson et al. (2003) offers a perspective on incorporating cultural safety into a Canadian context. Framed by a postcolonial feminist discourse and the concept of cultural safety, these authors undertook two feminist ethnographic studies, one hospital-based and one home- based. The goal was to extend understanding of how patients and registered nurses from linguistically and culturally different backgrounds negotiated decision-making during health care. The second study investigated the way patients managed health care in the home on discharge from hospital. Key to their investigation was identifying the extent to which cultural safety could be used to explain their interpretations of their findings. Their participants were representative of people from diverse social and cultural backgrounds and included new migrants, South Asian and Chinese, and non-migrant Canadians of European descent.

Anderson et al. (2003) identified complexity in interpreting processes underpinning cultural safety in their research to such an extent that the process of undertaking the research engendered feelings of cultural unsafety in research participants. They commented that the act of categorizing people as being from specific ethnic groups essentialised people, suggesting that they were other than Canadian. They observed that some of their participants saw themselves as Canadian first. The researchers concluded that the act of categorising had the potential to marginalise people. A tension associated with transferring cultural safety into practise is highlighted by this study. It draws attention to the difficulty of responding to a person as an individual in the context of their culture, while at the same time resisting a cultural or racial discourse. Similarly, Giddings (2005) claims that focusing on health disparities risks marginalising people further.

Anderson et al. (2003) used the concept of cultural safety as an interpretive tool to make connections between cultural safety concepts and the person’s experience. For example in one category, communication, patients who did not speak English reported that their safety depended

on their ability to communicate with health care providers rather than on feelings of being diminished or demeaned due to any lack of ability to speak or understand english. The authors note that not being able to communicate may result in feelings of disempowerment and question if this could also be read as being demeaned. Another finding centred on the experiences of english-speaking Canadians of European ancestry who had experienced difficulty negotiating the health care system. Anderson et al. commented that such people could be overlooked as needing culturally safe care and consequently written out of a cultural safety discourse. They consider that cultural safety should be able to account for power for all of their research participants. This study made visible complexities inherent when working cultural concepts in nursing. The researchers grappled with taken for granted cultural aspects such as ethnicity and race and at the same time made visible, tensions associated with interpreting cultural safety in a multicultural setting and keeping a focus on the health provider as a key shaper of health care.

In this thesis I have focused on not so much who is doing the interpreting but rather what is being interpreted and, more importantly, the cultural lens through which cultural safety is being examined. Suffice to say that cultural safety consciousness is a requirement in all nurse-patient encounters and while not subscribing to an essentialist position it needs to be recognised that essentialist notions of ethnicity, gender and age for example can be brought more to the fore when differences between the nurse and patient are perceived to be greater than differences between a nurse and a patient who share apparently similar identifying characteristics such as ethnicity, colour, gender or language.

Anderson et al. (2003) concluded that in a multicultural context a rewriting of cultural safety was necessary. They suggested that a postcolonial, feminist perspective would provide a more useful theoretical lens through which to examine colonisation and neo-colonialism, thereby revealing “the varied intersecting social relations of people’s lives” (p. 211). This study raises some important issues in the transferring of the concept from a national setting to an international setting. Anderson et al. capture the complexity in recognising cultural safety in research data when they say that “cultural safety did not announce itself in the transcripts-it was not a thing to be found” (p. 206). They found that finding cultural safety depended very much on their interpretation. This resonates with the application of cultural safety in a New Zealand context in that ‘finding cultural safety’ in everyday health encounters is not always immediately apparent.

Australian authors, Johnstone and Kanitsaki (2007) used a naturalistic inquiry approach to data collection, interviewing 145 participants in focus groups or in one to one interviews. The

research questions asked what health care providers and consumers of diverse cultural backgrounds know and understand about the notion of cultural safety. Other questions asked about the perceptions and experiences of cultural safety as a process in multicultural Australia, and to what extent the construct can be interpreted and advocated for as a cultural risk management strategy in a multicultural context. A key finding in this study is that, although cultural safety has been talked about by Aboriginal proponents, it is poorly understood and does not have currency within mainstream, multicultural health care contexts in Australia. The authors also found that there was an idea that cultural safety meant that “things were done safely” and that people from diverse backgrounds “got safe care and did not receive less than adequate care because of poor communication or staff lack of cultural knowledge” (p. 251).

Johnstone and Kanitsaki (2007) conclude that within multicultural Australia there is a lack of understanding of the concept and how it is applied in practice. For Johnstone and Kanitsaki cultural safety fails to provide a practice framework for the delivery of culturally appropriate and responsive care to people from diverse backgrounds. One other finding worthy of mention are the risks associated with upholding user definitions of cultural safety. By this the authors mean that cares and treatments may be preferred by an end user but that these treatments may be harmful to them. This implies that nurses or other health professionals are for some reason unable to use their clinical judgement when working with these situations, or that the recipient of care is unable to engage in a dialogue with the health professional concerning their health needs.

In early cultural safety practice it was considered that cultural safety involved a transfer of power from the provider to the recipient of care (Ramsden, 1990a). In hindsight it is clear that this framing is somewhat simplistic, although not intended as such. When a person seeks health care, they do so because they believe that the health professional has the power, that is knowledge to treat their illness or condition and to make them well. Ramsden’s concept of transfer of power in practice means that the nurse maintains an environment where the person is involved fully in their care, their identity is maintained and they feel able to comment on their care. The transfer of power does not mean that perceived harmful cultural practices are accepted uncritically. A transfer of power can mean that the person should have the right to comment on health care practices that they perceive as harmful to them. This could include an attitude, a belief or an intervention. Johnstone and Kanitsaki’s final conclusion is that in multicultural Australia cultural safety is problematic. They comment that if cultural safety is to function as a meaningful framework for guiding delivery of culturally and linguistically appropriate and responsible health care outside of Aotearoa New Zealand, its processes need to be better informed by, and

incorporated into, a cultural competence framework. Johnstone and Kanitsaki (2007) suggestion that cultural safety be incorporated into a cultural competency framework outside of Aotearoa New Zealand only serves to create tensions between cultural safety and transcultural care and detracts from the intent of cultural safety as providing a framework for a practical workplace analysis of power.

Anderson et al.(2003) and Johnstone and Kanitsaki (2007) rework cultural safety so that it makes sense to their health care settings and this is understandable. I argue that the political landscape, in this case, multiculturalism, shapes the way cultural safety is interpreted hence any approach to cultural safety can only be interpreted within specific broader national and social contexts. Given that influential Western nations, such as North America, Canada, England and Australia function socially and politically in a multicultural context where a transcultural paradigm dominates, there are implications in how cultural safety is interpreted in such contexts. Anderson et al.’s (2003) work could be seen as a reframing of cultural safety conform transcultural concepts in a multicultural society. If this is so then there is a risk that cultural safety becomes reinterpreted within a narrow focus of cultural ethnicity. Any focus on culture alone invokes the presence of binary or dualistic relationships which may unconsciously guide a person’s actions. Fletcher (2006) observes that a binary approach, by definition, constructs relationships of right or wrong, creating conditions of conflicting power. This she suggests can “close us down” (p.54) and can lead to the development of “habitual tactics” with which to defend ourselves from threat. This means that “we are reluctant to abandon old ways of behaving because they serve a purpose” (p.54). Binary constructions are by definition unequal as both partners are defined in relation to each other in a hierarchal way, in this case where one is identified as having power and the other as not. Anderson et al. (2003) do go some way toward teasing out their interpretation of cultural safety by separating out and identifying the different paradigms informing cultural safety and transcultural nursing, thus highlighting complexity in applying cultural safety in a clinical context.

Anderson et al. (2003) and Johnstone and Kanitsaki (2007) share with Aotearoa New Zealand a similar colonising history where indigenous populations have been excluded from decision- making, informed by their own worldviews, in mainstream health services. All the authors seem to have missed the point that cultural safety is about the nurse or health care provider and

institutional power which is relevant in any care setting even if this is interpreted according to local conditions. Fletcher (2006) observes that behaviour is determined by the organisational structure rather than solely by intrinsic character. The researchers started from the premise of

transcultural care in a multicultural environment and these discourses shaped the findings which led them to their conclusions that cultural safety was not an appropriate or suitable model for their communities. It is recognised that, within an Aotearoa New Zealand context, the implementation of cultural safety may be problematic (Ellison- Loschman 2001; Ramsden, 2002; Richardson, 2000). The problem is not only with misreadings of cultural safety as ethnicity and transcultural care but also with the support for it in practice, the focus on power, attitudes and the quality of the relationship between the nurse, the health care provider and the recipient of care.

The above literature identifies that transcultural care holds a dominant position within international health care. Other North American authors have offered critiques of transcultural care (Culley, 2006; Gray & Thomas, 2006; Gustafson, 2005; Mulholland, 1995), all of whom support a move away from essentialising concepts of culture, however, only Culley refers to cultural safety as a way forward. Culley like other international researchers review, positions cultural safety within health inequities experienced by indigenous peoples. She identifies health risks when ethno-cultural-racial identity is demeaned, suggesting that cultural risk is related to social disparities in postcolonial societies. Culley is accurate in her assessment of what cultural safety is but limits her thinking to aspects of cultural safety that link ethnicity and inequity. She argues for a non-essentialist approach to cultural difference “to unmask the assumptions of transculturalism and develop possibilities of practice which do not solely represent the particular habitus of dominant ethnic groups” (p.150). Culley raises an important point when she posits how ethnicity is to be taken seriously in a way that does not fix cultures in set of fixed cultural properties. She then goes on to suggest that there are no conceptual tools to address this. While Cully draws on cultural safety to inform her thinking, she does not consider that cultural safety could be one such conceptual tool. While addressing the need to shift away from transcultural care, she narrowly positions cultural safety as ethnic safety rather than safety for all in relation to all nurse-patient relationships.

Gustafson (2005) like Cully, critiques transcultural care as being essentialist, suggesting that transcultural nursing theory “centres culture as a way of understanding individuals and their response to health care”(p.3). Using a critical cultural perspective, Gustafson sets out to deconstruct transcultural nursing theory as a framework for thinking through, talking about, valuing and engaging with human and social differences. She makes the claim that transcultural theory texts “legitimates whiteness as a politically neutral identity position from which to interpret race difference”(p.9). A critical cultural perspective for Gustafson means that thinking differently about diversity requires challenging categories of difference which may be held up as

distinct, bounded and static biological facts or essentialist categories of human identity. Extrapolating this theme she then turns her attention to problematising culture. She recognises that nursing texts generally do not problematise race or other discourses of difference and therefore continue to use racial categories as a tool for classifying people (Jacob, Holmes & Buus, 2008).

Cooney (1994), Coup (1996) and Smith (1996) and Gustafson (2005) consider that while transcultural theory opened up spaces and possibilities for discussing difference, and the politics of difference, the concept is flawed. She claims that it will not“transform the social practices and relations that institutionalise the dominant approach to social and human differences” (p.14). However, in advocating for a critical cultural perspective, she fails to draw on cultural safety literature to support her argument for a different approach.

This section explored literature identifying different representations of cultural safety internationally. Another area of contention is that of cultural competency and culture specific models of care. The following section touches briefly on cultural competency as it is gaining traction in nursing but to date has not been investigated as an appropriate framework for measuring cultural care.