Procedimientos analíticos

Wilson’s (2008) grounded theory research examined the way Māori women draw on their day-to- day strengths to maintain their health and well being and that of their whānau. Wilson argues that these strengths can sometimes go undetected and yet they are vital to improving health. She observes that:

A culturally appropriate health service is contingent on the inclusion of a client’s cultural beliefs and practices into intervention plans… not establishing key cultural beliefs and practices risks providing a health service that lacks relevance and compromises its efficacy for its recipients.(p.173)

In other words, health care providers do not always provide culturally safe care because of the absence of an environment of safety for a person.

Wilson asserts that the ability to provide culturally appropriate and acceptable health services is a requirement for gaining the client’s trust and this extends beyond the establishment of relationships to respecting the person’s world-views and cultural preferences. She notes that when outcomes are not achieved for the health of the client then it is not unusual for the client to be blamed or labelled non-compliant. According to The Nursing Council of New Zealand (2008), competency is “the combination of skills, knowledge, values and abilities that underpin

effective performance as a nurse”. Wilson points out that Competency 1.5 of the NCNZ (2005/2009) requires nurses to practise nursing in a manner that the client determines as culturally safe. This means the recipient of care needs to experience a level of trust where her needs and wants can be conveyed to the nurse in a way which will keep her safe. It also means that the nurse needs to have the knowledge, ability and resources to listen, assess and interpret communication and actions which may indicate compromised safety. Although the experience of the recipient is a key tenet of cultural safety, in some nursing encounters, the recipient of care is sometimes the least able to comment on care. Often they do not challenge at the time of an encounter but as Wilson (2008) found, a recipient of care may act on poor quality of care by discontinuing use of a service or ‘walking away’ rather than speaking up about the service. Wilson’s research identifies that a recipient’s experiences of health care are, however, given voice in other venues such as group discussions and research settings.

Wilson’s (2008) research explored Māori women’s understandings of health and their interactions with mainstream health services. A Māori-centred approach informed by the work of Durie (1997) was used to ensure a research process reflecting Māori values and processes from the beginning of consultation to the dissemination of the findings. A Glaserian grounded theory approach (Glaser, 1998), was used in conjunction with Durie’s model (2001), to analyse data using a constant comparative analysis to generate codes, emerging concepts and categories. Wilson’s findings briefly were as follows. Nga Kairaranga Oranga – weavers of health and well- being was the substantive grounded theory finding that explains the health and well-being of Māori women and provides a framework for Māori women’s insights into their interactions with mainstream health care services. This overarching theory was further explained as Mana Wāhine24

, the important components for health and well-being such as whānau, spirituality, traditional and contemporary knowledge and self care behaviours. Mana Wāhine explains the barriers to experiencing positive health outcomes for Māori women. Challenges and barriers include a strong socialisation to put others first, fear of past experiences of health care and negative encounters with health care providers. Engaging with health services was a key ingredient of safe care expressed in the need to develop positive relationships with health care providers. The way relationships are woven together determines the nature of engagement a Māori woman has with a health service. The Māori women that Wilson worked with found that health services were problem-focused, that the services compartmentalised health issues or problems and this resulted in their overall needs not being recognised and interventions being inappropriate - in short a biomedical approach was the usual approach experienced.

Wilson’s (2008) findings raise the concern that, although nurses have been educationally prepared in cultural safety since the 1990s, this training may not translate easily into practice. Wilson notes the need for nurses to maintain a reflective stance to their practice through examining their personal cultural beliefs and values in order to consider how these might impact on the care they deliver. Moreover, nurses need to recognise and value the beliefs and practices of health consumers and integrate these in care planning. All these factors are dimensions of cultural safety. Wilson notes that The New Zealand Nursing Council competency reviews of culturally safe practice are somewhat problematic as there is nothing in the assessment structure which caters for feedback from the recipient of care. Even if there was, there is the vulnerability factor on the part of the client who may feel unable to comment. Her research identified that, while Māori women knew what they wanted from a health service and health care providers, knowing what they wanted contrasted with their experience. Participants reported that at times health providers did not listen when something was wrong, or were unable to respond in a way that indicated they knew what to do to correct a situation. Wilson draws on Durie’s (2001) work and offers another approach, drawing on a cultural competency framework based in the nurse’s ability to articulate and demonstrate care where the client feels safe. The nurse does this by articulating an understanding of links between knowledge, beliefs, attitudes and power and demonstrates this by situating their actions within this framework in order to explain how they improved a person’s health status and to demonstrate how they integrated the person’s culture into clinical practice. Contingent on this process is the health professional’s willingness to address issues of power and to acknowledge how the interplay of values and attitudes affects the health care relationship.

While cultural safety is part of the same lexicon of nursing, the literature identifies that there are tensions between cultural safety and other conceptualisations of culture in health care. Nursing knowledge has evolved over time and has been largely informed by dominant discourses of humanism and positivism. The following sections consider nursing work as a political project and begin to outline how postmodern ideas about culture and critical theories of difference, which underpin this research, may contribute to new developments in cultural safety in the twenty-first century.