CHAPTER 19. Diversity in the context of multicultural Australia
implications for nursing practice
Akram Omeri and Lynette Raymond
LEARNING OBJECTIVES
• outline the cultural and linguistic demographic characteristics of Australia’s diverse population groups
• describe the evolution of Australia’s immigration and multiculturalism policy for all Australians
• explore the major multiculturalism policy directions and their impact on the healthcare system and practice domains in Australia
• examine how the diverse cultural and social structural influences impact on health access and outcomes for multicultural Australia
• understand the importance of addressing the inequities in the provision of healthcare services in Australia and in contemporary nursing practice, and
INTRODUCING MULTICULTURAL AUSTRALIA
Cultural and social structures, such as race, religion, language, education, ethnicity and economic status, are major influences on people’s health and wellbeing. The Australian people represent a wealth of cultural diversity. The term culture in this chapter is used in the broad sense to mean the cultural and social structural dimensions or institutions in the environment that influence the development of an individual’s beliefs, values and behaviour patterns.
In addition to the Indigenous population, Australia’s cultural diversity has increased through immigration. Australia has one of the largest proportions of immigrant populations in the world, with an estimated 24% of the total population (4.96 million people) born overseas (Commonwealth of Australia 2008c). Well over half of these, one in seven Australians, were born in a non-English-speaking country (Australian Institute of Health Welfare 2008). In excess of 200 cultural and linguistic groups are represented in today’s Australian population (Commonwealth of Australia 2008a 2008 International year of languages, 2008 and Commonwealth of Australia 2008c Year book Australia, 2008).
Diversity exists too in the wide range of contexts and environments in which people live. Variations in land, climate and settings compound diversity in social and cultural characteristics of people, as reflected in the diversity of settings in which healthcare is delivered. Healthcare is delivered in rural–remote areas, in community health settings, in the home, and in a number of acute settings within or outside hospitals in urban settings.
The purpose of this chapter is to inform student nurses and to develop in them an awareness of the benefits and challenges of diversity, with the aim of promoting the delivery of nursing care to diverse populations in culturally meaningful and safe ways. The desired outcomes are to:
• create an incentive for nurses to pursue transcultural nursing studies in order to further their sense of knowing about diversity beyond multiculturalism
• build upon the existing transcultural nursing knowledge through research and to understand the implications of culture-specific knowledge for improving nursing practice, and
• develop sensitivity and self-awareness towards cultural diversity that brings unity, respect for the other person, fairness for each other, and benefits for all.
Issues on Indigenous communities are not discussed in this chapter as this topic is addressed elsewhere in this book.
The term multicultural is used by the Australian Government to describe the cultural and linguistic diversity that exists in Australian society (Commonwealth of Australia 2003 Multicultural Australia, 2006 and Commonwealth of Australia 2007a Fact sheet 6, 2008). From an historical perspective, Australia’s policies on immigration have evolved in response to social changes and a commitment to the development of society as a whole (see Table 19.1). Since 1947, Australia’s immigration policies have shifted between phases of assimilation, integration, multiculturalism and mainstreaming, to inclusiveness and being united in diversity.
| Years | Policy | Features | Health policy implication |
|---|---|---|---|
| 1945–70 | Assimilation | Predominantly White Australian Anglo-Saxon policies | Absence of government assistance |
| 1970–80 | Integration | White Australia policy relaxed and gradually abandoned Some cultural characteristics tolerated | Relevant services provided Welfare needs of migrants being addressed |
| 1980–89 | Multiculturalism | Pluralistic approach to immigration Policies to limit discrimination on racial and ethnic grounds Cultural and ethnic diversity becoming more accepted in Australian society Cultural identity, social justice and economic efficiency were adopted | Provision of various health services Equality of access to culturally appropriate services |
| 1983 | Mainstreaming | Redirecting service delivery from marginal to a central base Concern of government institutions based on social equity and access; economic efficiency and cultural identity | Promotion of culturally sensitive health services Equality of access to health services by immigrants |
| 1999 | Inclusiveness | Diversity Multicultural policies built upon civic duty, cultural respect, social equity and productive diversity The term multiculturalism to remain Inclusiveness | Promotion of culturally sensitive health services Equality of access to health services by immigrants |
| 2000–08 | United in diversity | National agenda for a multicultural Australia Policy framework including: all Australians are expected to have a ‘loyalty to Australia and its people, and to respect the basic structures and principles underpinning our democratic Society. These are: Constitution, Parliamentary democracy, freedom of speech and religion, English as the National language, the rule of law, acceptance and equality’ (Commonwealth of Australia 2003:6). The current Rudd Labor Government has reaffirmed its support for the relevance and constitution of Australia’s Multiculturalism Policy | Main components of ‘Multicultural Australia: united in diversity policy 2003–06’: responsibility, respect, fairness and benefits for all |
The principles of Australia’s multiculturalism emphasise the importance of valuing differences, and utilising the cultural knowledge and skills of people from different backgrounds (Commonwealth of Australia 2003 Multicultural Australia, 2006 and Commonwealth of Australia 2007b Fact sheet 66, 2008). The policy is intended for all Australians, not just for those people from non-English speaking backgrounds. The ‘Multicultural Australia: united in diversity policy 2003–06’ is based on four principles:
1. Responsibility for all. All Australians have a civic duty to support those basic structures and principles of Australian society that guarantee us our freedom and equality and enable diversity in our society to flourish.
2. Respect for each person. All Australians have the right to express their own culture and beliefs and have a reciprocal obligation to respect the right of others to do the same.
3. Fairness for each person. All Australians are entitled to equality of treatment and opportunity. Social equity allows us all to contribute to the social, political and economic life of Australia.
4. Benefits for all. All Australians benefit from the significant cultural, social and economic dividends arising from the diversity of our population. Diversity works for all Australians (Commonwealth of Australia 2003:6).
To gain a deeper understanding of the historical perspectives of multicultural policies, students are encouraged to refer to the many recommended references provided throughout this chapter.
CHARACTERISTICS OF DIVERSITY
The remainder of this chapter will explore a number of Australia’s diversity characteristics, along with the implications they have both individually and collectively for nursing practice.
Economic status: impact of poverty on health
As a welfare state, Australia prides itself on meeting the health needs of all Australians, not just those economically advantaged. This approach to health services is based on the belief that a healthy society is a wealthy society. The International Council of Nurses (2004) states that poverty and health are linked in four ways:
1. ill health leads to poverty
2. poverty leads to ill health
3. good health is linked to higher incomes, and
4. higher incomes are linked to good health.
Income is a key factor in relation to poverty, but other factors are also significant for good health. In a broader definition of poverty, such things as access to health services, clean water, sanitation, literacy levels and infant mortality are included (United Nations Development Programme 2002–03). Poverty and disease are inextricably linked in a direct correlation with wealth; the poorer the person the greater the incidence of ill health, the richer the person the less frequent the incidence of ill health. Disease often further impoverishes the poor (McMurray 2007). In addition, cultural factors in combination with poverty are recognised as having a significant impact upon health (Australian Institute of Health and Welfare, 2000, Commonwealth of Australia 2004, Fuller et al., 2004, International Council of Nurses (ICN) 2004 ICN on health and human rights, 2008, Royal College of Nursing Australia 2004 Issues paper, 2004 and Sacs, 2005).
Socioeconomic and environmental factors, such as low income, poor housing, overcrowding, job insecurity, unemployment, few community resources, poor education, social exclusion, reduced social approval and self-esteem, are known to have an impact upon health. While government policy can have a significant impact upon health by redistributing wealth and ensuring access to health services, poor social and economic circumstances contribute to disempowerment and hopelessness among the poor and serve to keep the poor in ill health (McMurray 2007).
Language diversity
Culture is a shared experience that is mediated through language and other symbols. Australia’s national language is English, with a further 200 languages spoken among the more than 200 diverse cultural and linguistic groups they represent (Commonwealth of Australia 2008a 2008 International year of languages, 2008 and Commonwealth of Australia 2008c Year book Australia, 2008). Spradley (1979) states that language is an important cultural expression and the major means for humans to share, construct and understand the world around them. He goes on to say that the decoding of cultural symbols and identification of meaning involves the discovery of relationships between the symbols, their usage and the cultural context in which they are expressed. Accordingly, language needs to be understood in relation to the cultural and social structures that influence the development of an individual’s beliefs, values and behaviour patterns (Spradley 1979).
In response to the diversity of languages that exist in Australia, a number of both government and non-government interpreter and translator language support services and resources are currently available for both healthcare workers and clients of healthcare services. There are benefits to accrue from a heathcare workforce that is either bilingual or multilingual, particularly one that reflects the demographic language characteristics of Australia’s population as a whole (Commonwealth of Australia 2008a).
Education
Educational attainments are known to influence an individual’s lifestyle choices, employment opportunities, and perceptions of health and wellbeing.
Given the diverse knowledge and skill levels that exist in Australia’s population, healthcare workers when planning, developing and delivering educational programs and services need to take into consideration the age, language, culture and educational background of the target population. Working in collaboration with the intended recipients of resources and services during the planning, development and delivery stages enhances the effectiveness of the information provided and health outcomes for all population groups (McMurray 2007).
Religion
The religious, spiritual and philosophical beliefs adopted by people influence the way that individuals, families and community groups respond to significant life events such as birth, illness, death and dying, as well as their behaviours to maintain health and wellbeing.
There is diversity in the religious affiliations of Australians. They comprise 26% Catholic, 19% Anglican and 19% other Christian denominations. Major non-Christian religions comprise 6% and include Buddhism (2.1%), Hinduism (0.8%), Islam (1.7%) and Judaism (0.5%) (Commonwealth of Australia 2008c).
Religious diversity has enormous implications for the planning, development and delivery of mainstream health services. Religious ceremonies may involve family members, requests for religious representatives or prayer sessions during hospitalisation or procedures. In compliance with the codes of ethical and professional nursing practice (Australian Nursing and Midwifery Council (ANMC) 2008a Code of ethics for nurses in Australia, 2008 and Australian Nursing and Midwifery Council (ANMC) 2008b Code of professional conduct for nurses in Australia, 2008) and competency standards for nurses (Australian Nursing and Midwifery Council 2006), nurses are required to demonstrate respect for the beliefs and values of diverse cultural groups in their care. Knowledge of different cultural rites and ceremonies and accommodation of such requests is one example of how a nurse can demonstrate respect for diverse beliefs, values and lifeways.
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