Theoretical frameworks for practice

Two theoretical frameworks have been developed in New Zealand that can provide some guidance for midwives engaging in these types of relationships with women. Midwifery partnership describes and explores how midwives can work in partnership with women. Cultural safety supports partnership relationships through focusing on invisible structures of power that exist between any two partners and in wider contexts within healthcare service institutions and society. Cultural safety, like midwifery partnership, seeks to make these power differentials visible so that both partners can negotiate how they work together and ensure that the woman, as the recipient of care, receives care that meets her needs and leaves her individuality intact and strengthened.

Cultural safety and midwifery partnership both also have a political imperative. Cultural safety challenges any personal, professional, institutional and social issues and structure that ‘diminishes, demeans or disempowers the cultural identity and wellbeing of an individual’ (NCNZ 2002, p 7). Midwifery partnership challenges professional power structures and medical dominance over childbirth, through recognising childbearing women as active partners of equal status in the shared experience of maternity care (Guilliland & Pairman 1995).

What is meant by ‘culture’?

The understandings of culture expressed in nursing and midwifery in New Zealand today have evolved over a long period. It is important to be familiar with this evolution of understandings in order to appreciate the significance and place of cultural safety.

Historically, in New Zealand and elsewhere, culture was invisible in nursing and midwifery curricula. In part this reflected a context in which assimilation was prevalent. Despite the existence of the Treaty of Waitangi, assimilation policy influenced the social thinking of the 19th and early 20th centuries, and led to the establishment of structures and processes that denied differences between Māori and Pākehā (non-Māori) in an attempt to make Māori more like Pākehā and absorb them into Pākehā-dominated culture and society (Walker 1987).

In this context, nurses and midwives were encouraged to give care to patients ‘irrespective of differences such as nationality, culture, creed, colour, age, sex, political or religious belief or social status’ (Ramsden 1990, p 79). This understanding of culture informed the practice of nurses in New Zealand until the early 1970s. It was well intentioned but served only to reinforce assimilation (Spence 2001). The long-term consequences of assimilation are suppression and destruction of the culture of Indigenous people, which results in mental, physical and spiritual stress (NCNZ 1992). This stress is seen only too readily in the present-day health statistics of Indigenous peoples in New Zealand and Australia and throughout the world.

In the 1970s a new understanding of culture developed. In New Zealand, as elsewhere, anthropological understandings of culture emerged which led to greater cultural awareness and cultural sensitivity. Transcultural nursing theory, developed by nurse theorist Madeline Leininger in the early 1970s, influenced nursing education. Transcultural nursing was based on nurses having knowledge about a range of different cultures from which they could respond therapeutically to their clients’ needs (Papps 2005). Nurses and midwives were taught to gather information about the beliefs, patterns and behaviours of other cultures, so that they would be able to identify ‘specific cultural patterns that occurred’ and provide culturally sensitive care (Richardson 2000, p 32; Spence 1999). Nurses and midwives were taught about the concepts of cultural awareness (becoming aware of difference) and cultural sensitivity (sensitivity to the legitimacy of difference and the impact the midwife’s own culture may have on others) (NCNZ 2002). Nursing and midwifery knowledge considered culture and race from the perspective of the nurse or midwife, as an observer, exploring and understanding what makes the other person different from themselves (Ramsden 2000; Richardson 2000). Such approaches allowed the nurse or midwife to be patronising and powerful as they identified the needs of people from other ethnic groups, and did not require any self-knowledge or change in attitude (Ramsden 2000). In New Zealand, the dominance of transcultural nursing in nursing education and practice was challenged by the alternative theory of cultural safety.

Developed in the 1980s by Māori nurse educator, Irihapeti Ramsden, cultural safety or kawa whakaruruhau provided another theoretical framework for understanding culture. This sociopolitical definition of culture had the Treaty of Waitangi as its starting point, and involved recognition that power needed to be shared and racism de-institutionalised (Spence 1999). Cultural safety focused on the sociopolitical factors that affected healthcare (Richardson 2000).

By contrast, notions of cultural sensitivity and cultural awareness avoided the more difficult recognition of power relationships that existed in the delivery of healthcare and led to cultural stereotypes and simplistic notions such as cultural checklists (Ramsden 2000). Cultural safety focused not on the ‘other’ but on the nurse and midwife. The process of cultural safety began with self-reflection and attitude change (see Fig 16.1). This process required the nurse or midwife to recognise themselves as ‘powerful bearers of their own life experience and realities and the impact this may have on others’ (Ramsden 2000, p 117).

Figure 16.1 Developing understanding of cultural safety

(based on Ramsden 2002)

The notion of power is inherent in the concept of and processes associated with cultural safety. The nurse or midwife is challenged to recognise her or personal power and the power of the institutions and society in which they work and live (Richardson 2000). Cultural safety is primarily about establishing trust, gaining a shared meaning of vulnerability and power, and carefully working through the legitimacy of difference (Ramsden 2000). Cultural safety makes visible the invisible structures of power (including our own), and attempts to transform anything that creates inequality and inequities in the healthcare services. In the New Zealand context this also includes actions that do not uphold the Treaty of Waitangi in the delivery of healthcare services.

Figure 16.1 describes the progression of students towards understanding cultural safety and the difference in meaning of the commonly used terms ‘cultural safety’, ‘cultural sensivity’ and ‘cultural awareness’.

Thus cultural safety and transcultural nursing present different theoretical understandings of culture. Transcultural nursing exists in a multicultural context and focuses primarily on defining culture as race and ethnicity (Ramsden 2002). Transcultural nursing places the nurse or midwife in the position of ‘external observer’ for the purpose of providing culture-specific care. On the other hand, cultural safety addresses the issue of power between the client (woman) and the nurse (midwife) and interprets ‘culture’ in the broadest possible sense (Ramsden 2002).

This movement from ‘regardless to regardful’ is one of the most important contributions cultural safety makes in ensuring the safety of the care that midwives give.

The development of cultural safety

Irihāpeti Ramsden’s theory of cultural safety arose from her experiences in the late 1980s in teaching student nurses, and her attempts to include Māori health issues and the Treaty of Waitangi in her teaching (Ramsden 2005). Her frustrations in trying to teach about difference and racism in a context of assimilation, where culture was seen only as ethnicity, led her to develop strategies for teaching about Māori health issues in nursing. These strategies were articulated in her framework, ‘A Model for Negotiated and Equal Partnership’, which was adopted by all schools of nursing soon after (Ramsden 1989).

In 1988, Irihāpeti Ramsden was commissioned to run a national hui (meeting), the Hui Waimanawa, which involved over 100 participants including Māori nursing students. According to Irihāpeti, it was a first-year nursing student at that hui who first coined the term ‘cultural safety’ and permitted Irihāpeti to use the term in her subsequent work. The student stood at the hui and spoke about the expectation of legal safety, ethical safety, safe clinical practice and safe knowledge bases for nurses and asked, ‘What about cultural safety?’ (Ramsden 2005, p 17). Irihāpeti Ramsden published her document, ‘Kawa Whakaruruhau: Cultural Safety in Nursing Education in Aotearoa’ in 1990. The Nursing Council of New Zealand accepted it, along with ‘A Model for Equal and Negotiated Partnership’, thus legitimising the term ‘cultural safety’ in nursing and midwifery language (Ramsden 2005).

At several hui held in the late 1980s and early 1990s, a variety of definitions for cultural safety were debated. The hui of the Whānau Kawa Whakaruruhau defined culturally safe practice as ‘actions which recognise, respect and nurture the unique cultural identity of tangata whenua and safely meet their needs, expectations and rights’ (Hill, cited in Whānau Kawa Whakaruruhau 1991, p 7). This hui also defined ‘culturally unsafe practice’ as ‘any actions which diminish, demean, or disempower the cultural identity and well being of the individual’ (ibid).

Cultural safety required appropriate healthcare services to be provided for all New Zealanders. However, the need to address Māori health as a result of the enduring effects of colonisation had become urgent (Spence 2004). Therefore, much of the early work around cultural safety was concerned first and foremost with trying to identify ways in which healthcare services could address the poor health status of Māori (Ramsden 2002). While colonisation was primarily the reason for the poor health status of Māori, it was also the reason for the development of cultural safety, and the initial processes of teaching cultural safety needed to deal with colonial history. Therefore cultural safety teaching included analysis of the historical, political, social and economic realities that were affecting Māori health (Ramsden 2002). Nursing and midwifery students needed a ‘profound understanding of the history and social function of racism and the process of colonization’ to become culturally safe practitioners (Ramsden 2002, p 180).

In 1991, the Nursing Council commissioned Irihapeti Ramsden to write guidelines that would assist schools of nursing (and midwifery) to incorporate cultural safety (kawa whakaruruhau) into the education curricula (Papps 2002). In the council’s view it was important that such guidelines would provide a process through which students would understand difference and dominance and so ‘demonstrate flexibility in their relationships with people who are different from themselves’ (NCNZ 2002, p 12).

These guidelines became council policy in 1992 and required student nurses and midwives to be educated:

The incorporation of cultural safety into nursing and midwifery curricula from 1992 meant that education required:

Unfortunately, few nurse educators had the educational preparation to teach cultural safety or to understand that culture was an important influence on people’s health, and students were not provided with clear definitions of culture. Where culture was equated with ethnicity, students were often taught Māori language, songs and dance instead of learning about their own cultural identity and its impact on their nursing or midwifery practice (Papps 2005).

The confusion continued in media reports that condemned the teaching of cultural safety in nursing, claiming that attention to this aspect of the curriculum was to the detriment of other more important areas such as ‘medical’ knowledge. Papps suggests that opposition to and confusion about cultural safety arose because it aims to do two separate but interrelated things. First it aims to address nurses’ and midwives’ conscious or unconscious attitudes towards any cultural differences, and second, it aims to raise awareness about imbalances in the health status of Māori (Papps 2002). Because it teaches about the effects of colonisation on the health of Māori, cultural safety has been misunderstood as being about only one culture (Papps 2002). What was not understood was that cultural safety is about addressing power relationships between nurses or midwives and the recipients of their care. Where historically nurses were taught to provide care irrespective of colour or creed and to treat everyone the same, cultural safety requires nurses and midwives to be ‘respective of the nationality of human beings, the culture of human beings, the age, the sex, the political and the religious beliefs of other members of the human race’ (Ramsden 2005, p 7). Rather than the nurse or midwife deciding what is culturally safe, it is the patients or clients who determine whether they feel safe with the care they have received (Ramsden 1995, cited in Papps 2002).

Intense political and media scrutiny of cultural safety eventually led to an investigation by a Parliamentary Select Committee in 1995. Cultural safety was ‘depicted as politically inspired while the curriculum of clinical nursing practice was apolitical and neutral’ (Papps 2005, p 26). Several recommendations from this inquiry were actioned by the Nursing Council, but it remained firm that the name ‘cultural safety’ would not change and that the Treaty of Waitangi would remain as the basis for nursing and midwifery education (Papps 2005).

In 1996, the Nursing Council published new guidelines in which the definition of cultural safety was broadened and focused less on Māori issues such as structural, political or social causes of the poor health status of Māori (Ramsden 2002). It emphasised relationships between nurses and midwives and clients who differ from them by age, gender, sexual orientation, socioeconomic status, ethnicity, religious or spiritual belief and disability (NCNZ 1996). The council recognised that while cultural safety originated from the experience of Māori, its principles needed to be broad-based and apply to all people. ‘Culture, in the cultural safety sense, includes all people who differ from the cultures of nursing and midwifery’ (NCNZ 1996, p 8).

By 1996, the Nursing Council definition of cultural safety had evolved to include the consumer in determining ‘effective nursing or midwifery care’ (NCNZ 1996, p 9). The council said:

Ramsden (2000) argued that this all-inclusive definition of cultural safety meant that there was a need for a new curriculum design. She believed it was time for a stand-alone course in Māori health, so that the integration of cultural safety in its broadest sense could occur without threat to the issues of Māori health and the Treaty of Waitangi (Ramsden 2000).

Guidelines released by the Nursing Council in 2002 made this distinction. Cultural safety teaching was separated from teaching of the Treaty of Waitangi and Māori health in order to avoid confusion about the nature of cultural safety (NCNZ 2002). Nursing and midwifery education is now expected to prepare nurses and midwives to face and deal with personal, professional, institutional and social issues that affect the provision of safe midwifery care to women and their families.

It was Ramsden’s view that future evolution and direction for cultural safety would not focus on the customs, habits and cultural practices of any group, but rather would continue to be about an analysis of power and relationships of power (Ramsden 2002). Cultural safety is simply an instrument that allows the woman and her family to judge whether the health service and delivery of healthcare is safe for them (Kruske et al 2006; Ramsden 2002). Therefore, the next step in this journey of cultural safety will need to be centred on the facilitation of a process whereby women and their families can tell midwives about the safety of the care they receive (Ramsden 2002). This next step will facilitate the focusing of cultural safety not just on ‘ethnicity’, but increasingly will ‘promote the uniqueness of each person resulting from multiple intersecting cultural layers’ (Clear 2008, p 4).

Principles of cultural safety

Cultural safety is facilitated by communication, understanding the diversity in worldviews, and understanding the impact of colonisation (NCNZ 2002).

There are four principles of cultural safety:

Both nursing and midwifery education programs in New Zealand are based on these principles, in order to develop nursing and midwifery workforces that practise in a culturally safe way as defined by recipients of the care. Cultural safety education expects nursing and midwifery students to have:

In her doctoral thesis, titled ‘Cultural safety and nursing education in Aotearoa and Te Waipounamu’, Irihapeti Ramsden (2002) makes a number of statements that may also be interpreted as principles of cultural safety:

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