Foreword
The Practice and Politics of Indigenous Health Nursing
Denise Wilson
Māori Health, Taupua Waiora Centre for Māori Health Research; School of Public Health and Psychosocial Studices, AUT University, Auckland, New Zealand
PP: x - xiii
Article Text
The focus of this special issue of Contemporary Nurse on Indigenous health and nursing is timely as concerns about Indigenous health status are linked not only to the deprivation and socio-economic positioning many experience, but to the access and use of health services. Indigenous health is shrouded in politics at the level of Indigenous communities up to the level of the government where policy and resource decisions are made. As registered nurses we are invariably mandated to implement policy and service delivery decisions that affect Indigenous people and their communities. Tension arises when health services are not always accessible to, and appropriate or acceptable for Indigenous users of health services, and outcomes are not realised. Disparities arise through differential access to essential determinants of health (such as housing, education, income, and nutrition) and health services, and cracks in the quality of services available (Jones 2000). In Aotearoa New Zealand during 2004 and 2005, 'race based' politics attacked the provision of services targeted for Maori that aimed to reduce the disparities in the health status they experienced compared to others living in New Zealand. This political groundswell associated with Maori health services moved the focus of service provision from 'race' to 'need', further marginalising Maori health needs and access to vital resources required to reduce the inequalities by making invisible race and ethnicity - determinants of health. Australia, Canada and New Zealand have all recognised the imperative to improve the inexcusable health status of their Indigenous populations.
Indigenous Health Context
The burden of disease and ill-health experienced by colonised Indigenous populations globally is greater when compared to other groups within their nations. Globally, these Indigenous populations have been forced to move from being socio-economically healthy pre-colonisation to being socially marginalised and socio-economically deprived. Globally, Indigenous peoples have diverse historical and socio-political contexts and differ demographically, geographically and politically. For example, New Zealand Maori are unique in having the Treaty of Waitangi that establishes their rights and the nature of their relationship with the government. The Indigenous peoples of Australia, Canada, United States and New Zealand also differ demographically in their population composition (see Table 1).
TABLE 1: PERCENTAGE OF INDIGENOUS POPULATIONS OF A NATION’S POPULATION
|
UNITED STATES |
AUSTRALIAN |
CANADA |
NEW ZEALAND |
|
1.2% |
2.4% |
4.4% |
15% |
|
Sources: |
|||
1Statistics Canada acknowledges the undercounting and incomplete data of Indigenous census data for 2001.
The relatively low numbers of Indigenous people impacts on their efficacy to politically affect changes to address their health status and service issues, compounded by the utilitarian approach to rationalising and allocating resources for health service delivery by diverting essential resources away from Indigenous health need to those with less need and health risk (Reid & Robson 2006). The rurality and geographical isolation also experienced by some Indigenous groups in Australia and Canada also presents issues that differ from those in Aotearoa New Zealand. Diversity among, and within, contemporary Indigenous groups as a result of colonising experiences, inter-ethnic marriages, urbanisation, rurality, socio-economic status, educational experiences, capitalism, and technological advances also need to be considered.
Similarities also exist for Indigenous populations with histories of colonisation. The colonising agenda to civilise 'savages' and re-create Indigenous peoples in the effigy of their colonisers was aided by policies of assimilation and integration, and legislation banning language and many cultural practices. The resultant loss of people, land, language, socio-economic viability and cultural practices, along with changes in social structure and roles imposed a legacy on Indigenous people that survives today, causing spiritual distress that impacts on health status.
Indigenous Understandings of Health
'The understanding of difference is a shared responsibility which requires a willingness to reach out into the unknown.' (Trin T Minh-ha cited in Sharples 2006)
Global Indigenous populations share a holistic, spiritual worldview, a collective orientation, and have a strong connection to the land, environment and other living things (Suzuki & Knudson 1992). The reduction of health issues to disease states or physical causes evident in many western health services is the antithesis of an Indigenous worldview and can create barriers to the optimal access and use of health services.
According to Chino and DeBruyn (2006), western approaches to health services are limited in meeting needs and the life circumstances of Indigenous people. Determining Indigenous understandings of health and illness, along with important beliefs and practices, must be a priority and is essential for individualised care. This enables holistic, spiritual and collective approaches to health and wellbeing, and provides insight into the essential needs from the perspective of the Indigenous patient and their family that require consideration and incorporation into intervention and treatment plans.
Moving Forward
It is no longer acceptable to deliver a 'one size fits all' biomedical-based health or nursing service. Providing appropriate and acceptable services is vital if meaningful and genuine relationships are to be established with Indigenous people and communities. Indigenous people have the right to quality and effective health services (World Health Organization. 1978; World Health Organization Secretariate 1998). Even with complex and multiple health determinants nurses have a role to develop effective relationships with, and to support Indigenous people and communities to improve their health outcomes (Wilson 2003). Cultural safety provides a framework to build effective relationships based on the understanding that patients may have a worldview that differs from the nurse (Ramsden 1990, 2002). It requires each nurse to explore their own culture, and the potential negative impacts beliefs and practices may have on those they work with. It also requires us to understand the historical and socio-political positioning of Indigenous populations within our midst (Ramsden 1990). Cultural safety provides us with the tools to move our gaze from negative stereotypes, deficit explanations and victim blaming, to recognising the strengths and capabilities that Indigenous people possess to enable self-determination of priorities and to develop self-management strategies. Reframing practice may, however, require time due to the socialisation of both the nurse and the Indigenous patient to the patriarchal health services delivery where the health provider 'knows best.'
Indigenous access and use of health services compound health disparities. It is no longer acceptable to view Indigenous people and communities through lenses coloured by assumptions, negative stereotypes, victim blaming, and deficit explanations. At best these are unhelpful and perpetuate marginalisation within the health sector, removing the right to count. Maloney-Moni (2006: 131) suggest that the so-called non-compliant provides '...the opportunity to implement the tolerance and patience necessary to meet whatever is needed at the time...identify and work with the social, cultural and physical barriers that inhibit clients and their families from accessing quality care in their lives.'
Research by Wilson (2004) with Maori women found health seeking behaviours are influenced by their ability to overcome barriers encountered to accessing health services and the quality of interactions with a health service. Interactions can be promoted by:
- Promoting 'connecting' and 'relating' with Indigenous patients and their families through positive relationships and an individualised approach to establish trust.
- Maintaining the integrity of the Indigenous person and their family by respecting their worldview and incorporating their knowledge and healing practices.
- Facilitating access and use of health services by creating an environment conducive to enabling informed choice.
- Building on existing strengths by recognising the concept of resilience, the patient's life circumstances and the knowledge and skills they possess.
Indigenous health and nursing Indigenous people is a political endeavour, and having an appreciation of this provides a platform for nurses to make a difference. Contemporary Indigenous people are testimony of their resilience and ability to survive amidst the adversities they have experienced. They come to health services with established health care practices that may be different to mainstream approaches, but they have worked. Nurses need to capitalise on these strengths by establishing positive relationships and working 'with' rather than 'over' them.
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