Indigenous Health Care: Advances in nursing practice

Vicki Smye
Assistant Professor, New Investigator, Canadian Institutes of Health Research, School of Nursing, University of British Columbia, Vancouver, Canada

Maria Rameka
Principal Lecturer, School of Nursing, Auckland University of Technology, Auckland, New Zealand

Eileen Willis
Department of Palliative and Supportive Services, School of Medicine, Flinders University, Adelaide SA

PP: 142 - 154

Article Text

The submissions in this issue provide a glimpse into some of the challenges and advances in nursing with Indigenous peoples across all areas of practice - clinical, education, research (including theory development) and policy. They highlight the need for a continued commitment to the development of a critical consciousness in nursing - both an inward critical reflection by the nurse and nursing more broadly, as well as attention to the broader social, political, and historical factors that shape health care and Indigenous health. In order to bring this agenda into relief, we have divided the papers into four sections.

In the Introductory section, the paper by Annette Browne and Colleen Varcoe challenges us to examine the way in which 'culture' is taken up in nursing. They argue that this is not a neutral concept; rather it is located within social, political, and historical processes that impact on Indigenous health and how health care is provided to Indigenous peoples. Adding to a growing body of critical scholarship in nursing, the authors challenge us to think beyond cultural sensitivity and the pursuit of knowledge about the values, practices and beliefs across diverse 'ethno-cultural' groups, to engage critically with notions of 'culture'. They do not discount the fact that cultural differences exist or that nursing needs to understand and respond to cultural meanings, rather, the authors argue that nurses and nursing need first to examine how understandings of 'culture' shape attempts to respond to 'cultural issues' or 'cultural needs'; that is, nursing practice with real consequences for Indigenous health. For example, although recognition of 'Aboriginality' draws attention to health inequities in a population, it runs the risk of attaching health problems to a 'culture' rather than to the context in which those health issues occur, and of reinforcing existing stereotypes. This paper provides us with a critical lens for reading 'culture' across the articles in this issue, along with our brief Introductory critique of the use of language and, in particular, the terms used to capture 'Indigenous' identity and 'sense of community' touched on in papers presented in this Issue. As with 'culture', the language used to identify groups of 'people' is not an impartial activity; it is complex and influenced by a number of contextual features, with similar potential for negative consequences for Indigenous peoples.

In Section 1, Nursing in the Indigenous Context, the papers challenge nurses to think critically about health provision in the Indigenous context. In their paper entitled, Decolonisation: a critical step for improving Aboriginal health, Tahnia Edwards and Juanita Sherwood argue for decolonizing nursing practice that begins with a respect for and recognition of the credibility of Indigenous knowledge and voice. In addition, they implore nursing to engage with research and education (including non-Indigenous university staff) that begins with knowledge of Indigenous histories, ie the impact of colonial processes on Indigenous health, and to work towards addressing needed structural change within health care. In the paper, Amorphous practice: Nursing in a remote Indigenous community, Jennifer Cramer presents the findings of an ethnographic study, with nurses in a remote Indigenous community, which underlines the important role of nursing in shifting the care provided to Indigenous peoples. The erosion of the nursing role through the medicalization process, in addition to escalating health and social problems, particularly in remote Indigenous communities, poses serious challenges for nurses to care within the scope of 'best practices' and for Indigenous peoples to be provided with health care that meets their health needs. This paper draws attention to the need to examine professional obligations [of all health care practitioners] using the lens of 'cultural safety' in these settings. Importantly, it illuminates the political and practical nature of cultural safety in the remote context. This practical work done in recent years by the Council for Remote Area Nurses (founded by Cramer in the 1980s) is outlined by Sue Lenthall in her review (in this issue) of Cramer's book, Sounding the Alarm, from which this paper is taken. Both Cramer's paper and Lenthall's critique provide a useful starting point for discussion on issues raised about nursing Indigenous peoples in remote contexts.

The paper by Victoria Simon, Characterizing Maori nursing practice, addresses the question of 'what might constitute Maori nursing practice.' The findings of this qualitative study conducted with Maori nurse participants led the author to recommend that Maori nurses need to be alert to: i) the impact of western scientific models on Maori healthcare; ii) the (often passive) non-acceptance of Maori within mainstream institutions; and iii) the benefits of valuing Indigenous nursing programmes. They concluded that being able to identify as Maori and use Maori practices and models of care is important to Maori nurses.

In Section 2, Indigenous Understandings of Mental and Physical Health: Indigenous Health Care Issues, the papers provide some insight into the way in which nurses and others have attempted to understand the Indigenous worldview around birth, healing, illness and death. The section begins with a brief introduction by Laurie 'Lali' McCubbin who identifies a number of universal issues for Indigenous peoples across the world, echoed in papers in this issue that focus on Australia, Canada, and New Zealand.

Claire Fenwick's paper, Assessing pain across the cultural gap: Central Australian Indigenous pain assessment, makes the necessary point that the human experience of pain is universal; it is the cultural expressions that may differ. As Fenwick argues, these differences in cultural expression are the underpinning of racist assumptions by non-Indigenous health professionals. Pertice Moffatt and Ardene Vollman then describe Tlicho women's medical travel for childbirth. Their analysis goes beyond the individualised nurse's assumptions about Indigenous experiences of pain or suffering to expose the way in which policy can ride rough over people's needs. As they note, constructing childbirth as risky denies that hospital births, away from community and kin, might also be risky for Tlicho women.

In their paper, Insights on Aboriginal peoples' views of cancer in Australia, Pam McGrath, Hamish Holewa, Katherine Olgivie (confirming spelling), Robert Rayner and Mary Anne Patton provide an in-depth account of Northern and Central Australian Aboriginal views of the etiology of cancer. McGrath and her colleagues move from the myths held by non-Indigenous health professionals 'that cancer is not an issue here,' to illuminate some of the metaphysical and spiritual understandings and explanations held by some Aboriginal people. McGrath et al tread delicately in recording these views, noting the difficulties with language and confidentiality. We have picked up on some of these issues in our own discussion of Language across the cultural and colonial divide.

In the final paper in this section, The experience of Whanau caring for members disabled from the effects of a cerebro-vascular accident, Andrea Corbett, Karen Francis and Ysanne Chapman sought to understand the Maori experience in accepting responsibility for the care of a Whanau member following a cerebro-vascular accident (CVA). Individual and focus group interviews were undertaken with Maori patients and their caregivers to explore this phenomenon. Findings point to the central place of family in the caring process, but also challenge non-Maori health professional assumptions that this means care-givers can be left to cope alone. A thread coming through all these papers is the centrality of kinship in the experiences of birth, illness, healing and death.

In Section 3, Nursing Partnerships in Indigenous Health, the papers provide examples of where nurses have endeavoured to bridge the divide between the profession and Indigenous peoples. As Tzu-I Tsai notes in her overview of the issues, this is a challenge for community health nurses and includes revealing the issues to health policy makers. The first four papers deal with the issue at the collective level, while Janet Kelly takes a very personal approach in her paper, Is it Aboriginal friendly? Searching for ways of working in research and practice that support Aboriginal women. The first paper in this series by Sandra Basendowski, Pammla Petrucka, Marlene Smadu, Chief Roger Redman, and Carrie Bourassa describe relationship building for research, using the example of a Southern Saskatchewan urban Aboriginal health coalition. In the second paper, A nursing partnership for better outcomes in Aboriginal alcohol, other drugs and mental health, Charlotte Crespigney, Inge Kowanko, Helen Murray, Jackie Ah Kit and Scott Wilson outline the practical and political ways in which they work with their Indigenous partners. They see their role as including on-going political lobbying in the interest of health policy for Aboriginal people and they act accordingly. Both papers, Meeting the health needs of Indigenous people: How is nursing education meeting the challenge? by Sally Goold and Kim Usher, and The Yapunyah Project: Embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum by Robyn Nash, Beryl Meiklejohn and Sandra Sacre, deal with the provision of appropriate nurse education for non-Indigenous students. They can be read as the state of 'Best Practice' in Australia to date. The final paper in this section by Janet Kelly, Is it Aboriginal friendly? Searching for ways of working in research and practice that support Aboriginal women, details one nurse's journey. Kelly outlines the commitment and learning required, but also the rewards of partnership enjoyed.

It should not surprise the reader that many of the issues are familiar across the three countries, nor that a number of the authors in this issue have turned to cultural safety as a guiding framework for understanding the impact of colonialism on Indigenous peoples and as the starting point for reforming nursing practice. The invited commentaries by Laurie 'Lali' McCubbin and Tzu-I Tsai reveal for us that Indigenous peoples, whether they be in Taiwan, Hawaii, New Zealand, Canada or Australia share a similar history of colonization and its consequent devastation on their health.

It is this similarity of colonial experience and its aftermath, as it relates to the health of Indigenous peoples and, in particular, inequities in health status, that draw our attention to the need for nursing to engage with a critical social and political consciousness in all areas of practice.

Developing a critical consciousness in nursing: from cultural sensitivity to cultural safety

As argued in the paper by Browne and Varcoe and several other authors, without tools or strategies for thinking critically about issues of culture, history or race, evidence of discriminatory policies and practices in the health system go largely unrecognized by most health professionals (Anderson 2000a, 2000b; Anderson & Reimer Kirkham 1998, 1999; Browne 2003; Browne, Smye & Varcoe 2005; Meleis & Im 1999; O'Neil 1989; Reimer Kirkham 2000; Smye 2004). For example, in Smye's (2004) dissertation study it became apparent that the lack of attention to Aboriginal mental health within the mental health system in British Columbia, Canada, was related, at least in part, to the way in which dominant discourses - now taken for granted - factored into institutional policies and everyday practices. In a Canadian context, an assimilationist ethos continues to prevail, in large part masked by the seemingly neutral and universal aspects of institutional structures, policies and practices that both mediate and support its existence. Consequently, Indigenous health and attendant 'differences' from mainstream understanding (such as strong family, community and kinship ties that challenge notions of 'family') and Indigenous beliefs about health and healing are largely glossed over or ignored by health authorities. According to Henry, Tator, Mattis and Rees (2000), as long as health care institutions, policies and practices remain unexamined, discourses operating as social practices will continue to reinforce the status quo.

The question to be raised is 'What is nursing's responsibility in disrupting the status quo?' As Starzomski and Rodney (1997: 232) argue, intervention by nursing in socio-political structures is as essential to promoting health and preventing illness as are nurses' activities with the individual client[1]. By shifting the locus of change in nursing from the individual to focus on uncovering and critiquing the oppressive social structures that constrain people's health (Butterfield 1990; Meleis & Im 1999; Stevens 1989), nursing will be better positioned to meet the needs of the client. As Stevens (1989: 63) argued almost two decades ago-

...the more actively and extensively nurses are able to perceive and reflect upon their social, political, and economic environment, the more effective they become in their interactions, a condition that is the essence of health.

Stevens arguments remain current and are perhaps all the more pressing in today's context. Take for example a case illustrated quite poignantly by a colleague of Smye's working as a community health nurse in a remote Canadian First Nations community, as she relayed a story about the seemingly mundane topic of diaper rash. Apparently, on a regular basis, nurses had been giving mothers a salve to apply to babies' bottoms as treatment for recurring diaper rash. However, as the nurses came to know the mothers better in the community and, as they sought to understand the pervasiveness of diaper rash, they came to realize that a lack of clean water for many of the residents was the most likely source of the problem. The outcome was twofold: there was a shift to an upstream approach - the formation of an alliance with the community (mothers, elders, and Aboriginal governance structures) to advocate for clean water; and this shift in the nurses' focus dislocated the health issue from any thoughts that the mothers might be at fault. Thus, health was affected at both the relational and structural levels.

Because of the profound but often invisible or taken-for-granted influences on health institutional policies and practices, we argue that special attention must be directed toward fostering critical consciousness among nurses[2]. Critical consciousness characterized by self-awareness, insight into societal ideologies, mainstream stereotypes and social agency is required to understand the influence of one's own social identity and interpretive lens on health care provided (Reimer Kirkham 2000). It is marked by insight into one's own complicity in racializing practices and discourses, and into how one is caught up and participates in power situations, consciously or unconsciously reproducing patterns of the dominant society (Lather 1991; Reimer Kirkham 2000).

To develop critical consciousness in nursing requires educational strategies and frameworks that focus on the responsibilities and implications of practicing nursing in a postcolonial[3] context where race and power continue to create patterns of inclusion and exclusion in health care settings (Anderson 2004; Browne, Smye & Varcoe 2005; Smye 2004). In the postcolonial context, nursing is challenged to remain cognizant of 'how domination and resistance mark intercultural health encounters at individual, institutional and societal levels' (Reimer Kirkham & Anderson 2002: 10). A deep understanding of our colonial histories and the current workings of internal colonialism might result in more subtle understandings of the history of Indigenous-State relations (Kelm 1998: xxiii), the embeddedness of ideologies and the way in which institutions, policies and practices mediate and support colonial structures (Smye 2004). These are not, however, typical areas of study within nursing. For example, in Canada, mandatory Indigenous health courses are generally not found within the nursing curriculum. Instead, the issue of Indigenous health is often subsumed within other courses, for example, 'Culture and Health' or the 'Sociocultural Context of Health and Illness', or is missing altogether. In addition, the content of these courses is often defined by the instructor who may or may not be well versed in this specialized knowledge area.

As the papers in this issue illustrate, there is a pressing need for tools or frameworks that will help nurses and other health care providers to situate patients' experiences in the larger context of mediating socio-political, economic and historical forces - this to avoid the trap of making sense of difference (in this case, Aboriginality) in ways that 'succumb to racialization, Othering, and reinforcement of existing power inequities' (Reimer Kirkham & Anderson 2002: 9). As Smye's (2004) research indicates, while not intended as such, the erasure or rendering invisible of Indigenous perspectives is a political act (Young 1990). Therefore, fostering an understanding of the political nature of our institutions, policies and practices - particularly in relation to peoples who are disproportionately disadvantaged by politically mediated social conditions - will be required to shift entrenched attitudes. In addition, strategies will be needed to make transparent the political ideological underpinnings of discourses and practices related to Aboriginal peoples, even when we assume a seemingly neutral, apolitical position (Browne 2003; Smye 2004; Young 1990). For example, nurses need to be prepared to question decision-making processes, to query the absence of Indigenous peoples at the decision-making table and the invisibility of Indigenous perspectives/worldviews in practice settings. They need to be aware that policy discourses support the embeddedness of ideologies - that they signify particular aspirations, fears, beliefs and values. Policies determine who has authority and who accepts it (Edelman 1988: 12-13).

Health care delivery systems are not ahistorical, apolitical or transparent. Rather, the lack of attention paid to examining the socio-political and historical positioning of particular groups results in discourses that unwittingly support further disadvantage, oppression and marginalization. If, as Essed (2002) claims, access to knowledge about the nature of domination and inequities leads people to accept more responsibility for changing their practices, nursing must view critical analyses of these issues as central aspects of nursing education, research, theory and practice. However, before nurses can critically engage within the wider context of politically charged health care relations - including health policy and policy making - there is a need for critical engagement with nursing knowledge that is focused on the historical context of Indigenous health and ongoing processes of colonialism.

In the following section, we engage with the notion of cultural safety as a means of fostering a critical political and social consciousness in nursing to create an opportunity for social transformation. In any discussion of Indigenous health, cultural safety provides the vehicle of analysis in ways that push beyond notions of cultural differences. We argue that within nursing circles Transcultural nursing may be adequate for directing nursing practice in some contexts (see for example, Contemporary Nurse 15(3)) - however, among First Nations and other Indigenous peoples, the critical lens offered by Cultural Safety would seem to offer a more robust and authentic approach.

Fostering Critical Engagement in Nursing: Applying Postcolonial Perspectives from Cultural Safety

It seems brutally evident that 'if present trends in [Aboriginal] unemployment, social exclusion and anomic conditions continue unchecked, the results for both Aboriginal and non-Aboriginal peoples will be catastrophic' (Cairns 2000: 208). If this is the case, then how can nursing assist in creating a health care environment in which Indigenous poverty, social malaise and high suicide rates become priority issues; and how do we assist in creating a moral bond that remains attuned to Indigenous perspectives, promotes a united responsibility, but does not create prospective cultural imperialism or new colonialisms, for example, assimilation in a new guise? To form our responses, we put forward an analysis of how the theory of cultural safety embedded within postcolonial perspectives can assist nurses to critically engage with their practice. Conceptualizing the challenge from a cultural safety perspective opens up the possibility for and fosters critical engagement.

Recognizing the strengths and limitations of culturalist discourses (such as the notion of cultural sensitivity), Irihapeti Ramsden (1993), a Maori nurse-leader and scholar in New Zealand, with other Maori nurses, developed the concept of cultural safety within a nursing education context in response to the poor health status of Maori and continuing neo-colonial processes in Aotearoa New Zealand. These processes historically disregarded the illness and health belief systems of Maori, and instead privileged those of the dominant Pakeha or White culture in the construction of the health care system.

Cultural safety is a relational concept. It begins with the nurse who is expected to reflect on her/his own social, political and historical location as a means of understanding what lens she/he brings to the practice encounter. In addition to understanding that the patient has a culture, the nurse must recognize herself/himself as a 'bearer of culture' (Ramsden 1993) and work to understand how that 'culture' influences the provision of care. In this sense, the nurse-patient relationship is 'bicultural.'

In our view, one of the strengths of cultural safety is its linkage to the postcolonial project, with its recognition of power imbalances and inequitable social relationships - a legacy of the postcolonial past and neo-colonial present. With this in mind, the nurse needs to remain cognizant of the ways in which power operates in the health care setting, including in the nurse-patient relationship, and work to minimize power differentials (Papps and Ramsden 1996). In addition, more broadly, there is an expectation that the nurse work to understand the patient's health and illness experience in the context of social, political and historical processes that shape health care and health.

Thus, cultural safety was never intended to be a 'cataloguing of culture-specific beliefs' of the Maori people (Anderson et al 2003: 197; Ramsden 1993); rather it was meant to provide a critical lens through which to examine health care relations within the context of wider historical, social and political forces. As Ramsden (1993: 3) writes-

...Nurses in New Zealand, without the benefit of a broadly based social education, were confusing the cultures of indigenous people with the culture of poverty into which the indigenous people have been driven. It follows then that cultural safety requires nurses to become expert in understanding the poverty cycle and the various histories and socio-political conditions which establish and maintain it.

In essence, cultural safety provides direction for the development of socio-political insights about the disparate power relations within and beyond health care, and the historical and social processes that organize these relations (Reimer Kirkham et al 2002: 227). Importantly, it reminds us that individual health problems are located within the domains of historical and structural disadvantage that shape them, and requires us to unmask the ways in which racism and unequal power relations have resulted in marginalization and poverty with its associated illnesses. For example, incorporating perspectives from cultural safety into nursing discourses would draw attention to how the history of relations with Indigenous peoples has been lived out within the health care system and how the legacy of colonialism continues to be embedded in institutions, policies and everyday practices. It would draw attention to how poverty and social isolation impact on health, understanding that not all Indigenous peoples are living in poverty or are socially isolated, but that there is a disparity between Indigenous health status and non-Indigenous health status linked to socio-economic status and geographic isolation. Importantly, socio-political and historical factors continue to shape health care and Indigenous health.

Increasingly, nurses are taking up the discourse of cultural safety to analyze the complexity of Indigenous health care delivery. In an Aotearoa New Zealand context, cultural safety has been taken up widely in nursing education and practice to provide tools for improving the health outcomes for Maori and other minority groups (Wepa 2004). In their research in Canada, Reimer Kirkham et al (2002) recognized that cultural safety was not an entity, fact or process that could be identified in any realist sense. Instead, they saw it as being constructed through interactions within particular contexts, with recipients and providers of health care, as well as researchers and participants, all continually appraising exchanges as culturally safe or unsafe, depending on their individual perceptions (Reimer Kirkham et al 2002: 228-229). Cultural safety has been conceptualized as a reflexive and interpretive lens for examining how the politics of history, race, and socio-cultural and political positioning are played out in the everyday practices and policies of the health care complex to sustain or disrupt relationships (Anderson et al 2003; Browne & Fiske 2001; Browne & Smye 2002; Smye 2004; Smye & Browne 2002).

Cultural Safety as a Moral and Political Discourse

Because cultural safety links us to the broader socio-political and historical context in which health and health care are shaped and prompts us to ask questions about how systems of dominance permeate research, institutions, policies and everyday health encounters, it raises a set of ethical questions about processes and practices (Anderson et al 2003; Polaschek 1998) and the consequent benefits and risk to peoples' health (Smye 2004). It engages us in a moral and political discourse. Conceptualizing the problem from a cultural safety lens reminds us of the moral goal and therefore provides direction to researchers, educators, policymakers and practitioners to identify and alter any practices or policies that make people feel demeaned or that extend colonizing influences to them as individuals or groups. For example, speaking directly about the responsibility of researchers to address issues of colonization, oppression and domination, LaRocque (1996:12), a Canadian Indigenous scholar, asserts-

I find it impossible to study colonial history, literature, and popular cultural productions featuring Native peoples, particularly women, without addressing the social and ethical ramifications of such study. To study any kind of human violation is, ipso facto, to be engaged in ethical matters. And we must respond - as scholars - as men and women, Native and white alike.

Querying what is moral and just prompts us to interrogate the assumptions that might, unwittingly, underpin our research, education, policies and practices.

In research with Indigenous peoples we need to be vigilant to the ways in which research might be colonizing rather than decolonizing (Smith 1999). Cultural safety provides us with a reflective lens to ask questions such as:

• Whose agenda is being served in this research?
• Is there any danger inherent in doing this work?
• Will Indigenous people benefit from this research?
• Whose voice and knowledge is being represented here?

(Royal Commission on Aboriginal Peoples [RCAP] 1993; Schnarch 2004)

We must be vigilant to the dangers of any 'cross cultural' gaze (Duran & Duran 1995, 2000) - a gaze that implies that there is a relative platform from which all observations are to made, and that the platform that remains in place in our neo-colonial discipline is one of Western subjectivity (Duran & Duran 2000: 87). Such vigilance requires that the researcher be fully engaged with the ongoing process of reflexivity (Anderson 1991; Lather 1991; Reimer Kirkham & Anderson 2002) and to a scholarship committed to re-evaluating frameworks of interpretation, conclusions and portrayals (LaRocque1996) and to building ongoing partnerships with Indigenous researchers and communities (Battiste 2000; Duran & Duran 2000; RCAP (1993); Schnarch 2003; Smith 1999).

In nursing education, cultural safety prompts us to ask questions inside our educational institutions such as:

• Where and how we are creating opportunities for Indigenous students to gain entry into post secondary institutions, understanding that entry requirements assume a level playing field?
• How are we creating safe environments for Indigenous students within the institution to support them to graduation, knowing that many students come from outside the urban setting leaving behind strong community and kinship ties?
• How are we addressing institutional and everyday racism in the classroom, including addressing the beliefs, values, and assumptions of faculty, staff, and students - is a safe space and time being created for such activities?
• What are the pedagogical approaches being used - are opportunities being created for non-Western critical pedagogies to emerge (LaRocque 2001)?
• Is there evidence of innovative learning opportunities such as visits and interactions with Indigenous communities, agencies and scholars as a means of addressing assumptions, stereotypes and dominant images from a critical perspective (Ramsden 1992)?
• Are students being supported to focus on developing methods for influencing change within the health care system, for example, in curriculum development and student projects in partnership with Indigenous communities?

It is our view that cultural safety also provides us with a critical cultural lens for examining health policy. As Ahuarangi (1996:15), a Maori nurse notes-

Institutional changes must begin in the highest echelons of power, where mana Maori motuhake [Maori independence, autonomy and self-determination] and crown sovereignty are in partnership within judiciary, executive and legislature.

Nurses (Indigenous and non-Indigenous) need to be present at the policy table to ask questions such as-

• Where and Who are the Indigenous peoples at the policy table?
• Where are the Indigenous health issues on policy agenda, for example, suicide, diabetes, TB and poverty?
• Who wrote this policy?
• Who does it benefit? and
• Who does it place at risk?

In an analytic sense, cultural safety prompts us to think critically about issues such as institutional racism. For example, how are we to read the lack of attention to Indigenous issues such as poverty and suicide within our policies and institutions? Is it simply an example of institutional racism with its adjunct, long-term disregard for notions of difference, or is it also about how racism intersects with other equally powerful forms of oppression such as class, gender, sexual orientation, age, ability, and so on. For example, considering the erasure of Indigenous suicide from the policy agenda as related to multiple intersections which create a situation of deep-disadvantage and unsafety takes us to a different place in terms of action than simply reading it only as institutional racism (Smye 2004).

As one strategy for fostering critical consciousness regarding the failure of current health policy to meet the most pressing health concerns of Indigenous peoples and to raise accountability, policy decision-makers need to be invited into research projects and health forums and discussions where there may be implications for policy. In addition, in keeping with the above sentiments of LaRocque, Anderson (2000a) argues that research for praxis aimed towards helping participants to understand their situation is the first step toward policy change. In short, the empowerment[4] of people that allows them to engage with policy-makers will have the most profound impact. Notably, this does not imply that Indigenous peoples, as one example, are not aware of the structural inequalities that shape their experiences of health and illness. Rather, it suggests a particular level of engagement - to make explicit the forces that have an influence on our health (Anderson 2000a). In addition, the development of local and global networks to articulate clearly the nature of these oppressive forces is a good starting point towards effecting change.

Lastly, in clinical practice, cultural safety provides us with the tools for thinking critically about notions of 'culture' and attending to issues of difference without giving way to essentializing and stereotyping (Ramsden 1992). The nurse needs to be supported to reflect critically on practice - to be supported to engage in excellent relational practice. Critical reflective practice would include asking what are the beliefs, values, and assumptions leading my thinking and actions? What does my patient and their family believe is important to health and healing? What are the ways in which power is operating in my relationship with this patient/family? Are there policies and practices which exclude my patient and their family in this setting or create risk for them?

Neo-colonialism continues to pervade health care provision (Browne 2003) and. as a consequence, nurses and other health care providers need to be supported to develop a language for discussing the tensions and disjunctures that arise in their relations with patients/clients and one another - to open a space for dialogue within the institutional setting and in nursing at large to discuss the ways in which everyday practice is influenced by socio-political, economic and cultural factors. Notably, cultural safety demands that the nurse and nursing not only engage in critical reflective practice but also engage in action to disrupt the status quo - to engage with the social mandate of nursing.

Critiquing/analyzing research, institutions, policies and practices from a critical postcolonial vantage point using a cultural safety lens has the potential for revealing the taken-for-granted processes and practices that continue to marginalize Indigenous voices and needs - it provides us with something to look through. Raising critical consciousness in nursing is crucial to addressing the broader socio-political and economic determinants of Indigenous health. As nurses, we must make space for analyses of politics and history, and the ways in which these have variously positioned us, shaped people's health and structured our relations with one another - only then will we be able to transform those relations.

Conclusions

The factors most often identified as contributing to the discrepancy in health status between non-Indigenous and Indigenous peoples are multiple and include poverty, unemployment, changes in diet due to factors such as forced relocation, poorer education for many, threats to cultural identity and racism and discrimination (Dodson 1997; Kilshaw 1999; Royal Commission on Aboriginal Peoples 1996a, 1996b), at both individual and systemic/institutional levels - in short, the consequences of colonial and neo-colonial processes. These are moral issues that nurses in practice, education, research and policy must attend to in the provision of health care involving Indigenous populations.

In research with Indigenous peoples, cultural safety provides a postcolonial framework to examine unequal power relations and the social and historical processes that organize these relationships (Browne, Smye & Varcoe 2005; Smye 2004). The notion of 'culture' in cultural safety is used to address the importance of recognizing and respecting Indigenous perspectives related to health and illness, and the desired/needed responses to health issues, in addition to the utilization of those responses in the shaping of health structures, understanding that meanings shape systems and practices, and vice versa. The notion of safety helps us, as practitioners, to focus on health outcomes - that is, are Indigenous people benefiting from the health care system as it currently exists, or does it place them at risk? For example, do suicide prevention strategies address the root causes of despair and hopelessness apparent for many Indigenous people, and fit with Indigenous perspectives (understanding that this is not one perspective)?

Although applicable to service delivery, research, and policy across diverse populations, it is our view that cultural safety is particularly useful in the area of Indigenous health because of the historical context of Indigenous health and health care, and relations within the political economy. By viewing cultural safety in this broader context, issues of institutional racism and discrimination that continue to shape the provision of health care for Indigenous peoples can be better critiqued (Smye & Browne 2002; Smye 2004).

In summary, we share the vision expressed by Anderson et al (2003: 198) that cultural safety be used in a way that-

...transcends the boundaries of race and nationalism to emphasize realignments that expose our common humanity and vulnerabilities and lead to new epistemologies of human suffering and pathways to healing. The opening up of such a space to foster the negotiation of hybrid cultural meanings, and new epistemologies of human suffering and pathways to healing, might be a step forward in working toward transformative social practice.

[1] Client is defined here broadly as considering the needs of the aggregate as well as the individual (Starzomski & Rodney, 1997: 227).

[2] Ideally, all nurses - front line nurses, educators, administrators, academics, researchers and policy analysts - would demonstrate critical consciousness. Students would demonstrate an increased ability for critical consciousness as they charter their way through the educational process.

[3] Rather than signifying a temporal location, McConaghy (2000) asserts that the 'post' in postcolonial does not mean the notion of 'after colonialism' but rather explains the postcolonial 'as a place of multiple identities, interconnected histories, and shifting and diverse material conditions. It is also a place where new racisms and oppressions are being formed' (p.1). For example, in Canada today, the lives of many Aboriginal people are still organized in large part by the Indian Act. Drawing on Homi Bhabha (1994), McConaghy (1997) describes the postcolonial as a time for reflecting, a moving back and forth and beyond the colonial. This reflexive process, which characterizes the postcolonial 'is a sign that we are now more aware of our historical locatedness, less sure of the rightness of our policy decisions, more alert to the possibility that our decisions may be colonizing rather than decolonizing in their consequences, more able to be responsive to new situations of disadvantage and more able to correctly analyze and redress the specifics of local oppressions.' (p.86; as cited in Smye, 2004).

[4] The term empowerment is used with some reticence. The concern Anderson (1996: 703) suggests 'is that the politicizing of 'empowerment' could provide the rationale for 'off-loading' of responsibilities to people who have been made vulnerable through illness, who have few resources, and who are least able to assume the responsibilities that the empowerment movement suggests.' Lather (1991: 4) defines empowerment as 'analyzing ideas about the causes of powerlessness, recognizing systemic oppressive forces, and acting both individually and collectively to change the conditions in our lives.' Importantly, people come into a sense of their own power - it is not something we do 'to' or 'for' someone.

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