Critical Cultural Perspectives and Health Care Involving Aboriginal Peoples
Annette J Browne
School of Nursing, University of British Columbia; New Investigator, Canadian Institutes of Health Research, Vancouver BC, Canada
Colleen Varcoe
Associate Professor, School of Nursing, University of British Columbia, Vancouver BC, Canada
PP: 155 - 167
Abstract
Despite a growing body of critical scholarship in nursing, the concept of culture continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care. In this paper, we take a critical look at how assumptions and ideas underpinning conceptualizations of culture and cultural sensitivity can influence nurses' perceptions of Aboriginal peoples and Aboriginal health. Drawing on examples from our research, we examine how popularized assumptions about culture can shape nurses' views of Aboriginal patients. These assumptions and perceptions require closer scrutiny because of their potential to influence nurses' practice with Aboriginal patients. Our specific aims are to:
- consider some of the limitations of cultural sensitivity in relation to health care involving Aboriginal peoples;
- explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and
- explore the relevance of a 'critical cultural approach' in extending our understanding of culture in relation to Aboriginal peoples' health.
We discuss a critical cultural perspective as one way of broadening nurses' understandings about the complexities of culture and the many facets of culture that require critical consideration. In relation to Aboriginal health, this will require nurses to develop greater critical awareness of culture as a relational process, and as necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which we live.
Keywords
Aboriginal peoples, Indigenous people, First Nations, Canada, cultural sensitivity, culture, colonialism, cultural safety
Article Text
Attentiveness to issues of culture in health care continues to be a major priority in Canada. In nursing and medicine, the concept of culture has been widely integrated into theory, practice and scholarship. The importance of cultural sensitivity continues to garner particular attention. Recently, the need for greater 'cultural sensitivity' was endorsed in a national Commission on the Future of Health Care in Canada. The Commission also identified Aboriginal[1] health as a particular priority, and specific mention was made about the need for 'training for non-Aboriginal health care providers' to 'learn their [Aboriginal] particular needs and culture' (Romanow 2002: 220). Calls for culturally sensitive programs and services continue to abound, and nurses working in Aboriginal communities or with Aboriginal patients and families are under increasing pressure to provide culturally sensitive care. In this paper, we take a critical look at the assumptions and ideas underpinning the concepts of culture and cultural sensitivity in nursing. In particular, we explore how conceptualizations about culture can influence nurses' perceptions of Aboriginal peoples and Aboriginal health. The specific objectives of the paper are to:
- consider some of the limitations of ideas that often underlie cultural sensitivity in relation to health care involving Aboriginal peoples;
- explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and
- explore the relevance of a 'critical cultural approach' in extending our understanding of culture in relation to Aboriginal peoples' health.
While we follow others such as Swendson and Windsor (1996) by contrasting the ideas underlying 'cultural sensitivity' with ideas generally associated with a critical approach, these are not the only approaches, nor are these various approaches discrete or mutually exclusive. Rather, there are a range of approaches that fall under the rubric of cultural sensitivity, cultural appropriateness, cultural competence, and others. We are less concerned with the labels used to refer to these approaches. Instead, our interest is in the ideas about culture that underlie these approaches, and the consequences that ensue from holding particular ideas.
To begin, we examine the complexities inherent in attempting to define culture. We examine the problems that can arise when culture is defined too narrowly or from a culturalist perspective. Next, we consider the implications of applying narrow definitions of culture in the area of Aboriginal health. Drawing on examples from our research, we examine how popularized assumptions about Aboriginal culture can shape nurses' views of Aboriginal patients. These assumptions and perceptions require closer scrutiny because of their potential to influence nurses' practice with Aboriginal patients. To counter these tendencies toward narrow understandings of culture, we discuss a critical cultural perspective as one way of broadening nurses' understandings about the complexities of culture and the many facets of culture that require critical consideration.
In large part, the arguments we put forward have been influenced by our work (in research, clinical practice and teaching) in the area of Aboriginal health. Both of us are involved in partnership-based research with Aboriginal communities, researchers, and leaders in health. Examples of projects that continue to shape our thinking include: a study exploring access to primary care from the perspective of Aboriginal patients coming to a busy emergency department; a study exploring the working relationships of public health nurses and families who face multiple challenges, some of whom are Aboriginal families; a study applying the concept of cultural safety with hospital nurses who care for diverse patient groups; a study of rural Aboriginal women's experiences and hopes for maternity care; and a study of the interacting risks of HIV and violence for rural and Aboriginal women.
Through these studies, and in our ongoing attempts to push our own thinking, we have had the opportunity to 'unpack' the concept of culture as it is being used in nursing with Aboriginal peoples. We build on the work of numerous authors who offer critical approaches to culture, diversity and difference, including those within nursing such as, for example, Swendson and Windsor (1996), Culley (1997), Allen (1999), Anderson and Reimer Kirkham (1999), Reimer Kirkham and Anderson, (2002), Anderson et al (2003), and Gustafson (2005). Our aim in this paper, therefore, is to examine notions of culture from a critical cultural perspective, particularly as they apply in the context of health care for Aboriginal peoples. To illustrate some of the points we raise, we draw on examples from these various studies.
Culture: A Complex Concept
As Doane and Varcoe (2005a: 304) illustrate in their recent book on nursing as a relational practice[2], attending to cultural differences is central to nurses' ability to provide high quality care to increasingly diverse patient groups. As they write, 'differences cannot be overlooked, discounted, erased, or trivialized - they must be taken seriously.' Critical consideration to 'difference' is particularly crucial in terms of culture because assumptions about what culture is or how to attend to issues of culture have implications for nursing, patients, and health care more generally.
At the outset of this paper, we want to stress that the arguments we are presenting are not intended to discount the fact that cultural differences exist or that nurses need to understand and respond to cultural meanings. Rather, borrowing from arguments put forward by Lock (1993: 145), we wish to draw attention to the potential dangers inherent in 'jumping into a culturally sensitive approach...without first examining what we mean by culture and, even more important what our own values are with respect to the culture of the Other.' To do this, we must first take a look at how understandings of culture have been shaped over time within our profession, within health care more widely, and by wider societal discourses.
Far from being transparent or readily identifiable, culture is a concept that is exceptionally difficult to define (Reimer Kirkham et al 2002). How we have come to conceptualize culture in nursing has been historically and politically mediated, and continues to be influenced by our ever-changing political and economic climate. One need only look at how the events of 9/11 have further institutionalized patterns of 'cultural valuing' (or devaluing) by constituting some members of society as Other, inferior, potentially dangerous, hyper-visible and requiring surveillance (Fraser 2001: 24). The question for those of us involved in health care is: how do understandings of 'culture' shape our attempts to respond to 'cultural issues' or 'cultural needs' - and what are the implications for nursing practice (in this case, nursing practice with Aboriginal peoples)? Critical thinking about these issues is particularly warranted as nurses and other health care providers are increasingly called on to provide 'culturally sensitive' services and programs.
In part, the ease and eagerness with which cultural sensitivity has been adopted in nursing and health care reflects an inclination within the biomedical paradigm to simplify culture into systematized facts that can be elicited as a formula for practice (Lock 1993). Incorporated into everyday nursing discourses through the proliferation of highly accessible textbooks and articles, cultural sensitivity models typically encourage nurses and health care providers to 'become appreciative and sensitive to the values, beliefs, lifeways, practices, and problem solving strategies of clients' cultures' (Campinha-Bacote 1999: 204). Transcultural nursing textbooks are now widely used to provide nurses with systematized, taxonomic descriptions of cultural characteristics for various groups. These guides encourage nurses, for example, to accommodate peoples' diet preferences, communication styles, family dynamics, and culturally-based responses to pain, childbirth, childrearing, etc. While there is no doubt that 'we all come to interactions with cultural and symbolic meanings that organize the ways we experience our worlds' (Anderson 1998: 205), and that cultural orientation shapes our ideas and practices in relation to health and illness, the question remains - how can we engage with ideas about culture without reducing people to stereotypes and without invoking damaging assumptions about culture and differences?
Culturalism and 'Narrow' Definitions of Culture
As Razack (1998: 58) points out, the definition of culture that continues to have the widest currency in Western society is one in which culture is 'taken to mean values, beliefs, knowledge, and customs that exist in a timeless and unchangeable vacuum outside of patriarchy, racism, imperialism, and colonialism,' an understanding that 'reduces all facets of social experience to issues of culture.' Razack is referring here to the process of culturalism - the complex practice and ideology that uses popularized, stereotyped representations of culture as the primary analytical lens for understanding presumed differences about various groups of people (McConaghy 1997).
As a pervasive discourse in nursing and health care, culturalism promotes an understanding of culture that is quite narrow in scope (Culley 1997; Doane & Varcoe 2005a; Reimer Kirkham et al 2002). This narrow conceptualization of culture is founded on the idea that culture is something fixed or static, and as primarily comprising the beliefs, values, behaviours and customs inherent among ethno-cultural group members. These assumed 'cultural traits' are typically those that are identified as different from 'ours,' with the unspoken comparison being with the assumed dominant norm. That is, 'Others' routinely are considered culturally different - with the reference for judging differences being the dominant cultural norm. Narrow assumptions about what constitutes culture are therefore intertwined with the process of culturalism.
Examining the ideology of culturalism provides a framework for understanding the continuities between notions of culture, difference, 'race' and racism (McConaghy 2000). Referring to culturalist discourses about Indigenous people in Australia, McConaghy (2000: 83) writes:
...frequently these images and stereotypes limit and contain Indigenous people and prevent them from attaining material and symbolic gains. In a real sense, these images objectify and de-humanise Indigenous people..... It is this notion of culture which allows Indigenous people to be othered in colonialism.
The process of 'Othering' in the particular instance of Indigenous people is accompanied by racialization. By racialization we mean the social process by which people are labelled according to particular physical characteristics or arbitrary ethnic or racial categories, and then dealt with in accordance with beliefs related to those labels (Agnew 1998). Labelling such as distinguishing people as 'First Nations,' 'Aboriginal' or 'Indigenous' - categories associated with particular ethnic or racial categories and/or physical characteristics - is a racializing process. So, for example, when Aboriginal peoples are characterized as 'strong' or 'spiritual,' such characterizations may support ideas that they need less material wealth, and therefore undermine efforts such as Aboriginal business ventures or land claims.
Culturalist discourses operate by assuming and constructing sharp binaries between Western cultures and particular Other cultures (Narayan 2000). As Ahmad (1993: 18) explains, by 'defining the Other (usually as inferior) one implicitly defines oneself against that definition (usually as normal or superior).' In current times, both within the wider society and in health care more specifically, culture continues to be used as synonymous with difference - differences that are most often based on stereotypes (Reimer Kirkham & Anderson 2002). As Reimer Kirkham and Anderson (2002: 5) argue, 'the concepts of culture and ‘race' continue to operate in tandem, most often with ‘race' as a silent subtext to discourses of culture.' By substituting culture for 'race,' issues of racialization are discussed in less contentious terms. Instead of expressing racism directly, 'coded signifiers' such as culture or cultural differences are increasingly used. Thus, 'common applications of the construct of culture may draw on historical and colonial notions of race and, in so doing, reinforce longstanding patterns of domination and inequities.' It is in the context of culturalism that understandings of culture have become increasingly problematic in nursing and health care, and as we argue, in the specific context of providing health care to Aboriginal peoples.
Implications for Health Care Involving Aboriginal Peoples
In today's political context, the concept of 'democratic racism' helps to explain how Canadians can hold negative, racialized views of Aboriginal peoples while at the same time espousing liberal principles of equality, tolerance, fairness and justice (Henry et al, 2000). Democratic racism refers to an ideology in which two sets of values coexist yet fundamentally conflict - that is, members of the dominant society espouse outward commitments to democratic principles of egalitarianism, 'colour blindness' and equal opportunity, and at the same time, operate on the basis of discriminatory attitudes (Henry et al 2000). This does not imply that members of society are intentionally discriminatory or are even aware of the biases they hold. As Henry et al (2000: 383) explain, organizations and institutions are:
...filled with individuals who are deeply committed to their professional work, who are regarded as highly skilled practitioners, who believe themselves to be liberal human beings - and yet they unknowingly, unwittingly contribute to racial inequality.
One of the features of democratic racism is the framing of culture in the context of multiculturalism. In this context, culture is understood to be something that is celebrated, appreciated, and preserved (Henry et al 2000). Although multiculturalism has drawn attention to the importance of supporting diversity within our societies, it is based on a narrow understanding of culture and focuses attention on practices such as, for example, the customs, food preferences, and artistic works of ethno-cultural groups who are perceived to be different from the dominant cultural norm. As Mullard (1982 cited in Henry et al 2000: 338) wrote almost 25 years ago, multiculturalism focuses on 'saris, samosas, and steel-bands' in order to diffuse the 'three R's: resistance, rebellion and rejection.' Critiques of multiculturalism and related policies have thus focused on how these provide a veneer for liberal-pluralist discourses without providing a way of addressing the existing structural disadvantages and inequalities which persist into the present (Harding 1995; Henry et al 2000).
Understanding the limitations of culture as conceptualized in multiculturalism brings us back to the limitations of cultural sensitivity in nursing and health care. In Canada, the models of cultural sensitivity and cultural competence that continue to predominate are founded on the ideals of multiculturalism (Doane &Varcoe 2005a). Cultural sensitivity thus emerges as one of the central practices of multiculturalism. Given the value placed on multiculturalism in countries such as Canada, the USA, Australia, and the UK, it is not surprising that cultural sensitivity has become the predominant model in nursing and health care.
Cultural sensitivity, as it has been applied in nursing and health care, is founded on liberal principles of tolerance (Doane & Varcoe 2005a). Tolerance, however, is not a politically neutral term. Rather, as McConaghy (2000: 41) argues:
The tolerance and intolerance binary masks the more significant underlying binary of the tolerating majority and the tolerated minority, a power-laden division which lies at the heart of Australian [and we would add Canadian] multiculturalism.
Henry et al (2000: 30) similarly explain that:
the emphasis on tolerance and sensitivity suggests that while one must accept the idiosyncrasies of 'others,' the underlying premise is that the dominant way is superior.
As we continue to argue, in health and nursing contexts, these liberal calls for tolerance, respect and even appreciation of Aboriginal peoples' culture can sometimes mask the racialized assumptions embedded in such discourses.
At the heart of liberal tolerance is a fundamental ambivalence toward the Other (Henry et al 2000). Not unexpectedly, members of the dominant society can slide ambivalently between fascination and disdain for others' cultural differences (Furniss 1999). For example, exaltations of Aboriginal peoples as 'more 'spiritual,' more 'interesting,' or more 'cultural'' than the Euro-Canadian majority can be as objectifying as negative stereotypes (McConaghy 2000: 42). As Newhouse (2004: 12) explains:
most non-Aboriginal people are still caught up in the stereotypical images they see in the media and overlook emerging Aboriginal modernity, viewing Aboriginal people in cultural terms while Aboriginal people see themselves in cultural and political terms.
To illustrate his point, Newhouse refers to a recent Canadian survey[3], which suggests that most Canadians believe that 'it is beneficial to all Canadians that the distinctive cultures of Aboriginal peoples remain strong.' In Newhouse's words, this finding largely represents an endorsement of 'Aboriginal culture' as 'all singing, all dancing, 24/7.' By this, Newhouse means that although Canadians would agree that Aboriginal peoples have a right to practice and express their culture-
...through singing and dancing all they want...[t]ension arises when aboriginal people express a desire and act as more than just a cultural group, when we want to do more than just sing and dance, when we want to develop institutions of governance...and when we want our institutions to be visible, respected and paid attention to. (Newhouse 2004: 12)
Assumptions about Aboriginal peoples and Aboriginal culture - organized quite narrowly around notions of 'singing and dancing' as markers of Aboriginality - can also be given expression in clinical settings. In a recent study conducted in a Canadian hospital where there is a high proportion of First Nations people, nurses discussed their experiences providing care to some of the First Nations patients they encountered (Browne 2003). A nurse in this study seemed to speak with reverence about patients' spirituality:
RN: I find I cannot think of a Native person I have ever looked after that was not a gentle person. I really can't. They are very gentle people.....I think my basic premise, especially with elderly Native people, is that they have a wisdom and a spirituality that many of us, I think, never achieve. They just know things. And I am very respectful of that and...how that is viewed by the other members of their family.
These descriptions could be interpreted as romanticizing or exoticizing First Nations culture; the cultural gaze[4] could be interpreted as a colonial gaze. Fascination with Aboriginal elders and spirituality has the potential to reinforce representations of Aboriginal peoples as exotic Others. At the same time, this nurse could be expressing genuine admiration for the elders she has encountered in her practice. Perhaps the soundest interpretive stance is one that considers both possibilities. The point here is not to determine which interpretation is most valid. Rather, the point is that behaviours and meanings are complex and contextual, and in a research context, narrative excerpts can be read in different ways. Most importantly, perhaps, this excerpt highlights the utility of being continuously self-reflective about how we construct others; to be aware of the language we use to refer to others; to be conscious of the assumptions that underlie our constructions; and to be critical of how we may inadvertently take up and reproduce potentially damaging discourses (Varcoe & McCormick 2007).
Just as discourses that romanticize Aboriginal peoples as purely 'cultural beings' can be mirrored in various ways in the clinical setting, so can discourses that construct people in ways that reflect popularized negative stereotypes. Seeing how negative stereotypes are recreated through discourses of 'culture' provides one of the most explicit illustrations of the relationship between culturalism, racialization, and Othering. One of the most powerful illustrations of this draws on moral discourses of Aboriginal inferiority - discourses that continue to proliferate in Canadian society today. As Furniss (1999: 162) explains:
...[t]he idea of the inherent moral inferiority of Aboriginal people - whether due to race, culture, or historical circumstance - underlies the widespread conviction that Aboriginal people simply do not 'deserve' treaty settlements.
As was done to justify colonial intervention in the past, current social conditions - poverty, high rates of substance abuse, unemployment and poor living conditions - are drawn upon (in decontextualized ways) as evidence of Aboriginal peoples' inability to govern their own affairs. Although economic interests are the fulcrum around which Aboriginal land claims and treaty issues are discussed in Canada, public oppositional discourses and everyday conversations draw on various strands of colonial discourses and common-sense assumptions about 'undeserving Indians' who 'are not ready' for treaties and for whom self-government would be 'a disaster' (Furniss 1999: 151-2). In Canada, these dominant social views about Aboriginal peoples as 'dependent,' as 'getting everything for free,' or as undeserving recipients of government programs continue to be pervasive in the media, in public debates within our communities, and in everyday conversations (Browne 2005; Furniss 1999). The point we wish to stress here is that these perceptions cannot be accounted for as the misinformed opinions of a few individuals. Rather, these are ideas and images that originated in the last century and that continue to shape Canadian pubic consciousness today. The hospital nurses in the study cited above who believed that it's 'just the way their culture is...you get a lot more social things,' or 'they pretty much expect you to look after them...It starts when they are little...The government looks after them, and it filters right on down' are reflecting discourses, language, and messages conveyed in our nation's newspapers, other media, and ordinary social conversations. As Browne (2005: 79) explains:
...[w]ithout a broader base of knowledge about the economic and historical issues that have contributed to marginalization from the wage economy, or the necessity for some communities to rely on government subsidies to maintain a basic standard of living, it can be challenging to see 'dependency' as anything other than a cultural way of life.
In the health care context, assumptions about Aboriginal peoples as 'dependent on the system' or as incapable become linked to assumptions about Aboriginal patients as dependent on pain medications, or as necessarily struggling with addictions, or as less than capable of caring for themselves, or as irresponsible in relation to their families or children (Browne 2003; 2005). For example, in a study of nurses' practices in relation to violence, nurses routinely anticipated violence among 'native' women, claiming that 'native women are more vulnerable to that sort of thing' and feeling 'more comfortable questioning native women' about violence (Varcoe 1997; 2001). A social worker in that study pointed out that referrals she received about child abuse tended to be regarding First Nations families, whereas questionable parenting behaviors by non-First Nations parents would not be as likely to generate such referrals. Such assumptions can have pernicious effects. For example, such dynamics may lead health care providers to withhold pain medication, underestimate the capabilities of certain patients, erroneously attribute stigmatizing experiences to certain people, contribute to the continuing high rates of state apprehension of Aboriginal children, and fail to treat each person with dignity.
Despite the emphasis in health care on culturally sensitive approaches, or perhaps in part because of the ideas underlying such approaches, assumptions about Aboriginal peoples founded on popularized, narrow conceptualizations of 'Aboriginal culture' make it ripe for health care providers to relate to Aboriginal peoples as objectified Others. While at first glance cultural sensitivity seems a laudable approach, when it is built upon Othering and liberal ideas about tolerance, it leaves health care providers open to drawing upon stereotypes and generalized assumptions in their practice.
Shifting the Gaze: Toward a Critical Cultural Perspective
To move beyond practices founded on culturalist views that derive from narrow conceptualizations of culture, nurses and other health care providers will require more complex understandings of the issues involved. The following features of a critical cultural perspective are particularly pertinent to the arguments raised in this paper. These involve:
- understanding culture as a complex, shifting relational process (Allen 1999; Doane & Varcoe 2005b);
- recognizing that popular views of culture, which conflate culture with ethnicity and race, dominate western thinking and promote racialization; and
- understanding that culture is enacted relationally - that is, that we all participate in and create culture for different purposes and have choices regarding how we do so.
From a critical cultural perspective, we understand culture as a relational aspect of ourselves that shifts over time depending on our history, our past experiences, our social, professional and gendered location, and our perceptions of how we are viewed by others in society. Building on the work of Anderson and Reimer Kirkham (1999), one of the definitions that we increasingly turn to defines culture in this way:
It is located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes. It is not therefore reduced to an easily identifiable set of characteristics, nor is it a politically neutral concept.
Consistent with the views held in western society more widely, nurses and other health professionals have been socialized to view culture in fairly narrow terms. Therefore, shifting the gaze to a critical cultural perspective requires critical thinking and self-reflection. A narrow understanding of culture as confined to 'singing and dancing' or food and art, or language and custom allows those who identify with the dominant norm to see themselves as not having 'culture,' rather than seeing themselves as embedded in dominant culture to the point that it is difficult to see that culture and their daily enactments. A critical cultural perspective, and understanding culture as relational, shifts the gaze from cultural Others to the self and examinations of how each individual is enmeshed within historical, social, economic and political relationships and processes. This then leads to questions such as: How am I reinforcing certain norms (for example, Eurocentric norms perhaps) within the culture of health care? How am I seeing certain behaviours, beliefs and practices as 'normal' and others as 'cultural'? How am I serving certain economic and political interests through my daily practices?
A critical cultural perspective simultaneously draws attention to power and to the historical, social, economic, and political relationships and processes themselves. Thus, it can also help us to appreciate how discourses about culture - both in health care and in the wider society - can be interpreted and mobilized in many different ways for different purposes. Razack (1998: 58) refers to these multiple modes of 'culture talk' as analogous to a double-edged sword. As we have seen in some of the examples cited above, discourses about culture can sometimes be used to 'package difference as inferiority' (Razack 1998: 58). In other contexts, a group's claim about the importance of cultural considerations in health programming may be essential for justifying claims for improved access to services or 'for requiring dominant groups to examine the invisible cultural advantages they enjoy.' For example, claims about 'cultural needs' are often used strategically to argue for adaptations to existing health services or for increased funding targeted to particular populations. In these situations, culture may need to be named and brought to our attention in order to illuminate inequitable practices that are related to culture, or to argue for services or programs that will counter discriminatory practices (Doane & Varcoe 2005a). In Canada, for example, it is critical for Aboriginal organizations to argue that residential schooling has had a deleterious effect on Aboriginal culture, so that appropriate healing programs can be designed and funded, and so that communities or organizations can claim their right to healing program funds (for example, programs through Canada's Aboriginal Healing Foundation[5]. Making claims about the cultural damage incurred as a result of many peoples' shared experiences at residential schools can be understood as using one's cultural positioning for strategic purposes. From a critical cultural perspective, this can be appreciated as a legitimate claim made about a group's culture, a claim which ought to be heeded in order for past inequities to be redressed (Doane & Varcoe 2005a). And, from a critical cultural perspective, it would be equally important to look at the other side of the double-edged sword, to see how ideas about culture can also, quite paradoxically, reinforce negative stereotypes.
Viewing culture from a critical cultural perspective helps to remind us that people enact their culture differently, depending on their situation or context. Here we draw on an example from a study done in a rural area of a Western Canadian province, where First Nations women from the local area were asked about their experiences accessing services in a nearby rural town (Browne & Fiske 2001). One of the issues the women described was their sense that providers sometimes became frustrated with them because they (or their family members) were seemingly 'quiet,' or 'passive,' and didn't 'speak up' or engage in small talk during clinical encounters with doctors or nurses at the local clinics or hospitals. What the women realized was that some of their doctors and nurses were framing these forms of 'quietness' as a characteristic of 'First Nations culture.' What we learned from the women who were involved in this study was that for some First Nations women from their region, quietness during health care encounters did signify a culturally specific way of conveying respect to people who are consulted for advice or assistance. But they also explained that, especially for older women, residential school staff reinforced and exploited this culturally defined behaviour to encourage conformity and lack of assertiveness. So, what might have its roots in a cultural tradition of showing respect for authority also became influenced and shaped by intergenerational issues of power and paternalism. The same kind of analysis could be applied to members of particular groups who do not make eye contact, or for whom avoidance of eye contact is thought of as a 'cultural norm' (Doane & Varcoe 2005a: 306). As Doane and Varcoe emphasize, drawing on Razack (1998), interpreting eye contact (or its avoidance) as purely 'cultural' overlooks the influence of power and racism on how people relate in social circumstances, and the extent to which avoidance of eye contact may be a safety strategy for some (though certainly not all) people.
The issue we wish to stress is not whether quietness or eye contact are cultural characteristics or not. Rather, certain relational styles may stem from one's cultural orientation and/or from historical issues such as residential school experiences (in Canada, in particular), or the long-term, intergenerational effects of discrimination and marginalization. Viewing quietness or passivity narrowly, in terms of purely 'cultural characteristics' or 'cultural behaviours,' diverts our attention away from the wider issues of long-standing inequities and paternalism that may be affecting the lives of many (though not all) Aboriginal peoples. Assuming that an individual's communication style is necessarily a reflection of their cultural customs overlooks the significance of the 'burden of history' in shaping everyday interactions and experiences - for example, the fact that status First Nations women were systematically discriminated against through policies enacted in Canada's Indian Act; or that status First Nations people were not granted the federal vote until 1960 and the effect that has had on entire generations of people; or the intergenerational traumas accruing from residential school experiences that many families and communities continue to deal with. Indeed, Smith and colleagues' recent work (Smith, Varcoe & Edwards 2005; Smith et al in press) shows that safe and responsive health care is predicated on understanding the intergenerational impact of residential schools.
When we are called on as health professionals to deliver cultural programs, or culturally-sensitive services, we must first give critical consideration to how we are conceptualizing 'culture' - and become better attuned to the blind spots that may affect our perspectives when we are influenced by a narrow view of culture. It is in this context that we put forward the notion of a critical cultural perspective as a way of shifting our gaze in nursing, so that what becomes problematized is our very understanding of culture itself. Our challenge then is to foster a more complex, multi-dimensional understanding of culture as inherently power-laden, and as enmeshed within a web of political, historical, and socio-economic influences. In the case of Aboriginal health, this will require nurses and other health care professionals to develop greater critical awareness of culture as a relational process, and as necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which we live (Doane & Varcoe 2005a).
Conclusion
Despite a growing body of literature critiquing the limitations of culturalist perspectives, nursing educational programs, continuing education workshops, in-service training, and institutional mission statements continue to promote a relatively narrow understanding of culture and cultural sensitivity. In nursing and health care, we have not given enough attention yet to Lock's (1993: 145) warning issued over a decade ago:
...that the notion of culture is in danger of being seized on as a panacea, as the key which will open the door to a trouble free health care system, while once again, the deeper more persistent problems which lie at the root of so much ill health, most particularly poverty, exploitation, and discrimination, remain unexamined.
Yet, the issues we have raised in relation to current conceptualizations of culture are not intended to discredit the notion of cultural sensitivity or the intention behind it. Rather, our arguments are intended to draw attention to the problems inherent in adopting the narrow definitions of culture embedded in cultural sensitivity models, and how these narrow understandings can perpetuate stereotypes about particular ethno-cultural groups - in this case Aboriginal peoples. Unlike New Zealand, where nurses are required to learn about cultural safety, the historical roots of present day inequities, and marginalizing practices in health care (Nursing Council of New Zealand 2002; Papps & Ramsden 1996; Remsen 1993; 2000), no such formal strategies exist in Canada, the USA, the UK, or Australia. Unfortunately, in the absence of competing frames of reference, nurses will continue to draw on established theories of culture - underpinned as they are by culturalist discourses - to interpret the presumed health and social needs of Aboriginal peoples.
Kelm (1998: xxiii) argues that:
a deep understanding of the nature of colonial relations and of their impact upon Aboriginal lives...[and] health is essential to any process that seeks to undo the racist teachings in our history and to promote social and political change.
Nursing as a discipline must consider how committed we are to unravelling the intricacies of racism and to engaging in the political activity of social transformation. To begin, we must hold up for scrutiny the theories, discourses and assumptions that shape our understanding of Aboriginal peoples and cultures. The point is not to preclude attentiveness to cultural meanings of health and illness; recognizing and responding to the tremendous diversity among Aboriginal cultures is part of relevant, socially responsible nursing care. However, cultural knowledge without attention to structural, political, historical and gendered constraints has the potential to further marginalize and disadvantage patients (Meleis & Im 1999). As nurses, we must, therefore, make space for analyses of politics, culture, and history, and how these have variously positioned us, shaped people's health, and structured our relations with one another. Only then can we work to transform these relations.
[1] The term 'Aboriginal peoples' refers generally to the Indigenous inhabitants of Canada including First Nations, Métis and Inuit peoples (Royal Commission on Aboriginal Peoples, 1996: xii). These three groups reflect 'organic political and cultural entities that stem historically from the original peoples of North America, rather than collections of individuals united by so-called 'racial' characteristics' (xii). Specifically, the term First Nation replaces the term Indian, Inuit replaces the term Eskimo, and Métis refers to people of mixed European and Aboriginal ancestry. The labels 'Native' or 'Indian,' however, continue to be used in federal legislation and policy enshrined in the Indian Act, and in statistical reports and wider public discourses. Under the Indian Act, First Nations peoples are categorized as 'status Indians' or non-status Indians, which distinguishes those who receive legal recognition by the state and those who do not. In this paper, the term 'Aboriginal peoples' is used to refer generally to the diverse groups within Canada. First Nations is used more specifically to refer to research participants who self-identified as First Nations in the studies we cite. In 2001, 1.3 million people reported Aboriginal ancestry comprising 4.4% of the total Canadian population (Statistics Canada, 2003).
[2] A relational approach to practice is based on the understanding that people, situations, contexts, environments and processes are integrally connected and shape each other. In this approach, 'relational' refers to much more than relationships among people, but relationships are considered important and are understood to be shaped by all participants and the contexts within which the relationships occur. Thus, importantly, both nurses and patients shape their relationships with one another, both simultaneously being shaped by and shaping the physical, political, historical, and economic contexts within which they occur (Doane & Varcoe, 2005a; 2005b).
[3] This survey, titled Portraits of Canada 2003, focused on relations between Aboriginal and non-Aboriginal Canadians (Centre for Research and Information on Canada 2004). The findings 'generated significant media interest, raising red flags about public views on matters central to the aspirations of Canada's Aboriginal people' (1).
[4] We use 'gaze' as Bannerji (1993) and Dyck (1998) do, and as originally conceived by Michel Foucault, as a lens of and for power.
[5] Information about the kinds of programs funded through the Aboriginal Healing Foundation can be found at http://www.ahf.ca/.
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