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Nursing, Indigenous Peoples and Cultural Safety
So what? Now what?
Madeleine Dion Stout
Past President of the Aboriginal Nurses Association of Canada
Bernice Downey
Former Executive Director of the Aboriginal Nurses Association of Canada; former Chief Executive Officer of the National Aboriginal Health Organisation
Article Text
Cultural safety is a powerful nursing concept conceived by Irihapeti Ramsden, a Maori nurse. Today this concept is moving the nursing of Indigenous people in a new trajectory as the many articles in this issue demonstrate. Its explicit purpose is to consider historically determined power relations between nurses and Indigenous people and to bridge the differences that have evolved. Significantly, cultural safety finds expression in caring spaces that are equality seeking and rights oriented. The over-arching goal is the health development of Indigenous people. However, too much can be taken for granted when a perceived panacea like cultural safety emerges.
First, the caring spaces that are occupied by Indigenous people and nurses are also potentially the new arenas of struggle for both sides. For example, Indigenous people in North America are agitating to have historic trauma defined as a disease at a time when they have placed the bio-medical model (of which nursing is a part) under siege.
Second, a tension between the totality of self and the totality of one's environment is inherent in cultural safety affecting both nurses and Indigenous people. For the former group, there is the constant risk of being professionally 'dumbed down' when providing care to Indigenous people in remote areas. For the latter, leaning heavily against risk pile-up conjures up everyday, often unconventional, forms of health and healing which can evade recognition and understanding by nurses. How many nurses perceive substance abuse as the oldest form of protest by Indigenous people?
Third, an overemphasis on culture as a health determinant can bring about an abdication of responsibility over all other health determinants by health determiners like Indigenous people and nurses. In this case, both are relegated to deficit positions reduced either to cultural or non-cultural beings. Finally, while cultural safety attempts to cast Indigenous people as key actors in their health development, their response to this concept and its reflection of their linguistic and cultural diversity - let alone their nested identities and drifting ethnicities - have yet to be thoroughly tested.
For their part, nurses have to grapple with the 'cellular knowledge' possessed by Indigenous people as a result of living their traditions and customs. Indigenous people are knowers, doers and givers of health and healing and so must be respected as their own witnesses in encounters with nurse clinicians, managers and researchers. Therefore the imperatives of nursing practice, traditional knowledge and healthy policies have to be factored into any discussion of cultural safety. The very fact that cultural safety was conceived by catalysts for health development (nurses) suggests that at least two other levels need to be considered. A bottom-up approach will reveal the grass-roots imperative while a top-down approach should underscore the roles and responsibilities of high level decision makers. Cultural safety is the cross-cutting theme at all three levels and none can be given short shrift, particularly if this concept is to be institutionalized in health systems.
Nursing and Indigenous Populations
The International Council of Nurses (1999) reports that there are more than 300 million Indigenous peoples in the world. They also report that Indigenous peoples are over-represented among the world's vulnerable groups ... suffering low incomes, living in poor conditions and lacking adequate access to employment, education, safe water, food and health care service. Available morbidity and mortality data exceed non-Indigenous data by far[1]. It would be safe to say that there is a heightened awareness and little debate required within nursing and other health professions regarding the need to address the health inequities of Indigenous peoples around the globe. There are many outstanding questions however, regarding whether and how to go about doing this. In addition, as nursing practice specific to Indigenous peoples evolves, how does/will health service infrastructure and government policy support it? What are the missing areas of scientific inquiry to further establish the evidence base?
So what? Is nursing practice under the banner of 'culture' enough?
Davis (2005) states that questioning; debating and developing new definitions and knowledge are at the heart of any profession that wants to continue to be relevant. One also needs to consider that existing knowledge for Indigenous peoples needs to be included and that it is not 'new' knowledge but knowledge that has guided Indigenous peoples for thousands of years and that has been handed down in the oral tradition over the generations. As encounters between nurses and Indigenous peoples are considered, the following questions are raised:
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Does the nurse 'instinctively' know how to nurse her client in a culturally appropriate way?
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Would she attribute it to how she was educated in nursing?
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Does she consider her own cultural perspective?
The relationship between theoretical concepts of Indigenous health care provision and culture is one with many complexities. While definitions of culture appear rampant in the literature, the task of defining culture in the context of Indigenous health is an evolving one. The United Nations Educational, Scientific and Cultural Organization (UNESCO) (1982), in the Mexico City Declaration on Cultural Policies, provides a holistic definition of culture:
That in its widest sense, culture may now be said to be the whole complex of distinctive spiritual, material, intellectual and emotional features that characterize a society or social group. It includes not only the arts and letters, but also modes of life, the fundamental rights of the human being, value systems, traditions and beliefs; that it is culture that gives man the ability to reflect upon himself. It is culture that makes us specifically human, rational beings, endowed with a critical judgement and a sense of moral commitment. It is through culture that we discern values and make choices. It is through culture that man expresses himself, becomes aware of himself, recognizes his incompleteness, questions his own achievements , seeks untiringly for new meanings and creates works through which he transcends his limitations.
The World Health Organization (WHO) reports that the most common definition of 'health' for the last fifty years is 'a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity' (Ustun & Jakob 2005). Ustun and Jakob report that the word 'health' originated from an old English word 'hoelth' which meant a state of being sound and 'was generally used to infer a soundness of the body.'
Indigenous peoples across the globe have identified the importance of articulating their own definition of health. Aboriginal[2] belief systems define health as a life lived in balance with other systems of which an individual is a part, such as environment, community and family[3]. An Australian Aboriginal definition notes that '...Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community. This is a whole of life view and includes the cyclical concept of life-death-life.' How do we address the concept and various definitions of 'culture' in the evolving dialogue without compromising Indigenous rights to the comprehensive array of resources and services required to address health status in a holistic way? Caution is needed to ensure that 'cultural approaches' do not become a way to 'hand-off' the work to Indigenous peoples given that spirituality and cultural traditions are so akin to them yet are often only legitimized by decision-makers because they are cost-effective, not because they are of the communities' making. A balance is needed so that commitments to self-determined approaches are supported by sustainable resources.
Culturally Safe Care - is this it?
Nurse leadership discussion on nursing practice and scientific debate is focused more than ever before on topics which include cultural competence, cultural safety and culturally congruent approaches. Several contributing authors in this issue demonstrate the importance of understanding the relationship between these overarching concepts of Indigenous culture and nursing practice. Wells (2002) discusses cultural competence in relation to the Cultural Development Model which is based on the realization that cultural awareness, cultural sensitivity, and cultural competence do not go far enough to achieve the level of cultural development required by health care professionals and institutions to effectively meet the health care needs of a diverse population. Within this model, cultural competence is defined as 'the routine application of culturally appropriate health care interventions and practices' (Wells 2002). As this dialogue unfolds, there remain many important questions and factors for consideration. For example, Indigenous peoples for thousands of year have passed on first-hand knowledge regarding the promotion of their well-being. As healthcare workers strive to 'get it right', they need to be conscious that Indigenous peoples do know how to take care of themselves. While current health statistics often paint a bleak picture, Indigenous peoples have also clearly demonstrated their own resiliency and strength to survive in the face of adversity. They possess a sense of pragmatism grounded in personal and political self-determination. The United Nations (UN) framework of treaties and covenants guarantees self-determination of peoples as a basic human right that all human beings share[4]. Health is also a basic human right and Boyer (2003) in The International Right to Health for Indigenous Peoples in Canada notes that it appears in a variety of UN instruments or conventions that comprise the UN framework of rights. Boyer (2003) argues that the right to health includes the right to health care and encompasses the right to a culturally appropriate health care system.
An important aspect of a culturally appropriate health care approach for Indigenous Peoples is the use of traditional knowledge or traditional medicine. WHO reports that the use of Traditional Medicine (TM) is on the rise and that one of the key factors in this increase is that it is firmly embedded in a wider belief system. For most Indigenous peoples, kinship, the cosmos and the universe form the basis of who they are. Their evidence stems from their intuition, ancestors, dreams, totems and stories but is often marginalized because it cannot be measured. This world view is embedded in their languages which connect them inextricably to the planet, not just to other people. Self-determination approaches have proven that there is strength in the romanticisation of their culture since its erosion and loss is prevented in the process. Cultural safety has made inroads for them in this respect. However, the living contexts of Indigenous peoples find them struggling under crushing burdens of disease, illness and sickness which cultural safety under-emphasizes. They continue to adjust to the net effects of historical wrongs even as they take up the mantle of self-determination. Are we certain then that 'cultural safety' is paving the path for self-determination? How will we ensure that a cultural safety conceptual model makes room for self-determination and traditional knowledge?
Knowledge gaps - Are we forgetting what we forgotten?
As we look to the future and acknowledge the notion of cultural safety as a conceptual nursing model for Indigenous populations, we also need to understand what it is that we do not know. Has the work been inclusive of front-line nursing and Indigenous communities? Is it driven from the ground up or is it a 'top-down' notion? In keeping with a self-determined approach, it is critical that we learn from the people we serve. What is it that they need from health care workers? Has it been articulated accurately? Do we know it works; what are the current research questions to consider? How is gender considered in it all? A gender-based analysis would surely enhance our existing knowledge base. It's important that we do move beyond the boxes of multi-culturalism and diversity where too often Indigenous populations are further marginalized. We also need to further 'indigenize' the knowledge base. For example, the ownership, control, access and possession (OCAP) principles in Canada present a political response from research malcontents in the Indigenous community who have disclosed and opposed institutionalized research approaches that have made a mockery of their rightful place in knowledge production. The OCAP principles are undergoing considerable debate because they assert the following self-determining principles:
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Ownership: a community or group owns information collectively in the same way that an individual owns his or her personal information.
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Control: affirms that Aboriginal communities are within their rights in seeking control over all aspects of the research process.
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Access: Aboriginal peoples must have access to information/data about themselves & their communities, regardless of where it is currently held. The right of Aboriginal communities to manage and make decisions regarding access to their information and resources.
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Possession: Actual physical control of data (ownership identifies the relationship between people and their information). A mechanism by which ownership can be asserted and protected. Most legally significant of all the OCAP principles (Schnarch 2004).
As we consider the research priorities, we also need to advocate for infrastructure support and achieve calls and funding support for scientific study that will advance these objectives. As we move forward in adopting and implementing culturally safe approaches, we will also need to establish indicators to measure our success along the way. These indicators will have to be multidimensional since they will not only have to measure process and outcomes but will also have to reflect faithfully the cultural, political, social and economic aspirations of Indigenous peoples. Cultural indicators are especially important given the expectation that cultural safety will increasingly inform the health and healing of Indigenous peoples.
Now what?
Nursing scholars are paving the way in articulating an indigenized approach to nursing Indigenous populations. The concept of 'self-determination' and the utilization of traditional knowledge and medicines among Indigenous peoples is not just 'nice to know' but a critical area of awareness and understanding that needs to be captured in educational curricula. A foundation of evidence is slowly being established towards the achievement of this objective with the development of theoretical information in the areas of cultural competency and cultural safety. We also need champions in our learning institutions who can break down the barriers towards developing and integrating such curricula and ensure that it is grounded in an accurate historical perspective consistent with the experience of Indigenous populations.
Similarly, governments need to acknowledge that true advancement of Indigenous population health is not possible if we continue to work within the same structural inequalities. If culturally safe approaches are applied within this same context, how effective will it be towards truly changing the status quo? How will we ensure that political will and policy will support the implementation of cultural safety? How will we challenge the 'multi-cultural' and 'diversity' pigeon holes into which Indigenous peoples are often lumped when it comes to government funding and programs? Will cultural safety be real or will it be another form of paternalistic control disguised as a panacea approach for Indigenous peoples? The Pan American Health Organization (PAHO) (2002) reported on a set of principles that included the need for a holistic approach to health; the right to self-determination of Indigenous peoples; the right to systematic participation; respect for and revitalization of indigenous cultures; and reciprocity in relations. In addition, there is a call for a systematic, integrated approach to disadvantaged populations[5]. A 'balance of universal and targeted interventions is needed to create environments supportive of change ...including Aboriginal Peoples' (Public health Agency Canada 2004: 5) In 1999, WHO called for a 'new' universalism that while recognizing government limits also holds governments responsible for the leadership, regulation and finance of health systems (WHO 1999: 15). Concepts of ‘universal entitlement' speak to the need for priorities to be set. Nursing associations are already working with governments on the identification and implementation of priorities (International Council of Nurses 2000). The advancement of culturally safe approaches for Indigenous peoples will require nursing leadership to advocate for effective policy reform,
[1] Life expectancy at birth is 10 to 20 years less than for the overall population in a country. Infant mortality rates are 1.5 to 3 times greater than the national average. Malnutrition, often associated with land displacement and contamination of food supplies, and communicable diseases (malaria, yellow fever, dengue, cholera, tuberculosis affect a larger proportion of indigenous peoples. Substance abuse (smoking alcohol and drugs), cardiovascular diseases, diabetes, unintentional injures and domestic violence are significant health and social problems. Many are associated with lifestyle changes resulting from acculturation.
[2] The terms Indigenous, Aboriginal, Aborigine, First Peoples are used interchangeably while it is acknowledged that there is broad diversity among the world's Indigenous groups with many tribal-specific designations.
[3] Ibid.
[4] The United Nations framework of treaties and covenants also guarantees equality rights, respect for human rights and fundamental freedoms for all without distinction as to race, sex language, religion and conditions of economic and social progress and development.
[5] The Federal Government of Canada via the Health disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security states that this approach places emphasis on building leadership and processes to address health disparities generally.
References
Boyer Y (2003) The International Right to Health for Indigenous Peoples in Canada, National Aboriginal Health Organization & The Native Law Centre, Ottawa/Saskatchewan
Davis AJ (2005) 'An Open Letter to the International Community asking What are we going to do about it?' International Council of Nurses. Accessed 18 April 2006 at www.icn.ch/INR/comment-inr_466.pdf
International Council of Nurses (1999) Nursing Matters Fact Sheet: The Health of Indigenous Peoples: A Concern for Nursing. Accessed 18 April 2006 at www.icn.ch/matters_indigenous.htm
International Council of Nurses Nursing and Development Policy Background Paper (2000). International Council of Nurses. Accessed 18 April 2006 at http://www.icn.ch/policy_paper1.htm#inequalities
Pan American Health Organization (PAHO) (2002) 'Traditional, Complementary and Alternative medicine and Therapies in the Americas: Policies, Plans and Programs 2002', National Aboriginal Health Organization (NAHO) Submission to the Commission on the Future of Health Care (2001) Ottawa.2-INDI-eng.doc. Accessed 17 April 2006 at www.paho.org/English/AD/HHS/OS/4
Public Health Agency of Canada (2004) Reducing Health Disparities - Roles of the Health Sector: Recommended Policy Directions and Activities, Ottawa.
Schnarch B (2004) Ownership, Control, Access & Possession (OCAP) on Self Determination Applied to Research: A Critical Analysis of Contemporary First Nations Research & Some Options for First Nations Communities, NAHO Journal of Aboriginal Health 1: 1.
United Nations
Educational, Scientific and Cultural Organization (UNESCO) (1982) Mexico
City Declaration on Cultural Policies, World Conference on Cultural Policies,
Mexico City, July 26-August 6. Accessed 10 July 2006 at http://portal.unesco.org/culture/en/ev.php-URL_ID=12762
&URL_DO=DO_TOPIC&URL_SECTION=201.html
Ustun B and Jakob R (2005) Re-Defining Health, accessed 17 April 2006 at www.who.int/bulletin_board/83/ustin11051/en
Wells (No first name) (2002) Aboriginal Health and Cultural Diversity Glossary. Accessed on 18 April 2006 at http://www.usask.ca/nursing/aboriginalglossary/c.htm
Wesley-Esquimaux C and Smolewski M (2004) Historic Trauma and Aboriginal Healing. Accessed 17 April 2006 at www.ahf.ca/assets/pdf/english/historic_trauma.pdf
World Health Organization (WHO) (1999) The World Health Organization: Making a Difference. Accessed 18 April 2006 at http://whr/1999/en/whr99_dgmessage_en.pdf
World Health Organization (WHO) (2002) WHO Traditional Medicine Strategy 2002-2005. Accessed 8 May 2006 at http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf
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