Cultural safety - more effective than cultural competency

Implementing cultural safety

Everyone has a role to play in ensuring kaumātua and whānau get the support they need at end of life. This requires health organisations and health professionals to adopts a cultural safety appraoch. Curtis et. al. (2019) explains:

Unfortunately, regulatory and educational health organisations have tended to frame their understanding of cultural competency towards individualised rather than organisational/systemic processes, and on the acquisition of cultural knowledge rather than reflective self-assessment of power, privilege [sic] and biases. This positioning has limited the impact on improving health inequities. A shift is required to an approach based on a transformative concept of cultural safety, which involves a critique of power imbalances and critical self-reflection.

Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

Curtis, E. Tipene-Leach, D., Walker, C, Loring, B., Paine, S-J and Reid, P. ‘Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition’. International Journal for Equity in Health. (2019) 18:174 https://doi.org/10.1186/s12939-019-1082-3

Cultural safety is about a willingness to learn, and the humility to accept that in trying to learn we will make mistakes however, it is better to acknowledge and learn from such mistakes than to see oneself as a failure or get upset about it. This will help to foster a sense of openness and genuineness to learning and growing.

Joy (health professional) says the DHB where she is employed is working towards a kaupapa Māori care model and cultural training days are provided for all staff to attend. Health professionals are more mindful of the way they communicate with Māori. She explains nurses and doctors are trying to improve health care for Māori, they are trying to get it right. Joy gives an example of this when a consultant asked her if she thought he was saying the right thing to patients:

...I think health professionals are trying to get better. [A] physician one day he said to me '[Joy], do you think I’m saying the right things to patients?' Because they’re really, really mindful of how they communicate to patients now. And I said, 'oh I think you’re doing a great job' because he said, 'oh how do you think patients feel after I’ve spoken to them?' I said, 'good. You know, because I haven’t had any negative feedback.' I said, 'no it's been good what they’ve said after your consultation.' So, it’s really good, they [non-Māori health professionals] really value what I say to them you know how I give feedback to them around what, how they are talking to patients. Yeah, they’re really mindful.

Equity and justice focused health care requires health organisations improve Māori health outcomes (prevention, early detection and quality health care). Health care initiatives, processes and practices must be culturally supportive to ensure Māori can access and benefit from these effectively.

The development and implementation of tikanga Māori is cultural safety in action. Having a high level of cultural competency can produce great results for kaumātua and whānau. Also, having an understanding of how culture shapes who we are, how we live, and how it influences our own end of life care preferences is critical for understanding the holistic care preferences of Māori.

Racism still exists in the health system, as Kahu (hospice nurse), highlights:

The nurse described comments she heard regularly from her non-indigenous colleagues about Māori whānau using the family room (this is the space where they can sleep over):

Yeah. I come across a barrier of, no space. [My colleagues say]; ‘Oh that whānau’s here again. Oh, I knew that was going to happen; I knew they’d want the [family room].’ … [Then] the white person comes in. Immediately it’s like [they say to that family], ‘Oh we have all this stuff. We have the family room, we have this. Anytime, yes, yous can have the room tonight, no problem. We’ll get these lazy boys into your room. Oh, we’ll put you in this big room. I know there’s only three of yous but that will be fine.’

You know, and then other [Māori] whānau it will be like, ‘Oh they’re going to want the room; oh, they’re going to want… they’re going to need…’

The tolerance, the tolerance for it is getting shorter and shorter. Like I can see that whole thing happening in one day. You know that, that escalation of intolerance happens in one day.

Whaea T. (health professional), reflected on her role to care for whānau; part of her role entails advocacy so the patient and whānau have the best outcomes possible:

A lot of my role is (because I’ve got a registered nurse background) … I do the health and wellbeing with the carer; my focus is on the carer and their health and wellbeing. Make sure that they’re okay physically, you know hinengaro, tinana, their wairua and whānau, if anything’s happening that’s impacting on the carer and their role. And it’s to help make sure that that person is okay to continue in that caring role.

Yeah so, my role is being an advocate, advocating for that whānau about their needs. And getting some clarity around the treatments for that carer so she [sic] can have a better understanding of what the treatments are so she can continue in that, yeah. And also reassure… I keep in touch with the GP.

Whaea T. also shared a story about a whānau she supported. They found it hard to believe that their kuia (older female relative) was unwell and close to passing away, particularly as the medical team did not communicate what was happening satisfactorily, and there was no support put in place for the kuia and her whānau:

… This ah kuia who’s at the end stage and relocated from [name of region] back [name of local place] here and living with the whānau now… told she was actively dying… Nurses said, ‘nothing they can do for her’. And more or less conservative [treatment]. But never really explained that you know… [The] whānau are wondering why they haven’t given her some antibiotics for her rattling [chest] you know because she was having… chesty problems and coughing… the whānau didn’t see her like she’s going to die… [The medical team] more or less assumed that she was actively dying, and she didn’t need the antibiotics and she’s just going to go home… and have comfort cares with the family more or less… The family picked up on their vibes and then yeah. And [I] said ‘oh no that’s not on’ you know. [The whānau were] unable to address- she’s still alive, she’s still living.

Whaea T. spoke about how she helped to support the whānau during this time:

I got there last week and listened to their story. And I say, ‘right this is what we’re going to do’... I talked about options and links and referrals to these services to come and awhi this whānau. They all agreed like for her chesty and CORD you know… I did a referral to [name of iwi] for the respiratory nurse to follow up you know and comfort the whānau around that… for all her tinana needs and all that… her wairua needs weren’t being met. So, I did all that and just went 'phew'. Did all the referrals with the whānau, so they know exactly what I’m doing and that…

Health professionals can help ensure the care kaumātua and whānau receive is culturally appropriate by developing a kind but critical self-reflexive approach to their own practice.

Observing one’s own attitudes and behaviours within one’s practice toward Māori and their cultural customs, and turning the lens to examine any cultural biases, values and assumptions will help to identify areas where cultural information is lacking or where improvements can be made. This will avoid conscious or unconscious bias, racial/ethnic discrimination and ignorance. It is not only cultural biases people need to self-examine; being self-reflexive about one’s personal attitudes towards sexual orientation and other aspects of social difference including social status, age, and so on are also important.

Whaea S. (health professional), reflected on one case where a whānau were caring for their father at home and he was taken to hospital for medical attention. He was sent home with a hospital bed that the whānau did not need or want. All they wanted was support:

I have had a whānau… [Where] their father was unwell at home. [He was] being managed at home not to the standard that health professionals would want it to be, but they were managing it at home. And then he came into hospital because he developed too much fluid... in his lungs and in his heart so he had a bit of congestive heart failure. We gave him furosemide you know but he was already under hospice. So, the hospital went to ring the hospice nurse. Can’t get the doctors to give palliative or come in and direct what we want. You know what we need to do? We need to give him comfort… clear his chest first so that he can go home. In the end it was, ‘Well, he needs a bed at home.’ … the secondary care facility then saw hospice as an ability to get gear. But there was no talk about, ‘How are the family going to cope? Who's the one who’s going to be there all the time? How are we going to do [it]?’ So, I had to have those conversations. Secondary care just went, ‘Nah, call the hospice nurse.’ And oh, and, ‘She’s Māori, and this is a Māori service, they’ll get it sorted.’ And so, there’s that kind of [thing going on] and that’s what I meant by the 'institutionalised colonisation', [it] is still there because you’re sitting there going, ‘Oh you’re Māori so you do it.’

Well I took a bed in. They even lived in a little two-bedroom house where they had eight people living in there, there were whānau in the shed things like that. And I went in and said, ‘How is the bed going to help you? So, if you take that bed and his bed out [it won’t fit], he won’t sleep on it. So then why are we bringing a bed in? Oh, because the nurse at the hospital said you could have it? What’s going on? Like what do yous want?’ [Quoting whānau] ‘Oh we just want you to come and check that we’re doing everything alright?’ I said, ‘By your standard or by my standard?’ And one of them, his wife said, ‘By ours.’ Said, ‘Well that’s perfect. You tell me what you want me to do and I will tell you whether I can do it within the constraints of my nursing, the constraints of… the organisation I work with. And if I can’t I’ll try and get someone to do it for you.’ So, all they wanted to do was… to retain the control on how they you know, how they managed him at home, but also to have him in comfort…

They took it up, the [bed] and it was in the shed and one of the kids slept on it. So, I said, ‘Oh well leave it there. If it’s an extra bed for yous leave it there. You know we’ll get it back when everything goes [back to the services].’

Recommendations

Training and education on Māori culture, identity and diversity, would help to reduce the risk of stereotyping and stigmatising Māori such as “Māori have big families” or “All Māori are poor”.

For health and palliative care services we recommend that staff:

Reflect on who they are; explore their own identity/ies including their cultural, ethnic and spiritual values, beliefs and practices.
Are supported by their employer (at every level), to increase their understanding of Māori identity and culture, and to eliminate unhelpful stereotypes or generalisations about Māori.
Introduce expert Māori advice to assist your organisation to develop and implement cultural safety policies.