For me the exciting thing about Cultural Safety is, if colonisation was about civilised England creating a "primitive other" whom they could dispossess, what Cultural Safety tries to do is make the pakeha the other. That’s why it’s so difficult for many pakeha, they are so used to being "it", and everything else is different. (Moana Jackson, interviewee)

Cultural Safety is based in a postmodern, transformed and multilayered meaning of culture as diffuse and individually subjective. It is concerned with power and resources, including information, its distribution in societies and the outcomes of information management. Cultural Safety is deeply concerned with the effect of unequal resource distribution on nursing practice and patient wellbeing. Its primary concern is with the notion of the nurse as a bearer of his or her own culture and attitudes, and consciously or unconsciously exercised power.

Prior to the development of Cultural Safety, the concept of Transcultural care had been widely accepted as an approach to nursing people from other cultural groups. In the traditional western anthropological sense this theory is based on the idea that the culture of nursing represents the norm and that the people who use the service are exotic. Transculturalism states that such cultures need to be learned and understood in order to permit predictions of the health of individuals, groups and cultures (Leininger, 1991). This activity is called ethno nursing and is based in the notion of ethnicity as the major driver of culture relating to anthropological concepts which were current in the 1950s when Leininger did her fieldwork in Papua New Guinea and first began publishing her theories of ethno nursing (Leininger, 1970). Interestingly, ethno nursing does not require the nurse to learn the language of the patient. This transgresses the basic premise in participant observation on which ethno nursing is based.

The most obvious differences between Cultural Safety and Transcultural Nursing lie in the anthropological and sociological definitions of culture and their interface with the related concept of ethnicity. A number of terms will be used in this chapter which are relevant to both approaches and recognise the respective philosophical and consequently practice related differences, which underpin these two theories. I have identified some of key concepts which are summarised inTable 1.

Comparisons and Contrasts

Cultural Safety has been developed from within Maori cultural reality. Maori people no longer accept that our world is a perspective on the reality of any one else. We have our own whole, viable, legitimate reality. It operates in different ways for different Maori but it is one of the realities in this country, not a perspective (Ramsden, 1990a).

Cultural Safety began with the Maori response to difficulties experienced in interaction with the western based nursing service. It does not accept that the culture of nursing is normal to patients. It assumes that the nurse is exotic to the patient, and that only the person experiencing service can say whether it is fully effective and will be approached again. Cultural Safety gives the power to the patient or families to define the quality of service on subjective as well as clinical levels. It contends that people are so diverse that teaching simple ritual and custom stereotypes and rigidifies ideas of culture and does not allow for human diversity (nurse or patient), nor does it take into account historical effects and socio-economic status (Ramsden, 1996).

Cultural Safety is concerned with the transfer of power from service providers to health care consumers, addressing issues of power imbalance (Cooney, 1994). The importance of this, in terms of the need to examine dominant power structures and how they impact on health, both within and between groups, has been recognised by a number of commentators (Bruni, 1988; Jiwani 2000; Kearns, 1997; Walker, 1995). While Transcultural Nursing theory identifies the existence of monoculturalism, it does not give nurses strategies for challenging it at a political level, rather they learn to work within this power structure to provide culture-specific care to individuals and groups at the practice level (Cooney, 1994).

Table 1
Key Concepts in Cultural Safety

History shows that through a process of colonisation Maori have been victims of oppression and racism and today their poor health figures represent the outcomes of 160 years of monocultural domination (Pomare & de Boer, 1988). Cultural Safety developed from the experience of colonisation and recognises that the social, historical, political and economic diversity of a culture impacts on their contemporary health experience. Thus, structural influences, which have a significant impact on health status, cannot be ignored. Bruni (1988) states that:

Any programme aimed at altering health status must address structural factors. Furthermore, attitudes, beliefs and expectations must also be considered within this context. (p. 30)

Bruni elaborates further on the need to move beyond descriptions of variables to the application of a critical framework that can meaningfully address change:

In order to explain the health-related attitudes and behaviours of various peoples, an historical perspective that addresses processes of change is vital. Indeed without a critical framework, explanation is not possible and the identification, amelioration or resolution of a problem an impossibility. Furthermore, 'descriptive’ understanding is at best interesting, at worst misleading and futile. (p. 26)

Information or even skill in traditional Maori ethnographic detail will not enable nursing or midwifery students to give effective and safe service to many of the urbanised casualties that comprise the Maori population. Psychiatric service, paediatric or antenatal service in highly urbanised areas may be completely untouched by nursing and midwifery knowledge of greetings in Maori or marae protocol. Furthermore, nurses and midwives possession of knowledge of traditional Maori activities and language skills encourages the employment of deficit perceptions of Maori, which are already internalised by many Maori and non-Maori alike.

Ethno nursing as used within the Transcultural Nursing programmes has developed from cultural anthropology and takes on an observational approach to other cultures (Cooney, 1994; Smith, 1997). While care remains focussed on the "cultural" activities of the patient, there remains the tendency to promote a stereotypical view of culture over time thus making it difficult to respond to individual diversity (Ramsden, 2001). Bruni (1988) agrees that this can lead to a static approach to culture where groups of people come to hold an unchanging and uniform set of beliefs:

The problem of stereotyping cultures is compounded by the assumption that the country of origin of a person (or his/her parents) identifies the most significant dimension of his/her experience. (p. 29)

Cultural knowledge belongs to the culture and as such, cultural identity and traditions should remain with the culture. Teaching nurses to be experts in Maori culture leads to further disempowerment of Maori, given that there are significant numbers who have been deprived of knowledge of their own identity and traditions (Coup, 1996). Ethnographic information is only one facet of many Maori health issues, albeit very significant. The question could be asked, how does Transcultural Nursing theory educate nurses to give service to culturally dislocated adolescents with perhaps a serious self destructive urge? This age group comprises a significant percentage of the current Maori population who are highly at risk of self-harming behaviours and suicide (Te Puni Kokiri, 2000). Cultural Safety is based in attitude change. If nurse and midwife practitioners hold safe attitudes, they will be able to work with the continuum of Maori people, from traditional practitioners of the culture to those who have been denied any information about Maoritanga.
Those who do not identify as Maori but are identified as such by the dominant culture comprise a further group. Maoriness encompasses a very wide range of experiences, responses and realities (Nursing Council of New Zealand, 1992).

Cultural Safety enables the provision of care which respects a person’s cultural values and preserves their well being regardful of differences. There needs to be a shift from both the philosophy of cultural sensitivity and providing care regardless of culture, towards one of Cultural Safety which is mindful of, or has regard for, the person’s culture. (Coup, 1996, p. 7).
Cultural Safety is viewed as a partnership between client and nurse/midwife based on the Negotiated and Equal Partnership Model (Cooney, 1994; Coup, 1996). This model has four identified stages which looks at a process for addressing attitudinal change. The first stage involves finding out what you have, the second stage is to dismantle it, the third stage is to put something else in its place and lastly, the fourth stage is translating the changes into action. The nursing skill lies in enabling people to say how service can be adapted and to negotiate compromise (Ramsden, 1997).

All interactions are by definition bi-cultural as they essentially occur between two people, the nurse/midwife and the client (Coup, 1996). However, bi-cultural in this instance again, is referring to culture in its broadest sense rather than being focussed on ethnicity. One of the people interviewed for this project discussed his understanding of bi-cultural when applied to Cultural Safety.

I suppose one way of trying to understand better that binary through Cultural Safety is to recognise that any situation is bi-cultural on one level. Yes, we live in a society that to some extent is a bi-cultural society; but let's not try to deal with the macro issue all the time and especially in one on one clinical interactions, let's recognise that even if I was a nurse or a doctor dealing with a fellow Pakeha patient that had many of the same characteristics as me, hypothetically, born in England, middle class, middle aged male; that would still be a bi-cultural situation because for better or for worse I've been socialised into being a health care professional. So I guess one of the key metaphorical spin offs for me in terms of thinking through Cultural Safety is this idea that bi-culturalism is not just something that operates on a macro level in our society that, [in] any sort of didactic situation you have two parts to a dynamic which can be bicultural because of issues of class, gender, professional identity. (Robin Kearns, interviewee)

From its inception, Transcultural Nursing has existed within a multicultural context, focussed on race and ethnicity (Leininger, 1978). It has assumed that nurses and the culture of nurses are normal and commonsensical. In talking about the need for Transcultural Nursing, Andrews states:
Given the multicultural composition of the United States and the projected increase in the number of culturally diverse individuals and groups in the future, it is apparent that there is an increasing need for nurses to focus on the cultural beliefs and practices of clients.
(Andrews as cited in Cooney, 1994, p. 9)

Cultural Safety is based on the premise that the term 'culture’ is used in its broadest sense to apply to any person or group of people who may differ from the nurse/midwife because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997). Transcultural Nursing is based on the premise that the term 'culture’ refers to ethnicity. Patterns of learned behaviours and values are shared among members of a designated group and are usually transmitted to others of their group through time (Leininger, 1985). Transcultural Nursing was established to enable nurses to study people from different cultures using humanistic and scientific methods (Leininger, 1978).
Cultural Safety is a requirement for Nursing and Midwifery registration in New Zealand. Successful passing of the State Examinations for nursing and midwifery registration is evidence of Cultural Safety competence (Coup, 1996). Certification is awarded by the Transcultural Nursing Society, to nurses who have educational preparation in Transcultural Nursing or the equivalent. In examining the fundamental differences between Cultural Safety and Transcultural Nursing I have used the approach set out in Table 2 which was first discussed with my colleague Kathie Irwin (personal communication, Wellington, 1997) and has been presented at many seminars since that time which views Cultural Safety and Transcultural Nursing in terms of "Life Chances" and "Life Styles".

The Redefinition of Cultural Safety

The redefinition of Cultural Safety into an idealized mixture of Transcultural Nursing and naïve often romantic reconstructions, based in versions of Maori Studies, has persisted in some Schools of Nursing. Although I have been clear that Cultural Safety and Transcultural Nursing are fundamentally different, there is a steady undercurrent of redefinition of Cultural Safety analysis away from the concerns of structural and multifaceted social inequality, to the culturally descriptive nature of Transcultural Nursing in New Zealand nursing education. Such terms as 'cultural competence’ requiring 'cultural supervision’ implying that culturally unsupervised nurses will be incompetent and therefore dangerous, have been used to describe nursing practice by an Associate Minister of Health at a nursing graduation ceremony in New Zealand (Turia, 2001). None of these terms have been defined or explained but they have their roots in the tenets of Transcultural and ethnonursing.

Table 2
Cultural Safety and Transcultural Nursing

Notes: A key part of Cultural Safety is that it emphasises life chances rather than life styles

An underlying premise of Transcultural Nursing is the idea of cultural difference, that a homogenous group of people who are nurses encounter patients who are culturally different, exotic and other, but are also homogeneous, possessing a body of finite cultural content, customs and traditions based on kinship. Transcultural Nursing also suggests that by studying the customs of other or exotic cultures, nurses will gain insight into their worlds. The power to define norms is retained by the nurse.

Elaine Papps (2002) asks the question:
Is Cultural Safety, then the same as the notion of Transcultural Nursing . . . or the same as cultural sensitivity . . . or the same as cultural competence . . . or the same as culturally competent nursing? (p. 101)

Papps suggests that it is not, and others have agreed with her conclusion (Cooney, 1994; Coup, 1996; Papps & Ramsden, 1996; Ramsden, 1995). However, Leininger (1997) maintains that Cultural Safety is an integral part of the Theory of Culture Care to provide culturally congruent care. Although Leininger argues that issues in relation to social inequality are an integral part of the Theory of Culture Care, they are not explicit nor easily determined and defined within any of the literature. This issue has similarly been identified in Bruni (1988), Swendson and Windsor (1996), and Coup’s (1996) work. Papps (2002) believes that understanding how Cultural Safety is different from other concepts requires an understanding of the term. She has suggested that the term Critical Social Theory may have been more understandable to most people than the term Cultural Safety.

The process towards achieving Cultural Safety in nursing and midwifery practice can be seen as a step-wise progression from cultural awareness through to cultural sensitivity and on to Cultural Safety. However, the terms cultural awareness and cultural sensitivity are not interchangeable with Cultural Safety. These are separate concepts.

CULTURAL SAFETY is an outcome of nursing and midwifery education that enables safe service to be defined by those that receive the service.

CULTURAL SENSITIVITY alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impactthis may have on others.

CULTURAL AWARENESS is a beginning step towards understanding that there is difference. Many people undergo courses designed to sensitise them to formal ritual rather than the emotional, social, economic and political context in which people exist (Ramsden, 1992a).

Figure 6
The process toward achieving Cultural Safety in nursing and midwifery practice

It is clear that Cultural Safety does not place an emphasis on sensitivity or an awareness of other cultures. Cultural sensitivity and Transcultural Nursing are both concerned with having knowledge about ethnic diversity. This seems to be the basis of misinterpretation of the concept of Cultural Safety. The term 'culture' is read as 'ethnicity'. But the skill for nurses does not lie in knowing the customs or even the health related beliefs of ethno-specific groups. The step before that lies in the professional acquisition of trust.

Its emphasis is to place an obligation on the nurses to provide care within the framework of recognising and respecting the difference of any individual. Rather than the nurse determining what is culturally safe, it is consumers or patients who decide whether they feel safe with the care that has been given, that trust has been established, and that difference between the patient, the nurse and the institutions which underpin them, can then be identified and negotiated (Ramsden, 1997).

Difference is always seen as legitimate and is always seen as negotiable between nurse and patient. Cultural Safety within nursing therefore addresses power relationships between providers and recipients of care (Kearns, 1997). One of the interviewees, Fuimaono Karl Puloto-Endemann, clearly articulates this issue;

I knew that as nurses [we] were very powerful people. I mean people say "oh but we don’t have the power," but that’s a load of rubbish because we have incredible power. They strip people down to absolute nakedness . . . literally, totally and expose them. I just think that Cultural Safety is a mechanism to monitor you because at the end of the day we have to become part and parcel of the culture of that institution we work in and we take on the persona of that culture. I would say that I’ve been in a very powerful position, particularly in the psychiatric area and in that situation I was a very dominant person, when the palangi becomes in effect, a minority, we actually swap roles. And when you see palangi in that situation, it’s when you leave that institution you know intrinsically what their experience is because you experience it outside of that world.
(Karl Puloto-Endemann, interviewee)

Transcultural Nursing suggests that curricula need to contain ethno-specific knowledge about a variety of cultural groups in order to help nurses or nursing students to work effectively with patients or clients of other cultures. The risk in this is that all differences can become stereotyped. This is precisely what Cultural Safety seeks to avoid. Transcultural Nursing in this respect can be seen as the antithesis of Cultural Safety teaching (Papps, 2002). Some key features of Cultural Safety and Transcultural Nursing are summarized in Table 3.

Table 3
Key Features of Cultural Safety and Transcultural Nursing

An example of culturally safe practice may be seen in the action of a self-aware nurse who recognises homophobia in their own personality and chooses not to work in the area of HIV/AIDS where chances of encountering homosexual people are higher than in some other areas of nursing employment. The nurse acknowledges that the effect of his or her homophobia on the recipient of care may be unsafe and detrimental to care and that it would take a great deal longer to establish trust in this context. This example could be applied to a wide range of situations.

People who have difference to protect from the powerful search first for the potential to trust. The trust moment may be fleeting and unspoken but the information load is high and influences all future interactions. Nurses are expert at creating and interpreting the trust moment but not at describing it as part of excellent practice. Establishing that moment is something we all do, or attempt to do. If trust does not happen very early in nursing interactions, people will continue to protect their difference from nurses and however transculturally informed we think ourselves to be, we will not be seen as safe to practice by others.

To most people, nurses are other. Cultural Safety therefore lies in the establishment of the trust moment and in shared meaning about the vulnerability and power followed by the careful revelation and negotiation of the specifics and the legitimacy of difference. It is our responsibility to translate the tired classroom clichés about respecting values and beliefs and the resulting behaviours into active and participatory practice.

A major issue in relation to Cultural Safety has been its name. As indicated earlier in this chapter, the definition of Cultural Safety refers to culture in its broadest sense. But the original definition was unacceptable to those who viewed the 'truth' about Cultural Safety in terms of ethnicity, and perceived it in relation to the multicultural nature of New Zealand society even while, in terms of the management of power and resources, New Zealand has been a monocultural society since it established self government under the New Zealand Constitution Act in 1852. Thus, the use of the term 'culture’ constantly linked Cultural Safety to the discourse of multiculturalism.

The entry of Cultural Safety into nursing and midwifery education in New Zealand has been rapid and has also been refined over time. This is not unusual in any developmental process of a theory which is based in emancipatory change and requires careful positioning, and in most cases, challenge to an existing status quo. What has been difficult for Cultural Safety is the lack of educational building blocks in place for many of the students entering nursing and midwifery on which to move forward such a concept. This has not only been problematic in the professions but also, within the perceptions of the public in understanding Cultural Safety.

The concept of Transcultural Nursing in current colonial New Zealand society should be constantly examined and debated. The traditional western anthropological stance of observation of other and the exploration of difference as a point of access to the lives of others assumes that people want their lives to be observed, predicted and responded to at the level of the exotic. My own academic training, experience as a member of several marginalised groups in New Zealand, interaction with the health service as a consumer, as well as in practice and teaching, tells me this is not so.

Cultural Safety in nursing education is doing two separate but interrelated things. Firstly it aims to identify attitudes that may either consciously or unconsciously exist towards cultural/social differences in the provision of nursing care. Secondly it attempts to transform those attitudes by tracing them to their origins and enabling students to see their effects on practice through a framework of practice related reflection and action. Cultural Safety always seeks to locate its action in the belief systems and behaviours of the caregiver rather than the patient.

Cultural Safety is about power relationships in all nursing and midwifery service delivery. As was my own experience, it is also about power relationships between teachers and students of differing cultures. It invesitgates setting up systems which enable the less powerful to genuinely monitor the attitudes and services of the powerful to comment with safety, and ulitmately, to create useful and positive change, which can only be of benefit to nursing, and to all the people whom nurses and midwives serve.

The final section of this work moves Cultural Safety into the public arena focussing on the narratives of those people interviewed for this project.