Professionally it was time to move out of secondary care and investigate nursing practice in a primary health care setting. The position I applied for as a Public Health Nurse was in a socially disadvantaged and economically impoverished area outside Wellington. The nurse manager advised me strongly not to work there because my skills and education would be wasted in such communities. Nurses with university degrees were not common then.
For all the liberatory education, professional and human experience I had, working in Porirua was again an exercise in learning about myself, my professional power and my own entrenched attitudes. Examining myself as a culture bearer I was astonished at the level of racism and victim blaming attitudes that I carried with me as part of the social class in which I had been raised. I was grateful for the education which enabled me to understand the origins of these attitudes and for the insight which helped me to think them through and to do something about them. I had no guilt about their presence because I understood them as social constructs but I knew they had to go if I was going to be effective as a nurse. As a member of the marginalised group I was well aware that people at risk automatically run emotional security checks on all strangers. Being among people who were trapped in cycles arranged outside their lives and devoid of almost any vestige of control gave me insight into global economic and political power. It was obvious that my education had given me a ticket into and out of their communities every day, that realisation was deeply humbling.

My view of what I was bringing into their communities began to pivot. I thought that I knew what my skills were and that I could be of some use to people. What I discovered about myself was close to the same set of insights which the patients in the respiratory and Tb wards taught me. My role and stereotype as a nurse did not make me automatically trustworthy and I could not assume that I could set up co-operative alliances (which at one level could be called friendships, culturally unprofessional at another) with people. Already I knew that I held power and controlled many resources and that the cultural institutions of which I was a member placed many people at risk because my attitudes would inform the selection and allocation of resources. Unless I understood myself very well as the bearer of culturally derived attitudes such as internalised racism and ideas of social class, I could very well become the oppressor of Maori and others who were less powerful than myself.
The tensions identified by Paolo Freire (1996) in his seminal discussion of the duality of discoveries for oppressed people who begin to think critically about oppression were very real for me as I entered parts of the Porirua communities as a Maori who was also a nurse. The expectations of my professional colleagues were that I would be a nurse who was also a Maori. Herein lay a profound ethical dilemma.

The central problem is this: How can the oppressed, as divided, unauthentic beings, participate in developing the pedagogy of their liberation? Only as they discover themselves to be the "hosts" of the oppressor can they contribute to the midwifery of their liberating pedagogy. As long as they live in the duality in which to be is to be like, and to be like is to be like the oppressor, this contribution is impossible. ( p. 30)

By this time Irakehu had become a very personal and protected reality as others now defined me publicly as Maori. Shared ethnicity and in some cases kinship with the people I was serving was not the critical factor in my relationship with them. Unless ethnicity held mutual meanings there could be no assumptions that I could be safe, I did not live in that community and had not grown up there. I did not speak English or Maori like they did and I was a Practising Certificate holding member of an authoritarian system which had not traditionally been beneficial to Maori or other Polynesians.

The critical factor required was trust. Over the years of teaching and learning I have compiled a list of factors which I believe contribute to setting up trusting relationships. They are defined in terms of expectancies and beliefs. Here are some words which describe perceptions of trust as I have come to understand them. Safety (this includes keeping confidences), benevolence, caring, concern, honesty, integrity, sincerity, competence, ability, capability, good judgement, credibility, predictability, consistency, goodness, morality, goodwill and intentions, shared understandings, reliability, dependability, open mindedness, personal attraction, responsiveness and dynamism, the idea that things will happen.

It was not difficult to see that the people I was working for might not trust me. What was much more complex was the examination of my own psychological and emotional interior. I was aware that there were expectations on the part of my pakeha managers that I would be able to gain access to people and places that they were unable to access and that I would be exposed to, and to some extent, participate in, what bell hooks has described as "cultural criticism" (1990, p. 9). I entertained uncomfortable visions of the Judas sheep kept at freezing works which lead the other sheep to the killing chain keeping them calm while turning away at the last minute to lead in the next batch of sheep.

There was a clear expectation on the part of my employers that I would reveal and describe the discoveries I would make in the communities from which most nurses were excluded. By virtue of my shared ethnicity I would be able to bring to the corporate consideration of my colleagues the information to which they were not privy. hooks (1994) warning is clear:
If there is not a mutual exchange between the cultural subjects…that are written about and the critics who write about them, a politics of domination is easily reproduced wherein intellectual elites assume an old colonising role, that of privileged interpreter, - cultural overseers. (p. 9)

It was at this juncture of beginning practice that I found the work of Paolo Freire (1985) again illuminating the invisible, shaping my attitudes toward the people and the communities I had decided to enter. The people there had not invited me. I had selected them. There was no initial nursing partnership. Why had I done this? Because I wanted to help? What did help mean? Friere discusses armchair revolution. He is clear that what he calls "true reflection" leads to "transformative action" (p. 48). Authentic praxis for Friere happens only if its consequences become the object of critical reflection. My entering the communities of people whom I saw as oppressed had the potential to fulfil needs, but whose needs were they? Fresh from university with a liberatory analysis, was I going to free people from their oppression and go home to my middle class environment daily and at weekends while they stayed there potentially for generations? I had some thinking to do. The last thing these people needed was another form of missionary. Freire warned against action without critical reflection simply becoming activism. As an activist nurse I could rush around all day being helpful within the range of my skills and job description, but what difference would that ultimately make? Already I was aware that nurses leave such communities and the social waters close behind them as another nurse with another job description and another set of attitudes, moves into place.

… it is necessary to trust in the oppressed and in their ability to reason. Whoever lacks this trust will fail to initiate (or will abandon) dialogue, reflection and communication, and will fall into using slogans, communiqués, monologues, and instruction. Superficial conversions to the cause of liberation carry this danger. (p. 48)

It was clear that I must therefore also ask myself whether I trusted the people I worked for to use their realities (where I could not go) as the templates for their lives and learning. That meant that I needed to divest myself of the ideas that I had the answers to their needs or that indeed I fully understood their questions. It further meant that I should see myself as a privileged stranger in their landscape to be guided at significant points by them. It was necessary for me to understand the rights of people to their full humanity and to learn, as I did from the Tb ward men, that I had power and the proper use of that power should be a negotiated process. As a Maori those ideas were very easy to accept because they are encapsulated in the concept of mokai.

Mokai

There is mana in the concept of mokai, in being able to give skilled and valued service which makes life easier for others. The concept of mokai differs from the notion of servitude in that the mokai is valued as a professional community member who has a set of skills which enhance the quality of life of individuals and the collective. The mokai can be a powerful and beloved servant. The familiar sight of aunts, uncles and grandparents performing quiet and thoughtful tasks was a normal one for us. However exalted they may have been in their birth status or their formal roles and however skilled in the performance of ritual and solemn observances they may have been, it was beneath none of them to wash dishes, clean tables or to see to the most minor comfort of their guests. While visitors were to be cared for none of them sat or saw to their own needs. If food was short they did not eat until guests were satisfied. It was done quietly and without fuss. We children were disciplined to wait until all others were served and comfortable and then our needs were met. Everybody knew that in the long scheme of things such consideration would be reciprocated when roles were reversed and visitors became hosts.

It was very easy for me to translate those life examples and concepts into practice as a nurse. The skilled servant concept was and remains comfortable to me because I understand that in the long term I, and those I care about, will one day be the recipient of nursing service which I hope will be based on such concepts.

Practice Issues and Ethical Dilemmas

My responsibilities and contacts as a Public Health Nurse in the 1980s extended from newborn infant welfare service, family liaison, through preschool health to primary and secondary education institutions, families, refugees, immunisation, vision and hearing testing, plus assisting with tracing contacts of communicable diseases. I claimed and was given, responsibility for Maori specific organisations, kohanga reo, urban marae and the two major Maori gangs resident in Porirua. It was not difficult to assert professional contact. These were not popular institutions with my colleagues although the health needs of their members were great. The issues and lifestyles associated with the generational entrenchment of poverty and poor educational opportunities were normalised, obvious and grossly unfair. The decision makers in these communities, school principals, medical doctors, business owners and administrators were men, almost totally from the non-Maori population along with several recent migrants from Asian countries. Polynesians indigenous or migrant were not well represented in the decision making positions.

The basis of any productive relationship with people who perceived me as the powerful carrier of a range of potentially risky differences was whether or not I was trustworthy. Would I do what I said that I would do and would I do it in a way that did not place people at risk?

"What hours do you work here in Porirua?"
"By the time I get here and then leave to go back to town, 9am to 4pm."
"Oh, pakeha hours."

Initially the differences between myself, as a Maori person, and the community Maori people were greater than our similarities. It was clear to me that I was being often, pleasantly, tested for trustworthiness. I was more of a potential liability to people in some ways due to my ethnicity. At least pakeha attitudes were a known entity, assumptions could be made about interaction with pakeha power holders until proven otherwise, but one of their own was a much less predictable proposition. As a member of an professional outsider group and an outsider social class it was possible with my insider socio/cultural knowledge that I might lead people into conflicts with authorities such as the Social Welfare system, Inland Revenue Department or the police.

Trinh T. Minh-ha (1995) observes:

Whether she turns the inside out or the outside in, she is, like the two sides of a coin, the same impure, both-in-one insider/outsider. For there can hardly be such a thing as an essential inside that can be homogeneously represented by all insiders; an authentic insider in there, an absolute reality out there, or an incorrupted representative who cannot be questioned by another incorrupted representative. (p. 216)

Working in this environment offered some of the most rewarding as well as some of the most frustrating times of my twenty-three years of practice. Community trust came quickly in some cases and more slowly in others. Word spread that I was non-judgemental and did not appear to abuse power. Doors opened. Entry to many places was enhanced by being previously known to significant community people, having good Maori manners, personal maturity and my own skills and personality. My formal education as a nurse and my job description had none of these factors integrated into them.

My practice differed from that of my non-Maori colleagues. Often it was essential to manage time quite differently. Time was allocated in ten minute sections on time sheets as part of time management and costing of nurses’ activities. This type of time management was simply not possible with the people of Porirua. To earn their trust I needed to work for the duration which people chose to take over their initial contact with me and it was essential to work at their pace. Although I knew that a morning spent with a matriarch would give me access to her whole family, if she approved of me and judged my skills as useful, that use of time was not factored into my management schedule. This necessitated my having to regularly falsify the timesheets because there was no professional opportunity to create another way to manage time. I saw the refusal of my manager to consider my version of effective practice as institutional racism in its most entrenched form.

Borders and Frontiers

The concept of borders is used in this work to convey distances between actors, and locations. The locations are physically geographical but also intangible, consisting of personal locations in intellect, emotion, attitude and politics. They are always political and consist of notions of history and power, justice and equality, which distil into local everyday activity as well as global webs of economic control. Henri Giroux (1992) has written extensively about the notion of borders and is concerned with the development of a critical pedagogy for teachers and students. He discusses the border metaphor as a series of ideas or ideological codes which must be recognised by those attempting to work across borders:

Cultural workers need to unravel not only the ideological codes, representations, and practices that structure the dominant order, they also need to acknowledge "those places and spaces we inherit and occupy, which frame our lives in very specific and concrete ways, which are so much a part of our psyches as they are a physical or geographical placement." The practice of social criticism becomes inseparable from the act of self criticism; one cannot take place without the other. (p. 79)

Practice Examples

Throughout this chapter I have identified issues of trust and safety as they became insights for me in relation to working with people in the community. Freire and others have helped further shape my understanding of these issues and the way they need to be regarded as central to effective health care. In reflecting on my early practice as a nurse, the connections between these issues and the emergence of Cultural Safety as a concept is clear. The following examples illustrate the necessity to think differently and to act differently in order to demonstrate trustworthiness, which is so central to safety.

Practice Example One: Informed consent on the border

Although I was extremely diffident about taking nursing students into the homes of disadvantaged people, it was part of the responsibility of Public Health Nurses toward the professional development of our potential colleagues. For a while I managed to deflect students into institutions such as schools, kindergartens and medical centres but the time came when I could no longer do that.

I asked permission of a young Tuhoe mother to bring a student into her home to observe my work in infant welfare. I also warned her that the student was likely to be a pakeha who would have her own opinions about the family and their environment. Neither the mother nor I could predict what those opinions might be, nor should we, but the potential for tension and stress was real. Although we did not discuss it, shared ethnicity did make a difference here. Both the young mother and I understood the politics and the experience of exposure to a pakeha stranger and the watchfulness which we would both be required to undertake. It was an extra tension in her day that I was asking her to accept and a series of borders that I was asking her to negotiate.

I learned that it was essential to establish informed consent in community nursing just as in secondary care. In a clinical environment informed consent is potentially less complex than in the community. Clinical, biological and technical boundaries maintain the cultural power called professionalism in secondary care. The selection and editing and language of clinical information enables the status of the actors to be maintained: doctor, nurse, patient, family roles are clearly delineated and the geography of the transaction, often in a hospital, usually favours the health professionals who can therefore sustain the locus of power with ease. Community settings require more negotiation since the nurse is essentially a mokai, a skilled servant or has a quasi guest status in a private home. Differences in social class and ethnicity where people have been exposed to a lifetime of racism, homophobia or other predetermined attitudes from authority figures require a degree of insight and skill on the part of the nurse for which our professional education does not prepare us.

The subjective response to the idea of bringing a student nurse, someone who was destined to have skilled employment and a very different future from this young sole mother of three preschoolers, could be predictable and understandable. I was an unsafe factor in this equation which required me to exhibit nursing skills to a pakeha stranger at a potential emotional cost to the young woman.

With grace, I was given permission to bring the student into her home. The trust relationship we had built up had worked for me but it carried with it reciprocal responsibilities. The setting was one of poverty and economic deprivation when viewed from one perspective, from another it was a site of integrity and creative energy and fierce commitment to motherhood.
It was winter. The family lived in a semi-detached state house with no garden, plenty of mud and minimal household effects. There were no curtains and no carpet. The mother smoked tobacco and both her toddlers had upper respiratory tract and chest infections. Their clothes were ragged at the edges. The new babe was thriving, there was no sign of the father. All the children wore disposable nappies and there was a VCR monitor with videotapes in the corner. I weighed the baby. His mother asked me to take her to the medical centre with the toddlers. We did this despite the rule that only international refugees could travel in Public Health Nurses’ cars. I was seen and later reprimanded by the nurse manager. My view that the indigenous peoples of this country are refugees from the process of colonialism would have held little water. The toddlers were prescribed antibiotics and their immunisations were updated. Payment was waived by the doctor and the pharmacist.

We debriefed and I asked the student to describe what she had seen and to feel able to be as frank as possible. Using the framework of her own realities the student made her assessment. The description of external deprivation was accurate. The tobacco use, chest infections, the presence of a new baby while the mother was receiving state funding, in the form of a Domestic Purposes Benefit (DPB), and no potential for a male contribution to the household economy, were all noted. The VCR and tapes were also discussed as being unnecessary items when there were curtains and carpets required. I saw one of my responsibilities to nursing and to that little family and to future families that this nurse might encounter, as helping the student to think critically about the situation of which she had just been a very brief part.
We reviewed the observations and reframed them positively in light of the assets available to the mother. It was important that the student realised that she and I were privileged to have been invited into other human beings’ lives and to be aware that we had the opportunity to leave if we were uncomfortable. The little family did not have that option. The young mother had chosen to keep her three children and to parent them as well as she could within the limits of her resources. Curtains, carpets and regular new children’s’ clothes were not available to people on the DPB who did not have sufficient discretionary money to allow accumulation of capital. The essentials were there, food was refrigerated, lavatories flushed, there was hot running water and the children’s heads, chests, genitals and feet were covered and warm. Although the mother was addicted to tobacco, there was a great deal else in that neighbourhood to which she could easily have become addicted if she had chosen. She did not choose to become involved with the marijuana and hard line drugs which were
procurable. Tobacco smoking took place outside the house and away from the children.
Disposable naps were used throughout the Porirua area in preference to cloth as easier to handle, less fuss to care for, not requiring hot water, washing and drying facilities. They had become part of the culture of the poor. Environmental issues were of secondary concern to ease of daily survival. No telephone and no transport meant that this parent could not easily get her children to the medical centre. Knowing that I was coming she waited, trusted me to arrive and exploited her opportunity for assistance very well and to the advantage of her family. And the VCR and videotapes, the luxury items? The mother chose to use the small amount of money available at the end of each payment to hire the VCR and tapes to keep her children inside and amused during winter. Whether her choices fitted our middle class value system was not the issue. To her credit the student saw what I was trying to say and began the process of critical examination in practice and in the evaluation of her education as a nurse.

What did this family teach me?

From that experience I began to explore the issues of informed consent in the community. The overwhelming importance of establishing and maintaining trust was again demonstrated. I became very interested in the assumption that the role of the nurse could be managed to facilitate entry to peoples’ lives as of right. The notion of the power underlying those assumptions was disturbing. There was little question that nurses believed that they had the right to enter the environment of the powerless in the name of public health and the public good and that those social practices were sustained by an ethical ideology which would support them. The issues of reciprocity were highlighted for me in the interaction with the young mother in gaining her permission to introduce a person who represented the 'other’. This Tuhoe woman had experienced a lifetime of 'other’ figures who were in positions to make a difference to her life: religious figures, schoolteachers, shopkeepers, doctors, pharmacists, Social Welfare workers, Work and Income assessors, and nurses. Taken in that context the trust she placed in me, was very great.

Of further interest was the idea of symbolic interaction between the nurse and the person to whom service is offered. The student nurse was unknown to the mother and also unknown to me, but she symbolised a system with which the young mother and I were both very familiar and which we needed to accommodate in our negotiation. This interaction was facilitated by our shared experience as Maori who had experienced marginalisation. There was little direct discussion but complete understanding.

The collective understanding of power held by another group and the potential for an encounter with personal and institutional racism was very real for us both. Here was an example of Fritjof Capra's concept of "shared meaning, unanalysed and mutually recognisable" (1989, p. 73). This experience stands out for me as a formative experience in the process of defining the ideas which came to contribute to the pedagogy of Cultural Safety in nursing education.

Practice Example Two: Doing things differently

A laboratory form describing gonorrhoea in a nine year old girl came my way accompanied by a very anxious GP. The family was Maori. The child had been raped by a family member and was now very ill. I was asked to become involved in supporting the family and helping to trace the contact. Her parents had no idea of the situation or the circumstances and it took a great deal of time to explain the condition of their daughter and then to mediate between the distraught parents and the equally distraught child who had been silent and blaming herself. Eventually the child confided in me and pleaded with me not to tell the by now enraged father, fearing his temper. She was happy to have her mother involved.

I arranged the admission to hospital for the girl and her mother and I sat with the father through the night. Eventually I persuaded him to phone older members of his family who lived rurally to come to be with him. Although I could not break the child’s confidence and name the rapist at that point, I thought that could I work with older and experienced family members whom the father respected and who could apply restraints on the murder threats which were being made in the heat of the moment.

When the distant family arrived and were able to take over the support of the local family I was faced with a new dilemma. Everybody was very clear that this matter was to stay within the kinship group and that the criminal activities of the rapist would be dealt with by his people. In their view my role as a Maori was to protect the family from pakeha intervention. Passions were running high. I explained that gonorrhoea was a notifiable disease and that the hospital people and the general practitioner were obliged to report it and would already have done so. The contact of the child would have to be traced because he was a danger to others. Although I had every confidence that the family would deal with the perpetrator, that did not solve the issue of the disease and other possibilities of infection and criminal behaviour. It was made clear that I was not expected to betray this family to the pakeha system in their distress and to add to their worries. They were united in that opinion. My whole being wanted to shield them from the system, especially the child, but I knew that this would not work eventually and that for the sake of others time was of the essence.
I decided to speak to the local policeman who was a colleague of many years and from the same area as the family. He went to visit informally out of uniform and as a relative, I went informally as another Maori person, we were both mokai of this family. We sat and answered questions, again stayed over the night, reassured the father and the rest of the family as they went through the normal process of discussion and decision-making. They eventually gave us permission to follow through with the tracing. The offender had raped other children who also were infected.

Had the policeman and I not used Maori process, involving trusted people who had authority, allowing time for the family to gather and come to their own decisions while giving them information and eventually obtaining their informed consent to activate the follow through process, there may have been other and more dramatic outcomes. Working this issue through required me to give a great deal of "off duty" time to the family, including two overnight sessions. To alter my preset timetable as best I could and to use my informal networks to help find a resolution required me to work in a covert and undeclared way.
Such situations place border workers in acute dilemmas. I did not report the matter in any depth because my use of time would have been questioned and the professional boundary issues would have been identified. At that stage I did not know how to explain or defend my actions nor did I have a network of colleagues to consult who could support my practice choices. It was unheard of for a Public Health Nurse to sit with a family through the night. The nurse manager noted that I had the official car out of the base for two nights that week and I was reprimanded. Again I saw the inflexibility of the system to allow these dilemmas to be identified and legitimated, as unethical and institutionally racist. Had I acted in any other way I would have rapidly lost trust in that community and become almost non-functioning. People would have become politely formal but trust would have been lost as word spread.
The question of an ethic of care as a moral dilemma situated in a framework of institutional racism was an obvious one. Although I had behaved in a caring way according to ideals of right and wrong behaviour, how the values of right and wrong were defined and by whom became a major practice issue. Giroux (1992) describes ethics as "a social discourse that refuses to accept needless human suffering and exploitation" (p. 74). It seemed to me that more suffering would have been induced by following established policy and formally initiating the reporting of sexual abuse and the consequent follow-up by police and health authorities, than by taking a little more time and using a different process to achieve the same ends.
In this case the values which underpinned the process we used were set by the family in reciprocal negotiation with the health professional and later, the policeman. They were processes which we all understood as Maori, but Maori of the same rural background and from the same age cohort. Other Maori, socialised differently may not have been able to draw on the mutual and shared understandings. The outcomes were eventually satisfactory for the parties involved. Ideally this was a valid resolution, except that every aspect of the process contravened departmental policy.

The very meaning of nursing care was highly ambivalent in these situations and could not meet the professional needs of workers needing to act in complex and non-linear ways in order to respond with relevance to human realities. I was attempting to practise what Potter (2001) describes as an "ethic of care" (p. 108) which I believed met the requirement to maintain high standards of practice and the ethical guidelines of beneficence, non-maleficence, justice and autonomy. Potter further describes the development of nurses as caring professionals:
As nurses deal with health and illness in their practice, they grow in the ability to care. Expert nurses understand the differences and relationships among health, illness and disease and become able to see clients in their own context, interpret their needs, and offer caring acts that improve clients’ health. (p. 109)

However, it was not possible for me to access resources that would normally be available to nurses working in the community, including the advice of experienced nurses, without compromising them.

What this interaction clarified and confirmed for me

• That formal and informal networks are utilised to help resolve many practice situations.
• That these networks are visible and systematised or invisible and unsystematised.
• That the invisible and informal networks can be highly effective, at times more effective than the formal ones.
• That the use of invisible networks leading to invisible solutions requires the redefinition of accepted codes of ethics and creates further ethical dilemmas.
• That such dilemmas often remain invisible of necessity because the formal systems of nursing policy and management do not accommodate them.
• That nurses are not able to be prepared for these practice dilemmas in their formal education because such situations are not formally acknowledged.
• That nurses are highly at risk personally and professionally when they are placed in situations where trust is a negotiable factor and the boundaries of trust are indefinable except by testing at the time of interaction.
• That the silences which are required to maintain trust are compromising for all people involved.
• That nurses from the marginalised insider group experience ethical dilemmas of which the health service is unaware.
• That institutional racism underpins the need to invisibilise the professional activities of border workers in cross cultural environments.
• In order to grow in their ability to care, nurses need to be able to discuss their practice, consult their peers and expert practitioners and to have the confidence that their experience and views will be respected. This is often very difficult for nurses who differ philosophically and politically from their colleagues
.
Practice Example Three: Establishing and maintaining trust

A Maori woman who had never given birth had raised thirty-six children. She was very well known in the community for her philanthropic life but was adamant that she had never received any state funding to help her with these children and was not about to start asking for it at this late stage of her life. She made it clear to me that if I wanted to work with her I had to undertake to support her and her very mobile family (my family was known to her), but I was not to introduce any outside agencies or to let them know what she was doing in relation to the several children and one disabled young woman whom she was currently caring for. Her income was minimal and the family often ate food which was not nourishing such as flour and water pancakes sprinkled with sugar cooked in fat, three times daily. There was little I could do but monitor the situation.

While I was working in the area, a baby girl of about three months was left on her doorstep during the night with a label around her neck which said, "My father is a Korean sailor, my mother is a Maori." That was that. The child was absorbed into the home. Because I thought that I might be of some use I accepted her terms but would dearly have loved to have intervened in a range of ways. The old lady began complaining of abdominal pain and I suggested a visit to the GP. That was not acceptable until she became acutely jaundiced. Still she refused. Eventually she agreed to allow me to bring the GP to her and it became clear that she needed admission to hospital for investigations.

Her refusal was based in distrust of state/pakeha interference in her way of life. This mistrust of state intervention was based on her personal experience but she made it clear as well that as a woman of Tainui, the history of land confiscation after the Anglo-Maori wars and the desperation which resulted from that experience had created a legacy of suspicion of pakeha activity in her family. She was able to recite each piece of land which had been confiscated from her hapu and describe the resultant effects on her people. By this time I automatically sought help from the Maori policeman in such situations. He knew the old lady well and tried to persuade her to enter hospital. When she had extracted a promise from us both to see that the few children at home were well managed, that there was sufficient food and competent care, and no state interference, she agreed. We then embarked on a community gathering up of people who knew and respected this extraordinary woman. The policeman sold cuts of meat in pubs and dug vegetables donated from home gardens. People gave liberally of their time and energy, I co-ordinated activities and helped where I could, managing to get the children to Health Camp. Two weeks later she emerged from hospital, sadly with a very poor prognosis, but thankfully with some time to put her affairs in order.

What did this family teach me?

Again my job description said nothing about being enjoined to silence by the people I served if I wanted to work among them. And again the ethical dilemma of keeping the promises which we made to her while trying not to contravene our own professional rules had created obvious stresses. The policeman and I did not overtly discuss these matters. The complexities of establishing and maintaining trust and the wish to protect people from the power of entrenched racism of the health system are crucial issues for people who work on social and emotional borders. They are subjective experiences which are integrally related to the emotions as well as to the intellect.

Practice Example Four: The power of attitude

This example was related to the Maori Asthma Review Team of which I was a member, at Maraeroa Marae, Porirua, November 1990. The purpose of this Review was to report to the Minister of Maori Affairs on evidence and public submissions about asthma among Maori people (Pomare et al. 1991). Although I was no longer practising as a Public Health Nurse, this was my former practice locality and the people and places concerned were well known to me.

A Maori mother of three children, two of whom were at school reported to the Review Team that she had decided to take the baby to the Medical Centre and enquire about immunisation. She escorted the older children to school and carried the baby on to the Centre, without an appointment. Dressed casually she entered the Centre and approached the nurse at the reception area. At first the nurse ignored the mother until she had completed her current task and before the young woman spoke the nurse turned to her with an expression of impatience and distraction.

The mother said that she felt so uncomfortable that she shrank away, excused herself and left. There was no exchange of words yet the interaction had been so powerful that it completely blocked access to health service. The young woman said that she felt shy and ambivalent, did not feel able to assert herself in the Centre and in the presence of the nurse who was exhibiting behaviour which the mother felt was an unspoken commentary on her care of her baby, her casual appearance, her social class and her being Maori. Whether the nurse had intended to convey a negative message was not the issue, her professionalism should not have permitted her to behave in a way that could have been interpreted as obstructive to contact by the mother seeking her assistance.

What this example clarified and confirmed for me

• That it is very possible to create active barriers to service without recourse to spoken words.
• That there are other discourses which are unarticulated and unanalysed but inform the behaviour of patient and professional.
• That the influence of attitude can be a powerful inhibitor, or initiator of professional interaction.
• That it is the responsibility of the nurse as the power holder to create an environment which enables people to feel safe in the presence of the nurse.
• That unfavourable attitudes are easily recognised by those who have been exposed to their negative effects.
• That those who have experienced the power of attitude imposition are always vigilant to the possibility of its presence.

Hence my concern with the construction of trust. Most nurses who have worked in the community have stories such as these to tell which have aspects of the stress and dilemmas in which I constantly found myself. I suggest that they do not happen in the way that they do for nurses who belong to marginalised groups. Because these issues are not addressed in nursing education or in the realities of clinical experience, nurses from the border realms are still required to say one thing officially and often to do another in practice.

Practice Example Five: Practice and research

My education in anthropology stood me in useful stead in asking questions of new admissions of five year olds to the public school system in Porirua. It was part of my role as a Public Health Nurse in 1985 to undertake a physical examination of all new entrants to the public school system. Included in the assessment were measurements of weight, height, gait and the usual physical attributes of children of that age. Also included were checks on the status of the testes of boy children. I had extreme difficulty in carrying out these checks because I regarded them as an unethical invasion of the privacy of these five year old sons of the poor. Very few children had available parents who could comfort and support them while a complete stranger handled and investigated their genitals. Their looks of discomfort and their utter powerlessness will not ever leave me. Finally I refused to put children in the helpless position of having to allow a stranger to require them to take off their underpants. Eventually I complained to the Chief Nurse Adviser at the then Department of Health and the health check was later revised.

Part of the assessment involved checking for head lice. I encouraged children to check my hair in return for my being permitted to look in theirs. If we found lice in each other’s hair (and mine was often infested) we celebrated the opportunity to have special shampoo. One day a small boy who was checking my hair asked me if I was from a Maori, noting a Maori ornament which I was wearing. I replied that I was and that I thought it was a very good thing to be from a Maori. He said that he did not think so but could not say why. From then on I added a question about ethnicity and identity to my assessment of five year olds. In a completely informal and undesigned survey of five year old views of their identity, I found some interesting consistencies. There were 58 children in a two-year period.

If they were Samoan I asked the child whether they thought that it was a good thing to be from a Samoan. Each Samoan child regarded me as though I had asked them a ridiculous question and answered in the affirmative. No Samoan child expressed discomfort about being Samoan. Pakeha children generally did not understand the question and Maori children answered consistently that they did not think that it was a good thing to be from a Maori. It seemed to me that further research into the construction of identity in preschoolers could be encouraged and could lead to some very useful findings in relation to parenting, the influence of the television media on identity in children, and pre-school education. These were exciting opportunities for nurses to undertake research which directly related to practice. I noted the responses in a special notebook and discussed my findings with my manager. The manager spoke to her manager and I was asked to hand over my notebook and informed that such activities were not part of the role of Public Health Nurses and that I should confine my investigations to the physical health checks of the children.

What this experience clarified and confirmed for me

• In that period of nursing in New Zealand post graduate education was not fully established, and its necessity in practice was not understood by nursing management.
• That the relationship between research and practice was not understood.
• That the relationship between the biomedical model of disease and health and the integrated notions of holism were not generally understood and were therefore unable to be included in nursing practice.
• That the design of national health policies although well intentioned required a more thorough process of community feedback, consultation and evaluation with the nurses required to implement them.
• That nursing colleagues did not see themselves as practising in a political context.
• That nurses were not comfortable when political action was taken and if possible would take steps to inhibit actions that they saw as likely to create future difficulty.

Although I found practice as a Public Health Nurse to be fulfilling in the short term, on another level it was profoundly frustrating. Systemic institutional failure of many of the New Zealand citizens I worked with was profoundly obvious, normalised and repetitive. I saw the chronic disadvantage in this community as an indictment of the New Zealand social structure but other nurses did not appear to see their work in the same context.

Moving On

I was in the unique position of working in the preschool, primary school and secondary education system simultaneously and daily. The older siblings of the families I visited to help with infant welfare were in the colleges euphemistically called educational institutions. Their health status was impaired from babyhood. Dentition, nutrition and hearing were all compromised, but probably the most severe impairment was in the collective ethnic and emotional identity of specific groups of children. These children were Polynesian, immigrant or indigenous their fate in terms of social indices appeared to me, to be sealed. By repeating its patterns I felt that I was colluding in the generational entrenchment of disadvantage in the future of the people for whom I was involved in caring. Again I questioned the meaning of care and whether the work of nurses in those communities was in fact making a difference in the long term. Despite the grim realities for many in this community there was and is a spirit of resiliency, vigour and energy to survive and to prosper. There are few existing resources on which to build but they have been identified, used to their advantage and in some places increased.

Among my colleagues there were no nurses with whom I felt that I could discuss these experiences and the concerns which arose from them or explore the ideas which might offer solutions. Our English born and educated manager attached a note to my file which was stored in the Department of Health to the effect that I spent too much time working in what he termed were "bicultural" environments. I felt that this comment was unjustified because it could not be explained and I discussed the matter with the senior nurse employed by the Department as advisor to the Minister of Health (Trixie Bradley). With the help of the anthropologist then employed by the Department (Dr Patricia Kinloch) and the Director-General of Health (Dr George Salmond), the note was removed.

One morning as I was testing the vision of new entrants, especially enjoying testing the Kohanga Reo children in Maori, at a local primary school, I was approached by the Head of Department of the newly established School of Nursing at Parumoana Polytechnic and invited to apply for a full time teaching position. After consultation with my family I decided to apply to become a nursing teacher. A family vote was taken and mine was the only one against leaving practice in public health. It was not a sense of vocation which induced me to leave Public Health nursing but family opinion and a belief that I could eventually be of more use teaching others to nurse as a result of my own learning than trying to help stem the social tide of disadvantage and the resulting human struggle, as a practicing nurse.

I joined the inaugural second year of the nursing course of the polytechnic. Here was an opportunity to help create a course with a curriculum which could address those health and disease issues experienced in colonial countries throughout the world. By understanding the problems which beset indigenous peoples we could design and teach educational material that would alter nursing service and therefore make a difference to the health status of all New Zealanders. Surely, I thought, if a country is to be judged by its service to the most vulnerable members of its communities then excellent nursing service for the tangata whenua would have the effect of reaching others who were also in need of excellent care. I believed, as hooks has said, that "the classroom for all its limitations does remain a location of possibility" (1994, p. 206).

Bright eyed I commenced work at Parumoana Polytechnic with recent education in liberal social science and a complementary practice base, only to be asked to teach surgical nursing, an area in which I had last had experience almost twenty years before. Working in formal education began the public section of my activities.

I look back on my nursing training and years as a practitioner first in hospital and then later as a Public Health nurse and try to remember the questions I asked myself over that time. One of the questions was: how could I offer some insight and ideas about positive change in the health service to those people working in proximity to Maori? The conclusion I have come to in trying to separate my point of view from my political stance is that, for me, that cannot happen. The cliché that the personal is political is how my life was and is. There is nothing I can do about it so that is what I have offered.

Working in a highly urbanised area only twenty minutes from the government parliamentary buildings taught me about abject and grinding poverty and about the control of the education process by pakeha teachers and administrators in schools which had mainly Maori and Polynesian rolls and high failure rates. Public Health nursing enabled me to see the children from pre-school to college, and to see bright youngsters become sullen and closed, or struggle to push through. Working in homes put me in touch with sole mothers struggling to educate, feed and clothe their children, and cope with the financial stress of it all.
Working there also showed me the the strength and determination, courage and energy of many of those people to retain their cultures and to make something good out of the colonial and the migrant experiences. I came away with enormous respect for those bound in there, and with cynicism for the systems which bound them.

The establishment of trust, learnt in those homes and communities, was to become a critical factor in my later work on Cultural Safety. This meant divesting myself of the ideas that I had the answers to their needs or that I even understood their questions. I was a privileged stranger and it was necessary for me to understand the rights of people to their full humanity and to learn, as I also had from the experience of working in the Tb ward, that I had power and the proper use of that power should be a negotiated process. My nursing experience to date had taught me that to understand this process, nurses and midiwives needed to understand the influence of attitude as a powerful inhibitor, or initiator of professional interaction. Unfavourable attitudes are easily recognised by those who have been exposed to their negative effects. Nurses and midwives are highly at risk personally and professionally when they are placed in situations where trust is a negotiable factor. Nurses and midwives needed to recognise this fact and accept that it is the practitioners responsibility, as the power holder, to create an environment which enables people to feel safe in their presence.

My own situation as a nurse from a marginalised insider group meant that I experienced ethical dilemmas of which the health service is unaware. Much of the difficulty lay with the institutional racism which underpins the need to invisibilise the professional activities of border workers, like myself, in cross cultural environments. In order to grow in their ability to care, nurses need to be able to discuss their practice, consult their peers and expert practitioners and to have the confidence that their experience and views will be respected. This is often very difficult for nurses who differ philosophically and politically from their colleagues.
My own experience had been one of comparative intellectual and emotional isolation from the beginning of my education as a nurse. Perhaps as a teacher I could teach from the ideology which I had developed from these experiences and help students to construct a political vision and a wider context from which to practice. Perhaps I could help them to think critically about issues relating to the health and disease of the tangata whenua. And perhaps, from that standpoint, they could expand their vision to their whole practice.