Chapter Six
Learning and Teaching: Students as Teachers

Although I had an undergraduate university degree which was unusual for a nurse practitioner or a nursing teacher in 1986, I had no theoretical training in teaching let alone teaching in the delicate area of antiracism or attitude formation and change. I had little formal analysis of the situations around me and no classroom experience. I entered the teaching environment with few tools other than my own nursing education and practice and a deep commitment to help create positive change.

The following year, the Standing Committee on Maori Health (1987) recommended that the Treaty of Waitangi be regarded as a foundation for good health. I was beginning my teaching practice at a very interesting time in New Zealand history. Although my first attempt to include Maori health issues in the curriculum of the Parumoana Polytechnic, a 35-hour paper called 'Intercultural Nursing’, was the subject of congratulations in a letter from the Nursing Council of New Zealand, there was no formal agreement between the Council as a professional body set up under statute, and Maori, based on the Treaty of Waitangi.

The idea of a cultural checklist in which heavily stereotyped cultures were able to be predicted by nurses leading to insight on the part of the nurse and conformity and compliance on the part of the patient, (Bruni, 1988), was something which I later came to describe as a cultural smorgasbord (Ramsden, 2000). The metaphor was one of "cultural tourism" or "voyeurism" where the nurse stood outside, secure in the culture of nursing, and surveyed the patient from the viewpoint of their interesting exoticism. The interesting exoticism was usually in deficit compared with the culture of nursing and allowed the nurse to be patronising and powerful. There were no grounds for the nurse to consider that change in their own attitude and self knowledge was needed before any trust could be established.

It was also assumed that nurses could speak for the perceived needs of people from other ethnic groups. The popular concept of culture remained ethnicity based while groups of people with clearly defined commonalities, sharing kinship, world views and ways of existing in the world such as religious groups, for example Jehovah’s Witnesses, closed religious sects, or the Salvation Army were not seen as exotic cultures. Nor did nurses see themselves as having the right to investigate or provide commentary on groups of people in the way that they felt they could about Maori.

A further philosophical underpinning of the multicultural debate, discussed in the previous chapter, and relevant to the nursing and midwifery education context, arose when Maori tried to assert political status as First Peoples. The disagreement lay in the nursing notion that all people should be nursed equally regardless of their difference from nurses or from each other. This ideology was expressed by the National Action Group in The Aims and Scope of Nursing (1988) that saw nurses as being providers of care irrespective of differences such as nationality, culture, creed, colour, sex, political or religious belief or social status. Very similar words are reiterated in the International Council of Nurses Code for Nurses which states:

The need for nursing is universal. Inherent in nursing is respect for life, dignity, and rights of man (sic). It is unrestricted by considerations of nationality, race, creed, colour, age, sex, politics or social status. (Johnstone & Ecker, 2001, p. 403)

The report which I wrote in 1990, Kawa Whakaruruhau, Cultural Safety in Nursing Education in Aotearoa (Ramsden, 1990a), refuted the premise that people could be nursed regardless of all the elements which made them unique in the world. In the introduction I wrote:

The idea of the nurse ignoring the way in which people measure and define their humanity is unrealistic and inappropriate…People are still prepared to die in order to maintain their cultural, religious and territorial integrity. It is not the place of the nursing service to attempt to deny the vital differences between people however altruistic the rationale may be. (p. 1)

In the graduation speech to the Diploma of Nursing students at Nelson Polytechnic, I wrote that:
Only one word needs to be altered in order to suitably change the old nursing philosophy to become appropriate for the end of the 20th Century and onward into the 21st. That word is irrespective…Nurses must become respective of the nationality of human beings, the culture of human beings, the age, the sex the political and the religious beliefs of other members of the human race. (Ramsden, 1988)

These statements lay two years into the future. Initially, I too adopted the multiculturalist/ethnic approach. Although I was uncomfortable about it from the beginning of my teaching experience I was not clear about how to analyse or express my diffidence. Fuimaono Karl Puloto Endemann, then Deputy Head of School Palmerston North Polytechnic School of Nursing, commented passionately on multiculturalism in his interview for this project:

I hate multiculturalism…yes I do…I hate it. Hate to me is a very powerful word. Because what multiculturalism does, it actually demeans people. I always say that for us Pacific Islanders it makes us into the hula girls, and the chop suey and rice kind of sentiment, like that’s what we are right across the board…. If we are all the same, how come you are rich and I’m not? (Karl Puloto-Endemann, interviewee)

The ideology of multiculturalism was deeply held by students and were expressed by many of them in a microcosm of New Zealand society. Common statements were:

"We are all the same in New Zealand."
"What is different about Maoris?"
"Why should they have more than us?"
"We are all one people. I grew up/went to school with Maoris and they were the same as we were."
"Maoris have special privileges that we don’t such as scholarships."
"New Zealand is a multicultural society, what about all the other cultures?"

I realised that it was essential to place this kind of discourse into a social context and then somehow teach what I had found to nursing students (Wetherall & Potter, 1992). From the beginning I tried to introduce an analysis of racism in New Zealand communities and describe its effect on Maori people. I began by describing differences between Polynesian and United Kingdom based cultures indulging myself, in a naive way, in stereotypes of each group. The cultural checklist approach (Figure 3) was satisfying for most students because it gave them something to quantify and to repeat back in assignments. For a short while I found it more convenient to teach from this position but my own life experience imposed itself on the information I was dispensing. It was clear that cultural stereotypes were simplistic and untrue and that the complexity of post colonial cause and effects on New Zealand society must be taught. I came to struggle hard against the checklist mentality and consequently made my own work much harder. Later I became able to use the treaty as a teaching framework but as yet there was no backup from the statuary nursing institution which could help teachers to formulate and uphold such a framework.

Figure 3
Levelling the playing field?
Source: Unknown

In 1994 the Nursing Council of New Zealand, the statuary regulatory body for nurses and midwives, acknowledged the Treaty of Waitangi in a three-year strategic plan (Nursing Council of New Zealand, 1994). Part of this plan identified the role of the Council in relation to the Treaty of Waitangi as a critical strategic issue. As a Crown agent, the Nursing Council is morally bound to observe the principles of the Treaty of Waitangi as are all Crown agencies although the Treaty of Waitangi does not appear in the Nurses Act 1977.

The Nursing Council of New Zealand is in effect, an agent of the Crown through its statutory role in the maintenance of standards of education and practice for nurses and midwives. It is empowered by the Nurses Act 1977 to act as such an agent by setting and monitoring standards to ensure safe and competent care for the public of New Zealand. (Papps, 2002, p. 98)

In an environment of assimilation and denial of difference this was the worst place to start teaching. Students were largely from the New Zealand islands and descended from United Kingdom immigrants. They were mostly young female school leavers with little travel or cross cultural experience. The polytechnic was situated in a low socio-economic area. Although the ratio of people from Pacific island communities was much higher in Porirua than other parts of Wellington, anecdotally, intimate interaction between groups was low apart from public activities such as attendance at schools.

These young people had come to be nurses and the work on racism, cultures and difference that I was offering appeared to have little bearing on nursing which was a profession in their view which cared for people regardless of who they were. Students were very clear about expressing their opinions. If they did not see the relevance of what I was teaching they protested loudly, ignored my presentations, spoke during visiting speakers’ presentations and eventually boycotted my classes. At one point I had only three students attending class, one was an older Samoan woman, another a scholarship student from the Solomon Islands and the third, a pakeha who had arranged her hair into three stiffly pointed projections dyed bright green. These three students stayed with me all year and I am grateful to them for their gentleness and patience to this day.

What I did learn from the students’ challenges?

Like me, the students lacked the capacity to analyse what was happening to them in my classes. They had less knowledge of the Treaty of Waitangi than I did and they were confronted and affronted by my challenges to their lifetime beliefs about race relations in New Zealand. Patti Lather (1991), in discussing the development of emancipatory social theory, is clear that an empirical stance is required which is open ended and grounded in respect to human capacity but also needs to be profoundly sceptical of appearances and "common sense" (p. 65).

While I was learning to explain issues in a professional context it was not quick enough to meet the students’ immediate educational and emotional needs, and their responses became collective and punitive. They exercised what power they could by refusing to participate in my classes as much as possible and I exercised what power I could by presenting them with information which I thought important for their practice. It was also critical that I did not demonstrate the passion I felt for this topic; although it was permissible for me to show stimulation, excitement and enthusiasm in the teaching of my other subject, surgical nursing.

Systems of education are not neutral (Freire, 1973) and are established to meet a set of agendas. Roy Shuker (1987) argues that the schooling system functions as a state construction to reproduce labour power and the means of production:

This involves producing a labour force with ideas values and practices which are consistent with, and in acceptance of existing power relations. (p. 21)

There was little question that the students who were entering nursing courses and had been educated in New Zealand (the majority) were fixed in their views on race relations and the locus of power. The power clearly lay with Anglo derived middle to upper middle class members of New Zealand society and not with Maori or other marginalised groups of people.

I learned that unless I could show an effect in the environment of health and disease then teaching the cause, ie land deprivation, social injustice and/or racism, was almost pointless. This was material students had never been exposed to. It was critical that like any other historical facts they made sense to the student and should be presented in the correct framework of their education. I needed to ask myself, why were they in the course? Then I had to address the facts that I was wishing to teach to the reason for the presence of students, which was to become graduate nurses and to deliver excellent service.

The next part of my developing pedagogy was to relate the facts to nursing practice. Here my nursing practice in the Porirua community stood me in good stead. I was able to illustrate the relationship of history to the people and communities around us and to the disparities and facts of life with which most of the students were more than familiar. It was also possible to link the Treaty of Waitangi breaches to health and social disparity. When I began to draw on practice my classes refilled and I was able to learn as I went along with students. Although we were learning different facts, we were both learning about power, mine to create emancipatory change in students’ view of the world and students to create teaching which would match their needs to become nursing professionals. Since I was also working with students in clinical practice it became possible to translate classroom teaching to the hospital or community environments and again back to the classroom. The following three practice examples illustrate particular aspects of this.

Practice Examples

The importance of attitude, recognising and understanding the powerlessness of patients and the power of nurses, and the centrality of open-mindedness and self-awareness, are illustrated in the following practice examples.

Practice Example One: Attitudes matter

Attitudes matter and when people need a nurse or need health care they are in a vulnerable state, extremely vulnerable, and they need respect and they need to be treated with love and justice. (Isabelle Sherrard, interviewee)

A Maori woman was admitted to a local hospital seriously ill from a rupture of a hydatid cyst in her abdomen. She was deeply unconscious when the student nurse and I came to help with her care in the Intensive Care Unit. We joined the ward round and were present during a full staff meeting around her bed as she lay unconscious her breathing maintained by a respirator. Apart from her present condition the woman did not look as though she had been healthy or prosperous prior to admission. She was tired looking, had no teeth and was clinically obese, white roots were growing through her hair. Although comment was made only on her obesity it was clear by the attitude that staff did not consider this woman to have been compliant when first diagnosed and that she had presented an extreme surgical risk. There was general conversation about her non-compliance with attendance at clinics and her irresponsible attitude toward her condition. The atmosphere during the discussion between surgeons was that she had brought a great deal of her trouble upon herself by not turning up at clinics and disappearing from the surgeons’ supervision until the dramatic rupture of the cyst.

It was clear that the student nurse was listening to the conversation carefully and that she was also absorbing the non-verbal communication that was happening between the lines. We decided to do some investigation into the background of this unfortunate woman. As we went carefully through her notes we discovered that she was a sole caregiver of eight children, some of whom were pre-school grandchildren. She had been trying to keep her family together by working a little piece of land with sheep and share milking, hence the exposure to the possibility of hydatids. The pressures of child rearing, poverty and prioritising for the needs of others had caused her to forgo her trips to town to attend at the hospital. There was one phone call of apology for inability to attend the clinic in the notes.

When the student had put together the background to the situation this woman was in I asked her to present her findings to the class, including the unspoken communication. The student nurse made an excellent and clearly thought out analysis of what she had seen and heard, as well as not heard but had understood and she unknowingly gave me two of the objectives that I later brought to Cultural Safety. They were:

• To educate student nurses and midwives not to blame the victims of historical process for their current plights.
• To educate student nurses and midwives to examine their own realities and the attitudes they bring to each new person they encounter in their practice.

Practice Example Two: Recognising powerlessness and power

A student and I were working together in a busy surgical ward. A young man was admitted from Western Samoa for elective surgery for an inguinal hernia. The young man spoke very hesitant English and preferred to sit quietly cross-legged on his bed waiting for something to happen. The student and I were anxious that there was no interpreter to assist with the preparation for surgery and as the time for his premedication approached it became obvious that nobody had spoken with this young man or helped him with his preparation. He still required a pubic shave, skin preparation and theatre garb. Finally we went to the nurse who was caring for him and asked about his preparation and suggested that an interpreter would be helpful, she told us to find one for him. Finally as the time for theatre approached we found a young Samoan nurse from another ward, negotiated her release from her ward and got to the bed just as the nurse arrived to shave the patient, the nurse with the intramuscular pre-medication hove into view and the theatre trolley arrived. The patient became frustrated as the interpreter tried to explain the procedures and each health worker pushed to complete their tasks. The patient was insulted by the attempts of the female nurse to shave his groin, something unacceptable in his own cultural environment, the staff were also frustrated as time passed.

This confusion had clearly arisen because of a poor initial nursing assessment and resultant inadequate planning on the part of the primary care nurse and the patient did his very best in a foreign setting to cope with the nursing mismanagement that had been visited upon him. Had the patient responded in ways that the staff considered inappropriate, for example by shouting or physically resisting attempts to touch him, the possibility of his being blamed for behaving in ways which were upsetting to staff and ward routines would have been very high. Intervention by the interpreter, who fortunately was a nurse (often non-health professionals are informally involved as interpreters) and could explain what was happening, and the locating of a male nurse to do the shave, saved the situation from being potentially quite disruptive to all concerned. The sheer grace and patience of the young man also made it possible to negotiate his way through the mosaic of dilemmas.

The students analysed this situation and applied the objectives of Cultural Safety to it recognising the powerlessness of the patient and the power of the nurse to create an environment in which these quandaries need not have developed. Had the nurse made an accurate assessment of the patient’s language status at admission most of the confusion could have been avoided. The issue therefore lay with the practice of the nurse rather than the behaviours of the patient.

Practice Example Three: Open-minded, self-aware

At the afternoon shift report the senior nurse giving the overview of the ward commented that a Samoan woman patient had had over twenty visitors who said they were family that morning, most of whom insisted on staying close to the patient. As the nurse gave this information she rolled her eyes, sighed and looked frustrated. She did not say anything pejorative about the patient or the amount of visitors or them being in the way of nursing cares being carried out, but it was clear that this was what she was thinking. Each time she mentioned the patient she non-verbally expressed impatience and gave the impression that the afternoon staff were in for a trying time.

This dilemma is a particularly good one for student group discussion because it highlights the rapid socialisation of student nurses. Most students by year two of their degree programme in my experience, agree with the nurse conveying the non-verbal messages relating to "inappropriately" sized family groups and other visitors upsetting ward routines and other patients. It takes an exceptional student to detect the underlying racism relating to the definition of family, and to see that the nurses on the previous shift should have negotiated their way through this situation with the large kinship group of the patient and should not have left this situation to become the legacy of the afternoon staff. There can be a range of solutions depending on the circumstances all of which can lead to successful negotiation and mutually beneficial outcomes. From this type of situation the final two objectives of Cultural Safety were drawn:

• To educate student nurses and midwives to be open minded and flexible in their attitudes toward people who are different from themselves, to whom they offer and deliver service.
• To produce a workforce of well educated, self aware registered nurses and midwives who are culturally safe to practice, as defined by the people they serve.

The issues highlighted by these practice situations and the teaching which was evolving from them produced dilemmas of their own. Questions arose not only in relation to how such material should be taught but who should teach it, how it should be assessed, even where and when it should be taught. Because cross cultural issues in the New Zealand context were perceived to be between Maori and non-Maori, most practice exemplars and test questions were based in this primary New Zealand relationship. Culture was uncompromisingly seen as ethnicity and it remained difficult to present the diversity of notions of culture which my anthropological training had given me. It was frustrating to see stereotyping questions used which were pejorative, patronising, treated Maori as exotic and did not relate to the ill health or otherwise of Maori people. Above all, they did not test nursing or midwifery practice. As highly diverse, colonised and urbanised people with mostly inter ritual contact with pakeha, there was little that Maori had to show apart from the postcard and tourist imagery. This is what appeared to be built upon when teaching and testing nursing assessments.

In some ways I think it was easier for pakeha institutions to dump Cultural Safety on a Maori or a Maori Department and then it could be, as so many Maori things are, marginalised. That, in the first few years of the programme, was my main fear about how it was developing. I don’t particularly want nurses to know how to sing waiata, I want them to treat my mother properly if she’s unwell. (Moana Jackson, interviewee)

The newly established Maori Studies Departments in polytechnics were called in to provide Maori teachers who were non-nurses, to assist in this process. This served to enhance the Maori Studies view of Maori health and to entrench it in the systems of teaching nurses and midwives. Maori Studies teachers were not teaching nursing and midiwfery because it was not possible for them to do so. In some schools, students were being taught to recite prayers in Maori and being tested on their capacity to remember the prayers, and in others to sing Maori songs and perform dances. Unfortunately remnants of this period still persist in some Schools of nursing and midwifery.

The political and economic realities of life for many Maori people became subsumed by romantic and sentimentalised colonial constructs (Bell, 1992). There was further debate over the place of teaching Maori issues and for several years it was thought useful to take students to traditional Maori locations to learn about "the habits and the customs of the natives." (Ramsden & Spoonley, 1994, p. 163). This was comfortably in line with Transcultural Nursing theory (Leininger, 1991) and is discussed in more detail in Chapter Eight. Although the Nursing Council of New Zealand was clear that this practice, if followed at all, should relate to nursing and midwifery educational aims, it remained popular as a group familiarisation process and an enjoyable class outing (Nursing Council of New Zealand, 1996).

For some groups the outings were not so enjoyable as politicised Maori began to challenge their audiences in a range of ways. My experience taught me that contentious issues such as race relations in New Zealand should not be raised in the first year of any nursing diploma, or later degree programme, for a range of very cogent reasons. A level of trust had not evolved within the class group by early in the first year (sometimes in the first week) when students were often taken out to marae for the 'Maori experience’. Another reason was that Maori students were placed in very emotionally vulnerable situations when they had often not defined their own identities. Students usually did not possess the social or educational building blocks on which to base such information in relation to nursing. By the second year, students had settled as a group and had some clinical experience to compare to classroom theory. As I began to learn the pedagogy which the students helped to teach me, and was more able to integrate practice exemplars having acquired some educational theory, I found my classes remained well attended.

Appointment to the Department of Education

Late in 1987 I was approached by the Department of Education to consider a secondment to research the health needs of young Maori trainees on government pre-employment schemes. This meant relocation to downtown Wellington and entry into education and research politics. At this time I was also appointed to the Education Committee of the Nursing Council of New Zealand, the first Maori appointment to this significant and powerful committee or to any committee on the Council. Nursing and midwifery education was the obvious place to start the work which became known as Cultural Safety and the juxtaposition of the appointment to the Education Committee and the opportunity to gain a national overview and national influence through the Departmental secondment, were extremely fortuitous.

On completion of the research project and the production of the educational video and poster package that emerged from it, I was further employed by the Department of Education to set up and facilitate a hui which was to be concerned with the recruitment and retention of Maori students in nursing courses.

At this period the Department of Education had a position called Senior Education Officer, Nursing, filled by Ms Janet Davidson (who was interviewed for this project), which had responsibility for the overall educational co-ordination of the fifteen polytechnics providing nursing courses. Such was the concern of the Department of Education to respond to the principles of the Treaty of Waitangi and to get Maori health issues successfully integrated into nursing education, that the position offered to me was especially created. The position was called Education Officer, Nursing and Maori Health, and was one of several which were involved with Maori issues in the tertiary sector.

Looking back it is possible to see that my time in the Department of Education provided an amazing opportunity to translate my prior experience, concerns and emerging insights as a teacher to conceptual and practical strategies for nursing education at a national level. It also provided opportunity to bring together issues of Maori health and the role and place of nurses within healthcare to make a critical difference.

My role was to help co-ordinate curriculum development and course content in all the polytechnics at a national level. This involved a series of visits over the next two years and resulted in the production of A Model for Negotiated and Equal Partnership (Ramsden, 1989a) (presented in Figure 4), which was accepted by all polytechnics and implemented regionally according to their own community settings. Relationships between local iwi, and nursing schools were critical to the model. A most innovative response was the relationship that the Otago Polytechnic Department of Nursing developed with Ngai Tahu, the local tangata whenua, where the School of Nursing and Ngai Tahu co-own the Cultural Safety curriculum to this day.
In the years following the writing and introduction of the model, discussions with educators teaching in polytechnics at that time have shown me that they regarded it as revolutionising for their thinking and for their practice. It provided a structure and

Figure 4
A Model for Negotiated and Equal Partnership

process for moving forward with this aspect of education. It also provided a basis for arguments for obtaining resources.

A number of nurse educators have shared with me that the Model came at a time when they were seeking alternative strategies in nursing education, as they recognised the importance of addressing these issues. However, in some places these educators were lone voices.

The Hui Waimanawa

The second critical impetus for the development of Cultural Safety, also associated with my role at this time, was a national hui, the Hui Waimanawa. This hui which I was commissioned to run in 1988 was significant in several ways. First, the budget allowed me to take the gathering to my home area so that I could be supported in the work by my grandparents and other family who came and sat with me for the week. My grandfather named the gathering, Hui Waimanawa, in recognition of the tears which had been shed over the years of colonisation and to recognise the importance of the hui being able to happen.

Second, since the gathering was concerned with the experience of Maori students, I invited Maori students to take part in the hui which had over a hundred participants. Third, the participation of Maori students produced the term 'Cultural Safety.’

Fourth, the report of the hui and the Model For Negotiated and Equal Partnership (Ramsden, 1989b) became critical turning points in the implementation of Cultural Safety into nursing education because they were accepted as national documents from the Department of Education and were reinforced by assistance from the Education Officer, Nursing and Maori Health.

Origin of the Term Cultural Safety

A first year student from Te Arawa studying nursing at Christchurch Polytechnic was at the Hui Waimanawa. Although shy because of the status of other participants she had been listening carefully to the talk and to the language being used. Finally she rose to her feet and said that legal safety, ethical safety, safe practice/clinical base and a safe knowledge base were all very well to expect from graduate nurses "but what about Cultural Safety?" This young woman was overwhelmed by her own courage. Sitting in the hui, I picked up what she said and with her permission from that time adopted the term Cultural Safety to refer to the work which has since emerged from the hui.

Acceptance by the Nursing Council of New Zealand and the schools offering nursing and midwifery education of the two documents A Model For Negotiated and Equal Partnership (Ramsden, 1989a), and Kawa Whakaruruhau: Cultural Safety in Nursing Education in Aotearoa (Ramsden, 1990a), legitimated the term Cultural Safety and admitted it to the nursing and midwifery lexicon. Linda Wilson, Head of School, Occupational Therapy, Otago Polytechnic, and I (personal communication, Dunedin, 1993) identified expected educational outcomes of a culturally safe graduate health professional presented in Figure 5.

All graduates ? develop the skills of critical analysis
All graduates ? recognise where things are wrong
Two thirds of graduates ? recognise the opportunities to create change and see where to intervene
One third of graduates ? contribute to change
Outstanding graduates ? initiate change

Figure 5
Outcomes of a culturally safe health professional

This is not a measure of any group of students at any time but simply a model to which students and teachers may aspire. It does not require concrete prescription but rather creates a set of aims which students and teachers can see as achievable alongside their own rhythm and pace of development. It does not stipulate that students will have reached a prescribed level of achievement by a given time but acknowledges the rate at which each student works and it also agrees that such learning may take place over a total lifetime, that learning does not need to confined to a three year programme.

Moving into a teaching environment and having direct contact with students from the very beginning of their training gave me further insight into both my own and their learning needs about emanicaptory change and ways in which this information could be approached and used meaningfully within nursing and midwifery.

To some extent, the key concepts of Cultural Safety education were already in place prior to my moving into teaching. However, there had been no education framework on which to "hang" the concepts, learnt as a practitioner, which could be relevant to those students in a classroom who were without a practice base. The two components of theory and practice needed to be brought together for me as a teacher, and from that position I could bring the same information and analysis to students as they moved through their training and were exposed to practice situations.

The key objectives of Cultural Safety education arose directly from these practice/classroom encounters:

• To educate student nurses and midwives not to blame the victims of historical process for their current plights.
• To educate student nurses and midwives to examine their own realities and the attitudes they bring to each new person they encounter in their practice.
• To educate student nurses and midwives to be open minded and flexible in their attitudes toward people who are different from themselves, to whom they offer and deliver service.
• To produce a workforce of well educated, self aware registered nurses and midwives who are culturally safe to practice, as defined by the people they serve.

These objectives formed the basis for the early Cultural Safety documents I produced which are discussed in the following chapter. They have remained, to this day, the fundamental cornerstones on which Cutural Safety education is based.