Indigenous nurses’ practice realities of cultural safety and socioethical nursing

Abstract

Background:

Persistent healthcare emphasis on universal moral philosophy has not advantaged indigenous and marginalised groups. Centralising cultural components of care is vital to provide ethical healthcare services to indigenous people and cultural minorities internationally. Woods’ theoretical explication of how nurses can integrate cultural safety into a socioethical approach signposts ethical practice that reflects culturally congruent relational care and systemic critique.

Aim:

To demonstrate the empirical utility of Woods’ ethical elements of cultural safety within a socioethical model, through analysis of indigenous nurses’ practice realities in Aotearoa New Zealand.

Research design:

The study used a qualitative indigenous narrative inquiry.

Participants and research context:

Participants were recruited nationally. Twelve Māori registered nurses and nurse practitioners were interviewed. All participants provided direct care in either primary or secondary health services.

Ethical considerations:

Research approval was gained from the Human Ethics Committee of the lead author’s tertiary institution. Participation was voluntary, and written informed consent was obtained.

Findings:

Analysis highlighted the following: (1) cultural needs, which for Māori were integral to care, were easily subsumed by clinical care being prioritised; (2) ethical care by non-indigenous nurses requires critical reflection about broader equity issues that impact Māori disengagement from healthcare; (3) retention of indigenous nurses was seen as essential because their advocacy and the cultural ‘fit’ for Māori contributed to positive healthcare outcomes; and (4) committed leadership ensured culturally safe care was not eroded through workplace efficiencies.

Discussion:

The data provide rich representation of Woods’ model. The data indicate that nurses must engage reflexively with a relational ethic of care and social justice dimensions in order to deliver culturally safe care.

Conclusion:

Woods’ model provides a critical lens for nurses to examine their relational practice and systemic factors that enhance or detract from culturally safe care when caring for members of any indigenous group.

Keywords

Cultural safety equity indigenous Māori registered nurse social justice socioethical

Introduction

The persistent healthcare emphasis on universal and rationally based moral philosophy has not advantaged indigenous and other marginalised groups.^1,2 We concur with Woods¹ that within dominant discourses in healthcare ethics, there is a relative disinterest in sociocultural contexts, and instead a focus on impartiality. This inattention is concerning, given that culturally driven socioeconomic and health disparities have not shifted significantly for decades in Westernised societies.^3,4 Centralising cultural components of care is vital to provide ethical healthcare services to indigenous people and cultural minorities.⁵ In Aotearoa New Zealand where the health infrastructure is largely publicly funded, reforms in the early 1990s resulted in public health service delivery by public health units, non-government organisations and Māori health providers.⁶ An ethos of cultural responsiveness is evident throughout policies, education and practice competencies.^7

–11 However, these practice ‘signposts’ occur within a neoliberal market economy. The neoliberal freedom of choice heralded by free-market capitalism, with commodified health choice, does not filter equally to all citizens.¹² Abundant evidence demonstrates that indigenous people typically experience alienation and further disenfranchisement when they attempt to use health services.^2,6,13

In this article, the authors draw from interviews with 12 indigenous nurses about their cultural and clinical practice realities. The percentage of practising indigenous Māori nurses in the Aotearoa New Zealand workforce remains static at 8%, while 16.5% of the population identify as Māori. The empirical data are used to highlight the components of Woods’¹ socioethical model, which incorporates the ethical elements of cultural safety. The aim is to illustrate the utility of the model in knowledge translation, to inform critically oriented practice. The data analysis highlights the complexities and tensions that contribute to cultural safety still being very much a ‘work in progress’ in Aotearoa New Zealand, decades after the inception of the concept.

Cultural safety is a concept that developed in Aotearoa New Zealand in the early 1990s and championed by the renowned indigenous educator, Irihapeti Ramsden.^14,15 The concept has been described in depth by other authors.^1,16 The concept was initially developed to make visible the power imbalances between health providers and indigenous people that impact adversely identity and well-being. Defined broadly in terms of safety and risk, the Nursing Council of New Zealand defines cultural safety as

the effective nursing practice of a person or family from another culture, and is determined by that person or family…unsafe cultural practice comprises any action that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual. (p. 8)⁸

This focus on power relations is in contrast to the mere accumulation of increased cultural knowledge that fails to recognise structural inequities.¹⁷ In Aotearoa New Zealand, cultural safety practice standards originate from the Māori term ‘Kawa Whakaruruhau’ (Table 1 in Appendix 1) and align with the partnership commitment made between the British Crown and Māori in 1840.^13,14,16 The cultural safety concept then widened to include diverse groups who may experience disenfranchisement.¹⁸ New Zealand Nursing Council guidelines call nurses to reflect critically on their own cultural positioning and how such influences shape professional practice.⁷ Pertinent to this study, providing culturally safe care requires nurses’ awareness and advocacy in relation to colonial structural inequities, as well as how culturally safe care is manifested relationally in direct patient care.¹⁹

Socioethical model of culturally safe practice

The socioethical model is a different ethical approach that recognises the needs of a given sociocultural group and can be utilised internationally. Typically, healthcare systems tend to promote the norms and values associated with Western or traditionalist ethics. In respect of cultural difference, Woods’¹ socioethical model challenges the notion of cultural safety as a stand-alone sociocultural concept in nursing practice. Within his article, Woods situates the model within two overarching concepts, intertwining social and ethical elements of culturally safe practice to illustrate potential links. The critical perspective offered views culture as a complex, fluid sociopolitical construct, where diverse ethical and sociocultural realities and moral viewpoints are better served. Woods’ model is depicted as three concentric circles, with culturally safe practice at its core. The outermost circle includes the two social elements of cultural safety: synthesising sociocultural practices and using sociopolitical dynamics, allied with the essential moral elements of operating within a socially oriented ethic. These elements together highlight that it is not possible to separate the ethical activities of caring from the wider social context. Synthesis of all components should result in culturally safe practice by the ‘socioethical’ nurse. The key concepts and elements within the model are explored further below and illustrated and analysed throughout the dataset and discussion.

Cultural tensions become more apparent for indigenous minorities within social systems such as healthcare where ‘the cultural practices of nursing and medicine may easily overwhelm the cultural needs of others’ (p. 717).¹ Therefore, culturally responsive care requires reappraisal and integration of sociocultural practices that ensure care recipients’ perceptions of culturally safe care are fostered. Further attention to sociopolitical dynamics means nurses are vigilant in their advocacy, willing to critique power imbalances and discrimination that contribute to indigenous health disparities. In Woods’ model, when practitioners have cognisance of the ‘bigger picture’ of sociocultural practices and sociopolitical dynamics, this awareness enables nursing practice informed by the socially oriented ethic.

Despite prevailing ideologies of Western ethnocentrism and moral universality, we concur with Woods¹ that fundamental to nursing ethics is the ability to respond to the cultural needs of patients. The ethical decisions made by nurses should ‘reflect the lived reality and experiences of the individuals, whānau, hapū, iwi and communities that make up our society’ (p. 8).⁶ The social ethics has three key attributes depicted in the middle circle. The ethical element of promoting social justice and empowerment acknowledges that predominant healthcare contexts are often incongruent with the cultural needs and values of minority groups. Social justice is promoted through equitable distribution and right of access to services and increased decision-making ability. Nurses enabling indigenous people’s cultural authority also contributes towards maintaining individual and collective autonomy and identity. The ‘socioethical’ nurse, who critiques professional power dynamics in cultural identity maintenance, understands the importance of relationships based on mutual trust and respect. Cultural safety has an explicit moral rationale whereby safe, effective care requires maintenance of these vital social phenomena.⁵

Methods

Design

Qualitative indigenous narrative inquiry was employed to obtain data.^20,21 Narrative inquiry research explores the ways people story their experiences, and when aligned with indigenous epistemologies exposes indigenous realities about self-determination, colonisation and the relationship between past and present.^20,22 The narratives provide insight into Māori nurses’ holistic indigenous world view and contextualise their professional practice experiences. Indigenous consultation occurred throughout all steps of the research process, in alignment with Māori research principles.²³ The lead author identifies as Māori.

Procedure and participants

Participants were recruited nationally utilising purposive sampling.²⁴ Criteria for inclusion included the following: to self-identify as Māori, be a registered nurse or nurse practitioner currently and provide direct clinical care. Twelve nurses from primary or secondary health services throughout Aotearoa New Zealand proceeded to interview. All participants identified as female, between 25 and 53 years of age. Seven worked in mainstream services, and five, including both nurse practitioners, were employed by dedicated Māori health providers.

Ethical considerations

Formal ethical approval was granted by the Human Ethics Committee of the lead author’s tertiary institution. Potential interviewees received an information letter about the aim, procedure, voluntary nature of participation and right to withdraw at any time. Written informed consent was obtained and confidentiality assured throughout the study. Interviews were digitally recorded and transcribed under a confidentiality agreement. Participants were invited to review and comment on their transcripts. Participants were assured of anonymity and provided with a summary of initial findings.

Data collection

Data were collected through a single semi-structured interview. Dialogue aligns with Māori oral tradition. Traditional engagement and relationship-building principles of te ao Māori – a Māori world view – were incorporated into each interview. Interviews were between 45 and 60 min and conducted by the lead author, either face-to-face or via telephone due to geographical distance.²⁵ Eighteen semi-structured questions provided prompts to guide the interviews. Questions included the following: How easy or difficult is it to hold on to your own Māori cultural values with the everyday pressures of nursing work? Are you consistently able to be culturally responsive to Māori clients within the parameters of your job description? What does culturally relevant care mean to you? Does your current workplace recognise and value proactivity from Māori nurses?

Data analysis

Narratives were initially reviewed, coded and thematically analysed by both authors.²⁶ A meta-theme of (waiting for) cultural safety was identified throughout the dataset, which led to a second coding cycle being undertaken utilising the social and ethical elements within Woods’¹ model of culturally safe practice to provide a depth of analysis.

Findings

The elements of Woods’¹ model are illustrated below and collectively support Woods’¹ call, with which we concur, for ‘a culturally focussed ethic…[that] reflect[s] the collective moral ideals of nursing and humankind, being simultaneously a relational and a socially oriented ethic’ (p. 723).

The social elements of cultural safety

Sociocultural practices

Some knowledge of cultural practices is included in the concept of cultural safety; however, this knowledge must be nested within an overarching awareness of the sociopolitical context. To work in a culturally safe manner, it is vital nurses are willing to learn that well-meaning common sense is not enough. In the following quote, the participant described a migrant colleague’s experience of being on the brink of causing cultural offence in his efforts to comfort a family. Through willingness to receive guidance, he learnt that for Māori the sacredness (tapu) surrounding death and a recently deceased person must not be physical proximity with that which is unrestricted (noa), such as food:

A Māori patient died, the whānau [wider family] were around the family member, and he thought he would offer them a cup of tea and biscuits, and brought it into the room, and then was shunted out of the room and he didn’t understand why, but now he knows why. So he said, learning through his bad experiences he’s learnt tapu [prohibited] and noa [everyday unrestricted]. And I said, ‘well that’s amazing that you can learn from something that was probably bad at the time, but you’ve learnt from it’. So I try and help as much as I can and explain, ‘this is why we do this and this’, and they [migrant nurses] absorb it, and they listen and they find it interesting, so they’re not predisposed to their whole life, or their opinions against us, like mainstream New Zealand. (Participant 1)

The above quote highlights that familiarity alone does not necessarily generate willingness to support cultural practices; this participant found that culturally and linguistically diverse migrant nurses, who were in a cultural minority, more readily grasped diverse practices compared to local nurses of English and European descent.

A participant who had worked in the peri-operative area described protecting a cultural practice just prior to a respected tribal elder’s major operation. She ensured the multi-disciplinary team (MDT) paused while the family gathered around a patient for prayers:

A kaumātua [Māori elder] was about to go through a huge operation; just giving that space for karakia [prayer]. So that was something really big that I facilitated, so that I communicated back to the MDT [multi-disciplinary team], they’re doing karakia, so we’ll just wait. (Participant 12)

Although the above experience went well, the nurse had to exercise vigilance and advocate for the pause for prayer, whereas in her current workplace with a Māori provider, protection of cultural practices was embedded in daily engagement:

Where I’m at now, it’s very easy to practise in a kaupapa [customary practice] Māori way, simply because all staff start with karakia [prayer] and waiata [singing], so that’s already a healing process that happens, and then nursing responsibilities come later, after our brief and things like that. So I find it’s quite easy to practise safely being Māori. (Participant 12)

In the above instance, the cultural needs were integral to care rather than overwhelmed by clinical aspects of care.

Sociopolitical dynamics

Participants reported that although institutional policies were legally obliged to reflect a bicultural commitment to Māori, underpinned by the Treaty of Waitangi, they were cautious about anticipating meaningful organisational change:

Working inside a hospital, I’ve noticed from the top, the leadership have gone on the offensive around culturally unsafe attitudes; well that’s the rhetoric…they’re changing their language. Whether it’s actually genuinely embedded change is still to be seen, because it hasn’t been going on that long. But if the leadership are setting down those types of terms, in the mainstream side, you can’t ignore that. So I think they can’t ignore the different needs of different cultures, and especially being tangata whenua [indigenous people of the land]. (Participant 11)

Participant 2 was also sceptical about the motivation for organisational change:

They [organisational leaders] like to tick their boxes. I think they’ve been on alert. That’s probably quite negative, but what I’ve observed, is with the changes to the funding, particularly the Well Child contract, and they’re talking about funding our vulnerable families, and our Māori and Pacific whānau [wider family], our resources need to be put where the needs are most. And so now, all of a sudden, they want to be culturally responsive, and we have to do things differently, because those who hold the money are saying you need to. We’ve had poor health outcomes for many years, but they won’t do anything unless they’re made to do something, and not from evidence, but from the funders. [Participant 2)

Across the dataset, participants spoke of the problem where shifts in policy to address indigenous inequities were not accompanied by healthcare leaders and frontline staff having a nuanced appreciation of the sociopolitical context.

The ethical elements of cultural safety

Promoting social justice and empowerment

Participants reported their pain in witnessing nurses’ fear through negative stereotyping of Māori that meant these patients were under-served:

Like district nurses…they might not go into the house because there’s too many people in there, or they don’t feel safe, and there’s no legitimate reason for them not to feel safe. That person will get left out, they won’t go and see them, and they’ll make an excuse like, ‘we think there’s drug taking behaviour in the house’, when they don’t know, instead of getting someone to go with them, and solve that barrier, they just choose not to go. I had a guy come into the clinic the other day because district nursing wouldn’t go in, and he had dishwashing cloths wrapped around his legs. And it was just because the nurse thought he was a drug taker. [He] couldn’t afford to buy the dressings, and his legs were just oozing. (Participant 8)

Participants repeatedly acknowledged that even when tauiwi (non-Māori) colleagues worked with the best of intentions and achieved positive results, Māori benefitted from care delivered by Māori nurses:

My target group are Māori, but I just have a natural rapport, an easy relationship, and even if the relationship is one where the person that you’re working with, the Māori that you work with don’t have that traditional understanding, or that connection, and just sort of displaced or fragmented in their culture, there’s still a commonality that we share, so I enjoy working with Māori. I find it the right place for me. (Participant 11)

All participants spoke of the cultural ‘fit’ and how it resulted in positive healthcare connections, especially for marginalised and vulnerable members of the indigenous population.

Maintaining individual and collective cultural autonomy and identity

Participants described the challenge of working within mainstream services, where practices that were culturally appropriate for Māori were frowned on as a boundary breach according to Western notions of professional practice:

We were taught very clearly what our boundaries are, and I was an older nurse when I did my training, and I remember going onto the wards and struggling actually because there would be Māori patients who would come up to give me a hug and I would back away, and say, ‘look I’m sorry, I’m not allowed to do that’, and I struggled with that initially, and it wasn’t until a few years later when I felt confident in my own clinical practise that I actually allowed myself to be able to respond to Māori patients who came up to me to greet me. (Participant 3)

Māori continue to have limited autonomy in shaping the conditions of their hospitalisation experience. Fundamental breaches that inappropriately associated tapu (that which has spiritual restriction) and noa (that which is common) caused offence, making people culturally unsafe. Participant 7 spoke of noticing an erosion of culturally safe practices; where once pillows for the head were clearly distinct from pillows used for other body parts, this distinction was no longer adhered to:

They [tauiwi with limited cultural knowledge] talk about the head being sacred and tapu, but a little bit more about that. Why we don’t put our hand on top of a patient’s head? Because your fontanelle when it’s open when you’re a baby, that’s your lifeline right up to the spirit world…Even when I first started nursing, six, seven years ago, all the blue pillows in the hospital used to be left for bums and feet, and all the white pillows are for heads. Not anymore. No, that’s not even a thing anymore. Everything gets used for everything. Yes! Hundred percent. And the amount of times I see pillows get put on the ground while they make a bed or propped up on the food tray. It’s those kinds of things that they need to talk a bit more about. (Participant 7)

The above participant highlighted that these seemingly inconsequential breaches were steeped in meaning and alienated indigenous patients. One participant spoke highly of cultural autonomy she had working in her hospital setting:

Even our Pākehā [non-Māori European] nurses know the [Māori cultural] ways. They know that when someone passes away, we get the water out and put it to the side, we get the room blessed, we talk to the family, the family stays. All of the things that we do naturally is not a big fight. I’m not saying this hospital’s perfect, but I’m saying in cultural ways, we’re getting there. It probably started because our head nurse. The director of nursing was Māori, and the assistant director of nursing is Māori. (Participant 9)

The above nurse attributed the relative ease with which she could integrate cultural practices to strong cultural leadership and a high percentage of Māori nurses working within the hospital.

Trust and respect

Participants who worked in mainstream services expressed relief when their tauiwi (non-Māori) colleagues responded in culturally fitting ways that demonstrated respect and did not automatically assume that the Māori patient would be the ‘problem’ patient:

So, a Māori patient in a wheelchair went out the front for a cigarette, fell out of his chair, came back in and told me. I rang the doctor; he came in, saw the patient was Māori, and just instantly changed his body language, and was more relaxed and didn’t stand over him, like most other people just stand over him and talk down to him. He crouched down a little bit, he was still professional, but his language was just like every-day language when he was talking to him to try and build a relationship with him, to try to get the Māori patient to be more forthcoming, because he didn’t want to tell us that he’d hit his head…I could see him try and build a good relationship to build trust in order to assess his injuries properly, so I was quite impressed by him. I could see in his body language what he was doing. Instead of coming in and trying to do an assessment, [in which case] the patient you know would be non-compliant, and then [the doctor didn’t] just walk away like most other doctors. (Participant 1)

The gap between cultural safety rhetoric and practice was never more evident across the dataset than when participants spoke about the struggle to ensure rituals around dying and death were upheld. An intensive care nurse spoke of how hard it was for her to care well for her patient and the woman’s family after her death:

When she finally did die, it’s like they [colleagues] just wanted the bed space cleared for the next patient to come in. And I got asked three times, ‘come on’, looking at their watch, and ‘no, she hasn’t been incontinent, she doesn’t need a wash’, and I was like, ‘no, no, no, I need to wash this lady, and I need to take all her lines out, and I need to get her looking good for the people that are going to be wanting to come up’. They were really rushing me to hurry up and deal with this lady, and get her out of there, so we can get the next patient in. And I thought that was disgusting. I was just so angry about that, and I said to them, ‘I’m not hurrying up’. I stuck up for myself, for them [whānau] and for her. I said, ‘you go and tell them if you want’. And they said, ‘well it’s nearly been four hours now and we need to move her’. That I couldn’t deal with. (Participant 7)

The above example illustrates nursing colleagues pressuring the indigenous nurse, endeavouring to uphold the workplace culture of task efficiency at the cost of this nurse feeling disrespected and not culturally safe within her team.

The socioethical nurse and culturally safe practice

Woods’¹ model proposes that ethical, culturally safe care is attainable when nurses draw from sociocultural and sociopolitical knowledge to inform their practice as moral agents. Participants described microaggressions and casual racism expressed by some tauiwi (non-Māori) colleagues and provided numerous examples of their moral courage in challenging colleagues’ remarks and drawing attention to the wider present and historical complexities of people’s lives. An intensive care nurse spoke of how shocked she was to hear a colleague speak dismissively of a dying man:

There was a gentleman who was maybe 350 kilos, the patriarch of his whānau [family], end-stage everything, a young man too, under 50, and he had his whānau in, and everybody knew that he was going to be palliative…And one of the nurses comes up to me and says, ‘Well, maybe if he had a few more salads’, and I just flipped…I said, ‘do you see that the condition that he’s in, is perhaps a result of in context of a whole lot of things, not just what he puts in his mouth?’…and I thought, well I doubt he needs dietary advice right now, because he’s pretty much going to die, but [sarcastically] thank you for cheapening his mana [status], for stepping on it, the only bit he’s got left. (Participant 4)

Mana is a complex concept to translate, as it pertains to spiritual connectedness with ancestors as well as a present-day personal and collective sense of pride, dignity and authority. This Māori nurse felt the pain of insult to the patient’s mana on his behalf and endeavoured to re-direct her colleague’s judgmental appraisal to a more holistic view.

One participant, who worked across locations for a Māori primary healthcare organisation, compared the holistic focus of one clinic serving a predominately Māori population to another clinic where care was driven by the presenting biomedical issue:

We [nurse colleague and I] can trust each other that we’re going to pick up not just the medical things. That we’re going to pick up all the other pillars of health [a reference to Mason Durie’s²⁷ model – see discussion], whether it be social, mental health, physical, it’s not just come in for medical reasons. Most people that I meet, if they’ve got social issues, then their health is way back on the back-burner, and that really needs to be addressed before all the social things are dealt with…So if I’m in the [other clinic], most of my colleagues there are European [staff], and they will only discuss what the person’s come in for. If we have an acute clinic there, if someone comes in that you can see that the kids have got no shoes or socks on, or runny noses, they won’t go into that, whereas if you come out [to the other clinic] you see the difference in practise. (Participant 10)

The above participant was clearly aware that culturally safe care was only achievable with knowledge and commitment to addressing the cultural and political factors that shaped people’s health. Participant 6 reflected on the centrality of critical reflection about broader equity and access issues that impacted Māori disengagement from mainstream healthcare:

What I’d like to see happen is that we go away from those handovers that say, ‘this Māori family is non-compliant, they’re not taking their medications, they’re not engaging’. To me, rather than just handing that over shift after shift there needs to be a change in, actually why are they not engaging? Have we not got the right staff with them, or do we need to engage another service to come and talk to them? I think it’s just so easy, because you’re so busy, to just not worry about it, you just say, ‘Oh well, they don’t want to do anything’, so you just disengage. Whereas, why are they disengaging? Do we need to get a social worker in? Do we need to get Māori Health [specialist staff] to come and see them? Does a Māori staff member need to just stop in? (Participant 6)

The reflective questions raised by the above participant are examples of socioethical nursing practice, illustrating the sort of moral deliberation that paves the way to culturally safe practice.

Discussion

The data presented provide rich illustration of Woods’¹ model, of where the dimensions of socioethical engagement are realised and where there are gaps in the empowerment of indigenous providers and recipients of care. Woods’¹ model clearly demonstrates that nurses must engage reflexively with a relational ethic of care and social justice dimensions beyond the level of inter-personal relationships in order to deliver culturally safe care. Browne et al.¹⁷ make the important point that the concept of cultural safety becomes diluted if it is used as a euphemistic buffer, to avoid possibly contentious dialogue about racism and social justice. The dimensions of Woods’ model fit well with Fraser’s²⁸ argument that there are two key obstacles to social justice: misrecognition, which relates to status subordination; and maldistribution, which pertains to resource deprivation.

The data relevant to the element of sociocultural practices illustrate the ongoing vigilance and educative role participants described to ensure that even commonplace practices were upheld. The persistent misrecognition, for example, that prayer (karakia) means a delay in treatment rather than integral to Māori health, demonstrates a clinical culture that all too readily slips into seeing cultural practices as add-ons rather than intrinsic parts of care. This theory-to-practice gap is concerning, given that every nursing programme at undergraduate and postgraduate levels in Aotearoa New Zealand incorporates Mason Durie’s²⁷ holistic Te Whare Tapa Whā model, where the Māori concept of spirituality – taha wairua – is central to well-being. Care-rationing, pressured clinical practice and an emphasis on biomedical treatment schedules in mainstream services side-line integration of the model.

The data illustrating the element of sociopolitical dynamics highlight the importance of leadership, where leaders’ commitment to cultural safety, equity and social justice are more than rhetoric. We concur with Woods¹ that this shift can only happen when nurses want to do more than comply with policies and legal edicts; they must experience a moral desire to ensure that all levels of the caring context are culturally responsive. The data in this element of sociopolitical dynamics also make visible Fraser’s²⁸ notions of misrecognition, whereby Māori are positioned as the problem, as evident in the quote about non-compliance; a persistence of victim-blaming.⁴ Maldistribution is also apparent, whereby the Māori nurse gave an example of having to coach colleagues through connecting indigenous people to services that already exist but may not be to the forefront of nurses’ minds when planning care. In order to embed the ethical elements of cultural safety within a socioethical model of nursing, what is required are changes to both economic structures that allow people independence and voice, and changes to the status of people, including that of indigenous nurses, where respect and esteem are shown through full partnership.²⁹ Nurses, as the largest global health workforce, are exceptionally well placed to articulate the ongoing problems associated with colonisation and the impacts on cultural safety. The International Council of Nurses 2017–2019 campaign slogan, Nurses – A Voice to Lead – Health for All,³⁰ actively focused on the vital role of nurses in policy development and implementation. However, to be empowering, nurses require ongoing education that views wider social justice concerns and direct relational care through an ethical lens. In nursing education, colonisation must be framed as an ongoing process rather than a historical event in order for solutions to be found through power-sharing. When issues of colonisation are not acknowledged as the root cause of health inequities, solutions address only surface manifestations of the problem with a single-issue focus.^2,3 The Meihana model,²⁹ which addresses both inter-personal and systemic levels of healthcare transformation, can be used to help practitioners see a way past misrecognition and maldistribution.

Data supporting the elements of promoting social justice and empowerment and maintaining cultural autonomy and identity demonstrate the importance of having a representative Māori nursing workforce, as these nurses act as especial clinical and cultural champions for indigenous people. Yet given the recruitment and retention challenges, Māori nurses can become overwhelmed and burnt out with what appears to be an insurmountable task.^31,32 The element of social justice and empowerment also offers examples of how misrecognition feeds maldistribution; that fear of the ‘other’ marginalises people, alienating them from existing services.^4,33 These data starkly illustrate the point that it is dangerous for nursing documents, such as competencies, to measure cultural safety, unless there are rigorous educational, guidance and role-modelling processes to support these measurements being more than a ‘tick-box’ exercise. There is the risk that by using the language of cultural safety and holistic care, nurses genuinely believe that they are delivering care that will be deemed culturally safe.^34,35

In the element trust and respect, the data show the importance of tauiwi working as cultural allies, although we need an increased indigenous workforce that will never absolve all healthcare workers from a moral commitment to culturally safe care. The Hui process, developed by Lacey et al.,²⁵ initially to educate medical students, provides a highly accessible framework for culturally safe direct-care engagement. The quote in the element, trust and respect, pertaining to the dying man demonstrates the interconnections between misrecognition and maldistribution. The participant was painfully aware that the tauiwi (non-Māori) nurse was unable to engage in a fundamental caring relationship, nor see the person’s status of the patient within his community, nor the context that may have contributed to his state of health. The three quotes supporting this element show that what was needed in each instance was not a sophisticated, in-depth knowledge of cultural practices, but rather an ethic of care and of sympathy, compassion and friendliness.³⁶

Conclusion

In the extant nursing ethics literature, universalist approaches typically continue to hold centre stage, with culturally focused ethics positioned peripherally. This article has used empirical data to highlight the utility of Woods’¹ socioethical model, which centralises a culturally focused ethic. The data illustrate that in order to provide culturally safe care, nurses require relational skills imbued with an analysis of wider systemic discrepancies. Socially just, equitable care and treatment cannot be taken for granted. The article, with its exploration of each of the elements in Woods’ model, offers a valuable resource internationally for nurses working with indigenous and other marginalised groups, as a means for further reflexivity about the relative cultural safety of practice settings. In addition, the article highlights the use of the model as an analytic framework to gain deeper appreciation of the practice experiences of indigenous nurses; how they role-model a culturally focused ethic in their work and how they navigate contexts where there is tokenistic attention to culturally safe practice at collegial and organisational levels. Although time and redistribution of resources may contribute to culturally safe care, the data in this study highlight that an ethic of care through the lens of cultural safety is often not complex and labour-intensive; it involves willingness of nurses to ‘refocus their gaze’ (p. 723)¹ beyond biomedical expediency and ethnocentric healthcare.

Footnotes

Acknowledgements

The authors would like to acknowledge the Māori nurse participants of this Aotearoa New Zealand study for generously sharing their reflections on their practice experiences. The authors would also like to acknowledge the support of the primary author’s educational institute Kawa Whakaruruhau Nursing Advisory committee.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was partially funded by the primary author’s educational institute.

ORCID iD

Kiri Hunter

Appendix 1

Table 1.

Glossary of Māori terms.

hapū	kinship group, sub-tribe
iwi	extended kinship group, tribe, descended from a common ancestor
karakia	incantations and prayers, to invoke guidance and protection
kaumātua	adult, elder, a person of status within the whānau
kaupapa Māori	Māori approach
Kawa Whakaruruhau	cultural safety within the context of nursing Māori
mana	prestige and authority
Māori	indigenous peoples of Aotearoa New Zealand
noa	to be safe and normal, unrestricted
Pākehā	non-Māori European
taha wairua	spiritual component
tapu	sacred or prohibited, restricted
tauiwi	foreigner, non-Māori, colonist
tangata whenua	indigenous peoples of the land
waiata	to sing, song
whānau	extended family, family group

References

Woods

. Cultural safety and the socioethical nurse. Nurs Ethics 2010; 17(6): 715–725.

Nelson

Wilson

. Understanding barriers to health care access through cultural safety and ethical space: indigenous people’s experiences in Prince George, Canada. Soc Sci Med 2018; 218: 21–27.

Hobbs

Ahuriri-Driscoll

Marek

, et al. Reducing health inequity for Māori people in New Zealand. Lancet 2019; 394(10209): 1613–1614.

Scott

. A Māori cultural reluctance to present for care, or a systems and quality failure? How we pose the issue, informs our solutions. N Z Med J 2014; 127(1393): 8–11.

de Souza

. Navigating the ethics in cultural safety. In: Wepa

(ed) Cultural Safety in Aotearoa New Zealand. 2nd ed. Melbourne, VIC, Australia: Cambridge University Press, 2015, pp. 111–124.

Came

McCreanor

Doole

, et al. Realising the rhetoric: refreshing public health providers’ efforts to honour Te Tiriti o Waitangi in New Zealand. Ethn Health 2017; 22(2): 105–118.

New Zealand Nurses Organisation (NZNO). NZNO guideline: code of ethics. Wellington, New Zealand: NZNO, 2019.

Nursing Council of New Zealand. Guidelines for cultural safety, the Treaty of Waitangi and Māori health in nursing education in practice. Wellington, New Zealand: Nursing Council of New Zealand, 2011.

Nursing Council of New Zealand. Code of conduct for Nurses. Wellington, New Zealand: Nursing Council of New Zealand, 2012.

10.

Health Practitioners Competence Assurance Act 2003, http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html (accessed 10 April 2020).

11.

United Nations General Assembly. United Nations Declaration on the Rights of Indigenous Peoples, resolution 61/295, 2007, https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html (accessed 10 April 2020).

12.

Prussing

Newbury

. Neoliberalism and indigenous knowledge: Māori health research and the cultural politics of New Zealand’s ‘National Science Challenges’. Soc Sci Med 2016; 150: 57–66.

13.

Theunissen

. The nurse’s role in improving health disparities experienced by the indigenous Māori of New Zealand. Contemp Nurse 2011; 39(2): 281–286.

14.

Ramsden

. Cultural safety/Kawa Whakaruruhau ten years on: a personal overview. Nurs Prax N Z 2000; 15(1): 4–12.

15.

Ramsden

. Toward cultural safety. In: Wepa

(ed) Cultural Safety in Aotearoa New Zealand. Auckland, New Zealand: Pearson Prentice Hall, 2005, pp. 2–9.

16.

Richardson

Carryer

. Teaching cultural safety in a New Zealand nursing education program. J Nurs Educ 2005; 44(5): 201–208.

17.

Browne

Varcoe

Smye

, et al. Cultural safety and the challenges of translating critically oriented knowledge in practice. Nurs Philos 2009; 10(3): 167–179.

18.

Kellett

Fitton

. Supporting transvisibility and gender diversity in nursing practice and education: embracing cultural safety. Nurs Inq 2017; 24(1): e12146.

19.

Woods

. Exploring the relevance of social justice within a relational nursing ethic. Nurs Philos 2012; 13(1): 56–65.

20.

Ware

Breheny

Forster

. Kaupapa Kōrero: a Māori cultural approach to narrative inquiry. AlterNative 2017; 14(1): 45–53.

21.

Grove

Gray

. Understanding nursing research: building an evidence-based practice. 7th ed. St Louis, MO: Saunders Elsevier, 2018.

22.

Smith

. On tricky ground: researching the native in the age of uncertainty. In: Denzin

Lincoln

(eds) The SAGE handbook of qualitative research. London: SAGE, 2005, pp. 113–143.

23.

The Pūtaiora Writing Group. Te Ara Tika guidelines for Māori research ethics: a framework for researchers and ethics committee members, 2010, https://www.hrc.govt.nz/resources/te-ara-tika-guidelines-maori-research-ethics-0 (accessed 10 April 2020).

24.

LoBiondo-Wood

Haber

. Nursing research: methods and critical appraisal for evidence-based practice. 8th ed. St Louis, MO: Elsevier Mosby, 2014.

25.

Lacey

Huria

Beckert

, et al. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J 2011; 124(1347): 72–78.

26.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.

27.

Durie

. Whaiora: Māori health development. 2nd ed. Auckland, New Zealand: Oxford University Press, 1998, pp. 68–74.

28.

Fraser

. Rethinking recognition. New Left Rev 2000; 3: 107–120.

29.

Pitama

Huria

Lacey

. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana. N Z Med J 2014; 127(1393): 107–119.

30.

International Council of Nurses. Nurses: a voice to lead health for all, 2019, https://www.icn.ch/news/nurses-voice-lead-health-all (accessed 10 April 2020).

31.

Wilson D and Baker M. Bridging two worlds: Māori mental health nursing. Qual Health Res 2012; 22(8): 1073–1082.

32.

Wilson

McKinney

Rapata-Hanning

. Retention of indigenous nursing students in New Zealand: a cross-sectional survey. Contemp Nurse 2011; 38(1–2): 59–75.

33.

Roberts

Schiavenato

. Othering in the nursing context: a concept analysis. Nurs Open 2017; 4(3): 174–181.

34.

Ermine

. The ethical space of engagement. Indigenous Law J 2007; 6(1): 193–203.

35.

Stansfield

Browne

. The relevance of indigenous knowledge for nursing curriculum. Int J Nurs Educ Scholarsh 2013; 10(1): 143–151.

36.

French

Weiss

. An ethics of care or an ethics of justice. J Bus Ethics 2015; 27(1–2): 125–136.