Culture and ethnicity: The delivery of health care

Maori people comprises a large proportion of users of health services and the health status of Maori is recognized as a health priority area (Nursing Council of New Zealand (NCNZ), 2009). To work effectively and providing Maori health centered nursing care, it is prerequisite for nurses to know history of New Zealand, understand Maori health and incorporate principles of Treaty of Waitangi in their nursing practice (Scryymgeour, 2009).

Treaty of Waitangi was signed on February 6, 1840. It is a formal agreement signed between British Crown and Maori (indigenous people of New Zealand). It is founding document of New Zealand and has great significance for health care professionals while working with Maori clients. There are three main principles of the Treaty commonly referred as 3P`s. These are Partnership, Protection and Participation (Ministry of health, 2002). Nurses being agents of the Government (Crown) are committed to recognizing the rights of Maori and honoring the Treaty of Waitangi by applying its principles.

Nurses apply the principle of Partnership by maintaining a therapeutic relationship with their client. Nurses work in collaboration with clients towards the common objective of attaining better health outcomes. Nurses respect the unique cultural identity of the client by involving clients in decision making. This strengthens clients` awareness regarding their treatment and emphasize the possibilities of positive health outcomes. It also preserves the integrity of clients. (NCNZ, 2009).

The second principle of the Treaty is Protection. As per this principle, the Crown has obligation to protect Maori health (Wepa, 2004). When caring for Maori clients, nurses are committed to the protection and improvement of Maori health by providing best quality care which is culturally safe and acceptable to Maori clients. Its aim is to reduce inequalities in health care delivery among Maori and Non-Maori.

Third principle of the Treaty is Participation. In health care setting, it is expected from the nurses to enable clients and encourage an active participation from them. It is very important for nurses to engage clients in all decisions related to their care. Nurses recognize that they can involve client`s family in planning individualized health care for the client. However, it can be possible only if the client wish to do so. (Scryymgeour, 2009).

Government ensures that treaty of Waitangi is recognized and honored in health care system. Waitangi Tribunal was established under Treaty of Waitangi Act 1975. If Maori clients do not acknowledge the given care as culturally safe or if there is a breach of Treaty, it can be addressed to the Tribunal to get a solution for such problem. Then, Public Health and Disability Act 2000 came into action to ensure that all health practitioners respect the Treaty. Besides this, the government developed the New Zealand Health Strategy (200…) for promoting adequate delivery of health care and combating inequalities in health. One of its principles is Acknowledging the Treaty of Waitangi.

Nurses can incorporate principles of the Treaty effectively to bring positive health outcomes once they understand concept of Maori Health. Maori Health Strategy (2002) identified various risk factors such as history of colonization, poverty, poor housing, overcrowding and unemployment; contribute toward poor Maori health outcomes. Nurses must understand Maori health. This will enable nurses to cater unique needs of Maori clients by providing nursing care which is relevant and appropriate to Maori cultural and personal needs of clients.

There are different health models, which can be used to gain better understanding of Maori health. For instance, Te Whare Tapa Wha and Te Wheke. According to Durie (2001), Te Whare Tapa Wha model represents four dimensions of health in form of four walls of whare (house). These are taha wairua(spiritual health), taha hinengaro (mental health), taha tinana (physical health) and taha whanau (family health). If any wall is weakened, it hampers the positive health outcomes. It is vital for nurses to recognize Maori beliefs and values in order to make constructive relationship with clients to achieve positive health outcomes.

Treaty of Waitangi serves as platform for culture safety. Nurses working in the New Zealand must be competent to practice culturally safe care and incorporate principles of the Treaty of Waitangi in their nursing practice (Scryymgeour, 2009). The term kawa whakaruruhau or cultural safety developed after dissatisfaction of Maori student nurses about adequate delivery of health care and its access to Maori population. Ramsden firstly introduced cultural safety in nursing in 1980, which was later included in nursing curriculum by the Nursing Council of New Zealand (NCNZ) in 1990. It is expected from nurses to provide culturally safe care by keeping in consideration all that makes every individual unique. Cultural safety is an outcome of nursing practice that empowers the recipient of care to define culturally safe practice

The key element in cultural safety is biculturalism. Ramsden (2002) described that every interaction between people is bicultural, because every person has a unique cultural identity. As per NCNZ (2009) guidelines for cultural safety in nursing education, in order to understand and become culturally safe, firstly, nurses must recognize their own cultural values, beliefs and attitude, which may affect the way they provide care to their clients. Secondly, nurses must have gained adequate knowledge and skills required to practice culturally safe. Nurses must also respect the cultural diversity of client by recognizing the similarities and differences between diverse cultures. It insists on changing the power in health care setting from nurses to recipients of care. Once this turnover occurs, the clients are empowered to define the culturally safe practice (Papps, 2007).

Culturally safe practice is really worthwhile when nurses work with patients from a culture different to their own. Nurses work to deliver culturally sensitive care. The clients` view about the given nursing care enables nurses to reflect back and evaluate their own nursing practice. Nurses are recognized as bearer of their own cultures, values and attitudes (Natinonal Abroginal Health Organisation, 2006). Nurses use power during their nursing practice and also empower clients. However, there may be power imbalances in which the client feels powerless. These issues require to negotiate and ensure that client receive culturally safe care. Nurses have obligation to maintain balance between power relationships. It can only be possible when nurse builds a therapeutic relationship with the client by allowing active participation from the client (Meyst, 2005).

Nurses confront many situations where cultural beliefs and values of clients may affect the delivery of health services. For example, blood transfusion is done in a good faith to improve the health condition or to save life of a client. However, if a Jehovah Witness pregnant lady does not agree for blood transfusion saying that it is against her religious beliefs (Levy, 1999). In such a situation, nurses respect the client`s decision; nurses can not enforce treatment on client for sake of betterment of client`s health. If they do so, it will be culturally unsafe. As it diminishes, humiliates and disempower the unique cultural identity of the client (NCNZ, 2005, p4). There are several models which guide nurses in providing care which is culturally safe. Particularly, Campinha-Bacote`s (1999) model of cultural competence and Walker`s (1994) `valuing difference` Model.

Becoming self aware is vital for nurses as it helps nurses in improving their personal and professional development. To ensure that nurses are competent to provide culturally safe care determined by recipient of care, the NCNZ (2005) has outlined competencies for registered nurses. As per this criterion, nurses are expected to reflect on their own practice and values that influence their practice. Nurses preserve the integrity of clients by respecting their personal values. Every person has their own values which determines their decision making process.

Nurses carry their own values and beliefs that help them in deciding what is good or bad. Woodbridge and Fulford (2003) state that value-based practice is one of the tool of effective decision making in healthcare setting. Nurses respect the values by demonstrating equality for all clients` values as a person, not only as an individual suffering from mental illness. Nurses must be able to recognize and differentiate their personal and professional values, because it may also affect the delivery of nursing care to the clients. It is likely for a nurse to confront a dilemma choosing her personal or professional values. The best way for the nurses to deal with such a dilemma is by deciding what values the most in providing quality care to the client. It is possible only if nurses understand the core values of client.

Self critiquing reflective practice is very important aspect of nursing care. It helps nurses to widen their sphere of learning by identifying significant and long term changes to their nursing practice (Paget, 2001). Nurses reflect back on their practice and critically analyze that how they dealt with a situation, how their own values and client`s values affected the delivery of health care. Reflective practice models can guide nursing practice. John`s model of reflection is one of them. It mainly emphasize on describing events. It outlines the various factors influencing the strategies and highlights the significance learning after experience.

Meyst, a registered nurse, shared her experience that exploring more knowledge about self awareness and culture safety has changed her practice (2005). She attended two-day workshop at her workplace. It challenged her attitudes, beliefs and stereotypes about providing care to particular group of clients. She shared a particular incident to explain its implication. A pregnant woman, Mrs. Jones (not her real name) along with her seven children arrived to day care surgery for an elective procedure. She apologized that she could not arrange a baby sitter for her children.

On confronting the situation, nurse accepted that she would have felt impatient with client if she would not have changed her viewpoint regarding values, beliefs and cultural safety. She may have imposed her judgment about the client`s seven children in relation to overpopulation in the world. In contrast, she actually faced the situation being more open minded. She welcomed client respectfully. As she is well aware that the focus of her care is client. Therefore, she made the client comfortable and established a constructive relationship. She prepared the client for surgery. It is very clear from above example that becoming self aware and recognizing cultural diversity impact nursing practice.

In conclusion, the cultural safety is introduced in nursing practice to ensure that clients receive culturally safe care. Clients are empowered to decide that the care they receive is culturally safe or not. As Maori people comprise significant proportion of health service users and their health is considered as area of priority in delivering health care. The Treaty of Waitangi, cultural safety and Nursing practice are interrelated to each other and incorporate the nursing care which is acceptable by clients.