Chapter 2
Thoughtful practice
25
The nurse should be sensitive to intra- and interracial
group applications of cultural competence. In these contexts,
cultural elements or attributes may be appropriated and rede-
fined in racial terms (Dayer-Berenson, 2011). Alternatively,
racial attributes may be redefined as cultural attributes. This
may result in tension, adding to the complexity of planning
culturally competent care. This tension may be minimised,
however, by having a clear understanding that race relates to a
major grouping of people with common ancestry and physical
characteristics (Caucasian, Asian, Melanesian, Polynesian,
and Eurasian); ethnicity refers to subgroups within a partic-
ular race that share a common origin, culture, and language
(e.g. Ma¯ori are an ethnic group of Polynesians, Chinese are
an ethnic group of Asians); and culture relates to the shared
values, beliefs, and practices of various groups within an
ethnic group that may be similarities and/or differences with
each other. In addition, it is crucial that nurses refrain from
culturally stereotyping a patient in an attempt to be culturally
competent. Some members of one ethnic subculture may, for
example, be offended or angered if mistaken for members of
another subculture. Similarly, if the attributes of one sub
culture are mistakenly generalised to a patient belonging to
a different subculture, extreme offence could result, as well as
inappropriate care planning and implementation. Instead, in
person-centred care, the patient or significant others should be
consulted regarding personal values, beliefs, preferences, and
cultural identification.
The term
minority
is commonly used to refer to a group of
people in a society whose physical or cultural characteristics
differ from the majority (Giger, Davidhizar & Purnell, 2007a).
It is also used to identify social groups that are in a powerless
situation relative to other groups in the society. At times,
members of a minority group may be singled out or isolated
from other members of society, or treated in different or
unequal ways. For example, within Australia, Aboriginal and
Torres Strait Islander people, immigrants, and refugees may
constitute clearly identifiable minority groups. Within New
Zealand minority groups include Ma¯oris, Pacific and Asian
people, and immigrant groups (NZNC, 2011).
Minorities are also context-specific. For example, men
may be considered a minority within the nursing profession,
but they constitute a majority within the field of medicine.
Likewise, people of Middle Eastern background are minorities
in the population of the country, but they may make up the
majority of some urban communities. As the term ‘minority’
can be used to denote inferiority, members of many cultural
and ethnic groups object to being identified as members of a
minority group.
Culturally safe nursing care
Culturally safe nursing care
refers to the appropriateness and
effectiveness of nursing care as experienced by patients or their
families whose cultural beliefs and practices differ from those of
the nurse. It extends beyond cultural awareness, cultural sensi-
tivity, and the learning of culturally specific beliefs, values, and
practices of various ethnic groups (Wilson, 2013). In addition,
it recognises the diversity that exists within a cultural group
and the need for astute assessment and incorporation of iden-
tified traits within the planning and delivery of person-centred
care.
The concept of cultural safety arose out of the concerns
voiced by Ma¯ori nurses in New Zealand regarding the
recruitment and retention of Ma¯ori nurses and the health
status of Ma¯ori people. Cultural safety involves recognising
the 1840
Treaty of Waitangi/Te Tiriti o Waitangi,
a bilingual
contract that was signed between the governing crown and
Ma¯ori the Indigenous people of New Zealand. The Treaty
sets out the duties and obligations of the government and its
agents, including nurses. Nurses are required to form partner-
ships with the Ma¯ori people, be responsive to their needs,
involve them in health planning and decision making, and
ensure that their beliefs and practices are protected. Crucial to
the delivery of culturally safe nursing care to the Ma¯ori people
is recognition of their tribal differences and the consequences
of European colonisation and contemporary socioeconomic
realities. Unsafe cultural practice is an action that ‘diminishes,
demeans or disempowers the cultural identity and well-being
of an individual’ (NCNZ, 2009, p. 4).
In New Zealand, all nurses undertake education in cultural
safety in their undergraduate program. This involves exam-
ining their own cultural identity and its impact on their
professional practice, including interacting with people of
different cultural identities. The Nursing Council of New
Zealand’s (Te Kaunihera Tapuhi o Aotearoa) scope of practice
for Registered Nurses encompasses competencies that specif-
ically look at; adherence to the
Treaty of Waitangi/Te Tiriti o
Waitangi
principles of partnership, protection and participa-
tion; in addition the application of culturally safe practice as
determined by the patient/client and family. In Australia, the
content, structure, and format of cross-cultural material are
decided upon by each education provider.
Culturally competent nursing care
Culturally competent
or
congruent nursing care
refers to the
complex integration of attitudes, knowledge, and skills (includ-
ing assessment, decision making, judgements, critical thinking,
and evaluation) that enables the nurse to provide care in a
culturally safe and appropriate manner.
Agency and institutional policies are important in support-
ing the achievement of culturally competent care, for example,
by establishing flexible regulations regarding visitors (includ-
ing the number, frequency, and length of visits), providing
translation services for non-English-speaking patients, and
training staff to provide care for patients with different cultural
values (Wilson, 2013). Culturally competent policies also
recognise the special dietary needs of patients from selected
cultural groups and create an environment in which the tradi-
tional healing, spiritual, and religious practices of patients are
respected and encouraged.
Nurses should be aware that patients’ actions and behaviours
are cultural constructions that can vary both within and
between ethnic groups. The nurse who assumes that all
members of any one cultural group act and behave in the
same way may be viewed as stereotyping people. In doing the
latter, the nurse may fail to consider important dimensions of
a person’s situation and so generate hostility in the patient,
which may in turn compromise their relationship.
A key component within the application of culturally com-
petent care is that the nurse should take into consideration the
power that exists within the relationship of client and nurse.
The client is the seeker of help who can be considered as vul-
nerable, they rely on the expertise of the nurse to guide and
support their individual needs towards progress of their goals in
healthcare. The nurse’s ability to acknowledge that she or he
