"Maori or Pakeha (White man/ European), it shouldn't make any difference.

Nurses care for

patients regardless of culture."

Discuss this statement in reference to Leininger's Tanscultural Theory of Nursing and the
Cultural Safety Model.

__________________________________

Introduction:

When it comes to optimizing nursing care the above statement does not reflect Leininger's
Theory of Transcultural Care which emphasises that appropriate regard is given to the cultural
differences existing between Maori and Pakeha. Neither does it reflect Ramsden's ideas of cultural
safety. To begin, let us consider Leininger's Transcultural model.

Transcultural nursing:

Leininger is an American nursing theorist whose approach is from a dominant culture and is
based upon an anthropological viewpoint. In American society, the cultural diversity is enormous.
Her work is an attempt to increase nursing effectiveness within this multicultural environment,
whilst at the same time recognising that the provision and source of medical care originates from
the more dominant Western culture. Nurses are encouraged to become educated about a wide
variety of cultural beliefs and sensitivities; and specifically, to identify those aspects that are
relevant to the context of nursing care.

Leininger has defined Transcultural Nursing as a major area of nursing that "focuses on a
comparative study and analysis of different cultures and subcultures, with respect to their caring
values, expression, health/illness beliefs and pattern of behaviour with the intention of being able to
develop a scientific and humanistic knowledge base that provides culture specific and/or culture-
universal nursing practice" (Alligood, 1998).

One of the key aspects within the Theory of Transcultural Nursing is the idea of the nurse
being an "Observer" of other cultures and having a strong understanding of the various concepts of
culture in relation to the cultural group they are working with. This role of "Observer" is also
extended towards the nurses own culture. By examining their own cultural beliefs and values, the
nurse will be more aware of how their own culture may be inadvertently imposed upon the cultural
identity of the patients they care for. Leininger defines this tendency of nurses to dominate their
clients cultural identity as "Cultural Imposition". (Cooney, 1994)

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 Leninger considers that cultural differences are scientifically identifiable and that it is
important to discover parallel beliefs between a patient's cultural values and those of Western
medicine in order for the patient to respond positively to nursing care delivery. Therefore, it is
essential for individual nurses to have a scientific knowledge base covering a range of different
cultures so that they can respond therapeutically to the needs of their clients.

Leininger argues that the essential goal for health professionals working with a cultural
group different from their own, is to initially determine the dominant cultural values, priorities and
characteristics of that group and then decide how best to assist them. (Cooney, 1994)

Cultural Safety:

In New Zealand the Treaty of Waitangi has been enacted so that the Maori people, have the
legal right to uphold their own cultural identity and not suffer persecution or deprivation in a society
predominantly governed by Europeans.

"The Maori people were to have the security and protection of the British Crown, indeed full
rights as British citizens" (Doms,1989).

Within the Maori version of the text, Maori understood that they could maintain their
chieftainship over their villages, lands, possessions, language, spirituality and health practices, as
well as kinship ties. However, the English version, in granting citizenship, usurped control of the
Maori social order by placing all New Zealanders, including Maori, under the sovereign rule and the
justice system of the British Crown. This enabled the Crown to facilitate rapid transfer of land
ownership into European hands and effectively made the Maori landless which in turn led to the
breakdown of the kinship groups that were so much a part of Maori identity.

Cultural Safety, developed by Irihapeti Ramsden, and specific to the New Zealand context,
emphasises the reclaiming of a partnership which was to have been effected in 1840 with the
signing of the Treaty. Her definition of cultural safety has not been formalized, but the goals it
entails has been stated as "nursing actions which recognise, respect and nurture the unique cultural
identity of Tangata Whenua, the indigenous people of New Zealand, and safely meet their needs,
expectations and rights" (Cooney, 1994).

Cultural safety as defined by The Nursing Council of New Zealand is: "The effective nursing
of a person/family from another culture by a nurse who has undertaken a process of reflection on
their own cultural identity and recognises the impact of the nurse's culture on the nursing practice
they deliver." (Cooney, 1994). This is a similar process to that recommended by Leninger who seeks
parallel beliefs in order to reframe the nursing care delivery, however the aim of cultural safety,
through a process of education, is intended to identify and change social and personal attitudes

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which have a negative implication for cultural safety. Furthermore, Ramsden extends the concept of
cultural-safety when she emphasises the need for nursing institutions to work in "partnership" with
Maori and train Maori nurses in areas of Western nursing practice so they can offer more "culturally
sensitive care" to Maori patients, in separate Maori-specific facilities wherever possible.

It is from the work of the American nursing theorist, Madeleine Leininger, who incorporated
anthropology (the study of various cultures) into many nursing programmes, that the theory of
cultural safety in New Zealand was further developed by Ramsden. In New Zealand Cultural Safety
is noteably bi-cultural and not multi-cultural. Ramsden applies the principals inherent in Leninger's
Transcultrual theory specifically to the Maori-Pakeha relationship and from this springs the
"Partnership Model of Care" implicit in the Treaty of Whaitangi. There is an obligation on Pakeha to
provide the Maori people with the education they need in order to meet their own health needs. This
in turn places an onus on the training institutions to be "culturally safe" in the way this education is
delivered.

Summation:

Referring to the statement: "Maori or Pakeha, it shouldn't make any difference. Nurses care
for patients regardless of culture." It is obvious from the work of Leininger and Ramsden, that they
agree that nurses today cannot ignore the issues of cultural diversity and expect to be professional
in their approach. The main difference between the Theory of Transcultural Nursing and Cultrual
Safety is that each is designed for a different societal application. Transcultrualism is rooted in the
requirements of a multicultural society, whilst, Cultural Safety is a conceptual framework that is
specifically fashioned for it's application to New Zealand's bi-cultural society. Ramsden would argue
that "yes", culture does matter and the difference between Maori and Pakeha should be taken into
consideration within the framework of client care. However, the statement that, "Nurses care for
patients regardless of culture" should be true in the view that nurses should be able to care for
people without their own cultural beliefs and values demeaning the client's own culture.

A key similarity between their theories and one of the most appropriate ways this, "Cultural
Imposition" can be avoided in nursing, is to focus on the need for nursing education in this area. The
onus is on the nursing professional to identify ways of increasing nursing effectiveness, and in New
Zealand especially, according to Ramsden, to focus specifically upon developing a more effective
partnership between Maori and Pakeha.

Within the context of Maori and Pakeha cultures, for example, there are beliefs held by
Maori which, if they are overlooked or ignored, will limit a health professional's effectiveness when
treating Maori patients. One such issue I've encountered, which seems relatively simple on the
surface, involves a person's beliefs about direct eye contact. In Pakeha society, it is considered a
mark of courtesy and a means of effective communication that direct eye contact be maintained
when speaking to a person. It is through eye contact that health professionals are often able to
determine the patient's state of wellbeing, or gauge their understanding of medical instructions.

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However, such a gesture could easily be misinterpreted by someone of strict Maori culture who is
unfamiliar with medical practices and who may see eye-contact as rude, confrontational and a sign
of disrespect.

Conclusion:

It is obvious that New Zealand health authorities have identified and acted upon the need
for bi-cultural care. Apart from translator services and resource personnel from many non-Western
cultures, Middlemore Hospital, in South Auckland, also has an established and assertive Maori
cultural service which protects and maintains the cultural integrity of Maori patients during their
stay in hospital. Within the main hospital and the acute psychiatric facility as well, there is a Maori
resource unit that provides a Mhari (traditional meeting house) and Kawamatua service (Maori
elders) to Maori patients and their families. Because Middlemore Hospital in South Auckland
services the most culturally diverse area of New Zealand, significant resources are allocated to
annual cultural-training updates for all nursing staff. Whilst Pakeha might consider New Zealand to
be a truly multicultural society, under the strict terms of the Treaty of Whaitangi the Maori nations
would see New Zealand as a bi-cultural society. All immigrants enter under Crown regulations and
by proxy are deemed Pakeha signatories to the Treaty. The implication is that persons from other
countries agree to the terms of the Maori version of the Treaty and in their dealings with any Maori
will apply the Treaty or "Partnership Model". In turn, immigrants will be recognised as Pakeha
regardless of culture or ethnicity. As one-sided as this may seem, it does in fact add a dynamic to the
New Zealand scene that strives for cultural equality and specifically places the onus on Pakeha to
always be inclusive towards the Tangata Whenua or Native People.

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