Cultural safety and its importance for Australian midwifery practice
Introduction
Australia is a multicultural nation with migrants and refugees from over 200 countries who practice more than 115 religions and speak more than 180 different languages (ABS, 2007, ADI, 2008, Johnstone and Kanitsaki, 2007). Women accessing maternity services in Australia have very diverse needs and these may be unknown to the midwives providing care. The provision of culturally safe midwifery practice is essential if health outcomes for women and their newborn infants are to be optimised.
Cultural diversity may relate to social context, religion and/or gender, as well as ethnic background. The concept of cultural safety is a broad one that aims to identify and protect the culture of groups. Internationally, much has been written about transcultural nursing, cultural competence and cultural safety when providing nursing care (Baker, 2006, Betancourt et al., 2003, Chenowthm et al., 2006, De and Richardson, 2008, Johnstone and Kanitsaki, 2007, Leininger, 2002, Narayanasamy, 2003). There have been studies concerning the concept of cultural safety in human services. These studies have investigated the meaning of cultural safety and its evolution (Belfrage, 2007, Bin-Sillik, 2003, Dowell et al., 2001, Ramsden, 1993, Ramsden, 2002, Wepa, 2001, Wepa, 2003), cultural safety in health and nursing care (Chrisman, 2007, Jacobs and Boddy, 2008, Richardson, 2003), and the promotion of cultural safety when providing health care (Hughes and Hood, 2007, Lipson, 2007).
Culturally appropriate nursing care has been widely explored in the literature (Belfrage, 2007, Chrisman, 2007, Purnell and Paulanka, 2003, Ramsden, 2002, Richardson, 2003, Wepa, 2001, Wepa, 2003, Wepa, 2004) however it is not well known what has been written about midwifery and cultural safety. A search of multiple electronic databases, including CINAHL, MEDLINE, Health Science, SocINDEX, and Psychology and Behavioural Sciences, from 1980 to 2008 was carried out. This period is relevant when establishing current and salient midwifery research concerning cultural safety, as cultural safety emerged in the nursing literature during the 1980s. To facilitate the search, keywords and terms, including cultural safety, cultural competence, cultural respect, cultural security, immigrant, refugees and women were used in conjunction with midwifery.
No previous research was located in the literature which specifically examined cultural safety in midwifery care. We were however able to locate six studies involving women from various multicultural backgrounds and their experiences of accessing midwifery care in Australia. These studies explored the midwifery care provided to Aboriginal and Torres Strait Islander Australians (Kruske, Kildea, & Barclay, 2006); the experience of pregnancy, labour and birth of Thai women in Australia (Liamputtong & Naksook, 2004); Vietnamese, Turkish and Filipino women's views about care provided during labour and birth in Australian maternity units (Small, Yelland, Lumley, Brown, & Liamputtong, 2002); antenatal care for African refugees (Carolan & Cassar, 2007); the meaning and experiences of motherhood among Afghan immigrant women living in Australia (Tsianakas & Liamputtong, 2008); and the perceptions of pregnant African women attending maternity services in Melbourne (Carolan & Cassar, 2008).
In all six studies women did not explicitly report or even imply feeling cultural safe and neither did the researchers discuss the importance of cultural safety. Given that no previous research was found, the remainder of this paper discusses how cultural safety has evolved and describes its importance for and application to midwifery care.
Section snippets
Concept of cultural safety
Cultural safety was developed in the context of nursing theory and is widely discussed in terms of health care practices (Ramsden, 1993, Ramsden, 2002, Richardson, 2003, Wepa, 2001). Cultural safety was introduced in Aotearoa/New Zealand in the late 1980s in response to improving Maori wellbeing, reducing the impact of colonisation and reducing culturally inappropriate practices in health care (Dowell et al., 2001, Jacobs and Boddy, 2008, Papps and Ramsden, 1996). Maori health status was
Evolution of cultural safety
The concept of cultural safety evolved from cultural awareness and cultural sensitivity (Ramsden, 1993, Ramsden, 2002, Richardson, 2003). Williams (1999) purports that cultural safety “extends beyond cultural awareness and sensitivity” and Eckermann et al. (2006) consider cultural awareness and cultural sensitivity as important foundations for the attainment of cultural safety. Fig. 1 illustrates that cultural safety builds upon cultural awareness and cultural sensitivity in developmental
Australian health
Johnstone and Kanitsaki (2007) argue that the health status of racial and ethnic minority groups, including immigrants and refugees, is poorer than that of the local population of the country they are living in. In Australia there are disparities in health among minority racial, ethno-cultural and Indigenous groups, and most recently, new immigrants and refugees (Allotey, 2003, ABS, 2007, AIHW, 2005, Wepa, 2004). This is despite the fact that Australians are one of the healthiest populations
Cultural safety in nursing and midwifery
Cultural safety is not synonymous with transcultural nursing. Transcultural, cross-cultural and inter cultural care are, however, terms that are often used interchangeably and are primarily concerned with cultural interactions (Leininger, 2002, Robb and Douglas, 2004). These terms are predecessors to the principle of cultural safety. The concept of transcultural care was developed by the American nurse theorist, Leininger in response to a lack of understanding by nurses in the United States of
Cultural safety in midwifery practice
The process of moving toward cultural safety in midwifery must acknowledge the uniqueness of the relationship between a midwife and a woman. This relationship is enhanced when there is continuity of care. Eckermann et al. (2006) describe this unique interaction or relationship as a convergence of two cultures, that is the professional culture of the midwife and the culture of the woman. It is likely that this interaction will encourage the development of trust between a midwife and a woman (
Strategies to help ensure culturally safe midwifery practice
Cultural safety puts the woman at the centre of midwifery care by identifying her needs and establishing a partnership built on trust. Culturally safe midwifery care strategies would incorporate optimal communication, building sound relationships and acknowledging women's cultural preferences. Clear, value free, open and respectful communication is fundamental in identifying and acknowledging the woman's requirements when planning care (De and Richardson, 2008, Eckermann et al., 2006, Ramsden,
Conclusion
As a matter of urgency, the strategies highlighted in this paper ought to be promoted to ensure cultural safety in midwifery practice. Midwives practising in Australia need to identify and acknowledge that cultural differences exist between themselves and all women. Cultural safety requires midwives firstly to engage in self reflection of their values, attitudes and beliefs in order to recognise that power imbalances occur during everyday midwifery practice. This should be followed by the
Conflict of interest
I wish to state that there is no conflict of interest of any kind in the event the article is published by the Collegian. There is no financial or other interest in the product or distribution of the product.
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