Critical Cultural Perspectives and Health Care Involving Aboriginal Peoples I’m very pleased to be here today. It’s a real honor to be able to speak with my nursing colleagues here at this international forum. And I would like to thank the organizers for inviting me to participate in this way. I’d like to begin by telling you a bit about how I came to be involved in the NP movement in Canada, and a research program in the area of Aboriginal health. This I think will give you a flavor for the kinds of issues I’ll be emphasizing in today’s talk, and a context for understanding where I am coming from philosophically speaking. Annette J. Browne, PhD, RN Associate Professor New Investigator, Canadian Institutes of Health Research Michael Smith Foundation for Health Research Scholar School of Nursing, University of British Columbia Vancouver, Canada

Objectives Examine commonly-held assumptions about “culture” in health care; Explore how conventional thinking about culture has the potential to become problematic in health care a. Distinguish cultural sensitivity from cultural safety Examine the relevance of “critical cultural approaches” in relation to health care involving Aboriginal peoples.

Culture is a Very Complex Concept! Anthropologist Margaret Lock (1993): “culture is “one of the two or three most complicated words in the English language”. Our ideas about culture are so strongly influenced by recent historical events, today’s political climate, and expanding patterns of globalization.

Conventional Notions of Culture in Health Care Founded on values of multculturalism, cultural defined in terms of: Beliefs, values, behaviors, customs, and lifestyles Fixed sets of characteristics that belong to particular groups Often presented as “lists” of cultural traits Tends to be based on fairly narrow definitions of culture

Examples from Research: Health Care Providers’ Understandings about Culture Health care providers’ ideas: “I find with Native people, just the way their culture is, I think you get a lot more social things that you need to deal with.” “It is in their culture to have a lot of violence, stabbing, alcohol abuse… more than what you see in other cultures.”

Culturalism: An Important Concept to Grasp Is a process of equating culture with social problems or health issues Is closely linked to ideas about “difference”, Othering, stigma, discrimination and racism

Additional Examples from Research: Perceptions about Culture Health care providers: “She [the woman] didn’t take care of any of her own responsibilities. She didn’t look after her own child. Now, I know that is a cultural thing.” “Quite often in this culture, they drink a lot”

Culturalism…… …….diverts our attention Problematic because: Our attention is diverted away from the wider social, historical and economic contexts that shape peoples’ lives Enables us to overlook the “burden of history”

“Othering”…. ….also an important concept Is the process of defining one’s self in relation to a differentiated Other, thus dividing the world into an “us” and “them”. People who are considered “different” are constructed as being even more different [from “us”] than they really are (Varcoe + McCormick, 2007)

Cultural Safety: An Alternate to Cultural Sensitivity Developed in New Zealand by nurse leaders, in collaboration with Maori people, to address Māori health concerns related to: Persistent health disparities Power imbalances in the delivery of health care Inequities in access to health care Discriminatory attitudes and practices embedded in health care CS is one of the pragmatic tools that we’ve been using in clinical practice, education, research and policy – as a critical cultural lens. We’d like to discuss this briefly…

20% of New Zealand’s Nursing Registration Exam Cultural Safety Moves beyond cultural sensitivity Toward shifting the attitudes and practices in nursing and health care that contribute to inequities 20% of New Zealand’s Nursing Registration Exam is on Cultural Safety

Cultural Safety: Founded on a Critical Cultural Perspectives Has an explicit social justice agenda Founded on a critical and politicized understanding of culture Critical Definition of Culture: Culture is understood to be located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes. Cannot be reduced to a set of characteristics Is not a politically neutral concept CS is one of the pragmatic tools that we’ve been using in clinical practice, education, research and policy – as a critical cultural lens. We’d like to discuss this briefly…

Cultural Safety versus “Cultural Risk” Situations that arise when people from a particular group believe they are “demeaned, diminished or disempowered by the actions and the delivery systems of people from another culture” (Wood and Schwass, 1993) Cultural Safety: Requires us to shift our gaze onto the culture of health care, and how practices, policies and research approaches can themselves perpetuate marginalizing conditions and inequities (Browne, Smye & Varcoe, 2005) CS is one of the pragmatic tools that we’ve been using in clinical practice, education, research and policy – as a critical cultural lens. We’d like to discuss this briefly…

Case Example: HIV Rates Among Aboriginal Women in Canada Aboriginal women represent 45.1% of all positive HIV test reports among Aboriginal people compared to 19.5% for non-Aboriginal women (McKay-McNabb,2006). Cultural safety asks: What social, economic and historical conditions led to this degree of vulnerability? How do assumptions about Aboriginal women shape their ability to access care? How do policies impact women’s capacity to access resources for health? What is it about the culture of health care that creates marginalizing conditions for Aboriginal women affected by HIV/AIDS?

Colonizing Messages in (Current) Neo-Colonial Times (III) Third, as many of you will realize, there continues to be a prevailing, dominant discourse in Canada that constructs Aboriginal people as the Inferior Other. - These constructions, propagated in - the media, - popularized texts, - and in everyday conversations, continue to shape public consciousness and attitudes toward First Nations people. - Without competing perspectives, or strategies for thinking critically about these issues, nurses uncritically ‘take-up’ these popularized discourses and incorporate them into their everyday practices. - What I also found was that nurses’ work environments were permissive of racializing discourses. - Thus, jokes about skin colour, - off-handed comments about land claims - or Aboriginal patients’ penchant for pain medications - were so routine and acceptable, they came to be seen as normal. Excerpt from Canadian Newspaper (2002): “It’s called a culture of entitlement and a whole lot of Canada’s aboriginals have it real bad. Those who suffer from this energy sapping affliction almost always grow lethargic and passive. People around them come to resent them, a situation that fosters an unhealthy society…Even the label ‘First Nations’ speaks of entitlement, as though all others are second in line…The truth is, however, impolitic it may be to say it, pandering to Native Indians has become a virtual industry in this county.”

Impact on Patients Without necessarily intending it as such: Social problems become reframed as “cultural” issues “Cultural differences” are presented as factual information

Pragmatic Applications: Applying Cultural Safety as a Conceptual Framework in Health Care Raises ethical and moral concerns: What is our responsibility in disrupting inequities that sustain the status quo? How might we be reinforcing “norms” of practice that may be alienating to indigenous people (and others)? How can we challenge and counter assumptions about “cultural Others”? CS is one of the pragmatic tools that we’ve been using in clinical practice, education, research and policy – as a critical cultural lens. We’d like to discuss this briefly… How can we work to raise critical consciousness in our own local practice areas? How do current policies cause people to feel “demeaned, diminished, or disrespected” as they seek health care?

“If all are like me, then all are my relations” (Little Bear, 2000, p. 68)