1. E nga rangatira, e nga hoa hoki, tena koutou katou
E nga rangatira, e nga hoa hoki, tena koutou katou. ko Ngati Pahawera me Ngati Hinepare me Ngati Hawea oku hapu, Ko Ngati Kahungunu te iwi. He tu mihi poto ki a tatou hui. He mihi hoki ki nga tangata whenua me te kaiwhakahaere o tenei hui. No reira, tena koutou tena koutou tena koutou katoa.
Greetings, thank you for the introduction. As tangata whenua of Aotearoa New Zealand presenting here at this conference I would like to acknowledge the tangata whenua or indigenous people of this land. I would also like to acknowledge the convenors for accepting my abstract. Greetings, thank you for the introduction. I’d first like to thank the convenors from the National Ethnic Disability Alliance and the Multicultural Disability Advocacy Association of New South Wales for asking me to share with you all my experiences in the field of kawa whakaruruhau or cultural safety.

2. Outline and mihi
Mihi/Acknowledgement: Irihapeti Ramsden, Nursing Council of NZ, EIT Hawkes Bay, Pearson Education.
New Zealand context
Brief history of cultural safety in New Zealand
Cultural awareness, cultural sensitivity and cultural safety
Before I discuss the outline of this presentation today I’d like to mihi and acknowledge Irihapeti Ramsden – the architect of Kawa Whakaruruhau or cultural safety and her whanau who have given me permission to publish Irihapeti’s work in my book Cultural safety in Aotearoa New Zealand. I’d also like to mihi to the Nursing Council of New Zealand, Eastern Institute of Technology Hawkes Bay and Pearson Education for the support they have provided to me. So from here I’ll provide a brief introduction to the unique bi-cultural context which has provided the backdrop to the development to cultural safety in Aotearoa NZ. The Treaty of Waitangi and it’s place in cultural safety will be discussed as well as the focus of shifting power from the provider of a health service to the person receiving the service. This shift in power serves to differentiate cultural safety from other terms such as cultural awareness and cultural sensitivity.

3. Outline (cont’d)
Journey of an indigenous woman to produce ‘Cultural safety in Aotearoa New Zealand’.
Lessons I have learnt in terms of cultural knowledge and the broad based concept adopted by the NCNZ.
Cultural competence, cultural security
Behaviourist debate
Ways of addressing relevant issues
From here I’ll share with you the journey I have taken, as an indigenous woman, to produce Cultural Safety in Aotearoa New Zealand. This includes the lessons I have learnt on the way in terms of indigenous perspectives of cultural knowledge and the broad based concept adopted by the Nursing Council of New Zealand. From here I will explore related concepts such as cultural competence and cultural security and then discuss the behaviourist debate that has been highlighted at the conference. I’ll then share with you how in New Zealand we have worked at addressing the issues inherent in this debate.

4. New Zealand context
With over a thousand years of human settlement it’s history is dominated by the relationship between Maori (indigenous people) and Pakeha (European descendants)
With over a thousand years of human settlement NZ’s history is dominated by the relationship between Maori and Pakeha. Relational history between these 2 cultures is still very recent in international terms and is continuing to develop. Such recency however is also the strength behind the relationship as other indigenous cultures watch with interest the lessons we have learnt.

5. The Treaty of Waitangi
The Treaty of Waitangi was signed in 1840 between the Maori chiefs and representatives of the British Crown.
Contains 3 articles
guaranteed Maori certain rights and privileges
including the protection of their customs, land, forests, fisheries and health.
The Treaty of Waitangi is the founding document of New Zealand. It was signed in 1840 between the Maori chiefs and representative of the British Crown. It contains 3 articles which guaranteed Maori certain rights and privileges including the protection of their customs, lands, forests, fisheries and health.

6. Treaty of Waitangi (cont’d)
The Treaty has always been the reference point from which Maori people have negotiated with the Crown for self determination over their resources.
The Treaty provides the reference point therefore for cultural safety in New Zealand.
The Treaty has always been the reference point from which Maori people have negotiated with the Crown for self determination over their resources. The Treaty provides the reference point therefore for cultural safety in New Zealand. An example of this is where the Crown, or agents of the crown such as the Nursing Council of New Zealand are required to fulfil their Treaty obligations by working in partnership with Maori.

7. Cultural Safety
The term “cultural safety” was coined by a Maori nursing student in the late 1980s. She made a plea at a meeting of health educators by saying “You talk of ethical safety, legal safety and physical safety…what about cultural safety?”
This partnership began in 1988 at a hui or meeting where the failure rate of Maori students sitting the State examination was discussed. At the hui a challenge was issued by a first year Maori nursing student, Hinerangi Mohi. She stood weeping and asked “ You talk about legal safety and you talk about ethical safety --- what about cultural safety? From here the new term “cultural safety” was added to the nursing lexicon.

8. Definition
Simply put cultural safety is defined by those who receive the service (1996)
The term Kawa Whakaruruhau is also used which was developed by Irihapeti Ramsden.
So what is cultural safety? Simply put cultural safety is defined by those who receive the service. In this way it becomes a qualitative definition based on the experience of the recipient of care. It is similar to ethical safety in that it depends on each individual event you could have a situation where someone practices safely 9 times out of 10, but one that 10th occasion the person receiving care may determine that you did not meet their cultural requirements in a safe manner. Irihapeti Ramsden, from Ngai Tahu, Rangitane and an educationalist sought a Maori interpretation of the term and her kaumatua Te Uri o te Pani Manawatu te Ra made reference to Kawa Whakaruruhau, a term which came to be used concurrently with the expression cultural safety.

9. Cultural safety
Cultural safety is well beyond cultural awareness and cultural sensitivity.
It gives people the power to comment on care and to be involved in changes in where their experience has been negative.
Cultural safety is well beyond cultural awareness and cultural sensitivity. These concepts are used more in transcultural nursing which can be argued still assumes that the nurse is a cultural and without cultural bias. Cultural safety gives people the power to comment on care and to be involved in changes that improve their care.

10. The process towards achieving cultural safety
Cultural awareness
is a beginning step toward understanding that there is difference. Many people undergo courses designed to sensitise them to formal ritual and practice rather than to the emotional, social, economic and political context in which people exist.
The process towards achieving cultural safety is based on the poutama or staircase analogy, somewhat similar to Tawara’s steps towards cultural proficiency. One of the differences between the two models however is where the comment was made that someone may be competent in say aged care but not in the area of disability. With cultural safety the person providing the service needs to be consistently safe no matter what the context is. So Cultural awareness is a beginning step toward understanding that there is difference. Many people undergo courses designed to sensitise them to formal ritual and practice rather than to the emotional, social, economic and political context in which people exist.
In the students first year of their degree they learn about cultural awareness in the class and on practicum where for many it’s the first time that they discover they have values and beliefs and indeed a culture.

11. Cultural sensitivity
Alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impact these may have on others.
In the students second year they explore cultural sensitivity. Cultural sensitivity alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impact these may have on others. Key sociological concepts such as power are introduced here. At this stage students are encourage not to be relativistic in this thinking and practice. So for example with regards to issues such as child abuse there are some stereotypes out there that state that child abuse is a cultural practice for some groups in society. Now for some students they sit on the fence with regard to this issue and believe that ‘as long as that practice doesn’t affect me then that’s fine for those people’. As we all know the practice of child abuse isn’t fine for any people. So within the cultural safety framework we explore and challenge these types of attitudes.

12. Cultural safety
is an outcome of nursing and midwifery education that enables safe service to be defined by those who receive the service.
   
By the end of the students’ 3rd year they are expected to have knowledge and skills in cultural safety so that they are able to provide a safe service defined by those who receive the service.

13. Founding concepts The inter-dependence of culture and ethnicity
The Treaty of Waitangi and Te Tiriti o Waitangi
Sociological concepts such as power
So the founding concepts include: An understanding of one’s own culture and ethnicity and celebrating the inter-dependence of each of these notions: an exploration of the differences contained within The Treaty of Waitangi and Te Tiriti o Waitangi and the implications this has for practice; and a grounding in sociological theories which focus on the dynamics of power and the capacity we all have to make changes that will benefit the people we provide services to.

14. Evolving nature of cultural safety
Collaboration of stories from health professionals, educators and commentators
Always mindful that the pain of the Maori experience of poor health provided the catalyst for cultural safety
When I started working on my book Cultural safety in Aotearoa New Zealand I needed to remember that cultural safety was still an evolving concept so I did not want to attempt to provide a definitive instructional book on ritualistic ways to work with all cultural groups. What I wanted to achieve was a collaborative book which builds on the founding concepts and explores the issues faced by health professionals in their practice. Similarly, as an indigenous writer I was forever mindful that it was the pain of the Maori experience of poor health that provided the catalyst for cultural safety. So one of the challenges was to be mindful of the tensions that exist between what some might see as a the Council’s broad based approach to cultural safety, where Maori compete for cultural space with other cultural groups, and a Treaty based approach where Maori stories that have never been heard before are equally shared and celebrated. Wherever the reader of this book positions themselves on this continuum they will no doubt be involved in lively discussions about the merits of which approach to take in practice.
Broad based
Treaty based

15. Related concepts Cultural security defined as:
“a commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people” (Western Australian Department of Health)
“…shift in emphasis from attitude to behaviour”
Source: Cultural security and related concepts: a brief summary of the literature, Professor Neil Tomson, Health InfoNet, Perth, WA, 2005
I’d now like to discuss related concepts that I have found very intriguing in my journey towards cultural enlightenment. Last year I was fortunate enough to be a hosted as a visiting scholar in Western Australia. During my visit, Professor Neil Tomson from the Australian Indigenous HealthInfoNet in Perth, put together a paper called Cultural security and related concepts: a brief summary of the literature. Here he provides the following definition of cultural security which states that “it is a commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people”. The definition goes on to say that cultural security “represents a shift in emphasis from attitude to behaviour”. Yesterday several presenters made reference to changing attitudes and or behaviour and posed questions around how to monitor or even measure the cultural competence of the work force in the helping professions especially where there are no agreed standards or measures across professions. I’ll talk about there not being agreed standards in a moment. For now I’d like to talk about attitudes and values. Essentially a competent practitioner must have the capacity to recognise and operationalise the shared values of their occupation, yet at the same time, make wise judgements when these values and principle come into conflict in the complex reality of work. Ethical positions, implicit values and work dilemmas must all surface, therefore, in any adequate description of competent practice.

16. The ‘behaviour’ debate
Is it to be assumed that one can perform a value? (Cairns, 1992)
Human action is nothing but behaviour Or
Human action is something that excludes behaviour
So how do you measure attribute acquisition by individuals?
It is difficult to imagine any occupation where attitudes or values are not important, yet many attempts to measure them in occupations have been notoriously difficult, unreliable and have met with little success. So firstly the question needs to be asked “is it to be assumed that one can perform a value?” This way of posing a problem demonstrates the discredited behaviourist myth that human action is nothing but behaviour. Previous presenters have already alluded to this in terms of reducing equity principles to nothing more than another box to be ticked. Rejection of this position however should not lead to the acceptance of the equally implausible proposition that human action is something that excludes behaviour. So how do you measure attribute acquisition by individuals?

17. Adaptive learning vs generative learning
Attributes such as empathy, patience, creativity, honesty, respect and compassion do not lend themselves to simple measurement
Solution: Devise competency standards that are restricted to describing knowledge & skills
“Empathising with the patient’ – can be assessed holistically in the workplace & above, beside and below
Adaptive learning vs generative learning
Attributes such as empathy, patience, creativity, honesty, respect and compassion do not lend themselves to simple measurement. One solution is to devise competency standards that are restricted to describing knowledge and skills. The major dilemma here is that you end up omitting attitudes and values which makes the assessment invalid. So what you can do is drill down further into what attitudes are considered important. For example where attitudes such as ‘empathising with the patient’ are important, it is not difficult to describe and assess in real, holistic work contexts where it is important part of overall performance. This is where validity is most important whereby the evidence on the person’s competency comes from ‘above, beside and below’, that is from people that someone reports to (above), a work colleague or client (beside) and someone that reports to the person being assessed if this is relevant. What is difficult is describing and assessing ‘empathy’ in the abstract. Without validation this assessment cannot be done, and as Tawara mentioned yesterday, we need to consider whether we are wanting to achieve adaptive learning where you just change the behaviour, or generative learning where the person thinks about what they are doing.

18. Specialised knowledge comes at a price
Self regulation vs externally imposed system
Legislation & governing/professional bodies regulates cultural safety practice in the same manner as ethical, legal and physical safety
Now getting back to the difficulty of measures of cultural competency across professions, where it was noted that there were cultural competencies within professions but not necessarily across professions. This basically is the silo effect created by ‘specialised’ knowledge whereby exclusivity comes at a price. When society surrenders a degree of social control to groups of practitioners, there are expectations that such groups will exercise a degree of social responsibility. Various mechanisms are used to regulate the exercise of this responsibility, where generally the trades are regulated through an externally imposed licensing system, together with some form of formal complaints mechanism, while professions are given the freedom to regulate themselves through internally imposed mechanisms. There in lies the problem. In New Zealand legislation such as the Health & Disability Act and governing bodies such as the New Zealand Nursing and Midwifery Councils require health providers and practitioners to practice in a culturally safe manner. Such groups self regulate to a certain degree however in order to maintain national consistency governing bodies have taken it on board to ensure that culturally safe practice is monitored in the same way that ethical, legal and safety requirements are met. This isn’t to say that the system in New Zealand is perfect, however I think they are making inroads into this issue.

19. Cultural safety & Cultural competence or cultural security
Achieve certain competencies to become safe Or
Achieve certain safety milestones to become competent
This now takes me on to the issue of whether cultural safety is the equivalent to cultural competence or cultural security or is it different. I’ve spent some time grappling with this issue as it hasn’t yet been debated in New Zealand. In my country the term cultural competence is not referred to much at all. The expectation is that competence is achieved over time in the workplace so it really is an employer issue. So Schools of nursing and midwifery for example are very clear that they are educating graduates at a beginner practitioner level and the workplace takes it from there. So I’m now faced with the dilemma of whether on an international stage cultural safety and cultural competence are two sides of the same coin. My immediate reaction to that proposition is an emphatic no! And I would say that wouldn’t I, but seriously my dilemma has been around, does a person achieve certain competencies to become safe or do they achieve certain safety milestones or requirements to become competent? I’d be interested to hear what you folks think of my dilemma. On the face of it I would say that competence can only be achieved over time within the workplace, whereas in terms of safety you are either safe or not safe which has a more serious overtone to it and places cultural safety as a priority alongside other safety considerations such as ethical, legal and physical safety. It would be difficult in New Zealand to discuss ethical, legal and physical competence, the meanings just aren’t the same. Similarly the nature of cultural safety will always place the defining with the person receiving the service or care so the power is maintained at that level. This is somewhat different to other approaches where groups of people other than the consumer or client determines a person’s cultural competence.

20. Where to from here?
Beginning step towards stimulating critical thinking about the ‘taken-for-grantedness’ in the health professions
Lessons learnt from the nurse-patient relationship in Aotearoa New Zealand can help inform new learning in countries outside New Zealand
So, where to from here? With my team of contributors we have begun the journey towards addressing the dearth of cultural safety knowledge that exists in Aotearoa New Zealand. As an indigenous woman I believe that this journey has gone some way towards addressing the poor health status of my people by stimulating critical thinking about the ‘taken for grantedness’ in the health professions. 14 years after its introduction cultural safety has evolved to keep pace with the ever-changing realities in which health care is delivered. It has been stimulated by community, political, media, student and indigenous pressures for change in nursing practice particularly in the nurse-patient relationship. The lessons learnt in my country provide an opportunity for health professionals here today to contribute to cultural safety knowledge within your own respective countries and territories, and to introduce skills and learning that have not been included in earlier training. This is a wonderful opportunity to give meaning to new knowledge. This opportunity as with any opportunity will involve challenges that will be unique to your areas of expertise, knowledge and domicile. A factor that did help me with the many challenges I faced was the guidance I received from other indigenous people. As I alluded to earlier, their stories are yet to be told. So with care, sensitivity, due diligence and an openness to hearing these stories I found that the lessons to be learnt in terms of addressing health disparities existed in those stories which were at times were both painful and promising. I’ll leave you with this whakatauki or proverb which I think epitomizes the end goal of cultural safety education in Aotearoa New Zealand and the rest of the Pacific.

21. Whakatauki / proverb Nahau te rourou Naku te rourou
Ka ora ai te manuhiri
With your basket of knowledge
and my basket of knowledge
the people will prosper
No reira, tena koutou tena koutou, tena tatou katoa.