Cultural safety in nursing

The meaning of the term culture in nursing has changed significantly in recent decades. Culture may be seen as the learned, shared value and beliefs of a particular group (Spence, 2001). Cultural expression assumes many forms, including language, traditions, stress, pain, anger, sorrow, spirituality, decision making and even world philosophy (Catalano, 2006).Cultural safety is a process that involves the individual knowing of their self and their own culture, becoming aware of, respectful of, and sensitive to different cultures, asking who is at risk, preventing unsafe situations, and creating a culturally safe environment (Wood and Schwass, 1993).

During my first night shift at clinical placement, I provided care for Anna (pseudonym), an 85- year old Maori lady, who was admitted to the ward following suicide attempt, which was related to the second anniversary of her husband's death. She had a 20 year history of depression. On admission Anna was agitated and fearful, stating that she could not do almost anything that was requested of her. She had some disorganized ideas. For example, she thought she would be scalded by meals, or accidentally fall out of a window.

We had just finished our handover when Anna rang the bell. I went to her room and found her sitting on the chair."Good evening Anna," I said." My name is Parisa. I am your nurse tonight". Anna looked worried and replied: "I am not sure if I have enough clothes!!!. " From the handover briefing I had understood that she was worrying about not having enough clothes. So I opened the door of the wardrobe and reassured her that she had plenty of clothes. Then I told her she needed to come back to her bed and have a rest. I helped her get back into the bed.

Twenty minutes later, while I was doing the ward check, I heard someone crying. The sound of crying came from Anna's room. I went to her room. It was midnight. Anna was lying alone; fearful, sad, and depressed. Left isolated, she wanted to call a nurse for help but she didn't know how to explain what she needed. " Anna, what happened?" I asked. "Are you crying?" She didn't reply. In this situation, it came into my mind that good therapeutic communication through the use of touch was very appropriate to calm her. I held her hand, looked into her eyes, and asked her if she wanted to tell me what she was thinking at the time. She replied:" I feel I am a horrible person, can't you see that? "I said, "A horrible person??!!, what I see is a frightened person. You are scared, aren't you?" She replied, "I am so scared of losing everything and everyone I love. Nurse, I am not a good person, I tried to commit suicide. I took an overdose of my pills, and I made my family worry about me". She started to cry again. I listened to Anna and let her speak out all her feelings. I said," I understand you feel it was the wrong thing to do" She replied: "Do you think God will forgive me? I need to cry, I need to pray". With my eyes full of tears I asked her," Would you like it if we prayed together?" She looked at me kindly and said "Yes, I would like to pray". We held hands, and both of us started to pray in our own languages...

Learning and then not acting on what you learn is like ploughing and then never planting (Unknown). When I was in unit 4, we had a Maori Health paper where I gained lot of knowledge about the Maori view of health. This incident with Anna was an occasion in which I put the knowledge I had learned at university into practice.

According to Durie (1998) the traditional Maori attitude toward health is one of holism. Health from a Maori perspective has always acknowledged the unity of: spiritual, emotional, physical, and family aspects. The spiritual perspective is the most necessary perspective for Maori wellbeing. It is defined as "attachment to religious values," but does not have the same meaning as "religious beliefs". When spiritual needs are met, an individual can function with a meaningful identity and purpose and can relate to reality with hope (Durie, 1998).

Nursing is a discipline that professes to address the human person in a holistic manner, focusing on all dimensions of the person: body, mind and spirit (Lemmer, 2005). Care of the spirit is a professional nursing responsibility and an intrinsic part of holistic nursing. The holistic nursing perspective requires nurses to view each person as a biopsychosocial being with a spiritual core. Thus, nurses must be sure to address the spirit along with the other dimensions to provide holistic care (Calatona, 2006, p.403).

In my situation, I had to support Anna's desire to pray and practise meaningful rituals. To confirm my assumptions about an underlying cultural issue, I asked Anna in a very respectful way about her cultural beliefs. I realized that Anna's religious beliefs could be a vital way in which she expresses her spirituality. I asked her if she would like the service of a Maori Chaplain, and she accepted. Therefore, during the morning handover I informed Anna's primary nurse that Anna wish to be referred to the Maori Chaplain Service. Fourie, Mcdonald, Connor and Bartlett (2005) clearly state that handover is a critical time where staff share information from which to base important decisions about patient care and management, particularly clients who appear unsettled and /or those who require extra intervention. Spiritual interventions have been demonstrated to be significant in the client's recovery from disorder. The dimensions of religious ceremony, prayer and the client, relationship with God have been shown to have positive associations with mental health (Catalano, 2006).

Reflecting on this experience I found that my therapeutic communication techniques of presence, and active listening, were very useful. "The affective aspects of nursing are related to emotional interchange between nurse and patient which includes presentation, active listening, therapeutic communication and discussion of spiritual issues" (Wichowski, Kubsch, Ladwig & Torres, 2003, p.1122). I used touch to help comfort her distress. Touch is a therapeutic tool which can provide sensory stimulation, induce relaxation, physical and emotional comfort, orient people to reality, improve level of awareness, convey warmth, respect, sensitivity and a powerful expression of a trusting relationship (Crisp & Taylor, 2003). I listened attentively to every single word that Anna said to show that I have a genuine interest in knowing more about her beliefs. Listening attentively and reflectively can help the client feel valued, understood and supported (Mohr, 2003). I have found out that through my active listening to her story, I displayed a caring attitude, and she is already participating in a culturally competent care. A nurse who is ready to listen to his/her patients, respects their cultural and social backgrounds and does not make any stereotypical assumptions delivers a culturally safe practice (Bunker, 2001).

My experience of nursing Anna, and learning how her cultural beliefs affected her mood helped me achieve and develop the skills to be culturally competent in my nursing practice. Culturally competent care involves the integration of knowledge, attitude and skills to provide culturally appropriate health care (Mohr, 2003). As I want to be a mental health nurse, my practice should be culturally appropriate through the sensitive and supportive identification of cultural issues (Australia & New Zealand College of Mental health nursing, 1995). I also learned that one of the skills that a mental health nurse should possess is the ability to integrate cultural perspectives within the delivery of appropriate interventions. This experience also gave me the opportunity to demonstrate my skill in communicating Anna's problem to the primary nurse effectively. It also enhanced my critical thinking skills for I was able to find the link between her beliefs and her illness, and that led to provision of a culturally competent care.