What is culture?
Shelley Hopkins; Trish Obst; and Mary-Claire Balnaves
Introduction
Cultural Safety seeks to address imbalances in power and privilege (unearned advantages afforded to some individuals) that exist in institutions such as workplaces, universities, schools, health care systems, as well as throughout society. It considers how individuals are treated in society, by examining the impact of systemic and structural issues. Cultural Safety examines all kinds of discrimination including racism. Racism creates and sustains inequalities in societies such as Australia and Aotearoa (New Zealand), where the impact of colonisation is ongoing. In 1788, under the doctrine of Terra Nullius (uninhabited land), the land of the Indigenous nations that made up Australia were invaded by British colonists to establish the colony of New South Wales. In 1840 New Zealand was established as an extension to the colony of New South Wales, but unlike Australia this involved the signing of the Treaty of Waitangi. In 1841 New Zealand became a separate colony. While the Treaty of Waitangi in New Zealand has given a stronger political recognition and voice to the Māori people compared to the First Nations peoples of Australia, the impacts of colonisation and colonialism are enduring. Colonialism refers to the economic and political domination of a country and its people by a colonial power. The primary goal of colonialism is to take power through the imposition of religion, language, political and legal systems to make profit through exploiting the resources of the colonised state. This power imbalance continues to drive the historic, political, social, and economic contexts of Indigenous/non-Indigenous relations concerning individuals and communities.
Cultural Safety evaluates how society and its institutions respond to inequalities arising from colonialism. These inequalities encompass racism, discrimination, bias and stigma and affect equitable and safe access to health and education.
The Cultural Safety model was developed by Māori nursing scholar Dr Irihapeti Ramsden in response to students’ concerns about the safety of Māori students undertaking nursing training in universities in Aotearoa (New Zealand), where the dominant cultural group was European.
What is culture?
There are many cultures, personal, professional/organisational and societal. Culture is learned and dynamic as it responds to different contexts and needs.
Cultural Safety recognises individuals, professions, systems and society as cultural entities. Cultural Safety’s definition of personal culture includes (but is not limited to) an individual’s:
- Personal cultural factors such as age, gender, class, ethnicity, and ability;
- Worldviews (values, beliefs, assumptions, and attitudes); and
- Aspects of the lifeworld (social experience, privilege, opportunity).
Importantly, Cultural Safety uses a broad definition of culture that does not reduce it to ethnicity only (Cox, 2016). For example, members of the same household can have very different cultural identities. This can be a product of age, social influences (including engagement in real-life interactions and with social media), gender, ability, position in the family, education, responsibility, and religion amongst other factors. Professionally in health care, different health care providers can hold different cultural norms and responsibilities which can also be influenced by context and organisational culture. For example, the interactions between health care providers working in a tertiary paediatric ward may differ compared to a community health setting.
Cultural Safety in practice
Cultural Safety focuses on the cultures of professions, institutions, and services as the sites of scrutiny and change. One key element of Cultural Safety is the recognition that services (including universities, schools, and health services) are designed by people from, and based on the assumptions of, dominant cultural groups. In Australia, the dominant cultures include patriarchy, whiteness, heteronormativity, classism, ableism, and Catholicism, to name a few. The application of Cultural Safety navigates the relationships between history, culture, society, and inequity and acknowledges all forms of power imbalance and discrimination including, but not limited to, racism. Cultural Safety in practice is an ongoing exercise of reflection by individuals on their personal, professional, and institutional cultures and the dimensions of power that inform them. Culturally safe individuals are aware of their own personal and professional values, assumptions, biases, power and privilege that affect the experience of others when accessing services (be it a health service, a university or other educational institution). This self-reflective work is essential to gain and maintain trust between services and service-users to ultimately improve equity within institutions. Culturally safe organisations accept and acknowledge the impact of their cultures on outcomes for their users; and a culturally safe environment enables individuals to feel safe and secure in their identity. The Cultural Safety of an organisation and environment is based on and determined by the service user’s perceptions of an encounter or interaction with the organisation.
Scenario
In providing care to a patient, you walk into a person’s room. You realise you are unable to pronounce their name. You consider the following options:
- Asking them what name they like to go by;
- Attempting to pronounce their name;
- Leaving the room and asking a colleague;
- Not using their name;
- Naming them a nickname that you can pronounce.
When weighing up the options, you determine that asking the patient how to pronounce their name would be the most culturally safe option to give power and voice to the person. They told you how to pronounce their name, and you feel the interaction went well. However, a family member shares with you that this has been a common occurrence and often left the person feeling othered and not belonging.
Reflections from the authors
Cultural Safety is a challenging space, as it is determined by the end user, which can be subjective. Individual feedback, particularly negative feedback about your care and practice can feel extremely confronting and vulnerable. This can be exacerbated in health care, where many health care professionals consider themselves well-meaning and person-centred.
Whilst challenging, Cultural Safety can allow health care professionals to understand there are many systemic factors that influence interactions. From the example above, for the person receiving health care, this feeling of othering was not a one-off occurrence. It may be a frequent occurrence across multiple health care workers and health care settings.
What Cultural Safety is not
Cultural Safety is not being an expert in someone else’s culture.
It does not require a deep understanding of a person’s ethnicity, gender, sexuality, or other attributes. This is different from other transcultural approaches such as cultural competence, capability or awareness. Recognising what makes others different seems straightforward but is always based on your own perspective. Identifying our own cultural identities, values, assumptions and biases and their influence on our behaviour, thoughts and feelings is more challenging; particularly if we are members of the dominant cultural group, where our cultural identities may seem invisible or the ‘social norm’.
Cultural Safety is not something you ‘achieve’, or master, it is ongoing.
Cultural Safety is an ongoing process of reflection and awareness. It is acknowledgement of the power culture has in professional and personal relationships (which can change over time) and the creation of respectful spaces in which individuals feel safe to express themselves.
Cultural Safety is not easy and requires courage and vulnerability to step into a learner position.
In health, many of our clinical skills are measured as competencies. As we gain experience, we believe we become experts. We are infrequently required to step into a learner position or admit that we do not know something. The health care systems we work in, that are time and resource poor often do not create the space required to step into a learner position.
“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 nursing practice” (NCoNZ 1996, p. 9)
Power is a highly contested concept involving deep and ongoing philosophical debates. Power is not a thing that one either has or does not have. It is an aspect of the social relationships betweeen individuals and structures and so we talk of power relationships, and imbalanced power relationships. Those in powerful positions in human relationships have the capacity to influence and control the actions of others.
Racism is the practice of using the idea of race to claim that some people are inferior to others. Racism discriminates against people based on the social construct of "race‟. Historically, Anglo-Saxons claimed that they were superior to all other people and that this gave them the right to control other people and to take their land for example. This assumed superiority of some societies over others is called “social Darwinism”.
The organisation of society (such as schools, hospitals) according to western (European) values and priorities which are seen as 'normal' and 'right' by those espousing them. Organising society according to the values and priorities of one cultural tradition is always at the expense of those of other cultural traditions. An example of eurocentrism in health is the assumption that only the biological parents are Mother/Father, while in some Indigenous societies relatives that western society calls Aunt/Uncles are also known as Mother/Father.
Culture occurs at different levels and is a contested concept because there is no universally agree definition but all cultures are learned, dynamic, changing, strategic, negotiated. There is personal culture, professional/institutional/organisational cultures and societal culture.
Personal culture: refers to multiple aspects of our identity (ethnicity, nationality, age, gender, gender identity, sexual orientation, education, occupation, ability, class and socio-economic status and political persuasion); our way of life; our social experience of belonging, status and opportunity; the values, beliefs, and attitudes that we use to make decisions and respond to situations in everyday life including in professional practice. The concept of personal culture as used in Cultural Safety focuses on the interaction between the lifeworld [aspects of life as it is experienced] and worldviews [beliefs, values, attitudes, assumptions].
Professional /institutional cultures: the beliefs, values, priorities, sensibilities, ways of doing business, dress, knowledge, jargon/language, techniques, social status and influence, and theories of professions. For example, health care cultures tend to value efficiency, competency, effectiveness, compliance, punctuality, science, intervention and technology and to prioritise completing tasks accurately and quickly.
Societal Culture: Whilst there is tremendous variation in the cultural ways of being amongst the members of a nation or society, there are dominating aspects of the society, which make up the dominant culture. Like personal, professional and organisational cultures, societal culture is about power, history, values, attitudes and priorities expressed in the ways things are done (practices). For example, although Australia is considered a secular and multi- faith society, the Christian religion dominates. While it is considered, multi-cultural the English language dominates and ways of doing business throughout society are based on European knowledges, philosophical traditions, pedagogical practices and biomedical practice.
Socially constructed group identification/belonging based on common ancestors (kinship) and history and traditions in language, food, dress etc.
The idea of the worldview is useful as we all have a worldview. We turn to our personal worldview to answer such questions as: How did the world come about? How did I get here? What am I doing here? What is my purpose in life? What happens when I die? Is there life on other planets? However, there is so much difference within cultural groups that the rigid idea that those who identify with the same culture exactly share a worldview leads to misguided assumptions and cultural stereotypes.
Values are guiding principles based on aspects of life that are held in high regard. We draw on our values to help us make decisions in life or to help us to decide how to behave in a given situation. Examples of values are honesty, hard work, fairness/equity and so on. So, if we are someone who values honesty for example we wouldn't decide to cheat in an exam or to keep the wallet we found in a taxi.
Beliefs are meanings or fundamental ideas that you have about the nature of the world and that you hold to be true or real but for which there is no generally acceptable evidence. Beliefs usually consider questions of how humans came to be on earth, how the universe came about and how it works. For example, someone may believe that aliens are humans' ancestors but there is no evidence for this proposition. Someone may believe in extra sensory perception but there is no proof of it. Others may believe in creationism but again there is no generally acceptable proof of this.
Our automatic responses and established opinions.
Our beliefs, feelings and values create states of mind (attitudes) about our self, others, the world, activities and so on. These states of mind determine how we behave toward people and situations. For example, if someone highly values paid work and believes that paid work is the foundation of happiness, then their attitude toward paid work will be positive and they will engage happily in paid work. Alternatively,if someone values leisure or creativity or community service they might hold the belief that paid work takes them from their true purpose in life and their attitude toward it may be negative and they might not want to engage in paid work.
The lifeworld defined as ‘the sum total of physical surroundings and everyday experiences that make up an individual's world’ (Merriam-Webster Dictionary online at http://www.merriam-webster.com/dictionary/lifeworld).
Generally accepted or expected standards of acceptable and unacceptable behaviour that operate in society.
However, norms are trends NOT RULES. For example, an expected norm would be that people hand in someone's lost property if they find it. Nevertheless, some people do and some people do not! Norms are also standards or occurrences regarded as typical in a society. For example, in Australian society, the norm is for many school leavers to go to a coastal area and party, but not ALL school leavers do this. I heard at a colleague's son's school the ‘Schoolies’ went to towns in Australia and offer to help with whatever that community needed e.g. cleaning up a park. I wonder if that might become a new norm.
