Competing paradigms

Chapter two provided a brief review of literature explaining the use of culture in the context of cultural safety to differentiate it from its representation in transcultural care. Ideas about cultural care in nursing had their origins in anthropology. Lipson and De Santis (2009) note that as early as the 1930s anthropologist, Esther Lucille Brown, wanted nurses to attend to a patient’s cultural background and the effect of environment on a person’s well being. They note that after World War II there was a growing need to address cultural care in nursing education. This desire was in part driven by the return, following World War II of North American military nurses who brought with them a broader understanding of cultural differences and in part, by a growing demand from nursing structures to include social science and behavioural content in nursing education curricula.

In the early 50s, Peplau (1952), a psychiatric nurse, formulated her theory of nursing as an interpersonal process developed in the context of relationship. Initially her contribution was toward articulating a theory of psychiatric nursing. However, as relational aspects of care became more central to general nursing the usefulness of her theory was realised in broader nursing contexts. Peplau’s focus is on interpersonal processes and therapeutic relationships that develop between the nurses and the client. Central to her thesis was the need for the nurse to understand her [sic] own behaviour and to work in partnership to assist the client in overcoming their problems.

From the 1950’s to the present day the development of nursing theory and the production of nursing knowledge has undergone a steady change. Trends in nursing scholarship have tended to parallel scholarship within philosophy, feminism, education and social sciences (Andrist, Nicholas & Wolf, 2006; Cody, 2006; Daly, Speedy & Jackson, 2006). Over time nursing

22 _{I have used wholistic to convey the idea that health care is whole and greater than the sum of its parts as in a systems model. It} includes holistic but encompasses more than the physical/spiritual and social/emotional and focuses on environment, relationships and cultural knowledge.

theorists have gradually identified and articulated new directions for nursing as a discipline by developing theories and conceptual models which can inform thinking and explain nursing actions in diverse contexts of health care. Henderson (1966), for example, sought to name contexts and the content of nursing work. Levine (2005) was concerned with conservation aspects of nursing by exploring the relationship between health and energy and the nurses’ role in conserving patient energy (Schaefer, 2006). Roy (1988) utilised four modes of adaptation to explain an interrelationship between the physical, self-concept, roles and interdependence as a way of organising nursing assessment and intervention. Leininger (1978) drew on her anthropological background to develop nursing theory in the context of transcultural care. Benner (1984) utilised humanist principles to identify the development of the nurse from a novice to an expert clinician while Newman (1980) considered the nature of nursing by exploring the concept of health as expanding consciousness in practice.

North American nurse academics Bevis and Watson (1989) summed up the shift of nursing from a landscape of objective measurement to one based in humanism. They urged a rethinking of nursing and called for a curriculum change by challenging the behaviourist approach in vogue in 1970s nursing. Bevis and Watson (1989) proposed an approach to the development of nursing knowledge more representative of humanist qualities associated with care and ethical behaviour. The behaviourist curriculum, and the assumption that learning may be measured through empirically observable objectives, was no longer a useful way by which to frame the changing reality of nursing and they wanted to transform nursing into a caring and relational endeavour. They considered that a caring and ethically based curriculum would be characteristic of all nursing and would influence the humanistic, compassionate treatment of patients and change the quality of nursing care. In proposing a curriculum change they also wanted to move nursing thinking away from a reliance on a medical model of care to a more relational framework. They claimed that this would align education with clinical practice and declared that caring theory could be applied in education and then be translated from this pedagogical practice into the clinical world.

The early work of another North American nurse theorist, Leininger (1978, 1991, 1995), explored the concept of care in nursing and linked this with notions of culture. Leininger’s theoretical premise was knowledge of what care means to a person both attitudinally and behaviourally, combined with basic knowledge about cultural values and beliefs, would enable nurses to provide culturally competent care (Andrews, Boyle & Carr, 1995). Leininger was a key motivator in shifting the shape of nursing in the 1970s and 1980s with her culture care theory of

diversity and universality (1978, 1991). Leininger’s (1991) work directed nurses to discover, and document, the cultural world of the client in order to use their interpretations of cultural knowledge and practices to develop cultural constructs of care which were applied within a transcultural care framework. Accordingly her original culture care theory provides a basis for making culturally congruent professional care actions and decisions. While Leininger’s theory established the importance of culture in explaining a person’s health behaviour, her work overlooked the complexity of multifaceted health care relationships and health care environments and how these influence patient care and health care outcomes. Since Leininger’s early work there has been an evolving critique of transcultural or culture care theory and there is a growing awareness that a single focus on ethnicity and cultural rituals and practices risks overlooking influences and practices shaping health care, for example (Cummings, Estabrooks, Midodzi, Wallin & Hayduk, 2007; Dreher & MacNaughton, 2002; Patterson, Osbourne & Gregory, 2004).

The theoretical propositions of Peplau (1952), Bevis and Watson (1989) and Leininger (1978, 1991) provided an impetus for changes in approaches to nursing knowledge and the construction of concepts of care in nursing. However the events and thinking leading to the development of cultural safety suggest that North American nursing theories and concepts, on their own, did not always ensure the provision of safe care in a New Zealand context. Early contributions of New Zealand nurse academics confirmed that while New Zealand nursing was part of a wider international nursing community, there was a need to develop a body of knowledge that reflected the needs of local populations (Chick & Rodgers, 1997; Salmon, 1982).