Overview of the study

Chapter one: Cultural safety – Introduction and overview

The first chapter provided a definition for, and a chronology of, the development of cultural safety in nursing. Key international and national events were highlighted to historically contextualise cultural safety within Aotearoa New Zealand. The research, arguments and methodology were outlined. Tensions within current understandings of cultural safety were identified and the potential contribution of this research to the future of nursing in Aotearoa New Zealand was considered.

Chapter two: Cultural safety - The Aotearoa New Zealand context

An overview of the cultural safety literature within Aotearoa New Zealand is provided in this chapter. The literature review database search for chapters two and three is documented within the chapter. The cultural safety literature may be divided into two distinct phases. The first covers the contentious period during which ideas about cultural safety were developed and integrated into nursing education. Irihapeti Ramsden, and her work on cultural safety, is considered as a key driver within this process. The second phase moves away from controversy surrounding the place of cultural safety within the nursing curriculum to consideration of how to effectively teach and apply the concept within nursing education and practice. The works of key Aotearoa New Zealand authors are reviewed in order to offer insights into ongoing attempts of theorise cultural safety from the perspectives of education and nursing practice. The overview of the local literature provides the context for chapter three which considers cultural safety in relation to the international nursing literature.

Chapter three: Cultural safety: In dialogue with the international literature

This chapter brings cultural safety into dialogue with international literature to draw out tensions between cultural safety and transcultural care, culture specific care and cultural competence. It examines a small selection of North American and Australian literature to show how researchers and nurse academics in an international context interpret cultural safety in Aotearoa New Zealand. An examination of literature identifying local and international tensions is included to illustrate how cultural safety evolved as a site of struggle in nursing. Chapter three also draws on literature from nursing to draw parallels with cultural safety and to align the concept with nursing. The chapter includes a brief examination of postmodern concepts of culture and critical theories about social structure, identity and difference that have relevance for this research. Finally, the review draws on the aims of the research to identify gaps in the literature and to summarise the relevance that the reviewed literature has for this study.

Chapter four: Theoretical underpinnings, methodology and method

This chapter provides an overview of the key theoretical ideas used within the thesis, the methodology and rationale for choosing a narrative approach to explore the research question. Taking the complexities of a qualitative research project, involving stories of cultural safety, into account, I considered that a single analytical approach was insufficient to guide the collection of

data, the translation of data into text for analysis and the writing up of the findings of the research. To account for this complexity, I utilised narrative method to conduct the research interviews, an abductive research strategy (Blaikie, 2000, 2010), to guide analysis of texts complimented by aspects of narrative analysis from Frank (2002), Labov and Waletksy (1997) and Somers (1994). The work of Bourdieu (1972, 1984, 1990a, 1990b, 1988). Bourdieu and Wacquant (2005) provided the theoretical lens through which to interpret narratives of cultural safety within this thesis and Bourdieu’s concepts of habitus, field, capital are identified to demonstrate how institutional relationships are shaped. Somers’ work on narrativity and identity is used to explain contexts for relating and taking action. Methods used to gather data are outlined alongside ethical considerations related to the study.

Chapters five through seven:

These chapters constitute the substantive body of the research. Each chapter provides a cross section of how the people who contributed to this research apply cultural safety knowledge in their everyday nursing practice. In order to build the analysis of cultural safety provided in this thesis, themes at work within larger extracts from some of the people interviewed for this research will be fore-grounded, supported by a range of smaller extracts from the remaining informants. The selected narratives will link a number of aspects of education and practice to provide an account of how registered nurses apply cultural safety in their everyday nursing practice. These include: learning about cultural safety, meanings of cultural safety, cultural safety- a settings approach and cultural safety as a relational field. Drawing upon these substantive themes, the application of cultural safety knowledge and limitations associated with applying cultural safety knowledge in nursing practice will be identified and analysed.

Chapter five: Learning about cultural safety and personal constructions of meaning

This chapter situates cultural safety within an environment of change by exploring the way in which ideas about cultural safety transferred unevenly from educational into health care settings. The analysis will focus on how participants viewed and/or experienced this shift from either the perspective of a student or an already registered nurse. It is suggested that participants’ attitudes towards learning about cultural safety were influenced by their experiences, personal views and the particular time period in which they were nursing students. Different meanings of cultural safety are identified in participants’ talk about how they understand cultural safety as nursing concept. The talk of nurses interviewed for this project suggests that understandings of cultural safety are shaped by their identity, time in practice, values and beliefs about nursing and how

they engage with their environment as individuals and as nurses. Although there is no consensus about the meaning of cultural safety, these accounts illustrate a range of themes relating to cultural safety that are at work in the field of nursing practice.

Chapter six: Towards a settings approach, identity and settings in cultural safety

This chapter focuses on cultural safety by considering how practice settings shape the relational and narrative identities of participants. Extended narratives of four participants are used to illustrate how participants make sense of their actions, who they are as nurses and how they strive to practise in a culturally safe way in their work settings. It is argued that personal, professional, cultural and historical influences work to structure the way nurses apply cultural safety knowledge in their everyday nursing practice. This chapter addresses in detail the way the participants interact with their clients to support and maintain their own and their client’s sense of self and cultural integrity within specific areas of practice. The accounts presented in this chapter illustrate how identity, setting, relationship and culture work to support and/or constrain culturally safe practice. The complex, multi- dimensional nature of practice is identified in this chapter through positioning the talk of participants within a matrix of cultural, institutional, material and symbolic practices and relationships of power that operate within the health care settings in which they work.

Chapter seven: Cultural safety as habitus, field and doxa

Issues of power embedded in material and symbolic practices identified in chapter six are also the focus of analysis in this chapter. The chapter will demonstrate how cultural safety might be understood through an analytical lens that employs Bourdieu’s conceptual mechanisms of field,

habitus, doxa, capital and interest in order to explore how the operation of the field works to constrain or allow culturally safe practice. Doxa (Bourdieu, 1972, 1984, 1990a, 1990b, 1998) may be thought of as the dominant social arrangements within a field which inform a person’s actions and thoughts. I argue that within each field conflicts over the nature and possession of capital, combined with the presence of doxic practices that either constrain or enable a nurse’s autonomy, influence her ability to determine how culturally safe care will be delivered. Incorporating the theories of Bourdieu into understandings about cultural safety draws attention to factors that impact upon care which are embedded within the personal and professional dispositions of the nurse as well as in the contexts within which she works.

Chapter eight: Discussion of findings and concluding thoughts

The discussion will provide an overview of cultural safety in nursing practice in the light of current knowledge and understandings of the concept. The chapter will discuss how the research aims have been met. The findings will draw on key theoretical concepts relating to narrativity, identity, habitus, practice, and field to argue for a reframing of health care relationships between the nurse and the person for whom she or he cares within networks of power relationships. Issues indicating directions for further research will be identified followed by possible methodological and practice implications of the study. Limitations will be addressed and the chapter will close with a reflection on the research process, concluding with a closing statement.

Chapter two: Cultural safety – The New Zealand context

Cultural safety is not about patients; it is about nurses, their behaviour and attitudes toward patients and their ability or otherwise to create trust. (Ramsden, 2002, p. 21)

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Introduction

Chapter one positioned cultural safety in an historical context and identified influences shaping its development and introduction into nursing education. I defined cultural safety and justified my reason for undertaking this research. Chapter two examines New Zealand literature which has relevance for the research question. The review is presented in two chapters, focusing on four themes: national literature, international literature, cultural safety and nursing, and sociological underpinnings.

Within the New Zealand literature related to education and practice, Irihapeti Ramsden is considered a key driver in the development of cultural safety. Her work forms the substantive cultural safety literature in this country; therefore her contribution to the development of cultural safety is explored in depth. When cultural safety was first incorporated into mainstream nursing education it drew resistance and another kind of protest which differed from the protest by Māori, anti racist groups against the impact of colonial history on health care delivery to Māori. This new protest came from a mainly Pākehā community therefore a second theme examines nursing literature and media texts to illustrate the way this protest affected cultural safety in nursing and education. This is followed by literature exploring educational pedagogies aimed at providing a structure for cultural safety education. Attention is then turned to New Zealand based cultural safety research to explore links between education and practice.