Sameness in contexts of difference, reflecting on marae-based learning

where there was a large Māori population.

I don’t remember cultural safety being driven home in terms of assessment and clinical. We were just told that we had to go onto a Marae and that was it– we had to give up a weekend and go on the marae. I think there was lot of resentment about that because there was not a lot of understanding, we didn’t know why it was seen as part of your cultural safety component.…I felt that we were actually really intruding, I’d describe us as a bunch of white girls turning up on the marae with no idea what was expected of us. (Mary)

Mary’s narrative demonstrates tensions between cultural safety, transcultural care and bicultural education. It was seen as an ‘add on’ to nursing rather than central to nursing. This was reinforced by the absence of any assessment of the concept in clinical practice. As a student, Mary was caught in emerging and conflicting paradigms. What cultural education she had been exposed to was drawn from North American transcultural concepts, which involved developing an understanding of cultural patterns and mores of a group in order to know how to care for them.

Another factor was the development of the New Zealand Government’s recognition of Aotearoa New Zealand as a bicultural25

25_{In New Zealand, biculturalism was the outcome of a close alliance developed between the leaders of the M}ā_{ori revival and a post-war}

new professional class. The latter group, mainly settler descendants of working class origin were redefining themselves according to the

nation and a strengthening of Te Tiriti o Waitangi relationship between the Crown and iwi. State recognition of biculturalism brought culture to the fore. It was therefore understandable that people new to concepts of two cultures would focus on culture as ethnicity. Cultural safety, with a focus on power, was just beginning to make its presence felt within nursing but was not yet officially part of the curriculum. Attending to power inequality in

a bicultural relationship was still to be realised. Part of calls by Māori for Pākehā recognition of their Tāngata whenua status was expressed in a desire to educate white Pākehā New Zealanders about the culture and health care needs of Māori. To achieve this, nursing students were taken onto to local Marae to learn about the health needs of iwi. Mary’s expression of discomfort and feelings about intruding suggests that she was suddenly confronted with her own whiteness and without any apparent support for the feelings generated by this awareness, she was bewildered, embarrassed, felt out of place and was unable to see the relevance of such visits to her future nursing. For Mary and her colleagues this had consequences.

We were so sick and tired of it, we saw it as something we had to do and we were told to do it. (Mary)

Mary’s comment refers to her overall experience of learning about cultural difference in her early education. She could not connect with the purpose of culturally focused education, experienced a sense of compulsion and did what she had to do in order to pass.

Joy had a similar experience but with different outcomes. Her narrative provides key insights into a critical time of change in nursing education.

I started my undergraduate nursing education from 1977 and finished in 1979. There was no term such as ‘cultural safety’ in those days and there was no recognition of nursing culturally diverse people as such, like I’d never heard of Madeline Leininger in those days or anything like that. However I do think that the nursing tutors that we had recognised in a basic way that there were different cultures within Aotearoa New Zealand and to that extent on a yearly basis the students were taken to a marae in [names town] called [names marae] and we stayed there over a weekend. We went up on a Friday and came back on a Sunday and I don’t think a lot of people appreciated what it meant for the people on the marae to actually be there to awhi26 for us, to cook for us and to look after us because they just didn’t have really any idea of what it meant to belong to a marae, so people would take off work to be our cooks and to do our cleaning and things like that. (Joy)

In contrast to Mary’s experience, Joy was supported during her visit to the Marae and had an understanding of the effort local people made to support the students. This may have been because she was an older Pākehā with Māori whānau. Significant in Joy’s story is her perception of the tutors at the time as having a growing awareness that there were different cultures in Aotearoa New Zealand. While it may have been evident that different cultures existed, the implications of this for health care delivery was not always as obvious, and in this context as in Mary’s situation it was appropriate that students learn about the health needs of people from different cultures by learning about their practices and finding out what was important to them. What was not obvious at this time were the consequences of inviting and imposing a dominant culture on the culture of a marginalised group.

Joy’s next memory recalls this consequence more fully.

I remember the speakers who came to speak to the students were really of exceptional value. In those days we wouldn’t have appreciated them like we do now because they weren’t quite so famous, but we always started off with a kaumātua who would talk about the meeting house and the tukutuku panels and the kowhaiwhai and the stories and what that meant to the tribe and spoke about the different aspects of culture within that marae and so that was usually done on the Friday night after we’d arrived and then I remember the very first time that I went there we had, well he’s professor or doctor, but anyway we had [names person] and he came and spoke to us about the importance of culture in terms of psychiatry and looking after people with psychiatric illness. We had a chap called [names person] who was ____’s brother, and came and spoke to us. Iremember we had a Māori midwife and a Māori psychiatric nurse who worked in [names institution] and they came over and gave freely of their time and spoke of the differences between caring for somebody within the Māori culture in particular areas of nursing. And another year I went up there after I had finished, we had [names person], and yeah, so that was kind of really in my whole recollection of my three years. There was nothing done to prepare us and having been familiar with the kawa or the protocol on the marae I remember being alarmed the first time I went up there when I was still a student because one of the tutors took her husband and her three boys, and I remember being mortified at their behaviour, I mean common sense would tell us that that’s not what you do when you visit somebody else’s house, but I remember

being a little bit mortified by all there. But as I said, there was no preparation given up for us for that experience and maybe that’s because the tutors didn’t have any experience, but they didn’t invite anybody else in either to prepare us.

(Joy)

Joy goes into some detail to explain the value and importance of visiting the Marae. She learns about the story of the people who have invited her to share their space with them and as result she develops a deeper understanding through this relationship. It is this understanding which she will take with her into her future nursing practice. At the same time her experience makes visible, behaviour which offends and Joy is aware of the lack of preparation students had for visiting the Marae. This kind of early experience has usually been framed as conforming to a transcultural nursing framework, however it also needs to be seen in relation to the introduction of ideas about biculturalism in Aotearoa New Zealand more generally. Joy and Mary’s stories of marae-based training reflect the experiences of many student nurses in Aotearoa New Zealand in the late 1970s and 1980s, experiences which foreshadow the development of cultural safety education in this country. Early cultural safety education brought about an awareness that imposing groups of Pākehā students onto Māori communities might mean that dominant Pākehā values may be challenged but not changed. It was also recognised that inviting people into a different cultural space meant putting the hosts at risk of being offended. At this time, the view that it was not appropriate to learn about different cultural practices in situations that had the potential to put the teacher at risk within their own culture was yet to be developed. When I asked Joy why the Marae visits might have happened, she said:

I have a funny feeling that it had to do personally with the nursing staff that we had on faculty at that time, and we had some very caring women in the department, and women who were all doing further study which wasn’t always the case, and I think that these women may not have had a very clear picture of what was coming up but they had enough of an idea to know that, how nursing was going was changing. (Joy)

Joy’s comment suggests that while there was no institutional commitment at this time to provide cultural education in an Aotearoa New Zealand context, there was a sense that things were about to change. Individual tutors were expanding their awareness of difference and social justice through their own studies and bringing it into their everyday teaching. This, and the political

climate associated with Māori protest, provided impetus for the development of cultural safety nursing education.

The advent of cultural safety in nursing affected student nurses and registered nurses in positive and negative ways. For some it provided a language to help with understanding and finding meaning in some of the health care practices the person was part of but felt discomfort with. For others the same language became an instrument to silence opposing voices of those who rejected the idea that culture and identity had any part to play in health care outcomes. Cultural safety education became a site of struggle for legitimacy and voice within monocultural educational and health care institutions.

The experience of cultural safety education was taken into clinical practice along with other educational experiences and learned skills. However, too often the negative experiences of cultural safety education silenced nurses rather than providing them with a voice and a structure to work with and manage day-to-day clinical situations in a culturally safe way. Cultural safety education provided nursing education with a critical framework by which to critique nursing and health practices. The very act of critiquing and dismantling dominant ideas disrupted and broke down roles and relationships in the social spaces in which nursing took place (Bourdieu, 1972, 1998). As already mentioned, just because the student nurse was equipped with this knowledge did not mean that this would be automatically transferred into practical application.

In the first section of this chapter participants reflected how their attitude towards learning about difference and/or cultural safety was influenced by their experiences, personal views and the particular time period in which they were nursing students. Sally and Mary’s stories illustrated the tensions that arose from the introduction of frameworks aimed at providing the nurse with knowledge about cultural difference. They were caught between transcultural care, cultural communication and the push for students to learn specifically about Māori tikanga and health care practices. Polly and June brought their own values and beliefs to their nursing practice and teaching and cultural safety provided them with a way to explain these values. Patricia, Louise and Ruby were the recipients of cultural safety nursing education. Their learning experience turned the focus of investigation onto the nurse but at the same time unleashed an overt expression of racism into nursing education for which enlightened students and well intentioned nursing tutors were unprepared and ill equipped. These intersections of the way culture has been addressed in Aotearoa New Zealand nursing over time have built on one another and continue to detract from a clear nursing-focused understanding of culturally safe nursing care. The next

section of this thesis examines stories relating to the meaning of culturally safe nursing which have embedded in them aspects of different understandings of culture in a nursing context.