Canada has a population of 35,158,300 (Statistics Canada, 2013). It is a multicultural society with the aboriginal peoples comprising 4.3% of the national population. According to the National Household Survey of 2011, there are 1,400,685 residents with aboriginal identity belonging to the First Nations, Metis, and Inuit groups. They are located all across the country, but are mostly concentrated in Ontario and the Western provinces. In Nunavut and in the Northwest territories, the aboriginals make up the majority of the population (Minister of Industry, 2013). Despite the diversity of Canada’s population and given its current culture and structures of healthcare, the opportunity to practice culturally safe nursing is abundant.
Definition of cultural safety
Cultural safety was first identified by Maori nurses of New Zealand in 1988. Douglas (2013) states that “cultural safety focuses on the individual patient, but considers the patient within the context of power relationships” (p.44). According to the Nursing Council of New Zealand, cultural safety is the “effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on [his/her] own cultural identity and recognizes the impact of the nurse’s culture on the nursing practice” (Eckermann, 2010, p.185). When one practices cultural safety, he/she does not only learn about the other culture. A key idea here is one’s reflection of where he/she comes from. This, therefore, refers to the “exploring, reflecting on, and understanding one’s own culture and [knowing] how it related to other cultures with a view towards promoting partnership, participation and cultural protection” (McMurray & Clendon, 2011, p.332). Cultural safety goes beyond cultural awareness, cultural sensitivity, and cultural competence, however these concepts are considered the first steps towards cultural safety (ANAC, 2009).
Being culturally aware means “others” are the “bearers of culture” and they are “culturally exotic” (p.20). The limitations of the concept also holds true with cultural sensitivity. Both do not translate into action, practitioners are not involved, and health care system is not challenge. In the concept of cultural competence, there is the emphasis of action and developing the skill of being able to communicate with and work with other cultures. However, there is still the limitation of the absence to identify and evaluate conflicts and power relations (p.22). In the nursing profession, culturally safe action means recognizing and nurturing the unique cultural identity and safety. Culturally unsafe actions are those that “diminish, demean or disempower the cultural identity and well-being of a individual” (Polaschek, 1998).
History of healthcare and health structures in Canada
Health care policies and programs. Canada provides basic health services to all its permanent residents, and the government spends for the national health insurance (Quigley et al., 2009). As early as 1974, there were laws that are aimed at attaining positive health outcomes. These documents include the LaLonde Report of 1974 entitled A New Perspective on the Health of Canadians (p.51). This was followed by the Epp Report of 1986 entitled Achieving Health for All: A Framework for Health Promotion. These documents show the changes that were happening in the health frameworks of Canada. The LaLonde report maintained that lifestyle, environment, even how health care services were organized, all influence health outcomes. Meanwhile, in the Epp Report, there was already a recognition of the effects of social conditions on the individual’s health. It was important, therefore, to reduce inequities.
Models of intercultural healthcare. During the 21st century, Canada’s population began to become more diversified. Immigrants from developing nations entered the workforce and became residents of the country. Since everyone was entitled to public healthcare, it was necessary that health personnel reach all members of the population. Failure to give access to everyone, especially those more vulnerable to sickness would have a negative impact on the health of the general population. To attain health targets it was necessary to forcibly treat those with contagious diseases. However, patients have become more aware and assertive of their rights, and health practitioners are faced with the need for strategies that are more culturally appropriate (Douglas, 2013).
The three models of healthcare in Canada are Cultural Sensitivity, Cultural Competency, and Cultural Safety. These three models are implemented for intercultural care in nursing and medicine. The discussion of Douglas (2013) about these models pointed out the advantages and disadvantages of each strategy. She says that cultural safety is the highest of these intercultural strategies. Before one reaches cultural safety, it was important for the health practitioner to have already become culturally-sensitive as well as culturally-competent.
Current issues in Canadian healthcare. Despite the popularity of Canada’s healthcare system, there have been recent studies that identified the issues that it is currently facing. An analysis by the Health Council of Canada by national and international data has shown that despite the government’s huge health spending, the results are not very impressive. Canada, compared to other high-income countries rank almost at the bottom in the aspect of health care services. For example in the length of time that a Canadian has to wait to get elective surgery or in the speed that he/she can access primary health care after office hours. There have also been health inequities identified across the different provinces. Specific statistics are as follows: (a) for primary health care, only 47% of doctors say they are immediately available that day or the next day; (b) for elective surgery, 25% of Canadians waited for at least four months for their schedule (South Asian Post, 2013).
Social structures in nurses’ work. According to Rodney & Varco (2014), reforms in the health care systems have “worsened the conditions of nurses’ work,” (p. 216). Hospitals have to implement mechanisms that are aimed at achieving corporate efficiency. For example, since time is a scarce resources, adult patients are asked to put on diapers so that nurses need not spend additional minutes to accompany them to the toilet.
Practice of cultural safety
Given the current health culture and structures in healthcare, it is still possible to practice culturally safe nursing in Canada because (a) there is a policy on multiculturalism; (b) the number of nursing students from aboriginal groups are increasing; and (c) promotion of cultural safety in organizations.
Policy on multiculturalism. In 2008, the Canadian Multicultural Act was signed into law. Such policy has been declared as early as the 1970s. This policy clearly stipulates that the Government of Canada “recognize the diversity of Canadians as regards race, national or ethnic origin, color and religion as fundamental characteristics” of the society (Preamble). It also states that Canada’s institution “recognizes rights of aboriginal peoples (Preamble). This policy is very important in the government’s succeeding actions to provide for the health needs of its citizens, including the aboriginals.
Increasing number of aboriginal nurses. In the study of Vukic, Jesty, Matthews & Etowa (2012), they found that almost 70 percent aboriginal nurses come from remote communities, and majority of these nurses have decided to go back to their local residences. They prefer to serve the members of their own communities. Another reason was raising their children in rural communities. At present, the number of aboriginal nurses is very small when compared to the dominant population. However, there are existing measures to increase the enrollment of aborigines in nursing. The increase in nurses from indigenous groups will facilitate the understanding about cultural beliefs and traditions. Having them within the system will involve them in the decision-making processes in the health-care field. According to the Aboriginal Nurses Association of Canada (2009), “aboriginal peoples will not access a health care system (and its practitioners) when they do not feel safe doing so—and where encountering the health care system places them at risk for cultural harm” (p.2 ).
Promotion of cultural safety in nursing curriculum. Culture is manifested in all aspects of a persons’ life. Shared experience contribute to the culture. Nursing students receive information during their schooling, at the same time each of them also contribute to the shaping of the nursing culture. One’s own perspectives and worldviews are likewise a result of the culture from where he/she has come from because culture is all-encompassing. Educators from the nursing field has acknowledged the role of culture in the nursing practice. Therefore, it is necessary to include in the nursing curriculum the idea of providing a culturally- safe nursing services. As early as 1996, there have been proposals from the Royal Commission on Aboriginal Peoples for educational institutions to collaborate with aboriginal organizations so that aboriginals who graduate from these institutions would increase. At the same time, there was also the proposal to revise the curriculum to accommodate culturally-appropriate methodologies and ideas (ANAC, 2009). The Aboriginal Nurses Association of Canada has then worked with the Canadian Association of Schools of Nursing, and the Canadian Nurses Association for this purpose. In particular, the aim of these organizations working together was to enhance and “strengthen First Nation, Inuit and Métis health human resources in Canada” (p.4).
Challenges to the practice of cultural safety
Traditions of other cultures. Canada is culturally-diverse society. Its population is comprised of people from different ethnic origins including the Aboriginal Peoples, Europeans, Chinese, South Asians, and Blacks. The variation in race and ethnicity is likewise manifested in the differences in religions and traditional practices. A clear conflict that arises from cultural differences of residents and health practitioners is the practice of female circumcision. In Canada, such practice is a criminal act as it is a case of mutilation. Health practitioners are not allowed to help, assist, or participate in such act. They are likewise required to report such incidents to the authorities. However, for those coming from countries that uphold such practice, this is a manifestation of their cultural beliefs (Douglas, 2013). In incidents such as, there is a clear conflict between cultural beliefs and policy of the national government.
Misunderstanding between cultures. A more common conflict arises from lack of understanding about procedures and practices. Aboriginals may not fully understand the reason for the gathering of specimens or extraction of samples from the patient for laboratory. Hospital staff may not likewise comprehend the indigenous practices of caring for patients. One example discussed by Vukic, et al. (2013) was the case of a Mikmaq patient in the hospital. It was the custom of this indigenous group to have about 50 or more people praying for a dying person. But then, in the hospital, there are policies about number of visitors and the length of visiting hours. In this case, the hospital had to call security to regulate the number of people inside.
Experience of oppression and colonization. A mistrust of the dominant culture is existing in Canadian society. Before colonization, the aboriginals were able to practice their own systems of governance, economy, and systems of healing. When colonizers arrived, the aboriginals indigenous systems were considered primitive and not good enough. Through the Indian Act of the 1920s, the aboriginals were forced to participate in activities that were not in accordance to their traditions (ANAC, 2009). Children were forced to attend school and the inculturation of new ideologues took place. The aboriginals experience of oppression has become integrated into the indigenous groups’ cultural history. Thus, the dominant population is regarded with caution because of this experience. At the other side, those belonging to the dominant population have inculcated views about the aboriginals that may be discriminatory. Sometimes, nurses who work in the rural areas, may not be aware of their own prejudices and biases against the indigenous populations. Thus, there is the need for the reflection process.
Reflecting on one’s own culture. Cultural safety is measured by the recipient of the health care. A Canadian nurse, therefore has to implement health care delivery in such a manner that would not offend the patient’s cultural beliefs. Apart from being sensitive to the culture and being competent, the nurse have to regularly reflect on his/her own beliefs and actions to be able to evaluate if he/she was able to provide nursing care that was culturally safe. The reflection is a very important process, because nurses, especially the ones who belong to the dominant culture have instilled the values and ideologies of that culture. Assessment, evaluation, and reflection are challenging processes as these would make the person acknowledge the conflicts and go beyond these to provide a better, culturally safe, nursing service.
The health care culture and health-care culture in Canada has come a long way. Canada has, for decades, recognized the rights to health of its indigenous populations. In the 1970s, the government has passed the Multiculturalism Act. Cultural safety is an intercultural model that would address cultural rights of patients. It involves not only cultural sensitivity and competence, but entails the practitioners’ own reflection of his/her method of health-care delivery. Canada has a long tradition of providing universal public health care, and to this day, it continues to enhance its health practitioners to provide a culturally safe nursing practice. Given the situation in Canada culturally safe nursing practice is very much possible because of the following reasons. There is an existing policy on multiculturalism. The number of aboriginal nurses is increasing, and the nursing curriculum is slowly integrating the concept of cultural safety. However, there are still challenges to the practice of cultural safety in nursing. These are (a) traditions of other cultures; (b) misunderstanding between cultures; (c) experience of oppression and colonization; and (d) reflecting on one’s own culture.
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