The closure of remote Aboriginal communities: What is the role of nurses in Indigenous disadvantage?

Jeanie Govan

The view expressed by Tony Abbott (Prime Minister and the Minister for Indigenous Affairs), that taxpayers shouldn’t be expected to fund the “lifestyle choices” of Aboriginal people living in remote regions in support of Colin Barnett’s (West Australian Premier) decision to close 150 remote Aboriginal communities in Western Australia reflects the repetition of the colonial project and Aboriginal dispossession. One of the mythologies of a white settler society is that white people are the first to arrive and develop the land, with colonisation a benign force (rather than one enacted through the processes of conquest and genocide and displacing the indigenous (Razack, 2002)). Closing the community draws attention away from governmental failures to ‘Close the Gap’ and instead displaces the blame on the supposed inadequacies and problems of Aboriginal communities (Amy McQuire) thereby individualising socio-political inequalities rather than revealing them as historic and structural. The paternalism of closing the communities “for their own good” and for the common good, appears benign but hides the brutality of forced removal and in doing so denies the significance of indigeneity as Mick Dodson notes:

It is not a “lifestyle choice” to be be born in and live in a remote Aboriginal community. It is more a decision to value connection to country, to look after family, to foster language and celebrate our culture. There are significant social, environmental and cultural benefits for the entire nation that flow from those decisions.

 

Hamilton action

The protests against this cruel action have resounded around the world and have resonated in Aotearoa where I have lived for most of my life although I now live in the lands of the Kulin Nations in Gippsland as a migrant. As a nurse educator and researcher I am shaped by colonialism’s continuing effects in the white settler nation of Australia.

Nurses have often played an important part in social justice. Recently nursing professional bodies made a stand against violent state practices with the Australian College of Nursing (ACN) and Maternal Child and Family Health Nurses Australia (MCaFHNA) supporting The Forgotten Children report by the Australian Human Rights Commission against detaining children in immigration detention centres. Others like Chris Wilson wrote in Crikey  about the many limitations of the Northern Territory Intervention:

I am saddened that the intervention has wasted so many resources, given so little support or recognition to the workers on the ground, paid so little attention to years of reports and above all involved absolutely no consultation with anyone, especially community members. The insidious effect of highlighting child abuse over all the other known problems in Aboriginal health is destructive to male health, mental health and community health, is unfounded in fact and is based in the inherent ignorance of this racist approach.

It has made me think about how nurses and midwives don’t often problematise our locations and consider our responsibilities within a social context of the discursive and material legacies of colonialism, neoliberalism, austerity and ‘othering’ (of Muslims, of refugees of Indigenous people) and “the ways in which we are complicitous in the subordination of others” (Razack, 1998, p.159). As Razack notes, groups that see themselves as apolitical must call into question their roles as “innocent subjects, standing outside of hierarchical social relations, who are not accountable for the past or implicated in the future” (Razack, 1998, p.10).

Colonisation and racism have been unkind to Indigenous people (term often used to refer to both Aboriginal and Torres Strait Islander peoples) with the health status of Indigenous people often compared to that of a developing country as I have pointed out elsewhere. The Overcoming Indigenous Disadvantage 2014 report measures the wellbeing of Australia’s Indigenous peoples. Briefly, Indigenous people:

  • Experience social and health inequalities (Australian Institute of Health and Welfare, 2004).
  • Are over represented and experience a higher burden of disease and higher mortality at younger ages than non-Indigenous Australians (Australian Institute of Health and Welfare, 2012b).

So, the question for me as a researcher and educator are what responsibility do nurses and the discipline of nursing have to Aboriginal health?

1) Recognise colonisation as a determinant of health

Indigenous people enjoyed better health in 1788 than people in Europe, they had autonomy over their lives, (ceremonies, spiritual practices, medicine, social relationships, management of land, law, and economic activities), but also didn’t suffer from illnesses that were endemic in18th century Europe. They didn’t have smallpox, measles, influenza, tuberculosis, scarlet fever, venereal syphilis and gonorrhoea. However, they were known to have suffered from; hepatitis B; some bacterial infections; some intestinal parasites; trauma; anaemia; arthritis; periodontal disease; and tooth attrition.

What’s often difficult for many nurses and students to imagine is that the past could have anything to do with the present, however, research in other settler colonial societies shows a clear relationship between social disadvantages experienced by Indigenous people and current health status. Colonisation and the spread of non-Indigenous peoples saw the introduction of illness (eg smallpox); the devaluing of culture; the destruction of traditional food base; separation from families; dispossession of whole communities. Furthermore, the ensuing loss of autonomy undermined social vitality, reduced resilience and created dispossession, demoralisation and poor health.

The negative impacts of colonisation on Indigenous led colonial authorities to try to ‘protect’ remaining Indigenous peoples, which saw the establishment of Aboriginal ‘protection’ boards (the first established in Victoria by the Aboriginal Protection Act of 18690. However, ‘protection’ imposed enormous restrictions eg living in settlements; forced separation of Indigenous children from their families. With between one-in-three and one-in-ten Indigenous children forcibly removed from their families and communities from 1910 until 1970. The result was irrevocable harm as one of the Stolen Generations stated:

We may go home, but we cannot relive our childhoods. We may reunite with our mothers, fathers, sisters, brothers, aunties, uncles, communities, but we cannot relive the 20, 30, 40 years that we spent without their love and care, and they cannot undo the grief and mourning they felt when we were separated from them

 

For the pain, suffering and hurt of these Stolen Generations, their descendants and for their families left behind, we say sorry. To the mothers and the fathers, the brothers and the sisters, for the breaking up of families and communities, we say sorry. And for the indignity and degradation thus inflicted on a proud people and a proud culture, we say sorry.

Also watch Babakiueria which uses role reversal to satirise and critique Australia’s treatment of its Indigenous peoples. Aboriginal actors play the colonisers, while white actors play the indigenous Babakiuerians.

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2) Recognise continuing colonial practices

This blog started with the news of the closures of 150 remote Aboriginal communities in WA. Only one example of continuing colonial practices. Mick Dodson suggests that the closure of the 150 WA communities reflects an inability of the descendants of settlers to:

negotiate in a considered way the right of Aboriginal people to live as Aboriginal peoples in our own lands and seas, while also participating in every aspect of life  as contemporary Australian citizens.

 

You can also read about proposed alternatives to the closure by Rebecca Mitchell.

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3) Develop an understanding of racism as a determinant of health

Racism (racial discrimination) is linked with colonisation and oppression and is a social determinant of health. Nancy Krieger (2001) defines it as a process by which members of a socially defined racial group are treated unfairly because of membership of that group. Too often racism is seen as individual actions rather than as structural and embedded as this video shows. We know that racism damages health and in the health sector health systems and service providers can perpetuate Aboriginal health care disparities through attitudes and practices (Durey).

Anti-racist scholars suggest that there are three levels of racism in health.

  1. Institutional: Practices, policies or processes experienced in everyday life which maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups (also called systemic racism);
  2. Interpersonal, in interactions between individuals either within their institutional roles or as private individuals;
  3. Internalised, where an individual internalises attitudes, beliefs or ideologies about the inferiority of their own group.

Krieger and others have written extensively about how racism affects health. People who experience racism experience the following:

  • Inequitable and reduced access to the resources required for health;
  • Inequitable exposure to risk factors associated with ill-health;
  • Stress and negative emotional/cognitive reactions which have negative impacts on mental health as well as affecting the immune, endocrine, cardiovascular and other physiological systems;
  • Engagement in unhealthy activities and disengagement from healthy activities

1 in 3 Aboriginal Victorians experienced racism in a health care setting according to a VicHealth survey. The respondents reported:

  • Poorer health status;
  • Lower perceived quality of care;
  • Under-utilisation of health services;
  • Delays in seeking care;
  • Failure to follow recommendations;
  • Societal distrust;
  • interruptions in care;
  • Mistrust of providers;
  • Avoidance of health care systems.

This video on understanding the impact of racism on Indigenous child health by Dr Naomi Priest is well worth a look.

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4) Develop a collective understanding of health and the importance of cultural determinants of health

Health is defined in the National Aboriginal Health Strategy (1989) as:

Not just the physical well-being of the individual but the social, emotional and cultural well-being of the whole community. This is a whole of life view and it also includes the cyclical concept of life-death-life

It is important that in considering the issues of colonisation, racism and inter-generational trauma that the diverse cultures and histories of indigenous people are not viewed through a deficit lens. So often mainstream media reinforce the myth that responsibility for poor health (whether it’s about people who drink, are obese or smoke) is an individual and group one rather than linked with social determinants including colonisation, economic restructuring or the devastating social consequences of state neoliberal policies. As Professor Ngiare Brown notes, there are significant cultural determinants of health which should be supported including:

  • Self-determination; Freedom from discrimination;
  • Individual and collective rights;
  • Freedom from assimilation and destruction of culture;
  • Protection from removal/relocation;
  • Connection to, custodianship, and utilisation of country and traditional lands;
  • Reclamation, revitalisation, preservation and promotion of language and cultural practices;
  • Protection and promotion of Traditional Knowledge and Indigenous Intellectual Property; and
  • Understanding of lore, law and traditional roles and responsibilities.

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5) Develop an understanding of the organisations, policies, levers and strategies that are available to support Indigenous wellbeing

  • Aboriginal Community Controlled Health Services (ACCHSs), which are primary health care services operated by local Aboriginal communities to deliver holistic, comprehensive, and culturally appropriate health care. There are over 150 ACCHSs in urban, regional and remote Australia.
  • Close the gap campaign targets (also see a recent blogpost) developed by a consortium of 40 of Australia’s leading Indigenous and non-Indigenous health peak bodies and human rights organisations, which calls on Australian governments to commit to achieving Indigenous health equality within 25 years.
  • 2007 United Nations Declaration on the Rights of Indigenous Peoples, Article 24 of which points out that Indigenous people have the right “to access, without any discrimination, [to] all social and health services” and “have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively full realisation of this right”.
  • Become familiar with the National Aboriginal and Torres Strait Islander Health Plan 2013-2023.
  • Support the WHO Closing the gap in a generation, which recommends three actions for improving the world’s health:
  1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.
  2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.
  3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

In recognising the linkages and operational relationships that exist between health and human rights, the nursing profession respects the human rights of Australia’s Aboriginal and Torres Strait Islander peoples as the traditional owners of this land, who have ownership of and live a distinct and viable culture that shapes their world view and influences their daily decision making. Nurses recognise that the process of reconciliation between Aboriginal and Torres Strait Islander and non-indigenous Australians is rightly shared and owned across the Australian community. For Aboriginal and Torres Strait Islander people, while physical, emotional, spiritual and cultural wellbeing are distinct, they also form the expected whole of the Aboriginal and Torres Strait Islander model of care

 

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6) Becoming a critical, reflexive, knowledgeable nurse who legitimates the  cultural rights, values and expectations of Aboriginal people

More than ever, social justice provides a valuable lens for nursing practice (see Sir Michael Marmot’s speech). Cultural competence and safety directly reduce health disparities experienced by Indigenous Australians (Lee et al., 2006; Durey, 2010). It makes sense that the safer the health care system and its workers are, the more likely Indigenous people are to engage and use the services available. Early engagement in the health care system results in early health intervention strategies, prevention of illness and improved overall health outcomes for Indigenous Australians. The key features of cultural competence identified in the Cultural diversity plan for Victoria’s specialist mental health services 2006-2010 are:

  • Respectful and non-judgemental curiosity about other cultures, and the ability to seek cultural knowledge in an appropriate way;
  • Tolerance of ambiguity and ability to handle the stress of ambiguous situations;
  • Readiness to adapt behaviours and communicative conventions for intercultural communication.

Nurses have a role in improving health outcomes, but this requires an understanding of the reasons why there are higher morbidity and mortality rates in Indigenous populations than in the general population. It requires that nurses engage in reflection and interrogate the existing social order and how it reproduces discriminatory practices in structural systems such as health care, in institutions and in health professionals (Durey, 2010). It’s important that as nurses we focus on our own behaviour, practice and skills both as professionals and individuals working in the health system.

I think this statement about Cultural security from the Department of Health, Western Australian Health (2003) Aboriginal Cultural Security: A background paper, page 10. is a valuable philosophy of practice:

Commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people. It is a recognition, appreciation and response to the impact of cultural diversity on the utilisation and provision of effective clinical care, public health and health system administration

To conclude, I leave the last words to Professor Ngiare Brown:

We represent the oldest continuous culture in the world, we are also diverse and have managed to persevere despite the odds because of our adaptability, our survival skills and because we represent an evolving cultural spectrum inclusive of traditional and contemporary practices. At our best, we bring our traditional principles and practices – respect, generosity, collective benefit, collective ownership- to our daily expression of our identity and culture in a contemporary context. When we are empowered to do this, and where systems facilitate this reclamation, protection and promotion, we are healthy, well and successful and our communities thrive.

 

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References

Universities of Australia. (2011). National best practice framework for indigenous cultural competency in Australian Universities.
Awofeso, N. (2011). Racism: A major impediment to optimal indigenous health and health care in Australia. Australian Indigenous Health Bulletin, 11(3), 1-8.
Best, O., & Stuart, L. (2014). An Aboriginal nurse-led working model for success in graduating indigenous Australian nurses. Contemporary Nurse, 4082-4101.
Chapman, R., Smith, T., & Martin, C. (2014). Qualitative exploration of the perceived barriers and enablers to Aboriginal and Torres Strait Islander people accessing healthcare through one victorian emergency department. Contemporary Nurse.
Christou, A., & Thompson, S. C. (2012). Colorectal cancer screening knowledge, attitudes and behavioural intention among indigenous western Australians. BMC Public Health, 12, 528. doi:10.1186/1471-2458-12-528
Downing, R., & Kowal, E. (2010). Putting indigenous cultural training into nursing practice. Contemporary Nurse, 37(1), 10-20. doi:10.5172/conu.2011.37.1.010
Durey, A. (2010). Reducing racism in Aboriginal health care in Australia: Where does cultural education fit? Australian and New Zealand Journal of Public Health, 34 Suppl 1, S87-92. doi:10.1111/j.1753-6405.2010.00560.x
Durey, A., Lin, I., & Thompson, D. (2013). It’s a different world out there: Improving how academics prepare health science students for rural and indigenous practice in Australia. Higher Education Research & Development, 32(5), 722-733.
Haynes, E., Taylor, K. P., Durey, A., Bessarab, D., & Thompson, S. C. (2014). Examining the potential contribution of social theory to developing and supporting Australian indigenous-mainstream health service partnerships. International Journal for Equity in Health, 13(1), 75. doi:10.1186/s12939-014-0075-5
Herk, K. A. V., Smith, D., & Andrew, C. (2014). Identity matters: Aboriginal mothers’ experiences of accessing health care. Contemporary Nurse. doi:10.5172/conu.2011.37.1.057
Hunt, L., Ramjan, L., McDonald, G., Koch, J., Baird, D., & Salamonson, Y. (2015). Nursing students’ perspectives of the health and healthcare issues of Australian indigenous people. Nurse Education Today, 35(3), 461-7. doi:10.1016/j.nedt.2014.11.019
Kelly, J., West, R., Gamble, J., Sidebotham, M., Carson, V., & Duffy, E. (2014). ‘She knows how we feel’: Australian Aboriginal and Torres Strait Islander childbearing women’s experience of continuity of care with an Australian Aboriginal and Torres Strait Islander midwifery student. Women and Birth : Journal of the Australian College of Midwives, 27(3), 157-62. doi:10.1016/j.wombi.2014.06.002
Kildea, S., Kruske, S., Barclay, L., & Tracy, S. (2010). Closing the gap: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health, 10(1383), 9-12.
Kowal, E. (2008). The politics of the gap: Indigenous Australians, liberal multiculturalism, and the end of the self-determination era. American Anthropologist, 110(3), 338-348.
Larson, A., Gillies, M., Howard, P. J., & Coffin, J. (2007). It’s enough to make you sick: The impact of racism on the health of Aboriginal Australians. Australian and New Zealand Journal of Public Health, 31(4), 322-329.
Liaw, S. T., Lau, P., Pyett, P., Furler, J., Burchill, M., Rowley, K., & Kelaher, M. (2011). Successful chronic disease care for Aboriginal Australians requires cultural competence. Australian and New Zealand Journal of Public Health, 35(3), 238-48. doi:10.1111/j.1753-6405.2011.00701.x
Nash, R., Meiklejohn, B., & Sacre, S. (2006). The Yapunyah project: Embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum. Contemporary Nurse, 22(2), 296-316. doi:10.5172/conu.2006.22.2.296
Nielsen, A. M., Stuart, L. A., & Gorman, D. (2014). Confronting the cultural challenge of the whiteness of nursing: Aboriginal registered nurses’ perspectives. Contemporary Nurse, 48(2), 190-6. doi:10.5172/conu.2014.48.2.190
Paradies, Y. (2005). Anti-Racism and indigenous Australians. Analyses of Social Issues and Public Policy, 5(1), 1-28.
Paradies, Y., & Cunningham, J. (2009). Experiences of racism among urban indigenous Australians: Findings from the DRUID study. Ethnic and Racial Studies, 32(3), 548-573. doi:10.1080/01419870802065234
Paradies, Y., Harris, R., & Anderson, I. (2008). The impact of racism on indigenous health in Australia and aotearoa: Towards a research agenda. Cooperative Research Centre for Aboriginal Health Darwin.
Pedersen, A., Beven, J., Walker, I., & Griffiths, B. (2004). Attitudes toward indigenous Australians: The role of empathy and guilt. Journal of Community & Applied Social Psychology, 14(4), 233-249. doi:10.1002/casp.771
Pedersen, A., Dudgeon, P., Watt, S., & Griffiths, B. (2006). Attitudes toward indigenous Australians: The issue of special treatment. Australian Psychologist, 41(2), 85-94. Pijl-Zieber, E. M., & Hagen, B. (2011). Towards culturally relevant nursing education for Aboriginal students. Nurse Education Today, 31(6), 595-600. doi:10.1016/j.nedt.2010.10.014Prior, D. (2009). The meaning of cancer for Australian Aboriginal women; changing the focus of cancer nursing. European Journal of Oncology Nursing : The Official Journal of European Oncology Nursing Society, 13(4), 280-6. doi:10.1016/j.ejon.2009.02.005
Rigby, W., Duffy, E., Manners, J., Latham, H., Lyons, L., Crawford, L., & Eldridge, R. (2010). Closing the gap: Cultural safety in indigenous health education. Contemporary Nurse, 37(1), 21-30. doi:10.5172/conu.2011.37.1.021
Rix, E. F., Barclay, L., Wilson, S., & Barclay, E. R. L. (2014). Can a white nurse get it?‘Reflexive practice’and the non-indigenous clinician/researcher working with Aboriginal people. Rural Remote Health, 4, 2679.
Stuart, L., & Nielsen, A. -M. (2014). Two Aboriginal registered nurses show us why black nurses caring for black patients is good medicine. Contemporary Nurse. doi:10.5172/conu.2011.37.1.096
Szoke, H. (2012). National anti-racism strategy. Australian Human Rights Commission.
Thackrah, R. D., & Thompson, S. C. (2014). Confronting uncomfortable truths: Receptivity and resistance to Aboriginal content in midwifery education. Contemporary Nurse. doi:10.5172/conu.2013.46.1.113
Thackrah, R. D., Thompson, S. C., & Durey, A. (2014). “Listening to the silence quietly”: Investigating the value of cultural immersion and remote experiential learning in preparing midwifery students for clinical practice. BMC Research Notes, 7, 685. doi:10.1186/1756-0500-7-685
Williamson, M., & Harrison, L. (2010). Providing culturally appropriate care: A literature review. International Journal of Nursing Studies, 47(6), 761-9. doi:10.1016/j.ijnurstu.2009.12.012
Ziersch, A. M., Gallaher, G., Baum, F., & Bentley, M. (2011a). Responding to racism: Insights on how racism can damage health from an urban study of Australian Aboriginal people. Social Science & Medicine (1982), 73(7), 1045-53. doi:10.1016/j.socscimed.2011.06.058

“Kiwi food is okay for Kiwis, but it isn’t okay for us”: Special food in the perinatal period for migrant mothers

I attended the 5th International Conference on Nutrition and Nurture in Infancy and Childhood: Relational, Bio-cultural and Spatial Perspectives from Wednesday, 5 November 2014 – Friday, 7 November 2014.

Those who know me or follow my work will know that I am deeply interested in eating and thinking about food. I’m interested in how food structures our days and our lives,it nourishes and sustains us, reminds us of people, events, history, all in a mouthful.

Birthday cake
A special birthday cake, made for a surfer on his special birthday.

I’ve written elsewhere about how migrants perform identity through food preparation and consumption. I’ve also written about consumptive multiculturalism. I’m also interested in the provision of food in (monocultural) institutional contexts such as health where people are racialised by the foods that they eat and how the processes of hospitalisation strip people of their cultural and social identities and often lead people into being unable to access culturally appropriate food. This presentation brings those ideas together.

Abstract

Food, its preparation and ingestion, constitutes a source of physical, emotional, spiritual and cultural nourishment. Food structures both daily life and major life transitions, including the transition to parenthood, where food is prepared and consumed that recognises the unique status of the mother. However, the reductive focus of hospitals where efficiency, economy and a focus on nutrients dominate and where birth is viewed as a normal event can mean that there is a mismatch between the cultural and religious dietary needs of migrant mothers with the food that is available from Western instititutional environments. In this paper I outline a research study, which examined the transition to parenthood among new migrant groups in New Zealand. Based on a number of focus groups with mothers and fathers, the data were analysed using a postcolonial feminist lens and drew upon Foucauldian concepts to examine the transition to parenthood. The findings show that Asian new migrant parents construct the postnatal body as vulnerable, requiring specific kinds of foods to facilitate recovery from the trials of pregnancy and delivery and optimize long term recovery from pregnancy. This discourse of risk contrasts with the dominant discourse of birth as normal, and signals the limitations of a universal diet for all postnatal mothers, where consuming the wrong food can pose a threat to good maternal health. Paying attention to what nutrition and nurturing might mean for different cultural groups during the perinatal period can contribute to long term maternal well-being and cultural safety. Health practitioners need to understand the meanings and significance attached to specific foods and eating practices in the perinatal period. I propose that institutional arrangements become responsive to dietary needs and practices by providing facilities and resources to facilitate food preparation.

I’m hoping that the written form of the paper becomes part of an edited book about mothers and food. Fingers crossed, it’s under review at the moment.

Nursing in media-saturated societies: implications for cultural safety in nursing practice

Nairn, DeSouza, Moewaka Barnes, Rankine,  Borell, and McCreanor (2014). Nursing in media-saturated societies: implications for cultural safety in nursing practice in Aotearoa New Zealand. Journal of Research in Nursing September  19: 477-487,doi:10.1177/1744987114546724

Great to be published in the Journal of Research in Nursing September 2014 issue on ‘Race’, Ethnicity and Nursing, Edited by: Lorraine Culley. I had the pleasure of being included in a previous issue in 2007, so it’s great to be in this one.

Abstract

This educational piece seeks to apprise nurses and other health professionals of mass media news practices that distort social and health policy development. It focuses on two media discourses evident in White settler societies, primarily Australia, Canada, New Zealand and the United States, drawing out implications of these media practices for those committed to social justice and health equity. The first discourse masks the dominant culture, ensuring it is not readily recognised as a culture, naturalising the dominant values, practices and institutions, and rendering their cultural foundations invisible. The second discourse represents indigenous peoples and minority ethnic groups as ‘raced’ – portrayed in ways that marginalise their culture and disparage them as peoples. Grounded in media research from different societies, the paper focuses on the implications for New Zealand nurses and their ability to practise in a culturally safe manner as an exemplary case. It is imperative that these findings are elaborated for New Zealand and that nurses and other health professionals extend the work in relation to practice in their own society.

One of my favourite pieces of the article proposes some ways in which nurses can engage in critical assessment of mass media, by asking questions like:

  • From whose point of view is this story told?
  • Who is present?
  • How are they named and/or described?
  • Who, of those present, is allowed to give their interpretation of the matter?
  • Who is absent?
  • Whose interests are served by telling the story this way?

One of the things that I love about this journal is that they ask for commentaries from a reviewer. My former colleague Denise Wilson (Professor, Māori Health Taupua Waiora Centre for Māori Health Research/School of Public Health & Psychosocial Studies, National Institute of Public Health and Mental Health Research, Auckland University of Technology, New Zealand), has reviewed our paper and says:

I would urge nurses to read this paper and reflect on how the media influences their own practice and engagement with minority and marginalised groups. Media portrayals of minority groups often reflect negatively geared dominant cultural sentiments, becoming ‘accepted’ fact within our communities. Nurses need to be aware that their efforts to be culturally safe in their practice can be undermined by the normalisation and acceptance of what is portrayed in the media. Therefore, nurses are encouraged by the authors to come together and question the ‘taken-for-granted’ dominant cultural media portrayals to create a stronger platform for culturally safe practice.

Mind the gap: Cultural safety in Australia

In August 2014 there was a wonderful story of how “people power” had freed a man in Perth, whose leg had become caught in the gap between a platform and train on his morning commute. You can watch the video here. What struck me about this story was that people taking part in their “regular” commute noticed something out of the ordinary and used their combined energy to free the man. Someone alerted the driver to make sure that the train didn’t move, staff then asked passengers to help and in tandem they rocked the train backwards from the platform so it tilted and his leg could be freed. It made me think about the gaps people are stuck in, that exist all around us, that have become so routine, that we are habituated to, and fail to notice.

One of the biggest gaps is in the health outcomes between Indigenous and non-indigenous people in settler nations. Oxfam notes that Australia equals Nepal for the world’s greatest life expectancy gap between Indigenous and non-Indigenous people. This is despite Australians enjoying one of the highest life expectancies of any country in the world. Indigenous Australians (who numbered 669,900 people in 2011, ie 3% of the total population) live 10-17 years less than other Australians. In the 35–44 age group, Indigenous people die at about 5 times the rate of non-Indigenous people. Babies born to Aboriginal mothers die at more than twice the rate of other Australian babies, and Aboriginal and Torres Strait Islander people experience higher rates of preventable illness such as heart disease, kidney disease and diabetes.

One of the most galvanising visions for addressing the health and social disparities between Indigenous and non-indigenous people is  The Close the Gap campaign aiming to close the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians within a generation. By 2030 any Aboriginal or Torres Strait Islander child born in Australia will have the same opportunity as other Australian children to live a long, healthy and happy life.

Mind the gap

 

Nurses play an important role in creating a more equitable society and have  been forerunners in the field of cultural safety and competence. For the gap to close, nurses need an understanding of health that includes social, economic, environmental and historical relations. Cultural safety from Aotearoa New Zealand has been an invaluable tool for me as nurse for analysing this set of relations. However, as a newcomer to Australia, I have a lot to learn about what cultural competency means here and how I fulfil my responsibilities as a nurse educator to Aboriginal and Torres Strait Islander peoples. To that end, this blog piece focuses on some of the frameworks in nursing that might enable nurses to close the gap. I am particularly interested in frameworks that enable nurses to widen the lens of care beyond the individual and consider service users in the context of their families and communities and broader social and structural inequities. I’m also interested in policy frameworks that can support practice.

Gosford Anglican church

A social determinants of health approach takes into account “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics” (WHO, 2010). A health equity lens has also been invaluable to my own practice, it refers to the absence of systematic disparities in health (or in the major social determinants of health) between groups with different social advantage/disadvantage. Social inequalities refer to “relatively long-lasting differences among individuals or groups of people that have implications for individual lives” (McMullin, 2010, p.7). While an inequity, refers to an unjust distribution of resources and services. “equity means social justice” (see, Braverman 2003). The term “social and structural inequities,” refers to unfair and avoidable ways in which members of different groups in society are treated and/or their ability to access services.

Equality justice

Principle Four of the New Zealand Nursing Council: Guidelines for Cultural safety in Nursing and Midwifery Education (2011) pay great attention to the issue of power:

PRINCIPLE FOUR Cultural safety has a close focus on:

 

4.1 understanding the impact of the nurse as a bearer of his/her own culture, history, attitudes and life experiences and the response other people make to these factors

4.2 challenging nurses to examine their practice carefully, recognising the power relationship in nursing is biased toward the provider of the health and disability service

4.3 balancing the power relationships in the practice of nursing so that every consumer receives an effective service

4.4 preparing nurses to resolve any tension between the cultures of nursing and the people using the services

4.5 understanding that such power imbalances can be examined, negotiated and changed to provide equitable, effective, efficient and acceptable service delivery, which minimises risk to people who might otherwise be alienated from the service.

The Australian Code of Ethics for nurses and midwives in Australia also pays attention to the role of nurses in having a moral responsibility to protect and safe guard human rights as means to improving health outcomes and having concern for the structural and historical:

The nursing profession recognises the universal human rights of people and the moral responsibility to safeguard the inherent dignity and equal worth of everyone. This includes recognising, respecting and, where possible, protecting the wide range of civil, cultural, economic, political and social rights that apply to all human beings.

 

The nursing profession acknowledges and accepts the critical relationship between health and human rights and ‘the powerful contribution that human rights can make in improving health outcomes’. Accordingly, the profession recognises that accepting the principles and standards of human rights in health care domains involves recognising, respecting, actively promoting and safeguarding the right of all people to the highest attainable standard of health as a fundamental human right, and that ‘violations or lack of attention to human rights can have serious health consequences’.

 

In recognising the linkages and operational relationships that exist between health and human rights, the nursing profession respects the human rights of Australia’s Aboriginal and Torres Strait Islander peoples as the traditional owners of this land, who have ownership of and live a distinct and viable culture that shapes their world view and influences their daily decision making. Nurses recognise that the process of reconciliation between Aboriginal and Torres Strait Islander and non-indigenous Australians is rightly shared and owned across the Australian community. For Aboriginal and Torres Strait Islander people, while physical, emotional, spiritual and cultural wellbeing are distinct, they also form the expected whole of the Aboriginal and Torres Strait Islander model of care.

The Code stops short of using words like colonisation and racism, but the National Aboriginal Community Controlled Health Organisation background paper “Creating the Cultural Safety Training Standards and Assessment Paper” (2011, p. 9) points out that awareness and sensitivity training, result in individuals becoming more aware of cultural, social and historical factors and engaging in self-reflection however if there isn’t an institutional response and the responsibilities for institutional racism remain individualised:

Even if racism is named, the focus is on individual acts of racial prejudice and racial discrimination. While historic overviews may be provided, the focus is again on the individual impact of colonization in this country, rather than the inherent embedding of colonizing practices in contemporary health and human service institutions

The focus is on the individual and personal, rather than the historical and institutional nature of such individual and personal contexts.

Cultural Respect
The concept of cultural respect (Aboriginal Cultural Security: Background Paper, Health Department of Western Australia) comes the closest to embedding the health care system with policies and practices to help improve the health care outcomes of Aboriginal and Torres Strait Islander peoples. Having a cultural respect framework means that there is an acknowledgement that:

the health and cultural wellbeing of Aboriginal and Torres Strait Islander peoples within mainstream health care settings warrant special attention.   Cultural Respect is the:  recognition, protection and continual advancement of the inherent rights, cultures and tradition of Aboriginal and Torres Strait Islander Peoples. ….   [it] is about shared respect ….[and] is achieved when the health system is a safe environment for Aboriginal and Torres Strait Islander peoples and where cultural differences are respected. It is commitment to the principle that the construct and provision of services offered by the Australian health care system will not compromise the legitimate cultural rights, values and expectations of Aboriginal and Torres Strait Islander peoples. The goal is to uphold the rights of Aboriginal and Torres Strait Islander peoples to maintain, protect and develop their culture and achieve equitable health outcomes.

The framework includes the following dimensions:
Knowledge and awareness, where the focus is on understandings and awareness of  history, experience, cultures and rights of Aboriginal and Torres Strait Islander peoples.
A focus on changed behaviour and practice to that which is culturally appropriate. Education and training and robust performance management processes are strategies to encourage good practice and culturally appropriate behavior.
Strong relationships between Aboriginal and Torres Strait Islander peoples and communities, and the health agencies providing services to them. Here the focus is on the business practices of the organization to ensure they uphold and secure the cultural rights of Aboriginal and Torres Strait Islander peoples.
Equity of outcomes for individuals and communities. Strategies include ensuring feedback on relevant key performance indicators and targets at all levels.
What I like about this framework is that it goes beyond attitudes and knowledge-based to also demand changed behaviour and action that leads to culturally safe healthcare for Aboriginal and Torres Strait Islander peoples. Central to cultural respect is the need for organisations to engage with and seek advice from local Aboriginal or Torres Strait Islander communities.
Cultural Security
Another new term is the notion of cultural security (developed by the Department of Health, Western Australian Health, 2003, Aboriginal Cultural Security: A background paper, page 10) which focuses on behavior: the practice, skills and behaviour of both professionals as individuals and the health system:

commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people. It is a recognition, appreciation and response to the impact of cultural diversity on the utilisation and provision of effective clinical care, public health and health system administration

Cultural Responsiveness
Defined by the Victorian Health Department as: The capacity to respond to the healthcare issues of diverse communities. This term broadly considers diversity rather than the unique needs of Aboriginal and Torres Strait Islander peoples which are a consequence of colonialism and racism.
Cultural Competence

The term ‘Cultural competence’ originates from Transcultural Nursing developed by Madeleine Leininger. Borrowing from anthropology, the aim was to develop a model that encouraged nurses to study and understand cultures other than their own. You can read my paper on the complementariness of cultural safety and competence here. Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand. Betancourt, et al., 2002, p. v define it as:

the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs

The Australian National Health and Medical Research Council (NHMRC)’s  Cultural Competency in Health: A guide for policy, partnerships and participation supports the notion of the capacity of the health system to improve health and wellbeing by integrating culture into the delivery of health services, but the scope of the document does not extend to cultural competency as applied to Aboriginal and Torres Strait Islander health care.
Government interventions to address health inequities are being deployed in tandem with neoliberalism and economic globalisation, which push back responsibility to individuals. Now, more than ever, attention needs to be paid to power relations and structures that contribute to inequality in society and injustice within nursing, using approaches that consider equity and the social determinants of health. I personally am looking forward to the day when we don’t need this sign, because there isn’t a gap.
Mind-the-Gap
What you can do:
Support the Close the Gap campaign
Dr Tom Calma’s (Aboriginal and Torres Strait Islander Commissioner )  Social Justice Report 2005 instigated a human rights-based approach Campaign to close the gap in life expectancy between Indigenous and non-Indigenous Australians (up to 17 years less than other Australians at the time). This report called on all Australian governments to commit to achieving equality of health status and life expectancy within a generation (by 2030).
A coalition drawn from Indigenous and non-Indigenous health and human rights organisations formed the Close the Gap Campaign, which was launched in April 2007 by Catherine Freeman and Ian Thorpe, the Campaign’s Patrons.  The CTG Campaign is currently Co-Chaired by the Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda and Co- Chair of the National Congress of Australia’s First Peoples, Kirstie Parker. The Campaign Steering Committee is comprised of 32 health and human rights organisations. The members of the Campaign Steering Committee have worked collaboratively for approximately nine years to address Aboriginal and Torres Strait Islander health inequality through two primary mechanisms: attempting to gain public support of the issue and demanding government action to address it.
Some useful videos
Aboriginal and Torres Strait Islander health videos:
http://blogs.crikey.com.au/croakey/2013/08/04/youtube-an-excellent-resource-for-aboriginal-and-torres-strait-islander-health/Cultural competence video:
https://www.youtube.com/watch?v=JpzLzgeL2sADr Tom Calma – Cultural Competency
https://www.youtube.com/watch?v=tnYuTY0fn3s
White privilege: Unpacking the invisible knapsack
http://amptoons.com/blog/files/mcintosh.htmlWhat kind of Asian are you?
https://www.youtube.com/watch?v=DWynJkN5HbQReverse racism, Aamer Rahman:
https://www.youtube.com/watch?v=dw_mRaIHb-M
Terminology
Aboriginal and Torres Strait Islander peoples are the first inhabitants of Australia.  Aboriginal people are extremely heterogenous groups differing in language and tradition. Torres Strait Islander peoples come from the islands of the Torres Strait, between the tip of Cape York in Queensland and Papua New Guinea but who may live on mainland Australia. The term ‘Indigenous’ is often used to refer to both Aboriginal and Torres Strait Islander peoples. In the spirit of being both relational and political then I’d like to share with you my learning about cultural competency and Aboriginal and Torres Strait Islander health care.

‘This child is a planned baby’: skilled migrant fathers and reproductive decision-making

Article first published online: 13 MAY 2014  De Souza, Ruth Noreen Argie. (2014). ‘This child is a planned baby’: skilled migrant fathers and reproductive decision-making. Journal of Advanced Nursing. doi: 10.1111/jan.12448

Risk management and life planning are a feature of contemporary parenting, which enable children to be shaped into responsible citizens, who are successful and do not unduly burden the state (Shirani et al. 2012). This neoliberal project of intensive parenting and parental responsibility (typically gendered as maternal) involves child centredness and detailed knowledge of child development (Hays 1998). Simultaneously, contemporary masculinities are increasingly being situated beyond the traditional Western binary of the active home-caring mother and passive breadwinning father. Following Connell (1995), the plural word masculinities refers to the many definitions and practices of masculinity (See e.g. Archer 2001, Cleaver 2002, Finn & Henwood 2009, Haggis & Schech 2009, Walsh 2011). Broader and more inclusive repertoires of fathering emerge from diverse family practices and formations including queer/homoparental families; cohabitation; new technologies; changing domestic labour arrangements; the changing organization of childcare and growing involvement of fathers; and social policy initiatives including parental leave and family-friendly employment practices (Draper 2003).

These rapid societal changes have ushered in new forms of participatory fathering and family involvement for men in the Western world. However, the pressure to integrate traditional breadwinner and authority figure roles with contemporary demands for involvement in all aspects of the perinatal period has not been matched by reduced work pressures or the provision of active societal support and preparation (Barclay & Lupton 1999). As a result, men often feel isolated, excluded, uninformed and unable to obtain resources and support in the perinatal period placing pressure on relationships, challenging feelings of competence and requiring negotiation of competing demands (Deave & Johnson 2008). Furthermore, men have gender- specific risk factors for perinatal distress including their more limited support networks; dependence on partners for support; additional exposure to financial and work stresses; a more idealized view of pregnancy, childbirth and parent- hood stemming from a lack of exposure to contemporary models of parenting; and lastly being less keen to seek help with emotional problems (Condon et al. 2004). All of these factors are compounded by practitioners and services oriented towards mothers and babies marginalizing fathers (Deave & Johnson 2008, Lohan et al. 2013).

Enhancing the role of fathers

First published in Viewpoint, March 2014 Issue of the Kai Tiaki: Nursing New Zealand.

March 2014 Midwives at work
March 2014 Midwives at work

Reference as: DeSouza, Ruth. (2014). Enhancing the role of fathers. Kai Tiaki: Nursing New Zealand, 20(2), 26-27 (download 3.2 MB pdf DeSouza Migrant Dads).

Mkono mmoja haulei mwana. A single hand cannot nurse a child. Kiswahili proverb

I spent the first ten years of my life in Tanzania and Kenya where this Kiswahili proverb comes from. My father played a prominent part in childcare and the raising of three daughters. We migrated twice, first to Kenya and then to New Zealand. As migrants we only had our nuclear family to fall back on and my father took a central role in raising us while my mother studied. His philosophy was that that everything that needed to be done to keep the household going was a labour of love that we should all expect to contribute freely and lovingly to. This idea of pulling together and being self-sufficient reminds me of another Kiswahili phrase Harambee which means to pull together. Jomo Kenyatta was the first president of Kenya and this catch phrase that he popularized can also be seen on the Kenyan flag. Which brings me to the purpose of this article, which is to talk about pulling together around a family, especially one that has migrated and in particular pulling “in” fathers during the transition to parenthood.

Including fathers in care

It is not possible to address the needs of women, infants and children in heterosexual families without addressing the needs of a child’s father (Buckelew, Pierrie, & Chabra, 2006). Pregnancy and childbirth are pivotal periods where individuals can grow as they adjust to the transition (Montigny & Lacharite, 2004).The perinatal period is a critical developmental touch point where health professionals can have a profound influence in assisting fathers and mothers in their transition. Often interventions focus on the mother and serve to increase her developing expertise, which subsequently tends to increase parental conflict (Montigny & Lacharite, 2004). Health professionals can have a significant role in fostering interactions between both partners (Montigny & Lacharite, 2004).

Most immigration studies focus on the negative consequences of immigration for families and for parenting. For example, immigration is perceived predominantly in the literature as a source of stress and a risk factor for families and children. Engaging women in groups or developing couples’ groups that would also serve the needs of new fathers could educate participants and provide support and information. Supporting the whole migrant family is critical, particularly when often a key motivation for migration is to provide a better life for children (DeSouza 2005; Roer-Strier et al 2005). Families can provide a buffer and the strength and safety to cope with what might seem an unfamiliar, and at times hostile, receiving community (Roer-Strier et al 2005).

Parenthood, combined with recent migration, can lead to a process of extended change and adaptation in all domains of a parent’s life. These changes can include adjusting to a new home, social environment, language, culture, place of work and profession. Often, economic, social and familial support systems are lost or changed. Under such circumstances, parents’ physical and psychological health, self-image, ability to withstand stress and anxiety levels may all be challenged (Roer-Strier, Strier, Este, Shimoni, & Clark, 2005). For new migrant families, support needs are critically important and in the absence of usual support networks, partners and husbands play an important role in providing care and support that would normally be received from mothers, family and peers. Systems need to be ‘father-friendly’ as husbands are the key support for migrant women who have often left behind friends and family.

So, what can be done to reorient services so that they are more father-friendly? Fatherhood is changing, influenced by diverse family practices and formations, which challenge the male breadwinner-female home carer division of labour. The shift from being a breadwinner and authority figure to being involved in all aspects of the perinatal period has become an expectation in the Western world (Deave & Johnson, 2008). Fathers play a crucial role in the couple’s relationship and the father-infant relationship and they contribute to individual and family well-being (Goodman, 2005). where men are required to provide practical and emotional support to mothers and children However, Barclay and Lupton (1999) suggest that active societal support and preparation are not readily available to men despite the expectation that men will fill the gaps that were previously filled by neighbours and women relatives.

Health and social services and nurses who work in them often fail to engage fathers successfully and can even pose a barrier to their engagement (Williams, Hewison, Wildman, & Roskell, 2013). The ‘new involved father’ benchmark (Lupton & Barclay, 1997a) requires that fathers participate in antenatal classes, labour and delivery. In the absence of social networks, family and peers groups, partners and health professionals often need to fill in the gaps. Fathers are key persons who strongly influence the perinatal decisions women make. Migration often requires changed roles for fathers, especially if they have not grown up with expectations about their roles as active participants.

Fatherhood can be difficult and fathers need support and guidance to prepare them for the transition and to develop competence Men can sometimes lack appropriate models and emotional support for fathering, requiring that they be encouraged to develop support for their parenting beyond their partner (Goodman, 2005). Each stage of the paternal lifecycle including pregnancy, labour and delivery, postpartum period and parenthood poses challenges for new parents to be. Labour and delivery are particularly difficult times for fathers who can feel coerced, ill-prepared, ineffective, and/or psychologically excluded from the event (Bartlett, 2004).

The postpartum period, particularly the first year after childbirth, is a time of emotional upheaval for first-time fathers, who have to adapt to the presence of an infant who is a priority. Research on first-time fathers’ prenatal expectations of the experience compared with perceptions after the birth found that they expected to be treated as part of a labouring couple, but were often relegated to a supporting role. Fathers were confident of their ability to support their wives, but labour was more work and scary than they had anticipated. The focus also changed postpartum from their wives to their babies. The study found that fathers need to be better included and supported in their role as coach and friend (Chandler & Field, 1997).

The first year of parenting is often experienced as overwhelming (Nyström & Öhrling, 2004). Anticipatory guidance is critically important for expectant fathers, as many men (like women) hold unrealistic expectations about parenthood that can hinder their adjustment to the realities of fatherhood (Goodman, 2005). Supporting fathers prenatally can improve their transition to fatherhood (Buist, Morse, & Durkin, 2003). Interventions that can help prepare men for the changes and stresses of becoming a parent include not only ensuring that men are included in childbirth preparation classes but that the content relates to the concerns of fathers and which promotes paternal involvement in all aspects of infant care. Fathers should be given opportunities to develop skills and confidence in infant care, both before and after their infant’s birth. Fathers- only classes could help men develop competence and confidence away from their partner whom they could perceive as being more capable.

Obstacles to greater involvement in fathering include work, parental modelling after one’s own father, maternal gate-keeping from wives or female partners, co-constructed processes of “doing gender” by both mothers and fathers, gender identities and ideologies and discourses of fatherhood (Doucet, (2005).

Fathers’ breastfeeding role

An infant’s father has a pivotal role in maternal initiation and continuation of breastfeeding (Littman, Medendorp, & Goldfarb, 1994), hence breastfeeding education and promotion should be directed to expectant fathers as well as mothers. Littman, Medendorp, and Goldfarb suggest that breastfeeding education should include appropriate anticipatory guidance related to managing feeling excluded when mothers are breastfeeding. Ways for new fathers to experience closeness with their infants can be suggested, and nurses can encourage the development of men’s nurturing qualities while supporting the importance of their particular role as father. Skill acquisition in infant care is a crucial step in facilitating father-infant bonding. 8. Fathers are excluded in research.

Maternal and infant health has enjoyed extensive attention from researchers, medical practitioners, and policymakers. However, little is known about the physical and psychological health of fathers, but with gender roles changing and an increasing emphasis on paternal involvement in all aspects of parenting, adjustments are required for both men and women (Goodman, 2004). Research on fatherhood lags behind that on maternal health, a disparity that is a significant gap in family research and theory. This disparity is a serious omission in knowledge and scholarship because becoming a father is a major developmental milestone (Bartlett, 2004). In order to provide optimal support to new fathers it is important to understand fathers’ experiences from the perspectives of fathers themselves (Goodman, 2005).

Interactions with significant others (nurses and partners) have a significant impact on both parents’ perceptions of parental efficacy (Montigny & Lacharite, 2004) Health professionals are well placed to support fathers in a way that empowers them to feel good about themselves, their abilities, and their infant, which in turn enhances their motivation to interact with and care for their infant (Bandura, 1996; (Bryan (2000) cited inMontigny & Lacharite, 2004)

Conclusion

The transition to fatherhood is significant with many men feeling overwhelmed or excluded. However, services that provide prior guidance and are male- friendly can increase involvement and participation. Little is known about how this transition is managed especially the needs of migrant fathers and the mediating role of social and psychological factors. However the participation of men is linked with positive outcomes for the whole family. By supporting father- friendly services, families can benefit especially families separated from support systems like migrant families. Nurses can play a pivotal role in pulling fathers ‘in’ and helping families pull together in the transition to fatherhood so that all families can thrive.

References

  • Bandura, A, Barbaranelli, C, Caprara, G V, & Pastorelli, C. (1996). Multifaceted impact of self‐efficacy beliefs on academic functioning. Child Development, 67(3), 1206-1222.
  • Barclay, Lesley, & Lupton, Deborah. (1999). The experiences of new fatherhood: a socio-cultural analysis. Journal of Advanced Nursing, 29(4 %R doi:10.1046/j.1365-2648.1999.00978.x), 1013-1020.
  • Bartlett, E.E. (2004). The effects of fatherhood on the health of men: A review of the literature. Journal of Men’s Health and Gender, 1(2-3), 159-169.
  • Buckelew, Sara M. , Pierrie, Herb , & Chabra, Anand (2006). What Fathers need: A countywide assessment of the needs of fathers of young children. Maternal and Child Health Journal,, 10(3).
  • Buist, A, Morse, C A, & Durkin, S. (2003). Men’s adjustment to fatherhood: Implications for obstetric health care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(2), 172-180.
  • Chandler, S., & Field, P.A. (1997). Becoming a father: First-time fathers’ experience of labor and delivery. Journal of Nurse-Midwifery, 42(1), 17-24.
  • Deave, T., & Johnson, D. (2008). The transition to parenthood: what does it mean for fathers? Journal of Advanced Nursing, 63(6), 626-633. doi: 10.1111/j.1365-2648.2008.04748.x
  • DeSouza, R. (2006). New spaces and possibilities: The adjustment to parenthood for new migrant mothers. Wellington: Families Commission.
  • Doucet, A. (2005). It’s almost like I have a job, but I don’t get paid’: Fathers at home reconfiguring work, care, and community. Fathering: A Journal of Theory, Research, and Practice about Men as Fathers, 2(3), 277-303.
  • Goodman, J.H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 26-35.
  • Goodman, J.H. (2005). Becoming an involved father of an infant. JOGNN – Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34(2), 190-200.
  • Littman, H., Medendorp, S.V. , & Goldfarb, J. . (1994). The decision to breastfeed: The importance of father’s approval. Clin Pediatr (Phila), 33(4), 214-219.
  • Lupton, D, & Barclay, L. (1997). Constructing fatherhood: Discourses and experiences. London ; Thousand Oaks, Calif.: SAGE
  • Montigny, Francine de , & Lacharite, Carl (2004). Fathers’ perceptions of the immediate postpartal period. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33(3), 328-339.
  • Nyström, K., & Öhrling, K. (2004). Parenthood experiences during the child’s first year: Literature review. Journal of Advanced Nursing, 46(3), 319-330.
  • Roer-Strier, Dorit, Strier, Roni, Este, David, Shimoni, Rena, & Clark, Dawne. (2005). Fatherhood and immigration: challenging the deficit theory. Child & Family Social Work, 10(4 %R doi:10.1111/j.1365-2206.2005.00374.x), 315-329.
  • Williams, Robert, Hewison, Alistair, Wildman, Stuart, & Roskell, Carolyn. (2013). Changing Fatherhood: An Exploratory Qualitative Study with African and African Caribbean Men in England. Children & Society, 27(2), 92-103.

Korean migrant mothers on giving birth in Aotearoa New Zealand

Cite as: DeSouza, Ruth. (2014). One woman’s empowerment is another’s oppression: Korean migrant mothers on giving birth in Aotearoa New Zealand. Journal of Transcultural Nursing. doi: 10.1177/1043659614523472.  Download pdf (262KB) DeSouza J Transcult Nurs-2014.

Published online before print on February 28, 2014.

Abstract

Purpose: To critically analyze the power relations underpinning New Zealand maternity, through analysis of discourses used by Korean migrant mothers. Design: Data from a focus group with Korean new mothers was subjected to a secondary analysis using a discourse analysis drawing on postcolonial feminist and Foucauldian theoretical ideas. Results: Korean mothers in the study framed the maternal body as an at-risk body, which meant that they struggled to fit into the local discursive landscape of maternity as empowering. They described feeling silenced, unrecognized, and uncared for. Discussion and Conclusions: The Korean mothers’ culturally different beliefs and practices were not incorporated into their care. They were interpellated into understanding themselves as problematic and othered, evidenced in their take up of marginalized discourses. Implications for practice: Providing culturally safe services in maternity requires considering their affects on culturally different women and expanding the discourses that are available.

Keywords: focus group interview, cultural safety, Korean women, maternal, postcolonial, Foucault.

Introduction

A feature of contemporary maternity is the notion that birth can be empowering for women if they take charge of the experience by being informed consumers. However, maternity is not necessarily empowering for all mothers. In this article, I suggest that the discourses of the Pākehā maternity system discipline and normalize culturally different women by rendering their mothering practices as deviant and patho- logical. Using the example of Korean migrant mothers, I begin the article by contextualizing maternity care in New Zealand and outlining Korean migration to New Zealand. The research project is then detailed, followed by the findings, which show the ways in which Korean mothers are interpellated as others in maternity services in New Zealand. I conclude the article with a brief discussion on the implications for nursing and midwifery with a particular focus on cultural safety.

You can read the rest at: Journal of Transcultural Nursing or download DeSouza TCN proof.

Multicultural relationships in supervision

Here’s an excerpt from a chapter I wrote on culture/ethnicity and supervision, the paragraph seems more than apt these days.

“We don’t colonise, these days, through the barrel of a gun, but through the comfortable words of those who change the hearts, minds and spirits of people” (Waldegrave, 2001).

Supervision provides a powerful learning environment that helps in the maintenance of integrity and is therefore a critical factor in practitioner development for learning to work with diversity. Freshwater (2005, p109) suggests that supervision provides a space for the “preservation or restoration of integrity in caring” and as such a supervisor needs to have integrity themselves. Supervision provides us with an opportunity to look at ourselves and resource ourselves so that we can then re-engage with our work in new ways, with new knowledge and skills and strategies. This revitalising quality of supervision allows us to then return to our work refreshed.  With the impact of neoliberal policy and increasing demands for quality and outcomes, the importance of having someplace to replenish ourselves takes on new urgency. Nowhere is this more apt than in working with people of diverse cultures, where policy has not kept up with practice so that few of us are resourced for working with difference in time stretched, resource poor systems. Supervision is one of the most powerful and intimate of learning environments and as such it needs to be a safe one, so that the work of learning can take place and enhance the delivery of care and support. The supervision experience can be a powerful facilitator of the development of knowledge and skills that meets the therapeutic needs of diverse groups. With our changing demographics, supervision needs to be more inclusive, not just in terms of working with diversity but also regarding worldviews from different locations and positions.

DeSouza, R. (2007). Multicultural relationships in supervision. In D. Wepa (Ed.), Clinical supervision in the health professions: The New Zealand experience. (pp. 96-109). Auckland: Pearson Education.

Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices

I’ve just had the first paper from my PhD published: DeSouza, R. (2013), Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices. Nursing Inquiry. doi: 10.1111/nin.12020

In contemporary Western societies, birthing is framed as transformative for mothers; however, it is also a site for the regulation of women and the exercise of power relations by health professionals. Nursing scholarship often frames migrant mothers as a problem, yet nurses are imbricated within systems of scrutiny and regulation that are unevenly imposed on ‘other’ mothers. Discourses deployed by New Zealand Plunket nurses (who provide a universal ‘well child’ health service) to frame their understandings of migrant mothers were analysed using discourse analysis and concepts of power drawn from the work of French philosopher Michel Foucault, read through a postcolonial feminist perspective. This research shows how Plunket nurses draw on liberal feminist discourses, which have emancipatory aims but reflect assimilatory practices, paradoxically disempowering women who do not subscribe to ideals of individual autonomy. Consequently, the migrant mother, her family and new baby are brought into a neoliberal project of maternal improvement through surveillance. This project – enacted differentially but consistently among nurses – attempts to alter maternal and familial relationships by ‘improving’ mothering. Feminist critiques of patriarchy in maternity must be supplemented by a critique of the implicitly western subject of maternity to make empowerment a possibility for all mothers.

 

 

How can we better support new mothers to sing?

I am a member of the Perinatal Mental Health New Zealand Trust (PMHNZ) whose vision is to : “improve outcomes for families and whanau affected by mental illness related to pregnancy, childbirth and early parenthood”. They produce a quarterly newsletter that includes information about research, training, workshops and courses, innovative projects and services, topics for discussion and stories. It was a privilege to share my research with other members in the February newsletter (pdf) and on this Women’s day it seems apt to share it with a broader audience.

One of my favourite stories that I would tell when we ran workshops in the nineties about postnatal depression was by Jack Kornfield. I would share this story and half the room would be in tears.

“There is a tribe in East Africa in which the art of true intimacy is fostered even before birth. In this tribe, the birth date of a child is not counted from the day of its physical birth nor even the day of conception as in other village cultures. For this tribe the birth date comes the first time the child is a thought in its mother’s mind. Aware of her intention to conceive a child with a particular father, the mother then goes off to sit alone under a tree. There she sits and listens until she can hear the song of the child that she hopes to conceive. Once she has heard it, she returns to her village and teaches it to the father so that they can sing it together as they make love, inviting the child to join them. After the child is conceived, she sings it to the baby in her womb. Then she teaches it to the old women and midwives of the village, so that throughout the labor and at the miraculous moment of birth itself, the child is greeted with its song. After the birth all the villagers learn the song of their new member and sing it to the child when it falls or hurts itself. It is sung in times of triumph, or in rituals and initiations. This song becomes a part of the marriage ceremony when the child is grown, and at the end of life, his or her loved ones will gather around the deathbed and sing this song for the last time.” A Path with Heart (1993, p. 334).

For me the message in this story reflects the importance of love, being loved by a community and the importance of acknowledgement. Painfully, however, it highlights the ways in which women’s experiences of maternity can be just the opposite. That is, they can feel isolated, disrespected and invisible. As a clinician, I’ve learned that there are ways in which we, and the system that we work in can make this most magnificent, sacred and profound time in a woman and her family’s life also one that is painful, one that leaves long lasting scars. Health professionals can cause harm even especially when we think we are doing good. As an academic for 13 years prior to which I worked as a clinician for 10 years, I am deeply interested in the issue of power and how professional frameworks of care can undermine women’s personal experiences.

This song has been the background soundtrack to my recently completed PhD. I used data from a study funded by the Families Commission and assisted by Plunket, where I talked to 40 migrant women about their experiences of becoming mothers in New Zealand. I also talked to Plunket nurses about their experiences of caring for women from ethnic migrant backgrounds.

My motivation for doing research was prompted by my clinical experiences. Several years ago I decided to make a move from working in mental health to working in maternity. As someone who had worked as a community mental health nurse I took a lot of concepts about my work in mental health into this new setting, for example, I believed that care should be client centred and driven, that services should fit around consumers of services and that taking time to be with people was important. What I found in the institutionalised setting of hospital maternity care and later community care was that some of the routine procedures that are administered in hospitals and in the community with good intentions had negative impacts and were oppressive especially for women who did not tidily fit into the mould for the factory style model that was in place then. The conveyor belt metaphor is apt given that women who were the wrong fit were viewed as a problem, as only a single way of becoming a mother was acceptable. I saw that staff were frustrated at the extra demands or complexity of working with ‘diverse’ women, they lacked resources like time and knowledge. In turn, I could see that women who valued particular kinds of social support, acknowledgement and rituals were not getting their needs met. It seemed like a situation where no one was a winner.

What I found out in my research was that there was a big gap in satisfaction among women who were familiar with the structure of maternity services in the west and women whose lives had been shaped by growing up in other cultural contexts. Fundamentally there was a schism in the ways in which birth was understood. To be simplistic, western modes of being a mother valued independence, autonomy, taking up expert knowledge and using it and being an active consumer. By that I mean the individualising of responsibility for maternity on the mother, to take up scientific knowledge through reading self help books and for the role of the partner to be a birth coach and the goal of birth to be “natural”.

This dominant Pakeha middle class model of being a mother clashed with other understandings of motherhood, where responsibility was more collectivised, so that embodied knowledge from cultural authority figures (mother and mothers in law) protected mothers and where a range of rituals and supports were available for the mother (including some which were also not necessarily helpful). Women who became mothers in New Zealand had to negotiate these two different models of maternity and come to terms with what they negotiated. However, in the context of an assimilatory maternal health system it was very difficult for women to maintain traditions that were important to them. For example many women were not supported if they wanted to bring in traditional foods with them or have support from grandmothers. Many of these encounters left migrant mothers feeling disempowered. Another important clash was the different philosophies and roles of professionals and mother in the context of midwifery models and medical models. Some women viewed birth as a risky process and wanted the reassurance of visualising technologies. The view of birth as a risky process clashed with midwifery models of birth as a natural process that women are physically prepared for but need encouragement and support with.

Conclusion How can we support all kinds of women with different values, beliefs and rituals around birth, to feel loved, nurtured, safe and supported? How can we give women who might be separated from their loved ones, support to access those values, beliefs and that will allow them to manage the transition into motherhood? Returning to the metaphor of singing, and the power of connection it engenders, how can we connect and support people who are singing different kinds of songs? Can we adjust our tone so that we can harmonise? Can new songs and rhythms infuse the songs we already know with new energy and possibility?

Having a baby in New Zealand without your support base http://www.mentalhealth.org.nz/kaixinxingdong/page/486- resources+dragon-babies+parents-stories