Unpublished manuscript for those who might be interested. Cite as: DeSouza, R. (2016, July 16). Using forum theatre to facilitate reflection and culturally safe practice in nursing [Web log post]. Retrieved from: http://www.ruthdesouza.com/2016/07/16/using-forum-theatre-for-reflective-practice/
High quality communication is central to nursing practice and to nurse education. The quality of interaction between service users/patients and inter-professional teams has a profound impact on perception of quality of care and positive outcomes. Creating spaces where reflective practice is encouraged allows students to be curious, experiment safely, make mistakes and try new ways of doing things. Donald Schon (1987) likens the world of professional practice to terrain made up of high hard ground overlooking a swamp. Applying this metaphor in Nursing, Street (1991) contends that some clinical problems can be resolved through theory and technique (on hard ground), while messy, confusing problems in swampy ground don’t have simple solutions but their resolution is critical to practice.
Australian society has an indigenous foundation and is becoming increasingly multicultural.In Victoria 26.2 percent of Victorians and 24.6 per cent of Australians were born overseas, compared with New Zealand (22.4 per cent), Canada (21.3 per cent), United States (13.5 per cent) and The United Kingdom (10.4 per cent). Australia’s multicultural policy allows those who call Australia home the right to practice and share in their cultural traditions and languages within the law and free from discrimination (Australia Government, 2011, p. 5). Yet, research highlights disparities in the provision of health care to Culturally and Linguistically Diverse (CALD) groups and health services are not always able to ensure the delivery of culturally safe practice within their organisations (Johnstone & Kanitsaki, 2008).
An important aspect of cultural safety is the recognition that the health care system has its own culture. In Australia, this culture is premised on a western scientific worldview. Registered nurses (RNs) have a responsibility to provide culturally responsive health care that is high quality, safe, equitable and meets the standards expected of the profession such as taking on a leadership role, being advocates and engaging in lifelong learning. RNs who practice with cultural responsiveness are able to ‘respond to the healthcare issues of diverse communities’ (Victorian Department of Health [DoH], 2009, p. 4), and are respectful of the health beliefs and practices, values, culture and linguistic needs of the individual, populations and communities (DoH, 2009, p. 12).
Culturally competent nursing requires practitioners to provide individualised care and consider their own values and beliefs impact on care provision. Critical reflection can assist nurses to work in the swampy ground of linguistic and cultural diversity. Reflection involves learning from experience: not simply thinking back over an event, but developing a conscious and systematic practice of thinking about experience in order to learn and change future behaviour. Critical reflection involves challenging the nurse’s understanding of themselves, their attitudes and behaviours in order to bring their views of practice and the world closer to the complex reality of care. This kind of process facilitates clinical reasoning, which is the thinking and decision-making toward undertaking the best-judged action, enhancing client care and improve practitioner capability and resilience.
Didactic approaches impart knowledge and provide students with declarative knowledge but don’t always provide the opportunity to practice communication techniques or to explore in depth the attitudes and behaviours that influence their own knowledge. Drama and theatre are increasingly being used to create dynamic simulated learning environments where students can try out different communication techniques in a safe setting where there are multiple ways of communicating. A problem based learning focus allows students to reflect on their own experiences and to arrive at their own solutions, promoting deep learning as students use their own experiences and knowledge to problem solve.
In 2015 I developed and trialed a unit for students at all three Monash School of Nursing and Midwifery campuses in their third year. The aim of the unit was to provide students with resources to understand their own culture, the culture of healthcare and the historical and social issues that contribute to differential health outcomes for particular groups in order to discern how to contribute to providing culturally safe care for all Australians. The unit examined how social determinants of health such as class, gender, race, sexual orientation, gender identity; education, economic status and culture affect health and illness. Students were invited to consider how politics, economics, the social-cultural environment and other contextual factors impacted on Aboriginal and Torres Strait Islander and Culturally and Linguistically Diverse (CALD) communities. Students were asked to consider how policy, the planning, organisation and delivery of health and healthcare shaped health care delivery.
The unit was primarily delivered online but a special workshop was offered using Forum theatre developed by Augusto Boal in partnership with two experienced practitioners Azja Kulpińska and Tania Cañas. Forum theatre is focused on promoting dialogue between actors and audience members, it promotes transformation for social justice in the broader world and differs from traditional theatre which involves monologue. Simulated practices like Forum theatre allow students to address topics from practice within an educational setting, where they can safely develop self-awareness and knowledge to make sense of the difficult personal and professional issues encountered in complex health care environments. This is particularly important when it comes to inter-cultural issues and power relations. Such experiential techniques can help students to gain emotional competence, which in turn assists them to communicate effectively in a range of situations.
Students were invited to identify a professional situation relating to culture and health that was challenging and asked to critically reflect on the event/incident focusing on the concerns they encountered in relation to the care of the person. Through the forum theatre process they were asked to consider alternative understandings of the incident, and critically evaluate the implications of these understandings for how more effective nursing care could have been provided. Through the workshop it was hoped that students could then review the experience in depth and undertake a process of critical reflection in a written assessment by reconstructing the experience beyond the personal. They were encouraged to examine the historical and social factors that structure a situation and to start to theorise the causes and consequences of their actions. They were encouraged to use references such as research, policy documents or theory to support their analysis and identify an overarching issue, or key aspect of the experience that affected it profoundly. Concluding with the key learnings through the reflective process, the main factors affecting the situation, and how the incident/event could have been more culturally safe/competent. Students were asked to develop an action plan to map alternative approaches should this or a similar situation arise in the future.
Forum theatre has been used in nursing and health education to facilitate deeper and more critical reflective thinking, stimulate discussion and exploratory debate among student groups. It is used to facilitate high quality communication skills, critical reflective practice, emotional intelligence and empathy and appeals to a range of learning styles. Being able to engage in interactive workshops allows students to engage in complex issues increasing self-awareness using techniques include physical exercises and improvisations.
My grateful thanks to two Forum Theatre practitioners who led this work with me:
Azja Kulpińska is a community cultural development worker, educator and Theatre of the Oppressed practitioner and has delivered workshops both in Australia and internationally. She has been a supporter of RISE: Refugees, Survivors and Ex-Detainees and for the last 3 years has been co-facilitating a Forum Theatre project – a collaboration between RISE and Melbourne Polytechnic that explores challenging narratives around migration, settlement and systems of oppression. She is also a youth worker facilitating a support group for young queer people in rural areas.
Tania Cañas is a Melbourne-based arts professional with experience in performance, facilitation, cultural development and research. Tania is a PhD candidate at the Centre for Cultural Partnerships, VCA. She also sits on the International PTO Academic Journal.
She has presented at conferences both nationally and internationally, as well as facilitated Theatre of the Oppressed workshops at universities, within prisons and youth groups-in in Australian, Northern Ireland, The Solomon Islands, The United States and most recently South Africa. For the last 2.5 years has been working with RISE and Melbourne Polytechnic to develop a Forum Theatre program with students who are recent migrants, refugees and asylum seekers.
- Australian Government. (2011). The People of Australia: Australia’s Multicultural Policy, Retrieved from https://www.dss.gov.au/sites/default/files/documents/12_2013/people-of-australia-multicultural-policy-booklet.pdf
- Boud, D., Keogh, R. and Walker, D. 1985. Reflection: Turning experience into learning. London: Kogan Page.
- Gibbs, G. 1988. Learning by doing: A guide to teaching and learning methods. Oxford: Oxford Further Education Unit.
- Johns, C. 1998b. Illuminating the transformative potential of guided reflection. In Transforming Nursing Through Reflective Practice (eds). C. Johns and D. Freshwater. Oxford: Blackwell Science. 78-90.
- Johnstone, MJ. & Kanitsaki, O. (2008). The politics of resistance to workplace cultural diversity education for health service providers: an Australian study. Race Ethnicity and Education 11(2) 133-134
- McClimens, A., & Scott, R. (2007). Lights, camera, education! The potentials of forum theatre in a learning disability nursing program. Nurse Education Today, 27(3), 203-9. doi:10.1016/j.nedt.2006.04.009
- Middlewick, Y., Kettle, T. J., & Wilson, J. J. (2012). Curtains up! Using forum theatre to rehearse the art of communication in healthcare education. Nurse Education in Practice, 12(3), 139-42. doi:10.1016/j.nepr.2011.10.010
- Nursing and Midwifery Board of Australia (2006). National competency standards for the registered nurse, viewed 16 February 2014: www.nursingmidwiferyboard.gov.au.
- Nursing and Midwifery Board of Australia (2008). Code of professional conduct for nurses in Australia, Nursing and Midwifery Board of Australia, Canberra.
- Schön, D.A. 1987. Educating the Reflective Practitioner. San Francisco: Jossey Bass.
- Street, A. 1990. Nursing Practice: High Hard Ground, Messy Swamps, and the Pathways in Between. Geelong: Deakin University Press.
- Turner, L. (2005). From the local to the global: bioethics and the concept of culture. Journal of Medicine and Philosopy. 30:305-320 DOI: 10.1080/03605310590960193
- Victorian Department of Health. (2009). Cultural responsiveness framework Guidelines for Victorian health services, Retrieved from http://www.health.vic.gov.au/__data/assets/pdf_file/0008/381068/cultural_responsiveness.pdf
- Wasylko, Y., & Stickley, T. (2003). Theatre and pedagogy: Using drama in mental health nurse education. Nurse Education Today, 23(6), 443-448. doi:10.1016/s0260-6917(03)00046-7
- Also see DeSouza, R (2015). Communication central to Nursing Practice. Transforming the Nations Healthcare 2015, Australia’s Healthcare News.
Cite as: DeSouza, R. (2016, June 1st). Keynote address-Providing Culturally Safe Maternal and Child Healthcare, Multicultural Health Research to Practice Forum: Early Interventions in Maternal and Child Health, Program, Organised by the Multicultural Health Service, South Eastern Sydney, Local Health District, Australia. Retrieved fromhttp://www.ruthdesouza.com/2016/06/11/cultural-safety-in-maternity/
A paragraph haunts me in The Namesake, Jhumpa Lahiri’s fictional account of the Indian immigrant experience. Ashoke and Ashima Ganguli migrate from Calcutta to Cambridge, Massachusetts after their arranged wedding. While pregnant, Ashima reflects:
Nothing feels normal. it’s not so much the pain which she knows she will survive. It’s the consequence: motherhood in a foreign land. For it was one thing to be pregnant to suffer the queasy mornings in bed, the sleepless nights, the dull throbbing in her back, the countless visits to the bathroom. Throughout the experience, in spite of her growing discomfort, she’s been astonished by her body’s ability to make life, exactly as her and grandmother and all her great grandmothers had done. That it was happening so far from home, unmonitored and unobserved by those she loved, had made it more miraculous still. But she is terrified to raise a child in a country where she is related to no one, where she knows so little, where life seems so tentative and spare. The Namesake, Jhumpa Lahiri
Ashima’s account beautifully captures the universality of the physical, embodied changes of maternity, the swelling, the nausea and other changes. But what Lahiri poignantly conveys is the singular emotional and cultural upheaval of these changes, the losses they give rise to. The absence of loving, knowledgeable, nurturing witnesses, the absence of a soft place to fall.
In 1994 I worked on a post-natal ward where I was struck by the limits of universality and how treating everybody the same was problematic. For example, ostensibly beneficial practices like the routine administration of an icepack for soothing the perineum postnatally, or the imperative to mobilise quickly or to “room in” have potentially damaging effects on women whose knowledge frameworks differed from the dominant Pakeha culture of healthcare. These practices combined with a system designed for an imagined white middle class user, where professionals had knowledge deficits and monocultural and assimilatory attitudes, led to unsafe practices such as using family members and children as interpreters (my horror when a boy child was asked to ask his mother about the amount of lochia on her pad). The sanctity of birth, requiring the special, nurturing treatment of new mothers and a welcome from a community was superseded by the factory culture of maximum efficiency. Not all mothers were created equal, not young mothers, not older mothers, not single mothers, not substance using mothers, not indigenous mothers, not culturally different mothers. The sense that I was a cog in a big machine that was inattentive to the needs of “other” mothers led me to critique the effectiveness of cultural safety in the curriculum. How was it possible that a powerful indigenous pedagogical tool for addressing health inequity was not evident in clinical practice?
Leaving the post-natal ward, I took up a role helping to develop a new maternal mental health service in Auckland. There too I began to question the limitations of our model of care which privileged talking therapies rather than providing practical help and support. I was also staggered at the time at the raced and classed profile of our clients who were predominantly white middle class career women. Interestingly, the longer I was involved in the service the greater the number of ethnic women accessed the service. For my Master’s thesis, I interviewed Goan women about their maternity experiences in New Zealand, where the importance of social support and rituals in the perinatal period was noted by participants.
As much as it was important to register and legitimate cultural difference, I was also aware of the importance of not falling into the cultural awareness chasm. As Gregory Philips notes in his stunning PhD, it was assumed that through teaching about other cultures, needs would be better understood as “complex, equal and valid” (Philips, 2015). However, it didn’t challenge privilege, class and power. As Joan Scott points out:
There is nothing wrong, on the face of it, with teaching individuals about how to behave decently in relation to others and about how to empathize with each other’s pain. The problem is that difficult analyses of how history and social standing, privilege, and subordination are involved in personal behavior entirely drop out (Scott, 1992, p.9).
The problem with culturalism is that the notion of “learning about” groups of people with a common ethnicity assumes that groups of people are homogenous, unchanging and can be known. Their cultural differences are then viewed as the problem, juxtaposed against an implicit dominant white middle class cultural norm. This became evident in my PhD analysis of interviews with Korean mothers who’d birthed in New Zealand. In Australia and the US, cultural competence has superseded cultural awareness as a mechanism for correcting the limitations of universalism, by drawing attention to organisational and systemic mechanisms that can be measured but as a strategy for individual and interpersonal action, several authors draw attention to competence as being part of the “problem”:
The concept of multicultural competence is flawed… I question the notion that one could become “competent” at the culture of another. I would instead propose a model in which maintaining an awareness of one’s lack of competence is the goal rather than the establishment of competence. With “lack of competence” as the focus, a different view of practicing across cultures emerges. The client is the “expert” and the clinician is in a position of seeking knowledge and trying to understand what life is like for the client. There is no thought of competence—instead one thinks of gaining understanding (always partial) of a phenomenon that is evolving and changing (Dean, 2001, p.624).
In Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand, I advocated for a combination of cultural competence and cultural safety. Cultural safety was developed by Indigenous nurses in Aotearoa New Zealand as a mechanism for considering and equalizing power relationships between client and practitioner. It is an ethical framework for practice derived from postcolonial and critical theory. Cultural safety proposes that practitioners reflect on how their status as culture bearers impacts on care, with care being deemed culturally safe by the consumer or recipient of care. In my PhD I wrote about the inadequacy of the liberal foundations of nursing and midwifery discourses for meeting the health needs of diverse maternal groups. My thesis advocated for the extension of the theory and practice of cultural safety to critique nursing’s Anglo-European knowledge base in order to extend the discipline’s intellectual and political mandate with the aim of providing effective support to diverse groups of mothers. In Australia, cultural responsiveness, cultural security and cultural respect are also used, you can read more about this on my post on Minding the Gap.
So let’s look at culturally safe maternity care. My experience as a clinician and researcher reveal a gap between how birth is viewed. In contemporary settler nations like New Zealand, midwifery discourses position birth as natural and the maternal subject as physically capable of caring for her baby from the moment it is born, requiring minimal intervention and protection. The maternal body is represented as strong and capable for taking on the tasks of motherhood. In contrast, many cultures view birth as a process that makes the body vulnerable, requiring careful surveillance and monitoring and a period of rest and nurturing before the new mother can take on new or additional responsibilities. The maternal body is seen as a body at risk (Mahjouri, 2008), and vulnerable requiring special care through rituals and support. Therefore, practices based on a dominant discourse of birth as a normal physiological event and neoliberal discourses of productive subjectivity create a gap between what migrant women expect in the care they expect from maternal services. These practices also constitute modes of governing which are intended to be empowering and normalizing, but are experienced as disempowering because they don’t take into account other views of birth. Consequently there is no recognition on the part of maternity services that for a short time, there is a temporary role change, where the new mother transitions into a caregiver by being cared for. This social transition where the mother is mothered is sanctioned in order to safeguard the new mother, a demonstration to value and protect both future capacity for mothering and long term well being, in contrast with dominant discourses of responsibilisation and intensive motherhood. Thus, instead of a few days of celebration or a baby shower, extended post-partum practices are enacted which can include the following (Note that these will vary depending on in group differences, urbanisation, working mothers, migration):
- Organised support- where family members (eg mother, mother-in-law, and other female relatives) care for the new mother and infant. Other women may also be involved eg birth attendants.
- Rest period and restricted practices- where women have a prescribed rest periods of between 21 days and five weeks, sometimes called “Doing the month”. Activities including sexual activity, physical and intellectual work are reduced.
- Diet- Special foods are prepared that promote healing/restore health or have a rebalancing function for example because the postpartum period is seen as a time when the body is cold, hot food (protein rich) chicken soup, ginger and seaweed, milk, ghee, nuts, jaggery might be consumed. Special soups and tonics with a cleansing or activating function are consumed eg to help the body expel lochia, to increase breastmilk. These foods might be consumed at different stages of the perinatal period and some food might be prohibited while breastfeeding.
- Hygiene and warmth- particular practices might be adhered to including purification/bathing practices eg warm baths, immersion. Others might include not washing hair.
- Infant care and breastfeeding- Diverse beliefs about colostrum, other members of family may take more responsibility while mother recovers and has a temporarily peripheral role. Breastfeeding instigation and duration may differ.
- Other practices include: binding, infant massage, maternal massage, care of the placenta.
If women are confronted with an unfamiliar health system with little support and understanding, they can experience stress, insecurity, loneliness, isolation, powerlessness, hopelessness. This combined with communication gaps and isolation, poor information provision, different norms, feeling misunderstood and feeling stigmatized. What could be a special time is perceived as a lack of care. Fortunately in Australia there are some excellent resources, for example this research based chapter on Cultural dimensions of pregnancy, birth and post-natal care produced by Victoria Team, Katie Vasey and Lenore Manderson, proposes useful questions for perinatal assessment which I have summarised below:
- Are you comfortable with both male and female health care providers?
- Are there any cultural practices that we need to be aware of in caring for you during your pregnancy, giving birth and postnatal period? – For example, requirements with the placenta, female circumcision or infant feeding method.
- In your culture, do fathers usually attend births? Does your partner want to attend the birth of his child? If not, is there another close family member you would like to be present? Would you like us to speak to them about your care?
- Are there any foods that are appropriate or inappropriate for you according to your religion or customs during pregnancy, birth and the postpartum period?
- Are there any beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period? Do you plan to observe these? – For example, a confinement period.
- What is the culturally acceptable way for you to express pain during childbirth? – For example, screaming or trying to keep silent.
- Are there any precautions with infant care?
- How many visitors do you expect while you are in the hospital?
- Do you have anyone in your family or community who can help you in practical ways when you get home?
Negotiating between cultural practices, values and norms, religious beliefs and views, beliefs about perinatal care is a starting point. It is also important to consider language proficiency, health literacy, quality of written materials, and level of acculturation. For further information on health literacy see the Centre for Culture, Ethnicity & Health (CEH) resources including: What is health literacy?, Social determinants of health and health literacy. Using professional interpreters improves communication, clinical outcomes, patient satisfaction and quality of care, and reduces medical testing, errors, costs and risk of hospitalisation. Lack of appropriate interpreter service use is associated with adverse health outcomes. Centre for Culture,Ethnicity & Health (CEH) has excellent resources in this regard: Interpreters: an introduction, Assessing the need for an interpreter, Booking and briefing an interpreter, Communicating via an interpreter, Debriefing with an interpreter, Developing a comprehensive language services response, Language services guide Managing bilingual staff, Planning for translation, Recruiting bilingual staff.
Assessment should also consider:
- Genetics and pregnancy: women’s age, parity, planning and acceptance of pregnancy, pregnancy related health behaviour and perceived health during pregnancy.
- Migration: women’s knowledge of/familiarity with the prenatal care services/system, experiences and expectations with prenatal care use in their country of origin, pregnancy status on arrival in the new industrialized western country.
- Culture: women’s cultural practices, values and norms, acculturation, religious beliefs and views, language proficiency, beliefs about pregnancy and prenatal care.
- Position in the host country: women’s education level, women’s pregnancy-related knowledge, household arrangement, financial resources and income.
- Social network: size and degree of contact with social network, information and support from social network.
- Accessibility: transport, opening hours, booking appointments, direct and indirect discrimination by the prenatal care providers.
- Expertise: prenatal care tailored to patients’ needs and preferences.
- Treatment and communication: communication from prenatal care providers to women, personal treatment of women by prenatal care providers, availability of health promotion/information material, use of alternative means of communication.
- Professionally defined need: referral by general practitioners and other healthcare providers to prenatal care providers
A review by Small, Roth et al., (2014) found that what immigrant and non-immigrant women want from maternity care is similar: safe, high quality, attentive and individualised care, with adequate information and support. Generally immigrant women were less positive about care than non-immigrant women, in part due to communication issues, lack of familiarity with care systems, perceptions of discriminatory care which was not kind or respectful. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women’s understanding of care provision and reducing discrimination. Clinical skills including—introspection, self-awareness, respectful questioning, attentive listening, curiosity, interest, and caring.
- Facilitating trust, control
- Delivering quality, safe care, communicating, being caring, providing choices
- Facilitating access to interpreters and choice of gender of care provider,
- Considering cultural practices, preferences and needs/different expectations for care
- Engendering positive interactions, being empathetic, kind, caring and supportive.
- Taking concerns seriously
- Preserving dignity and privacy
- Seeing a person both as an individual, a family member and a community member
- Developing composure managing verbal and non-verbal expressions of disgust and surprise
- Paradoxical combination of two ideas— being “informed” and “not knowing” simultaneously.
In that sense, our knowledge is always partial and we are always operating from a position of incompletion or lack of competence. Our goal is not so much to achieve competence but to participate in the ongoing processes of seeking understanding and building relationships. This understanding needs to be directed toward ourselves and not just our clients. As we question ourselves we gradually wear away our own resistance and bias. It is not that we need to agree with our clients’ practices and beliefs; we need to understand them and under-stand the contexts and history in which they develop (Dean, 2001, p.628).
In this presentation I have invited you to examine your own values and beliefs about the perinatal period and how they might impact on the care you might provide. I have asked you to consider both the similarities and differences between how women from culturally diverse communities experience maternity and those from the dominant culture. Together, we have scrutinised a range of strategies for enhancing trust, engagement and perinatal outcomes for all women. Drawing on my own clinical practice and research, I have asked you to consider an alternative conceptualisation of the maternal body when caring for some women, that is the maternal body as vulnerable, which requires a period of rest and nurturing. This framing requires a temporary role change for the new mother to transition into being a caregiver, by being cared for, so that her future capacity for mothering and long term well being are enhanced. I have asked you to reflect on how supposedly empowering practices can be experienced as disempowering because they don’t take into account this view of birth. In the context of differing conceptualisations of birth and the maternal body I have drawn special attention to: negotiating between health beliefs; having cultural humility; considering ways in which your own knowledge is always partial; and recommended a range of resources that can be utilised to ensure positive outcomes for women and their families. As health services in Australia grapple with changing societal demographics including cultural diversity, changing consumer demands and expectations; resource constraints; the limitations in traditional health care delivery; greater emphasis on transparency, accountability, evidence- based practice (EBP) and clinical governance (Davidson et al., 2006), questions of how to provide effective universal health care can be enhanced by considering how differing views can be incorporated as they hold potential benefits for all.
- Boerleider, A. W., Wiegers, T. A., Manniën, J., Francke, A. L., & Devillé, W. L. (2013). Factors affecting the use of prenatal care by non-western women in industrialized western countries: A systematic review. BMC Pregnancy and Childbirth, 13(1), 8.
- Dennis, C. L., Fung, K., Grigoriadis, S., Robinson, G. E., Romans, S., & Ross, L. (2007). Traditional postpartum practices and rituals: A qualitative systematic review. Women’s Health (London, England), 3(4), 487-502. doi:10.2217/17455057.3.4.487.
- Mander, S., & Miller, Y. D. (2016). Perceived safety, quality and cultural competency of maternity care for culturally and linguistically diverse women in queensland. Journal of Racial and Ethnic Health Disparities, 3(1), 83-98. doi:10.1007/s40615-015-0118.
- Small, R., Roth, C., Raval, M., Shafiei, T., Korfker, D., Heaman, M. Gagnon, A. (2014). Immigrant and non-immigrant womens experiences of maternity care: A systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth, 14(1).
Additional web resources
- The Victorian Refugee Health Network has maternity resources.
- Opportunities to improve maternal health literacy through antenatal education: an exploratory study, article by Susan Renkert and Don Nutbeam
On 15 February 2016, I spoke on 612 ABC Brisbane Afternoons with Kelly Higgins-Devine about cultural appropriation and privilege. Our discussion was followed by discussion with guests: Andie Fox – a feminist and writer; Carol Vale a Dunghutti woman; and Indigenous artist, Tony Albert. I’ve used the questions asked during the interview as a base for this blog with thanks to Amanda Dell (producer).
Why has it taken so long for the debate to escape academia to be something we see in the opinion pages of publications now?
Social media and online activism have catapulted questions about identities and politics into our screen lives. Where television allowed us to switch the channel, or the topic skilfully changed at awkward moments in work or family conversations, our devices hold us captive. Simply scrolling through our social media feeds can encourage, enrage or mobilise us into fury or despair. Whether we like it or not, as users of social media we are being interpolated into the complex terrain of identity politics. Merely sharing a link on your social media feed locates you and your politics, in ways that you might never reveal in real time social conversations. ‘Sharing’ can have wide ranging consequences, a casual tweet before a flight resulted in Justine Sacco moving from witty interlocutor to pariah in a matter of hours. The merging of ‘private’ and public lives never being more evident.
How long has the term privilege been around?
The concept of privilege originally developed in relation to analyses of race and gender but has expanded to include social class, ability level, sexuality and other aspects of identity. Interestingly, Jon Greenberg points out that although people of color have fought racism since its inception, the best known White Privilege educators are white (Peggy McIntosh, Tim Wise and Robin DiAngelo). McIntosh’s 1988 paper White Privilege and Male Privilege: A Personal Account of Coming to See Correspondences through Work in Women’s Studies extended a feminist analysis of patriarchal oppression of women to that of people of color in the United States. This was later shortened into the essay White Privilege: Unpacking the Invisible Knapsack (pdf), which has been used extensively in a a range of settings because of it’s helpful list format .
Many people have really strong reactions to these concepts – why is that?
Robin DiAngelo, professor of multicultural education and author of What Does it Mean to Be White? Developing White Racial Literacy developed the term ‘white fragility’ to identify:
a state in which even a minimum amount of racial stress becomes intolerable, triggering a range of defensive moves. These moves include outward display of emotions such as anger, fear and guilt, and behaviors such as argumentation, silence and leaving the stress-inducing situation
DiAngelo suggests that for white people, racism or oppression are viewed as something that bad or immoral people do. The racist is the person who is verbally abusive toward people of color on public transport, or a former racist state like apartheid South Africa. If you see yourself as a ‘good’ person then it is painful to be ‘called out’, and see yourself as a bad person. Iris Marion Young’s work useful. She conceptualises oppression in the Foucauldian sense as:
the disadvantage and injustice some people suffer not because of a tyrannical power coerces them but because of the everyday practices of a well-intentioned liberal society…
Young points out the actions of many people going about their daily lives contribute to the maintenance and reproduction of oppression, even as few would view themselves as agents of oppression. We cannot avoid oppression, as it is structural and woven throughout the system, rather than reflecting a few people’s choices or policies. Its causes are embedded in the unquestioned norms, habits, symbols and assumptions underlying institutional rules and the collective consequences of following those rules (Young, 1990). Seeing oppression as the practices of a well intentioned liberal society removes the focus from individual acts that might repress the actions of others to acknowledging that “powerful norms and hierarchies of both privilege and injustice are built into our everyday practices” (Henderson & Waterstone, 2008, p.52). These hierarchies call for structural rather than individual remedies.
We probably need to start with privilege – what does that term mean?
McIntosh identified how she had obtained unearned privileges in society just by being White and defined white privilege as:
an invisible package of unearned assets which I can count on cashing in each day, but about which I am meant to remain oblivious (p. 1).
Her essay prompted understanding of how one’s success is largely attributable to one’s arbitrarily assigned social location in society, rather than the outcome of individual effort.
From: The Birth of Venus: Pulling Yourself Out Of The Sea By Your Own Bootstraps by Mallory Ortberg
McIntosh suggested that white people benefit from historical and contemporary forms of racism (the inequitable distribution and exercise of power among ethnic groups) and that these discriminate or disadvantage people of color.
How does privilege relate to racism, sexism? Are they the same thing?
It’s useful to view the ‘isms’ in the context of institutional power, a point illustrated by Sian Ferguson:
In a patriarchal society, women do not have institutional power (at least, not based on their gender). In a white supremacist society, people of color don’t have race-based institutional power.
Australian race scholars Paradies and Williams (2008) note that:
The phenomenon of oppression is also intrinsically linked to that of privilege. In addition to disadvantaging minority racial groups in society, racism also results in groups (such as Whites) being privileged and accruing social power. (6)
Consequently, health and social disparities evident in white settler societies such as New Zealand and Australia (also this post about Closing the gap) are individualised or culturalised rather than contextualised historically or socio-economically. Without context white people are socialized to remain oblivious to their unearned advantages and view them as earned through merit. Increasingly the term privilege is being used outside of social justice settings to the arts. In a critique of the Hottest 100 list in Australia Erin Riley points out that the dominance of straight, white male voices which crowds out women, Indigenous Australians, immigrants and people of diverse sexual and gender identities. These groups are marginalised and the centrality of white men maintained, reducing the opportunity for empathy towards people with other experiences.
Do we all have some sort of privilege?
Yes, depending on the context. The concept of intersectionality by Kimberlé Crenshaw is useful, it suggests that people can be privileged in some ways and not others. For example as a migrant and a woman of color I experience certain disadvantages but as a middle class cis-gendered, able-bodied woman with a PhD and without an accent (only a Kiwi one which is indulged) I experience other advantages that ease my passage through the world You can read more in the essay Explaining White Privilege to a Broke White Person.
How does an awareness of privilege change the way a society works?
Dogs and Lizards: A Parable of Privilege by Sindelókë is a helpful way of trying to understand how easy it is not to see your own privilege and be blind to others’ disadvantages. You might have also seen or heard the phrase ‘check your privilege’ which is a way of asking someone to think about their own privilege and how they might monitor it in a social setting. Exposing color blindness and challenging the assumption of race-neutrality is one mechanism for addressing the issue of privilege and its obverse oppression. Increasingly in health and social care, emphasis is being placed on critiquing how our own positions contribute to inequality (see my chapter on cultural safety), and developing ethical and moral commitments to addressing racism so that equality and justice can be made possible. As Christine Emba notes “There’s no way to level the playing field unless we first can all see how uneven it is.” One of the ways this can be done is through experiencing exercises like the Privilege Walk which you can watch on video. Jenn Sutherland-Miller in Medium reflects on her experience of it and proposes that:
Instead of privilege being the thing that gives me a leg up, it becomes the thing I use to give others a leg up. Privilege becomes a way create equality and inclusion, to right old wrongs, to demand justice on a daily basis and to create the dialogue that will grow our society forward.
Is privilege something we can change?
If we move beyond guilt and paralysis we can use our privilege to build solidarity and challenge oppression. Audra Williams points out that a genuine display of solidarity can require making a personal sacrifice. Citing the example of Aziz Ansari’s Master of None, where in challenging the director of a commercial about the lack of women with speaking roles, he ends up not being in the commercial at all when it is re-written with speaking roles for women. Ultimately privilege does not gets undone through “confession” but through collective work to dismantle oppressive systems as Andrea Smith writes.
Cultural appropriation is a different concept, but an understanding of privilege is important, what is cultural appropriation?
Cultural appropriation is when somebody adopts aspects of a culture that is not their own (Nadra Kareem Little). Usually it is a charge levelled at people from the dominant culture to signal power dynamic, where elements have been taken from a culture of people who have been systematically oppressed by the dominant group. Most critics of the concept are white (see white fragility). Kimberly Chabot Davis proposes that white co-optation or cultural consumption and commodification, can be cross-cultural encounters that can foster empathy and lead to working against privilege among white people. However, an Australian example of bringing diverse people together through appropriation backfired, when the term walkabout was used for a psychedelic dance party. Using a deeply significant word for initiation rites, for a dance party was seen as disrespectful. The bewildered organiser was accused via social media of cultural appropriation and changed the name to Lets Go Walkaround. So, I think that it is always important to ask permission and talk to people from that culture first rather than assuming it is okay to use.
What is the line between cultural appropriation and cultural appreciation?
Maisha Z. Johnson cultural appreciation or exchange where mutual sharing is involved.
Can someone from a less privileged culture appropriate from the more privileged culture?
No, marginalized people often have to adopt elements of the dominant culture in order to survive conditions that make life more of a struggle if they don’t.
Does an object or symbol have to have some religious or special cultural significance to be appropriated?
Appropriation is harmful for a number of reasons including making things ‘cool’ for White people that would be denigrated in People of Color. For example Fatima Farha observes that when Hindu women in the United States wear the bindi, they are often made fun of, or seen as traditional or backward but when someone from the dominant culture wears such items they are called exotic and beautiful. The critique of appropriation extends from clothing to events Nadya Agrawal critiques The Color Run™ where you can:
run with your friends, come together as a community, get showered in colored powder and not have to deal with all that annoying culture that would come if you went to a Holi celebration. There are no prayers for spring or messages of rejuvenation before these runs. You won’t have to drink chai or try Indian food afterward. There is absolutely no way you’ll have to even think about the ancient traditions and culture this brand new craze is derived from. Come uncultured, leave uncultured, that’s the Color Run, promise.
The race ends with something called a “Color Festival” but does not acknowledge Holi. This white-washing (pun intended) eradicates everything Indian from the run including Holi, Krishna and spring. In essence as Ijeoma Oluo points out cultural appropriation is a symptom, not the cause, of an oppressive and exploitative world order which involves stealing the work of those less privileged. Really valuing people involves valuing their culture and taking the time to acknowledge its historical and social context. Valuing isn’t just appreciation but also considering whether the appropriation of intellectual property results in economic benefits for the people who created it. Kareem Abdul-Jabbar suggests that it is often one way:
One very legitimate point is economic. In general, when blacks create something that is later adopted by white culture, white people tend to make a lot more money from it… It feels an awful lot like slavery to have others profit from your efforts.
Loving burritos doesn’t make someone less racist against Latinos. Lusting after Bo Derek in 10 doesn’t make anyone appreciate black culture more… Appreciating an individual item from a culture doesn’t translate into accepting the whole people. While high-priced cornrows on a white celebrity on the red carper at the Oscars is chic, those same cornrows on the little black girl in Watts, Los Angeles, are a symbol of her ghetto lifestyle. A white person looking black gets a fashion spread in a glossy magazine; a black person wearing the same thing gets pulled over by the police. One can understand the frustration.
The appropriative process is also selective, as Greg Tate observes in Everything but the burden, where African American cultural properties including music, food, fashion, hairstyles, dances are sold as American to the rest of the world but with the black presence erased from it. The only thing not stolen is the burden of the denial of human rights and economic opportunity. Appropriation can be ambivalent, as seen in the desire to simultaneously possess and erase black culture. However, in the case of the appropriation of the indigenous in the United States, Andrea Smith declares (somewhat ironically), that the desire to be “Indian” often precludes struggles against genocide, or demands for treaty rights. It does not require being accountable to Indian communities, who might demand an end to the appropriation of spiritual practices.
Some people believe the cuisines of other cultures have been appropriated – is this an extreme example, or is it something we should consider?
The world of food can be such a potent site of transformation for social justice. I am a committed foodie (“somebody with a strong interest in learning about and eating good food who is not directly employed in the food industry” (Johnston and Baumann, 2010: 61). I am also interested in the politics of food. I live in Melbourne, where food culture has been made vibrant by the waves of migrants who have put pressure on public institutions, to expand and diversify their gastronomic offerings for a wider range of people. However, our consumption can naturalise and make invisible colonial and racialised relations. Thus the violent histories of invasion and starvation by the first white settlers, the convicts whose theft of food had them sent to Australia and absorbed into the cruel colonial project of poisoning, starving and rationing indigenous people remain hidden from view. So although we might love the food we might not care about the cooks at all as Rhoda Roberts Director of the Aboriginal Dreaming festival observed in Elspeth Probyn’s excellent book Carnal Appetites:
In Australia, food and culinary delights are always accepted before the differences and backgrounds of the origin of the aroma are.
Lee’s Ghee is an interesting example of appropriation, she developed an ‘artisanal’ ghee product, something that has been made for centuries in South Asia.
Lee Dares was taking the fashion world by storm working as a model in New York when she realized her real passion was elsewhere. So, she made the courageous decision to quit her glamorous job and take some time to explore what she really wanted to do with her life. Her revelation came after she spent some time learning to make clarified butter, or ghee, on a farm in Northern India. Inspired, she turned to Futurpreneur Canada to help her start her own business, Lee’s Ghee, producing unique and modern flavours of this traditional staple of Southeast Asian cuisine and Ayurvedic medicine.
The saying “We are what we eat” is about not only the nutrients we consume but also to beliefs about our morality. Similarly ‘we’ are also what we don’t eat, so our food practices mark us out as belonging or not belonging to a group.So, food has an exclusionary and inclusionary role with affective consequences that range from curiosity, delight to disgust. For the migrant for example, identity cannot be taken for granted, it must be worked at to be nurtured and maintained. It becomes an active, performative and processual project enacted through consumption. With with every taste, an imagined diasporic group identity is produced, maintained and reinforced. Food preparation represents continuity through the techniques and equipment that are used which affirm family life, and in sharing this food hospitality, love, generosity and appreciation can be expresssed. However, the food that is a salve for the dislocated, lonely, isolated migrant also sets her apart, making her stand out as visibly, gustatorily or olfactorily different. The resource for her well being also marks her as different and a risk. If her food is seen as smelly, distasteful, foreign, violent or abnormal, these characteristics can be transposed to her body and to those bodies that resemble her. Dares attempt to reproduce food that is made in many households and available for sale in many ‘ethnic’ shops and selling it as artisanal, led to accusations of ‘colombusing’ — a term used to describe when white people claim they have discovered or made something that has a long history in another culture. Also see the critique by Navneet Alang in Hazlitt:
The ethnic—the collective traditions and practices of the world’s majority—thus works as an undiscovered country, full of resources to be mined. Rather than sugar or coffee or oil, however, the ore of the ethnic is raw material for performance and self-definition: refine this rough, crude tradition, bottle it in pretty jars, and display both it and yourself as ideals of contemporary cosmopolitanism. But each act of cultural appropriation, in which some facet of a non-Western culture is columbused, accepted into the mainstream, and commodified, reasserts the white and Western as norm—the end of a timeline toward which the whole world is moving.
If this is the first time someone has heard these concepts, and they’re feeling confused, or a bit defensive, what can they do to understand more about it?
Here are some resources that might help, videos, illustrations, reading and more.
- Toby Morris has created a beautiful illustration of Privilege.
- A hilarious look at white male privilege by Elliot Kalan.
- Video White privilege glasses from Chicago Theological Seminar.
- 11 Common Ways White Folks Avoid Taking Responsibility for Racism in the US by Robin DiAngelo.
- A great edited book on whiteness in Australia: Whitening Race: Essays in Social and Cultural Criticism By Aileen Moreton-Robinson
- McSweeney’s have some hilarious writing on privilege including: a humorous product review of the invisible backpack of white privilege from by Joyce Miller; Don’t worry, I checked my privilege by Elliot Kalan; Some relatively recent College grads discuss their maids by Ellie Kemper and Privilege-checking preambles of varying degrees of singularity by George Morony.
- 4 Ways White People Can Process Their Emotions Without Bringing the White Tears by Jennifer Loubriel.
- The fairest — and funniest — way to split a restaurant bill by Emily Badger·
- See the excellent work on privilege by the Whariki Research Group, Massey University, New Zealand.
- Read about the reductive seduction of other people’s problems.
- Read more about whiteness, in an interview with Robin DiAngelo.
- Tim Wise has tons of resources.
- Check your privilege at the door.
- View the Unequal Opportunity Race. Screened as part of the Black History Month program at Glen Allen High School in Glen Allen, Virginia.
- This piece by Ali Owens about 4 problematic statements White people make about race — and what to say instead is useful: “I Don’t See Color.” “All Lives Matter.” “If racism is still a problem, how come we have a black president?” “Reverse racism is real.”
- The eight ways of being white by Gillian Schutte examines Barnor Hesses’ work (about whiteness studies from a radical black perspective) outlining the eight categories of white identity.
- An interesting read about privilege in sport using the example of Maria Sharapova and Serena Williams: The Benefit of the Doubt: A Case Study On White Privilege.
- Whiteness as Metaprivilege.
- The Subtle Linguistics of Polite White Supremacy.
- If you’d like to try the group exercise on privilege adapted from the Horatio Alger exercise by Ellen Bettman, you can read the questions here.
- Oscar Kightley’s terrific take down of the myth of Maori privilege.
- Brown eye asking about whether Maori seats in New Zealand is privileging Maori.
- A sobering read Death by gentrification: the killing that shamed San Francisco | Rebecca Solnit.
- Aarti Olivia has a lovely piece on when it is appropriate to wear Indian cultural items.
- An exploration of Orientalism & Asian cultural appropriation as found in American music by Ube Empress.
- A much-needed primer on cultural appropriation by Katie J.M. Baker.
- More about food and cultural appropriation by Niya Bajaj.
- Check out this exploration of visual and auditory appropriation in US culture by Portland artist Roger Peet, featuring local residents.
- A critique of appropriation in fashion, Valentino’s African summer in Parallel magazine.
- I’ve written about cultural consumption in this piece on food and festivals, also about the white saviour complex and moving from being a bystander to an ally.
- A useful explanation on the meaning of a Native American headdress and why not to wear one.
- Brilliant piece by Texta Queen on cultural appropriation, white privilege and art on the fabulous Peril site.
This is a longer version of a review of Damien Riggs & Clare Bartholomaeus’ paper published in the Journal of Research in Nursing: Australian mental health nurses and transgender clients: Attitudes and knowledge. Cite as: De Souza, R. (2016). Review: Australian mental health nurses and transgender clients: Attitudes and knowledge. Journal of Research in Nursing, 0(0) 1–2. DOI: 10.1177/1744987115625008
I have never forgotten her face, her body, even though more than twenty years have passed. She was not much older than me and she desperately wanted to be a he. I had no idea how to respond to her depression and her recent self-harm attempt in the context of her desire to change gender. There was nothing in my nursing education that had prepared me for how I might be therapeutic and there was no one and nothing in the acute psychiatric inpatient unit that could resource me. I feel embarrassed now that I had no professional understanding and experience to guide me to help me provide effective mental health care to my client. I was an empathic kind listener, but I had been immersed in a biologically deterministic (one’s sex at birth determines ones’ gender) and binary view of gender despite my own diverse cultural background which I had been socialized to see as separate from my mainly white nursing education. I had not been educated to critically consider discourses of sex and gender, to provide competent safe care to someone who wanted to change her gender and express her gender differently from normative gender categories (Merryfeather & Bruce, 2014). My work has since led me to consider the ways in which “differences” are produced culturally, politically, and epistemologically specifically in terms of categories including “race”, ethnicity, nationality, class, and more recently sexuality and gender.
Four critiques of biomedicine as a dominant framework for understanding ‘problems with living’ have inspired transformation of the mental health system. Firstly, the emphasis on participation and inclusion through consumer-led and recovery-oriented practice has profoundly changed the role of consumers from passive recipients of care to being more informed and empowered decision-makers whose lay knowledge and personal experience of mental illness are a resource (McCann and Sharek, 2014). This reconceptualisation has been formalised in the ‘recovery’ model, which has critiqued the stigmatising judgements of medico-psychiatric discourse about deviance and their accompanying social exclusion and disadvantage (Masterson and Owen, 2006). The third has been the recognition of cultural diversity and a critique of the limits of universalism. Finally, gender activism has exposed fractures in the sex/gender system and has led to a greater awareness of diversity, with regard to gender and sexual orientation.
Of these critiques, gender activism has received the least attention in mental health nursing; which is a concern, given the negative effects of heteronormativity and cisgenderism. Mental health nurses must continue to challenge or trouble the dominant binary views of gender and the discourse of biological determinism, the notion that the sex that one is assigned at birth determines ones’ gender (Merryfeather and Bruce, 2014). There is growing evidence of negative attitudes, a lack of knowledge, and a lack of sensitivity toward people whom are expressing diverse genders and sexualities. This discrimination creates barriers to the patients’ health gain and creates disparity (Chapman et al., 2012; McCann and Sharek, 2014).
The reviewed article on the attitudes of mental health nurses towards transgender people is therefore timely, given the relative invisibility of issues of gender identity within nursing theory, practice and research. As Fish (2010) wrote previously in this journal, the culture, norms and values of social institutions can inhibit access to healthcare and reinforce disparities in health outcomes. Cisgenderism (the alignment of one’s assigned sex at birth and one’s gender identity and gender expression with societal expectations) suffuses every aspect of clinical access to and through services, from written materials including mission statements, forms, posters and pamphlets; the built environment such as gender-specific washrooms; and interactions with both health professionals and allied staff, all of which reinforce a message of exclusion of transgender people (Baker and Beagan, 2014; Rager Zuzelo, 2014). In turn, these exclusionary practices are shaped through a dearth of policies and procedures, and scant educational preparation at the undergraduate and graduate levels (Eliason et al., 2010; Fish, 2010).
Nurses have a professional responsibility to challenge structural constraints and social policies, rather than passively accepting them. This paper provided compelling evidence for how nursing as a discipline and mental health nursing as a unique speciality can critically reflect on discourses regarding sex and gender; and on how these influence practice and consequently, can develop safer, ethical, effective and high-quality care for people whom either change their sex or express their gender differently from the standard culturally determined gender categories (Merryfeather and Bruce, 2014). Furthermore, this paper challenges mental health nurses to challenge heterosexism and cisgenderism; to speak out about social determinants of health that contribute to health inequities and health disparities, such as transphobia; and to address discrimination against transgender people. These challenges must be embedded into processes at the organizational, regulatory and political level (DeSouza, 2015).
Baker K and Beagan B (2014) Making assumptions, making space: An anthropological critique of cultural competency and its relevance to queer patients. Medical Anthropology Quarterly 28(4): 578–598. doi:10.1111/maq.1212.
Chapman R, Watkins R, Zappia T, et al. (2012) Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. Journal of Clinical Nursing 21(7,8): 938–945. doi:10.1111/j.1365-2702.2011.03892.
De Souza R (2015) Navigating the ethics in cultural safety. In: Wepa D (ed.) Cultural safety. Port Melbourne, Australia: Cambridge University Press, pp. 111–124.
Eliason MJ, Dibble S and Dejoseph J (2010) Nursing’s silence on lesbian, gay, bisexual and transgender issues: The need for emancipatory efforts. Advances in Nursing Science 33(3): 206–218. doi:10.1097/ANS.0b013e3181e63e4.
McCann E and Sharek D (2014) Challenges to and opportunities for improving mental health services for lesbian, gay, bisexual and transgender people in Ireland: A narrative account. International Journal of Mental Health Nursing 23(6): 525–533. doi:10.1111/inm.12081.
Masterson S and Owen S (2006) Mental health service user’s social and individual empowerment: Using theories of power to elucidate far-reaching strategies. Journal of Mental Health 15(1): 19–34. doi:10.1080/0963823050051271.
Merryfeather L and Bruce A (2014) The invisibility of gender diversity: Understanding transgender and transsexuality in nursing literature. Nursing forum 49(2): 110–123.
Rager Zuzelo P (2014) Improving nursing care for lesbian, bisexual and transgender women. Journal of Obstetric, Gynecologic and Neonatal Nursing 43(4): 520–530. doi:10.1111/1552-6909.1247.
This was first published in the Spring 2015 edition (Issue 41) of the Federation of Ethnic Councils of Australia (FECCA) national magazine, Australian Mosaic. Cite as: DeSouza, R. (2015). Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health. Australian Mosaic (FECCA). 41, 34-36.
Decades afterward, I still recall the frequent waking, getting out of bed and moving around our Nairobi house in the dark. Sometimes I moved pots and pans, re-arranged furniture, but mostly I caused a disturbance. My parents decided to address my distressing behaviour by taking me to an older woman from our Goan community who chanted
prayers and anointed me with chilli and garlic. Her incantations arrested the nocturnal disturbances, which never perturbed me again. The evil eye was diagnosed, the somnambulism caused by envy, inflicted on me with a look. I later learned that the
evil eye is seen as the cause of many problems and illnesses globally with a multitude of rituals and remedies to either prevent or cure it.
My own experience of being a multiple migrant and then a clinician, led me to consider many possible antecedents to mental illness. The dominance of biomedicine to manage health and illness, assumes cross-cultural universals. Yet, mental health is a contested specialty with problematic treatments. Culturally derived norms and values from a specific location impose labels on behaviour from another context, which drive treatments, or management that flattens those contexts. Psychiatry and counseling are often viewed skeptically by people from refugee and migrant backgrounds who instead turn first to informal sources outside the health system including self-help, family, community, social networks, various forms of spirituality, religion and church. Increasingly, clinicians are appreciating the part these sources of support play.
Once mental health services are accessed, if staff focus on mental illness without understanding the cultural context or without realising that clients and their families might integrate both biomedical and more “traditional” beliefs, quality psychiatric assessment can be impaired and the potential for inaccurate diagnosis and inappropriate treatment and care can occur. Incorrectly identifying culturally appropriate behaviour or experiences as psychopathology is problematic, just as assuming that something is cultural rather than psychopathology or symptoms. However, every culture has frameworks for understanding health and illness and how these are demarcated.
In Aotearoa New Zealand, where I have spent most of my life, Maori psychiatrist Mason Durie has conceptualised Maori health as encompassing mental (hinengaro), physical (tinana), family/social (whänau), and spiritual (wairua) dimensions. In Australia, the National Aboriginal Health Strategy (1989) views wellbeing through a communal lens, broadening the concept of well-being beyond the to the social, emotional and cultural well-being of the whole community. Situating Aboriginal and Torres Strait Islander mental health within a framework of social and emotional wellbeing emphasise wellness, harmony and balance rather than illness and symptom reduction (AIHW 2012). Connection to land, culture, spirituality, ancestry, family and community, interdependence between families, communities, land, sea and spirit are also seen as necessary for health. The Ways Forward National Aboriginal and Islander Mental Health Policy Report 3 (pp19-20) adapted from Swan and Raphael also prioritises holism, self-determination, the need for cultural understanding, the impact of history in trauma and loss, human rights, acknowledges the impact of racism and stigma, kinship, cultural diversity and Aboriginal strengths.
Contemporary neoliberal health discourses have co-opted patient rights movements and positioned patients as consumers -active partners in health who are responsible for their own health. Consumer engagement and health literacy form a suite of strategies for inducing medical citizenship, so that individuals can participate and become knowledgeable consumers. Some would argue these are assimilatory processes. However, in order for medical citizenship to be a two way process, one’s own beliefs about the causes of illness and the corresponding treatments must also be considered. Health literate organisations must also be open to a multiplicity of illness explanations and to those locations from which such beliefs are derived. As Beijers and de Freitas (p.245), note:
Health care is transforming social suffering into illnesses and diagnoses, while often denying the social and moral origins and implications of the suffering
David Ingleby suggests that two perspectives are available for thinking about culture and mental illness. A technical perspective assumes mainstream frameworks and treatments can be universalised to all patients/clients and that more sensitivity and overcoming linguistic and cultural barriers will assist therapeutic efforts. With a technical approach to mental health, the goal of care is to deliver it efficiently and increase utilization (efficacy). Strategies can include access to language matched information and professional interpreting services, or improving mental health literacy and awareness, supporting community resilience and coping strategies. However, technical approaches do not ask questions about power imbalances between groups.
On the other hand when care is given through a critical lens (equity), the questions become what is going on when interventions developed for one population are applied to another? What are the underlying power relations? Whose interests are being served? Is there a covert attempt to impose the values and perspectives of the dominant group? Ingelby suggests that becoming a user of Western health care involves accepting its underlying philosophy and values and “acquiring health literacy”.
It is important that collaborations between traditional healing mechanisms and western practice are made possible, however within professional discourses traditional healing is frequently viewed as primitive and unprofessional, yet people often utilize different health beliefs simultaneously in their search for optimal treatment. Furthermore, assimilation and acculturation into the dominant culture are thought to negatively impact on migrant health status and to contribute to migrant ill health and disparities as the healthy migrant advantage that people arrive with reduces after a year. Developing collaborative models that combine traditional and Western health knowledges and combining health literacy and consumer participation with better access and quality of staff can indeed facilitate better health outcomes.
As an educator, I am interested in how I can do my part to increase the awareness and openness to pluralism, so that the next generation of nurses can be effective and therapeutic. There is guidance available from The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services. There is an emphasis on being respectful and having non-judgmental curiosity about other cultures. Mental health workers are encouraged to seek cultural knowledge in an appropriate way, tolerate ambiguity and develop the ability to handle the stress of ambiguous situations. In addition, developing a family-sensitive practice, where family and community resources are viewed as partners in recovery as appropriate allow syncretism and innovation to take place. There are significant institutional barriers remaining to this in mental particularly the emphases on privacy, independence and the one-to-one relationship between consumer and professional.
Very excited about the 2nd Edition of Cultural safety in Aotearoa New Zealand being published by Cambridge Press in December 2015.
I’ve contributed two chapters and I have excerpted the introduction of each chapter below:
8. Navigating the ethical in cultural safety
Caring is an ethical activity with a deep moral commitment that relies on a trusting relationship (Holstein & Mitzen, 2001). Health professionals are expected to be caring, skilful, and knowledgeable providers of appropriate and effective care to vulnerable people. Through universal services they are expected to meet the needs of both individual clients and broader communities, which are activities requiring sensitivity and responsiveness. In an increasingly complex globalised world, ethical reflection is required so that practitioners can recognise plurality: in illness explanations; in treatment systems; in the varying roles of family/whanau or community in decision making; and in the range of values around interventions and outcomes. To work effectively in multiple contexts, practitioners must be able to morally locate their practice in both historical legacies of their institutional world and the diversifying community environment. This chapter examines the frameworks that health professionals can use for cross-cultural interactions.I then explore how they can select the most appropriate one depending on the person or group being cared for.
13. Culturally safe care for ethnically and religiously diverse communities
Cultural safety is borne from a specific challenge from indigenous nurses to Western healthcare systems.It is increasingly being developed by scholars and practitioners as a methodological imperative toward universal health care in a culturally diverse world. The extension of cultural safety, outside an indigenous context, reflects two issues: a theoretical concern with the culture of healthcare systems and the pragmatic challenges of competently caring for ethnically and religiously diverse communities. As discussed throughout this book, the term ‘culture’ covers an enormous domain and a precise definition is not straightforward. For the Nursing Council of New Zealand (‘the Nursing Council’) (2009), for example, ‘culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability’.
In an attempt at a precise two-page definition, Gayatri Chakravorty Spivak (2006, p. 359), captures the reflexive orientation required to grasp how the term ‘culture’ works:
Every definition or description of culture comes from the cultural assumptions of the investigator. Euro-US academic culture… is so widespread and powerful that it is thought of as transparent and capable of reporting on all cultures. […] Cultural information should be received proactively, as always open-ended, always susceptible to a changed understanding. […] Culture is a package of largely unacknowledged assumptions, loosely held by a loosely outlined group of people, mapping negotiations between the sacred and the profane, and the relationship between the sexes.
Spivak’s discussion of the sacred and the profane links culture to the more formal institution of religion, which has historically provided the main discourse for discussion of cultural difference. Particularly important for cultural safety is her discussion of Euro-US academic culture, a ‘culture of no culture’, which has a specific lineage in the sciences of European Protestantantism. Through much of the 19th century, for example, compatibility with Christianity was largely assumed and required in scientific and medical knowledge, even as scientists began to remove explicit Christian references from their literature. This historical perspective helps us see how the technoscientific world of the healthcare system, and those of us in secular education, are working in the legacy of white Christian ideals, where the presence of other cultures becomes a ‘problem’ requiring ‘solutions’. Cultural safety, however, attempts to locate the problem where change can be achieved in the healthcare system itself.
Other contributors include: Irihapeti Ramsden, Liz Banks, Maureen Kelly, Elaine Papps, Rachel Vernon, Denise Wilson, Riripeti Haretuku, Deb Spence, Robin Kearns, Isabel Dyck, Ruth Crawford, Fran Richardson, Rosemary McEldowney, Thelma Puckey, Katarina Jean Te Huia, Liz Kiata, Ngaire Kerse, Sallie Greenwood and Huhana Hickey.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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
http://amptoons.com/blog/files/mcintosh.htmlWhat kind of Asian are you?
https://www.youtube.com/watch?v=DWynJkN5HbQReverse racism, Aamer Rahman:
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).