Culture and ethnicity: The delivery of health care

Maori people comprises a large proportion of users of health services

Every country, race, ethnic group or society has its own culture. As it is, every culture is different from the other; this difference is reflected in the way day to day activities are carried out and in the way the society expects people to live their lives. Since the world over is becoming global, we should know how cultural sensitivity and competence affects those who we interact with. Basing on my cultural assessment, this paper clearly shows how cultural sensitivity and competence impacts the care of mental health clients and the possible risks or protective factors arising from my cultural assessment. All the results presented here are based on the cultural assessment which entails history of my cultural group, values orientation, cultural sanctions and restrictions, health related believes and practices and my religious affiliation.

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According to Flaskerud (2007) Cultural sensitivity means respecting the practices, the norms and the beliefs of other people. It is defined by; as an individual knowing your own cultural practices and beliefs and by not judging other people whose culture is different from yours and by treating them with respect. As professionals in the health industry, we should have flexibility and skill when dealing with those who have different cultural backgrounds so as to be effective in carrying out our duties in our profession.

Also according to Flaskerud (2007) Cultural competence is defined as the policies, behaviors and attitudes that are in an organization or among people who are of the same profession and make them work together in cross cultural environment. To an individual, it is the ability to work with competence in an environment of diverse cultures.

The two: cultural competence and cultural sensitivity are very vital in mental health; to a mental health and or a psychiatric nurse it will help them be successful in caring and treating mental ill patients regardless of their cultural background. According to Bowl (2007) good communication between the nurses and the mentally ill patients is enhanced by having cultural competence and cultural sensitivity. This is so because, in most cases the patients might not understand the language spoken by the nurses and this hinders the success of psychiatric assessment where it is important to understand what is being communicated. Being a culturally sensitive nurse, you will see the importance of having an interpreter who will make things easy for both parties as all needed will be communicated and got.

Having cultural competence and cultural sensitivity, helps in determining the right kind of approach to the patients. According to Bowl (2007) during a psychiatric assessment, the nurse or a doctor prepares a set of questions or tasks to be administered to the patient. It will be inappropriate to ask someone to do a simple subtracting and adding test and yet there are from background that does not go to school.

As a mental health/psychiatric nurse, having cultural competence and cultural sensitivity helps one understand and respect the patients’ needs. According to Bowl (2007) there is a very big need to understand and appreciate the patients’ religion. It will be in appropriate to tell all patients to go to the hospital chapel and pray. It will sound well to Christians but to the Muslim or Hindus will be like an insult. The nurses should also know and respect the patients need to pray many times a day. Bowl (2007) also noted that some nurses interpreted such as obsession and in the real sense it’s what their religion calls for.

Hygiene is important to everyone. Having cultural competence and cultural sensitivity, helps nurses understand the needs of hygiene for different patients. According to Bowl (2007) in some cultural backgrounds, it is a norm to use bowls or containers to clean themselves either after visiting the toilets or just as a mode of bathing, in some hospital it was noted that, this was seen as unacceptable and it was discouraged, this made them feel offended and some choose not to cooperate.

Having cultural competence and cultural sensitivity, enables nurses provide enough care and love to the patients and help them bridge a gap left by the patients’ loved ones or family. According to Bowl (2007) in some cultures mentally ill people are neglected by their families and they lack emotional support. As a nurse or medical personnel, being aware of how the patients are treated by their people will enable you give them the care they are missing and this makes them feel important and makes them willing to cooperate.

The findings from my cultural assessment may impact the way I care for my clients in mental health setting in the following ways: being an urban Filipino, I will find it hard to perform a full psychiatric assessment without the help of an interpreter when am faced with patients whose dialect I don’t understand. I grew up in the city I am exposed to Filipino and English which I know and understand.

In my culture, the mentally ill are seen as a shame to the whole family and they are not highly valued. With this mentality, it might not be easy for me to freely interact with the patients as I will not be expecting anything serious in terms of talk with them.

My cultural restrictions and sanctions might also influence the way I view and care for the mentally ill; since most of them have emotional distress, if they withdraw from other people I might fail to make them interact with people since my culture has made me view this as a normal reaction for people in such situation.

Most people in my culture associate mental illness with spirits and supernatural acts; during my interaction with the patients, I will say prayers to shun the spirits from attacking me during my care for the patients. But since I have learned that mental illness has a cause which can be scientifically explained I will try as much as I can not to be bound by any other mode of treatment apart from medical methods.

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My findings from my cultural assessment are protective factors. From the assessment, I have summarized my cultural expectations and norms and this has enabled me appreciate other cultures. I am now aware that people are different and as I want my culture to be respected I now know that others also want theirs to be respected. For example being an urban Filipino, I will know I am different from those from rural areas and I will expect them to behave and talk differently, I won’t let the diversity put a bias on the way we are going to relate to each other.

From the assessment I have learned that mentally ill people behave differently and are seen as shame to the society, as a care giver, this should make me step in and give them the care they lack, and this might cement my relationship with them and protect us from conflicting or miss understanding each other.

Expectations of my religion are different from another religion’s; this will make me appreciate beliefs of patients from a different religious affiliation and this will protect us from engaging in unnecessary disagreements concerning either: times or places of prayer in a hospital premises. In my culture it’s largely expected that medical personnel should take care and really help those who have been brought to the hospital for medical care. In order to guard and protect the name of my profession, I will try to help the patients so that a notable change will be seen.

In conclusion, there are so many cultures, and each culture is different; cultural sensitivity and competence are skills that should be acquired and practiced by those in the health setting and especially, mental/psychiatric setting. As noted, mental ill patients should be viewed with respect and given the care they need. Their way of life should be respected and maintained. As health workers, we should learn from our cultures; how we want to be treated and seen regarding our cultures, should be the same way we view and think about other people’s cultures.


and the health status of Maori is recognized as a health priority area (Nursing Council of New Zealand (NCNZ), 2009). To work effectively and providing Maori health centered nursing care, it is prerequisite for nurses to know history of New Zealand, understand Maori health and incorporate principles of Treaty of Waitangi in their nursing practice (Scryymgeour, 2009).

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Treaty of Waitangi was signed on February 6, 1840. It is a formal agreement signed between British Crown and Maori (indigenous people of New Zealand). It is founding document of New Zealand and has great significance for health care professionals while working with Maori clients. There are three main principles of the Treaty commonly referred as 3P`s. These are Partnership, Protection and Participation (Ministry of health, 2002). Nurses being agents of the Government (Crown) are committed to recognizing the rights of Maori and honoring the Treaty of Waitangi by applying its principles.

Nurses apply the principle of Partnership by maintaining a therapeutic relationship with their client. Nurses work in collaboration with clients towards the common objective of attaining better health outcomes. Nurses respect the unique cultural identity of the client by involving clients in decision making. This strengthens clients` awareness regarding their treatment and emphasize the possibilities of positive health outcomes. It also preserves the integrity of clients. (NCNZ, 2009).

The second principle of the Treaty is Protection. As per this principle, the Crown has obligation to protect Maori health (Wepa, 2004). When caring for Maori clients, nurses are committed to the protection and improvement of Maori health by providing best quality care which is culturally safe and acceptable to Maori clients. Its aim is to reduce inequalities in health care delivery among Maori and Non-Maori.

Third principle of the Treaty is Participation. In health care setting, it is expected from the nurses to enable clients and encourage an active participation from them. It is very important for nurses to engage clients in all decisions related to their care. Nurses recognize that they can involve client`s family in planning individualized health care for the client. However, it can be possible only if the client wish to do so. (Scryymgeour, 2009).

Government ensures that treaty of Waitangi is recognized and honored in health care system. Waitangi Tribunal was established under Treaty of Waitangi Act 1975. If Maori clients do not acknowledge the given care as culturally safe or if there is a breach of Treaty, it can be addressed to the Tribunal to get a solution for such problem. Then, Public Health and Disability Act 2000 came into action to ensure that all health practitioners respect the Treaty. Besides this, the government developed the New Zealand Health Strategy (200…) for promoting adequate delivery of health care and combating inequalities in health. One of its principles is Acknowledging the Treaty of Waitangi.

Nurses can incorporate principles of the Treaty effectively to bring positive health outcomes once they understand concept of Maori Health. Maori Health Strategy (2002) identified various risk factors such as history of colonization, poverty, poor housing, overcrowding and unemployment; contribute toward poor Maori health outcomes. Nurses must understand Maori health. This will enable nurses to cater unique needs of Maori clients by providing nursing care which is relevant and appropriate to Maori cultural and personal needs of clients.

There are different health models, which can be used to gain better understanding of Maori health. For instance, Te Whare Tapa Wha and Te Wheke. According to Durie (2001), Te Whare Tapa Wha model represents four dimensions of health in form of four walls of whare (house). These are taha wairua(spiritual health), taha hinengaro (mental health), taha tinana (physical health) and taha whanau (family health). If any wall is weakened, it hampers the positive health outcomes. It is vital for nurses to recognize Maori beliefs and values in order to make constructive relationship with clients to achieve positive health outcomes.

Treaty of Waitangi serves as platform for culture safety. Nurses working in the New Zealand must be competent to practice culturally safe care and incorporate principles of the Treaty of Waitangi in their nursing practice (Scryymgeour, 2009). The term kawa whakaruruhau or cultural safety developed after dissatisfaction of Maori student nurses about adequate delivery of health care and its access to Maori population. Ramsden firstly introduced cultural safety in nursing in 1980, which was later included in nursing curriculum by the Nursing Council of New Zealand (NCNZ) in 1990. It is expected from nurses to provide culturally safe care by keeping in consideration all that makes every individual unique. Cultural safety is an outcome of nursing practice that empowers the recipient of care to define culturally safe practice

The key element in cultural safety is biculturalism. Ramsden (2002) described that every interaction between people is bicultural, because every person has a unique cultural identity. As per NCNZ (2009) guidelines for cultural safety in nursing education, in order to understand and become culturally safe, firstly, nurses must recognize their own cultural values, beliefs and attitude, which may affect the way they provide care to their clients. Secondly, nurses must have gained adequate knowledge and skills required to practice culturally safe. Nurses must also respect the cultural diversity of client by recognizing the similarities and differences between diverse cultures. It insists on changing the power in health care setting from nurses to recipients of care. Once this turnover occurs, the clients are empowered to define the culturally safe practice (Papps, 2007).

Culturally safe practice is really worthwhile when nurses work with patients from a culture different to their own. Nurses work to deliver culturally sensitive care. The clients` view about the given nursing care enables nurses to reflect back and evaluate their own nursing practice. Nurses are recognized as bearer of their own cultures, values and attitudes (Natinonal Abroginal Health Organisation, 2006). Nurses use power during their nursing practice and also empower clients. However, there may be power imbalances in which the client feels powerless. These issues require to negotiate and ensure that client receive culturally safe care. Nurses have obligation to maintain balance between power relationships. It can only be possible when nurse builds a therapeutic relationship with the client by allowing active participation from the client (Meyst, 2005).

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Nurses confront many situations where cultural beliefs and values of clients may affect the delivery of health services. For example, blood transfusion is done in a good faith to improve the health condition or to save life of a client. However, if a Jehovah Witness pregnant lady does not agree for blood transfusion saying that it is against her religious beliefs (Levy, 1999). In such a situation, nurses respect the client`s decision; nurses can not enforce treatment on client for sake of betterment of client`s health. If they do so, it will be culturally unsafe. As it diminishes, humiliates and disempower the unique cultural identity of the client (NCNZ, 2005, p4). There are several models which guide nurses in providing care which is culturally safe. Particularly, Campinha-Bacote`s (1999) model of cultural competence and Walker`s (1994) `valuing difference` Model.

Becoming self aware is vital for nurses as it helps nurses in improving their personal and professional development. To ensure that nurses are competent to provide culturally safe care determined by recipient of care, the NCNZ (2005) has outlined competencies for registered nurses. As per this criterion, nurses are expected to reflect on their own practice and values that influence their practice. Nurses preserve the integrity of clients by respecting their personal values. Every person has their own values which determines their decision making process.

Nurses carry their own values and beliefs that help them in deciding what is good or bad. Woodbridge and Fulford (2003) state that value-based practice is one of the tool of effective decision making in healthcare setting. Nurses respect the values by demonstrating equality for all clients` values as a person, not only as an individual suffering from mental illness. Nurses must be able to recognize and differentiate their personal and professional values, because it may also affect the delivery of nursing care to the clients. It is likely for a nurse to confront a dilemma choosing her personal or professional values. The best way for the nurses to deal with such a dilemma is by deciding what values the most in providing quality care to the client. It is possible only if nurses understand the core values of client.

Self critiquing reflective practice is very important aspect of nursing care. It helps nurses to widen their sphere of learning by identifying significant and long term changes to their nursing practice (Paget, 2001). Nurses reflect back on their practice and critically analyze that how they dealt with a situation, how their own values and client`s values affected the delivery of health care. Reflective practice models can guide nursing practice. John`s model of reflection is one of them. It mainly emphasize on describing events. It outlines the various factors influencing the strategies and highlights the significance learning after experience.

Meyst, a registered nurse, shared her experience that exploring more knowledge about self awareness and culture safety has changed her practice (2005). She attended two-day workshop at her workplace. It challenged her attitudes, beliefs and stereotypes about providing care to particular group of clients. She shared a particular incident to explain its implication. A pregnant woman, Mrs. Jones (not her real name) along with her seven children arrived to day care surgery for an elective procedure. She apologized that she could not arrange a baby sitter for her children.

On confronting the situation, nurse accepted that she would have felt impatient with client if she would not have changed her viewpoint regarding values, beliefs and cultural safety. She may have imposed her judgment about the client`s seven children in relation to overpopulation in the world. In contrast, she actually faced the situation being more open minded. She welcomed client respectfully. As she is well aware that the focus of her care is client. Therefore, she made the client comfortable and established a constructive relationship. She prepared the client for surgery. It is very clear from above example that becoming self aware and recognizing cultural diversity impact nursing practice.

In conclusion, the cultural safety is introduced in nursing practice to ensure that clients receive culturally safe care. Clients are empowered to decide that the care they receive is culturally safe or not. As Maori people comprise significant proportion of health service users and their health is considered as area of priority in delivering health care. The Treaty of Waitangi, cultural safety and Nursing practice are interrelated to each other and incorporate the nursing care which is acceptable by clients.


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