Review

International Journal of Nursing Studies 47 (2010) 761769

Contents lists available at ScienceDirect

International Journal o

journal homepage: wwProviding culturally appropriate care: A literature review

Moira Williamson a,*, Lindsey Harrison b

a School of Nursing, Midwifery and Indigenous Health, Faculty of Health and Behavourial Sciences, University of Wollongong, New South Wales, Australiab School of Health Sciences, Faculty of Health and Behavourial Sciences, University of Wollongong, New South Wales, Australia

What is already known about the topic?

Caring for individuals from diverse backgrounds is adaily reality for nurses and midwives, who are expectedto provide care which is both clinically safe andculturally sensitive.

A R T I C L E I N F O

Article history:

Received 22 September 2009

Received in revised form 10 December 2009

Accepted 17 December 2009

Keywords:

Culture

Cultural diversity

Cultural safety

Indigenous populations

Practice

A B S T R A C T

Objectives: As part of a study that explored howmidwives incorporate cultural sensitivity,

into their practice, the literature was reviewed to ascertain how the concept of culture has

been, dened and what recommendations have beenmade as to how to provide culturally

appropriate care, to individuals from Indigenous and/or ethnic minority backgrounds.

Design: A systematic review of the literature was undertaken.

Data sources: Electronic databases including Medline, Cinahl, Socio-le and Expanded

Academic Index, were accessed.

Review methods: Several key search terms were used for example, midwife, midwives,

midwifery, nurse, nurses, nursing, culture or cultural, diversity, sensitivity, competency

and empowerment. The, results relating to midwifery were few; therefore nursing was

included which increased the amount, of material. References that were deemed useful

from bibliographies of relevant texts and journal, articles were included. The inclusion

criteria were articles that provided information about culture, and/or the culturally

appropriate care of individuals from Indigenous and/or ethnically, culturally and,

linguistically diverse backgrounds.

Materials reviewed for this paper satised the inclusion criteria.

Results: There are two main approaches to culture; the rst focuses on the cognitive

aspects of culture, the values, beliefs and traditions of a particular group, identied by

language or location such as, Chinese women or Arabic speaking women. This approach

views culture as static and unchanging, and fails to account for diversity within groups.

The second approach incorporates culture within a wider, structural framework, focusing

on social position to explain health status rather than on individual behaviours and beliefs.

It includes perspectives on the impact of the colonial process on the ongoing relationships

of Indigenous and non-Indigenous people and how this affects health and health care.

Conclusion: Most of the literature focuses on the cognitive aspects of culture and

recommends learning about the culture of specic groups which is presumed to apply to

everyone. This generic approach can, lead to stereotyping and a failure to identify the

needs of the individual receiving care. The concept of, cultural safety derived from the

second approach to culture and practice has potential but evidence to show how it is being

incorporated into practice is lacking and health professionals appear to be unclear about

its meaning.

Crown Copyright 2010 Published by Elsevier Ltd. All rights reserved.

* Corresponding author.

E-mail addresses: moiraw@uow.edu.au (M. Williamson),

lharriso@uow.edu.au (L. Harrison).

0020-7489/$ see front matter . Crown Copyright 2010 Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.ijnurstu.2009.12.012w.ef Nursing Studies

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M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769762oftofarticular about their health beliefs and (apparently)aditional behaviours, which will sensitise the nurse oridwife and allow him/her to provide appropriate care toeople from ethnically diverse backgrounds. Scholars alsoen refer to the need for nurses andmidwives to be awaretheir own culture (again, seen as values and beliefs) insuppdiscerned in the literature. One tends to focus on thecognitive aspects of culture, discussing traditions, valuesand beliefs, assumed to be shared by all with the samecultural background. Those working in this perspective

port learning about other (specic) cultural groups, incululture has been dened and the implications of this forractice.The paper argues that two distinct approaches toture and nursing and midwifery practice may beculcurses and midwives will provide culturally appropriateare. However it is not always clear how this may bechieved. To begin to answer this question, this paperviews the nursing andmidwifery literature in relation toture and practice, focussing in particular on howpronme countries also have Indigenous populations witheir owncultural identity. Professional bodies such as theternational Council of Nurses (2007) and the Interna-onal Confederation of Midwives (2005), as well as manyfessional bodies in individual countries, expect thatpasso This is important for all recipients of care, but especiallyso for Indigenous peoples who have higher rates ofadverse outcomes compared to non-Indigenous peoplesand who may have experienced discrimination in healthcare settings.

However, little is known about how the literatureinforms health professionals about culture, diversityand culturally appropriate care.

What this paper adds

A review of the nursing and midwifery literatureidentied two approaches for dening culture andproviding appropriate care.

The rst is a cognitive approach focusing on customs andtraditions. A criticism is that this approach fails to takeinto account broader social, political and economicfactors which affect health and access to health care.Stereotyping of individuals may result.

The second approach is broader and focuses on the socialposition of individuals rather than behaviours and beliefsto explain health status. Derived from the work ofpostcolonial scholars, this approach has recently gainedacceptance under the rubric of cultural safety.

However there is limited evidence in the literature onhow this approach has been, ormay be, incorporated intopractice and health professionals appear confused by itsmeaning.

1. Introduction

Most nurses and midwives routinely care for peoplefrom diverse ethnic and linguistic backgrounds (Burnardand Naiyapatana, 2004). Globalisation and migrations

t and present have contributed to this diversity andorder to facilitate their understanding and acceptance ofdifference (Duffy, 2001; Benkert et al., 2005).

There are a number of criticisms which may be madeabout this perspective and the assumptions that it makes.One is it assumes culture is static and unchanging but, evenwithin the same culture, the experience of the individualchanges over time and with it their practices, beliefs andviews (Burnard and Naiyapatana, 2004). It also fails to takeinto account diversity within groups and between gen-erations. This may lead to stereotypical images ofparticular groups, with the assumptions regarding theirnursing and midwifery needs being made by careproviders based on these stereotypical images. Thisapproach has led to the development of generic care plansfor people from particular cultural or ethnic backgroundsand the use of these care plans have been labelled as acookbook approach to care (Duffy, 2001).

The other perspective incorporates culture within awider, structural framework, focusing on social position,education and socioeconomic status to explain healthstatus rather than on individual behaviours and beliefs.Within this latter perspective is included a small group ofpostcolonial scholars who are interested in the impact ofcolonial processes on the ongoing relationships of Indi-genous and non-Indigenous people and how this affectshealth and health care. This approach has been particularlyevident in New Zealand (Ramsden, 2002) and Canada(Kirkham et al., 2002; Anderson et al., 2003) and is growingwithin Australia (Kruske et al., 2006). These countries allhave Indigenous populationswhich continue to experiencepoorer health outcomes than their non-Indigenous coun-terparts, though the gap in health status indicators is moststarkly seen in Australia (ABS & AIHW 2008).

The paper beginswith a review of transcultural nursing,the oldest approach, followed by the other types ofliterature which aims to describe other ways of providingculturally appropriate care. The paper then discusses theinuence that power has on providing appropriate culturalcare. In particular the concept of cultural safety will beaddressed.

2. Transcultural nursing

The growing interest in culture and health care can bedirectly related to the concept of transcultural nursing asrst depicted by Leininger (1988) in the United States.However, although transcultural nursing has beenendorsed by many in the nursing and midwifery profes-sion, it has also been criticised. This criticism is based onthe view that transcultural nursing provides a vehicle thatallows individuals to be stereotyped and also fails to lookat the effect of structural factors such as colonisation onindividual behaviours (Bruni, 1988; Smye and Browne,2002). None the less, transcultural nursing has beenextremely inuential and hence this paper begins with adiscussion of Leiningers work.

Leininger states that in the 1950s she became awarethat care is the essence of nursing and the central,dominant, and unifying feature of nursing (Leininger,1988, p. 152). She believed that people from a differentcultural background to the care giver had different

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769 763expectations; therefore nursing required a theoreticalframework in which to provide suitable care. Leiningerexplains how the aspect of culture was not considered atthis time. The main focus of nursing was on clinicalprocedures and so she completed a doctorate in anthro-pology to develop a theory to address this issue (Leininger,1988). This research led her to introduce transcultural andcultural care nursing theory into nursing curricula,particularly in the United States.

Leininger states that her:

. . .theory of Culture Care is not static, but rather adynamic theory that is being used worldwide by manyknowledgeable nurses as the most meaningful, timelyand relevant theory in nursing (Leininger, 2001, p. 37).

Leininger argues that transcultural nursing is:

. . .a formal area of study and practice focussed on

comparative holistic cultural care, health, and illness

patterns of people with respect to differences and

similarities in their cultural values, beliefs, and lifeways

with the goal to provide culturally congruent, competent,

and compassionate care [original in italics] (Leininger,1997, p. 342).

Leininger (1997, p. 342) states that to provide appro-priate transcultural nursing care, nurses must have anunderstanding of other cultures and look for culturespecic symbols, expressions, andmeaning of specic anddiverse cultures. It is evident from the literature that thereare many nurses internationally who support the theory oftranscultural nursing (see Luna and Miller, 2008) and areconcerned with its application to practice (Papadopoulosand Omeri, 2008).

Leininger is explicit in her belief that the concept ofcultural care focuses on the views of the patients. Theseviews, according to Leininger, provide the meanings,symbols, patterns and expressions of cultural care andnursing from a holistic perspective (Leininger, 1988, p.153). This view of culture espouses its cognitive aspectswithout taking into consideration the individual patientslife experiences, such as their status within their socialenvironment, socioeconomic factors and education level,which are known to affect an individuals well-being (Hartet al., 2003).

Leininger has been publishing on the topic of culturecare for over 40 years and she has provided differentinterpretations or denitions of the concept of cultureduring that time. In her earlier publications Leiningerdened culture as:

. . .the learned and transmitted knowledge about aparticular culture with its values, beliefs, rules andbehavior, and lifestyle practices that guides a desig-nated group in their thinking and actions in patternedways (Leininger, 1978, p. 491).

Subsequently, she has not dened culture per se but shehas instead focused on what culture care is:

The theory is a holistic, culturally based care theory thatincorporates broad humanistic dimensions about peo-ple in their cultural life context. It is also unique in itsincorporation of social structure factors, such asreligion, politics, economics, cultural history, life spanvalues, kinship, and philosophy of living; and geo-environmental factors, as potential inuencers ofculture care phenomena (Leininger, 2007, p. 9).

The rst denition is one which appears to view cultureas static and unchanging (Price and Cortis, 2000). It doesnot address the issue of agency in relation to how peoplechoose to act, as some individuals choose not to followtheir ascribed cultural customs. This interpretation ofculture does not allow for diversity (difference) withinlabelled cultural groups to be recognised and it also failsto take into account the effect of migration on individualsand the subsequent merging or loss of different practices.Indeed, Campesino (2006, p. 300) has pointed out thatcriticism of transcultural theory has focussed on theessentialist conceptualization of culture.

As identied in the second quote Leininger is nowincorporating social structural factors into care provision,such as the individuals economic position and their socialenvironment, although Campesino (2006, p. 300) stillcontends that transcultural theory is reluctant to addressstructures of power in health care contexts and betweenthe providers of care and its recipients. However,Leiningers emphasis is still on the nurse being able torecognise the cognitive aspects of culture by using anethnonursing research approach to care;

. . .that enables the researcher to enter the world of theparticipant and tease out the largely unknown andcovert care beliefs, values, and lifeways. The methodincludes ve enabler guides to facilitate discoveries ofspecic care phenomena. These enablers have beenextremely relevant and most helpful to enter thecultural world of informants and discover their covertculture care beliefs, values, and practices (Leininger,2007 p. 11).

Since Leininger began her work, the increasing changesbrought about by globalisation and the growing migrationof people (Duffy, 2001) have inuenced the continuinginterest of the nursing and midwifery professions inproviding care that is culturally appropriate. The voca-bulary used has also increased, including terms such ascultural diversity, cultural sensitivity, cultural compe-tency, cultural safety and empowerment. The literatureusing these terms is now discussed.

3. Being culturally appropriate

Cultural diversity is the term used by several authors(Henkle and Kennerly, 1990; Erlen, 1998; Kirkham, 1998;Homer, 2000; Callister, 2001) to describe the changingpopulation of the world through migration. These authorsare referring to the United States, Canada and Australia,however many other countries are experiencing or haveexperienced changes to their population through immi-gration. Callister (2001, p.209) refers to the worldbecoming a global village. Erlen (1998) and Henkle andKennerly (1990) expand on the concept of culturaldiversity to include those people who were born in the

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769764same country but who have different values or approachesto life to that of their health care provider.

According to Homer (2000), writing from an Australianperspective, cultural diversity refers to the recognition ofdifferent cultural groups and their needs. Homer isparticularly concerned with the lack of representationwithin midwifery research studies of non-Anglophonewomen and she argues that many Australian studies in thepast have excluded women whose rst language is notEnglish. Different cultural groups, from this perspective,are those whose rst language is other than the dominantlanguage of the country in which they live.

A denition of culture is not provided by Homer (2000),however, she seems to mean tradition and custom. Shepoints out that traditional practice may be important forsomewomenand not for others and she states that thismaybe because the women choose not to follow their customsbecauseof theeffect of their new livingand social conditions(Homer, 2000, p. 253). Homer refers to the cognitive aspectsof culture, such as traditions and customs but does notprovide examples. This term traditional is problematic. Itappears to assume that there is set of distinct unchangingpractices which are, or should be, performed by all peoplefrom the same cultural backgrounds.

The emphasis in a large proportion of the literature is onthe recognition of a consistent set of values exhibited byindividuals who are labelled as belonging to speciccultural or linguistic groupings, such as Asian women(Matthey et al., 2002; Liamputtong and Naksook, 2003).When health care professionals attempt to broaden theirawareness of difference by attending cultural trainingsessions that discuss cultural difference and subsequentlyadjust their practice tomeet the needs of these individuals,they are said to be culturally sensitive as they appreciatethe richness and the complexity that diversity brings to asituation (Erlen, 1998, p. 3).

It is argued by Erlen (1998) that to respect othercultures, the health professional must rst recognise theirown culture and any biases that may impact on theirpractice. As the literature on cultural sensitivity increases(Henkle and Kennerly, 1990; Erlen, 1998; Yearwood, 1998;Scholes and Moore, 2000; Omeri and Malcolm, 2004;Benkert et al., 2005) there is a growing consensus thathealth care professionals need to be aware of their owncultural beliefs, attitudes and feelings (Duffy, 2001, p.498) to facilitate their understanding of people who maybe from a different background. There are numerousmethods/teaching strategies, according to these scholars,to assist health professionals to recognise their own values,for example, value clarication exercises (Erlen, 1998, p.3), self assessment tool (Benkert et al., 2005, p. 225) andcontinuing education including case conferences (Omeriand Malcolm, 2004, p. 187). However there is littleevidence to show if these are effective.

It has been argued that when the focus of education ison cultural difference, there is a danger of reinforcing anethnocentric approach to care and, in some cases, apaternalistic approach to health care provision (Bruni,1988; Blackford, 2003). Blackford (2003) even asserts that,in Australia, a cultural difference approach has allowednon-English speaking and non-white populations to beseen as deviant compared to the health professionalnorm (p. 239) and in some cases to be invisible in healthcare policy and the provision of care (p. 242).

Endorsement of their culturally sensitive practice isachieved for the nurse or midwife when they are rewardedby health care organisations or professional bodies bybeing called culturally competent. Robinson denescultural competence as:

. . .a sensitivity to issues of culture, race, gender, sexualorientation, social class and economics. Cultural com-petence involves more than knowledge acquisition: itinvolves skills, awareness, encounters, desire andknowledge (Robinson, 2000, p. 131).

This denition goes beyond Leininger and transculturalnursing to include attributes such as awareness, skills andknowledge. However there is no mention of how theseattributes are measured in the context of the nurse ormidwifes workplace.

4. The generic approach to care

Duffy (2001, p. 489) argues that nursing educationcontinues to espouse distinct cultural components (localparticularities) without taking into account the interac-tion of the individual with global inuences such as mediaand the increasing use of technology. The individual getslost in an education that, focusing on cultural character-istics and customs, provides a cookbook approach to care(Duffy, 2001, p. 498).

This cookbook approach refers to generalised informa-tion that has been formulated about different specicgroups. As argued by Duffy (2001), transcultural literatureand texts are full of these generic cookbook approaches.An example is the text, Culture Care Diversity andUniversality, A Worldwide Nursing Theory edited byLeininger andMcFarland (2006). The text endorses culturespecic clinical nursing care which is a care plan that hasbeen formulated specically to make nursing caredecisions and take actions that are culturally congruentwith the beliefs, practices, values and life-ways of people(McFarland and Zehnder, 2006, p. 199).

This approach in themajority of cases is used to providegeneric information about people from specic culturallyand linguistically diverse backgrounds. Some authors dowarn the readers that this approach can lead to stereo-typing as it is impossible to cover the diversity withinculturally and linguistically diverse groups such as thosefrom South Asia (St. Hill et al., 2003). However despite theadvice to not stereotype, generic cultural information isoften provided for individuals from specic backgrounds,who are labelled as belonging to, or having the samecharacteristics as, a particular ethnic or linguistic group.

We respectfully ask you to avoid using this book as acookbook or to stereotype thewomen described in eachchapter. Please use it as a starting point from which tothink about and ask whether this particular family,client, or student is similar to or different fromwhat thechapter describes on the topic of interest (St. Hill et al.,2003, p. xviii).

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769 765The problem is that although the warning has beenprovided in the preface by St. Hill et al. (2003), it maynot be read by those health care providers or studentswho are seeking to enhance their knowledge of peoplefrom specic ethnic or linguistic groups. It is likely thatindividuals seeking information will turn to the chapterthat provides their required information. For example, inSt. Hill et al. (2003) text book entitled Caring for WomenCross-Culturally, chapters are labelled to providegeneric information such as Chapter 4 Arab Americans,Chapter Six Cambodians and Chapter 7 Chinesewomen.

Educational strategies tend to focus on learning aboutparticular cultures, as indicated above. Students may dothis, according to the literature, by spending time overseasor by interviewing other nurses who are from diversebackgrounds (Henkle and Kennerly, 1990; Robinson, 2000;Scholes and Moore, 2000). This practice is believed toenhance cultural competency. However these approachesto cultural competency have rarely been critically eval-uated (Suh, 2004). They suggest that an individual canembody culture in some way or that individuals fromsimilar backgrounds, either similar linguistic backgrounds,for example Chinese speaking, or similar national back-grounds, for example Greeks are all alike in some way.Lock (1990) suggests that this approach ignores differencessuch as age, gender, class, education and sexual orientationwhich shape each persons perspectives. As a result, healthprofessionals may be unsympathetic to health carerecipients whom they perceive as adhering to outdatedtraditional beliefs, despite the apparent sharing of a similarcultural background.

Anal criticismof the approach to practice that focuseson the cognitive aspects of culture, traditions, customsand values, is that it fails to take into account broadersocial, political and economic factors which affect healthand access to health care. As a result, and given theemphasis on the individual and individual responsibilitywithin Western societies, this perspective can be parti-cularly problematic for Indigenous peoples who mayoccupy a marginal position, as it can lead to victimblaming for poorer health outcomes, rather than focusingon peoples social and economic circumstances, margin-alisation and oppressive internal colonial politics(Browne and Smye, 2002, p. 29).

Browne and Smye (2002) state that oppressive internalcolonial politics occurs when the Indigenous populationare controlled by government policies that reect theviews of those in power, the colonisers. This in turn leads tothose with power inadvertently or advertently margin-alising the original inhabitants of the country. When theimpact of colonisation on an Indigenous population is nottaken into account by the relevant government, this isreected by the whole non-Indigenous community. Thereis a lack of understanding of the impact of colonisation onthe well-being of Indigenous populations worldwide. InAustralia, for example, there is an expectation that theIndigenous and non-Indigenous population should moveon and forget past injustices. The result is that legitimatedemands of the Indigenous population are not met(Jamrozik, 2004, p. 83).5. Culture and power

The idea that learning about the customs and beliefs ofparticular groups is benecial for the appropriate care ofthe individual and their families from ethnic minoritygroups, ignores more critical analyses of the cultureconcept. In particular, how it may be used in powerrelationships, which are usually detrimental to minoritygroups, including Indigenous populations. This criticalanalysis leads to an approach which is more explicitlytheoretical, utilising the insights from postcolonial dis-course theory. Proponents of cultural safety tend to comefrom this perspective.

Cultural safety was initially developed in New Zealandby Irihapeti Ramsden, who stated that:

Cultural Safety has been developed almost entirelyfrom the interactive experience of the indigenous[Maori] people with a nursing and midwifery servicelargely derived from amigrant ethic group thus makingit unique to this country [New Zealand] although thereare elements of international comparison (Ramsden,2002, p. 180).

Ramsden (2002) explained in her thesis that theconcept was derived from the need for the impact ofcolonisation to be acknowledged and for an understandingof the effect of colonisation on the Maori population to betaken into account when providing health care for thispopulation. The concept of cultural safety according toAnderson et al. (2003) can be written within a criticalpostcolonial discourse.

Although cultural safety originated in New Zealand(Jeffs, 2001), it has been taken up by scholars in othercountries such as Canada (Kirkham et al., 2002). Not allagree that it is transportable. As it is concerned withbiculturalism in New Zealand (the Maori and Pakeha),some suggest that there are difculties in utilising theconcept of cultural safety in countries where there aremultiple Indigenous groups (for example many differentFirst Nation peoples, Inuit etc), andmany differentmigrantgroups, as is the case in Canada (Kirkham et al., 2002; Smyeand Browne, 2002). However, these same authors (Kirk-ham et al., 2002; Smye and Browne, 2002) argue that byusing the concept of cultural safety, (even though it isrecognised to be a bicultural approach), the benetsoutweigh the negatives, and there are many similaritiesbetween New Zealand and Canada in the way colonisationaffected their respective Indigenous populations.

When discussing the concept of cultural safety, Kirk-ham et al. (2002, p. 227) describe it as requiring areconsideration of the disparate power relations withinand beyond health care and the historical and socialprocesses that organise these relationships. These Cana-dian authors state that by taking a postcolonial viewpointof the concept of cultural safety as developed in NewZealand, they are able to examine the extended history ofthe role of economic, political and social subordination ofIndigenous groups and other ethnic minorities in Canada,and the direct negative impact this has had on their healthoutcomes.

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769766Kirkham et al. (2002) argue that it is important tounderstand that the concept of culture, dened by somehealth care professionals as being a balanced system ofcommunal practices, beliefs and meanings, does not exist.On the contrary, when viewing culture from a postcolonialdiscourse perspective, it is seen as not being unitary orneutral. Kirkham et al. (2002, p. 224) argue:

. . .the concept of culture must be interrogated tounmask the relations of the ruling and dominationthat have shaped the constructions of the other, evenas attempts are made to bridge the gap between theWestern self and the colonised other in the appeal toideas such as cultural sensitivity.

Ramsden dened cultural safety as an outcome ofnursing and midwifery education that enables safe serviceto be dened by those that receive the service (Ramsden,2002, p. 117). She stated that the process of cultural safetyrequires a critical analysis of existing social, political, andcultural structures and the physical, mental, spiritual andsocial outcomes for people who are different (Ramsden,2002, p. 180).

Ramsden stated that the non-Indigenous population ofNew Zealand did not consider the impact of colonisationon the Maori population. She argued that:

For patients to be considered in terms of their politicalstatus and historical circumstances requires an under-standing and knowledge of history which continues tobe uncommon in New Zealand currently (Ramsden,2002, p. 180).

Using the concept of cultural safety, nurses andmidwives are encouraged to reect and analyse howpower relationships and history have impacted on thehealth of individuals (Spence, 2003; Kruske et al., 2006).Part of this reection includes how personal and institu-tional cultures impact on the delivery of health care(Spence, 2003, p. 224). The goal of cultural safety is toprovide care that is effective and determined by theindividual (Spence, 2003, p. 224).

Cultural safety has also been endorsed by the NursingCouncil of New Zealand, and their denition of the conceptof cultural safety is:

The effective nursing practice of a person or family fromanother culture, and is determined by that person orfamily. Culture includes, but is not restricted to, age orgeneration; gender; sexual orientation; occupation andsocioeconomic status; ethnic origin or migrant experi-ence; religious or spiritual belief; and disability.The nurse delivering the nursing service will haveundertaken a process of reection on his or her owncultural identity and will recognise the impact that hisor her personal culture has on his or her professionalpractice. Unsafe cultural practice comprises any actionwhich diminishes, demeans or disempowers thecultural identity and well-being of an individual(Nursing Council of New Zealand, 2005, p. 7).

In Australia, different approaches are apparent withregard to the Indigenous population. Some of the health,nursing and midwifery literature focuses on the empow-erment of Indigenous people and their participation inhealth care in direct response to unsatisfactory morbidityand mortality rates (Williams, 1999; Pyett, 2002; NSWDepartment of Health, 2003; Dahlen, 2006; Eckermannet al., 2006). Alongside this empowerment literature,however, is another literature which continues to focus ontraditional practice (Gaff-Smith, 2001; Sarzin, 2003). Forexample, there is sometimes an assumption that allIndigenous women continue to follow the same tradi-tional birthing practices (Carter et al., 1987; Gaff-Smith,2001; Sarzin, 2003), when this is not the case. Brady (1995,p. 1490) has critiqued this emphasis on notions of statictraditional culture, which fails to recognise that con-temporary Indigenous cultural forms are extraordinarilydiverse.

Williams (1999) cautions that for cultural safety to beutilised (as intended by Ramsden and by the New ZealandCouncil of Nursing) within an Australian context, theIndigenous population need to be empowered to be able todirect appropriate care. Although there are similarities inthe history of colonisation of Australia and New Zealand,there are also primary differences in the way in whichcolonisation was enacted (Kruske et al., 2006). Under theTreaty ofWaitangi enacted in 1840, the Maori people wereguaranteed to have their way of life protected and, at thesame time, they were granted full citizenship rights (NewZealand Government, 2005). In Australia the Indigenouspopulation were not treated in the same manner and fullcitizenships rights were not given until the 1967 Refer-endum (Hemming, 1998), 179 years after Australia wascolonised by the British. Excluded and marginalised, theIndigenous populations role in determining their well-being has been quite different to that of the Maoripopulation in New Zealand. That is why Williams (1999)recommends that the Indigenous population in Australianeeds to be empowered to direct the care that they wish toreceive under the banner of cultural safety.

However, as argued by Hunt (2006), the presentAustralian health care system is not conducive to allowingIndigenous women to be empowered, as health careproviders control pregnancy care. Hunt (2006) argues thatmany Indigenous women experience increased surveil-lance, as more assessments, tests or increased hospitalisa-tion takes place tomonitor the health of thewoman and herfoetus. Indigenous women will not be empowered untilhealth professionals and the health system recognise andrelinquish some of the control they currently exert overwomen (Hunt, 2006, p. 53). This is reiterated by Kildea(2006) who argues that Indigenous womens voices need tobe heard for cultural safety to be truly enacted and that thecurrent dominant Western medical system needs to bechallenged to improve the health outcomes for Indigenouswomen and children. Indigenous women from remote andrural communitiesare required tobirth inhospitals incityormajor town centres with little thought given to the impactthis has on their and their families social well-being. Thisremoval of women from their communities has notimproved their birth outcomes (Kildea, 2006).

There has been little education about Indigenous healthissues so it is difcult to envisage how all nurses and

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769 767midwives can have a full comprehension of what culturalsafety encompasses. An audit by the Congress of Aboriginaland Torres Strait Island Nurses of Australian nursingprograms found that only 22 out of 33 provided a distinctsubject on Indigenous Health (Australian Nursing andMidwifery Council, 2007). The Australian Nursing andMidwifery Council is now calling on all providers ofnursing and midwifery programs leading to registration orenrolment to include a distinct subject/module onIndigenous health, culture and history (Australian Nursingand Midwifery Council, 2007).

However, there is limited evaluation of how the conceptof cultural safety and the inclusion of this concept innursing and midwifery curricula have worked in reality(Richardson, 2004). Johnstone and Kanitsaki (2007) arguethat although cultural safety is a part of all nursing andmidwifery curricula in New Zealand, there is limitedevidence (if any) on how this concept has impacted on thehealth outcomes of the Maori population. These authorsundertook an Australian study to determine how theconcept of cultural safety was understood and applied inan Australian context. They interviewed a total of 145participants, including patients and their families. Theirresults showed that the concept of cultural safety is notreadily understood by health professionals and therefore itis not applied as intended in the clinical setting (Johnstoneand Kanitsaki, 2007).

Despite not being familiar with the term, health serviceprovider participants had a sense that cultural safetywas a complex process primarily concernedwith healthcare providers doing things safely and ensuring thatpatients from diverse racial, ethnocentric, and languagebackgrounds got safe care and did not suffer mishapsand harms because communication was not effectiveor because staff lacked cultural knowledge andawareness (Johnstone and Kanitsaki, 2007, p. 251).

When cultural safety is viewed in this way there is norecognition of the social determinants that may affect anindividuals well-being. The focus of the health profes-sionals in this studywas on providing safe clinical practice.The meaning of cultural safety has been totally misinter-preted.

Most importantly Johnstone and Kanitsaki (2007)research identies that consumers (patients) of healthcare were unable to dene cultural safety or to expresswhat they thought it may be. It should be noted thatalthough consumers were included in the study, it is notclearly identied by the authors the exact number ofparticipants who were Indigenous. This study undertook abroader approach to the concept of cultural safety byseeking to ascertain whether it was suitable in a multi-cultural context. This was not the original intention of theconcept of cultural safety as dened by Ramsden. The useof the concept for the provision of care to all individualssubverts the original concept of recognising the impact ofcolonisation on Indigenous populations. Immigration is adifferent issue. Although immigrants face many chal-lenges, they have not experienced the oppression orinjustices that many Indigenous populations have facedand continue to face.It can be argued, however, that the concept of culturalsafety has at least provided a focus for nursing andmidwifery education that has moved beyond providing acookbook approach to care.

The purpose of cultural safety in nursingeducation extends beyond the description of prac-tices, beliefs and values of ethnic groups. Conninglearning to rituals, customs and practices of a groupassumes that by learning about one aspect givesinsight into the complexity of human behaviours andsocial realities. This assumption that cultures aresimplistic in nature can lead to a checklist approachby service providers, which negates diversity andindividual consideration (Nursing Council of NewZealand, 2005, p. 7).

6. Conclusion

This paper has argued that there are two mainapproaches to dening culture in the nursing andmidwifery literature. The rst focuses on the cognitiveaspects of culture (beliefs and values). This approachtends to provide generic information about differentgroups of ethnically and linguistically diverse people,which is then used to develop a cookbook or recipes ofcare. This approach on the whole does not take intoaccount other factors which may impinge on theindividual such as their socioeconomic status or educa-tional level. Illness or prevention of illnesses may then beseen as the individuals responsibility regardless of theirposition within society.

The second approach to culture is broader andincludes a structural framework that focuses on theindividuals social position and how this has impactedon their health and well-being. Derived from the work ofpostcolonial scholars, this approach has recently gainedacceptance under the rubric of cultural safety which hasbeen adopted by various professional bodies. While theconcept of cultural safety has merit, there is littleavailable evidence in the literature to show how it isbeing, or may be, incorporated into practice. It is indanger of becoming rhetoric only and health careprofessionals appear to be confused by its exact mean-ing. On the other hand, for Indigenous populations, anyapproach to culture and practice which incorporates thehistory of contact provides a more meaningful insightinto the reasons for their poor health status than canbe achieved with a focus on traditional beliefs andvalues.

The concept of culture is difcult both to dene andoperationalise. How this is done potentially has conse-quences for practice. None of the available approaches hasbeen shown to overcome the problem of stereotyping theindividual whose background differs from that of thehealth care provider or provides a clear way to provideculturally appropriate care.

Conict of interest

None declared.

M. Williamson, L. Harrison / International Journal of Nursing Studies 47 (2010) 761769768Ethical approval

None declared.

Funding

None declared.

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Providing culturally appropriate care: A literature reviewIntroductionTranscultural nursingBeing culturally appropriateThe generic approach to careCulture and powerConclusionConflict of interestEthical approvalFundingReferences