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Models of Transcultural Care - Cultural Competence

Ramsden’s Cultural Safety Model

The concept of cultural safety was developed in Aotearoa (New Zealand) in the late 80s. A group of Maori nurses developed the concept as a means of analysing nursing practice from the perspective of the indigenous people who are a minority (Ramsden, 1990; Ramsden, 1992). The concept is very much embedded in the redefinition of post-colonial identity, redistribution of power and resources. Although framed in the context of New Zealand, its European colonisation and the disenfranchisement of the indigenous Maori people, Ramsden contends that the idea of cultural safety is relevant for any environment where the power sharing and resources distribution between people of diverse background is unequal.

Ramsden (1993) has outlined the concept in further detail and argued for its place in nursing education. In nursing practice, the concept of 'cultural safety' emerged in response to transcultural care with respect in particular to Leininger's model, which it was argued did not take into consideration the wider sociocultural and political issues in bicultural or multicultural environments of care. Ramsden argues that ‘Such a model does not allow for the diversity within cultures, for the differences between conservative and liberal, age and youth, urban and rural, rich and poor and gender interaction’ (Ramsden, 1993, p. 6). In developing the concept of cultural safety, Ramsden has been mindful of the nature of interactions that are bicultural in nature. Furthermore, participation in the assessment of service needs and the opportunity to influence service delivery are important aspects of cultural safety. In these processes, Ramsden argues that there exists an element of cultural risk. Cultural risk refers to the belief by a group of people from one culture that they are devalued and disempowered by the care delivery systems and the actions of people from another culture (Wood and Schwass, 1993, p.2). Culturally unsafe nursing practice includes ‘any actions which diminish, demean or disempower the cultural identity and well-being of an individual’ (Whanau Kawa Whakaruruhau, 1991, cited by Wood & Schwass, 1993, p. 5).

Thus, cultural safety ‘focuses on the elements in ethnicity ignored by transcultural theory. It makes clear the structural dimension in health care provision, that care is not simply provided for individuals but for members of groups whose care inevitably reflects the position of their groups as a whole within general society’ (Polaschek, 1998, p 456). The concept points to inequalities due to the power base of ethnic groups in their relationships, expressed in a range of inequalities and negative attitudes.

Polaschek (1998) outlines the development of the concept and contrasts it with other concepts used in culturally competent care:

• Cultural safety is neither the same as cultural sensitivity nor is it about cultural practices.
• Cultural safety is about the recognition and acknowledgement of the influences of the social structures in interactions between people of different cultural heritage, and the power relationships in service delivery.

Practice that is deemed culturally safe meets the needs, expectations and rights of people through actions that demonstrate recognition, respect and nurturing of their unique cultural identity.

Applications
The concept of cultural safety requires that the inequalities of power between groups and the within systems in society are taken into account when planning services and delivering care. Discrimination, racism, lack of equality of opportunity and stereotyping are issues that the concept assist in exploring.

Critical Overview
Polaschek (1998) has discussed the following:

• Criticism about whether cultural safety has to do with attitudes and not behaviours of nurses.

• There are ambiguities about the level at which cultural safety operates, that is whether it is focused at the individual level, or addresses issues mainly in relation to the collective identity of the minority ethnic group.

• Confusion about the societal and personal dimension in its application
• Does not address the societal dimension such as institutional racism
• Limited methodological rigour

Culley (2000) has taken up some of these issues in relation to education and training for health care professionals. The critique of multiculturalism that has been put forward again reiterates the importance of not ignoring the economic, social and political factors that account for inequalities and less than culturally safe practice.

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