A Message from U’ilani: Nursing & Cultural Safety

portrait of an Hawaiian teenager dressed in traditional cloths

Nursing and Cultural Safety

Aloha Colleagues!

Our Friend and Colleague, U’ilani Chow-Rule has earned her Doctorate in Nursing Practice at UH.  Congratulations, U’i!  As many of you are aware, her research topic was Cultural Safety.  She shares information on this important and timely topic with us as we consider bias impacting health:
The United States of America is a nation of many ethnicities and cultures. This multiculturalism is even more evident in Hawai’i. With the recent death of an African American male individual by a police officer and resulting civil unrest and protests, the USA is still dealing with racial bias.
Thus, the need for cultural awareness/Cultural Safety education is needed now more than ever!
The issue is that many do not recognize their own bias. Therefore, many people do not
recognize the need for cultural safety training. Awareness of one’s own biases is the first step towards improving inequalities and creating a fair and safe environment for all.
The people of Hawai’i are a mix of cultures and backgrounds. Culture plays a role in how
people interact with others. The lack of inclusion and consideration of native culture and values in health care leads to a lack of cultural safety. The belief that Western and European educational models and methods are the best, most accurate, and correct way nursing care should be delivered.

The goal of cultural awareness training for nurses and care providers is to increase  humility and change attitudes towards the importance of providing cultural safety, which will address the power imbalance and create a mutually trusting relationship between provider and patient. This increase in inclusion and trust may ultimately improve patient outcomes andspecifically address the health disparities commonly found in native peoples.
The relationship between provider and patient often presents an imbalanced power
relationship. Often the provider makes decisions on care and treatment with minimum inputfrom the patient, with the expectation that the patient will comply with the plan. A patient who does not comply with the care plan is labeled non-compliant, a label commonly attached to many minorities, including Native Hawaiians. Not coincidentally, Native Hawaiians sufferfrom many health disparities despite efforts to increase access to health care.According to a report from the Hawai’i State Center for Nursing (2019), only 11% of nursesemployed in Hawai’i have some Native Hawaiian ancestry. However, the population of Native Hawaiians is 26% (U.S. Census Bureau, 2018.) The imbalance of native caregivers to indigenous patients is another argument of the need for cultural safety and cultural awareness training.

What is Cultural Safety?
Cultural safety is a concept that describes the treatment of native peoples that is not respectful or inclusive of their values and customs. Cultural Safety is a term coined by the New Zealand Maori (Native people of New Zealand) and Maori nurses to describe discrimination present in medical care and nursing education. Their goal was to bring awareness and improvement to both the overt and implicit bias occurring in their health care system. Cultural humility is the goal of cultural safety and is a critical factor in building a foundation for a trusting, beneficial relationship. Cultural humility is the ability of the provider to recognize their own bias and
avoid imposing their values or opinions upon another (White, et al., 2017), practicing humility shifts the power of the relationship from the provider to a shared control between the provider and client.

The term cultural safety and cultural awareness is often confused with cultural competency.  Cultural competency is the “attitudes, knowledge, and skills necessary for providing quality care to diverse populations” (Isaacson, 2014). However, achieving cultural competency does not
necessarily lead to having the knowledge and skill to deal with every person or situation from a. specific culture. Also, cultural competency runs the risk of creating stereotypes by
oversimplifying diversity within a culture or group. It may give that person a false sense of
mastery, which may lead to decreased efforts to expand their knowledge (Isaacson, 2014).
The concept of cultural safety is similar to cultural discrimination but addresses explicitly the harm that can come from cultural bias. If being safe is to be free from harm, then providing health care that does not harm someone culturally would be care that is effective and culturally safe. While cultural competency refers to a person or organization’s ability to provide care to
people with diverse beliefs, values, behaviors, and linguistic needs (Health Research and
Educational Trust 2013), cultural safety refers to providing care that protects patients from bias and stereotype. Because there is an abundance of cultural norms, traditions, beliefs, and behaviors, providing cultural competency training would be lengthy and complicated to master. The approach of cultural humility is to have the provider become aware of their own bias so
that they can recognize when their behavior may be affecting the conversation, teaching, or treatment of their patient (Lee, Fitzpatrick, Sung-Yi, 2013). This approach provides a saferenvironment for patients to participate and feel comfortable working with the health careprovider. This approach aims at improving the relationship between the provider and patient to affect health outcomes positively.

Significance
Native peoples have long suffered from poor social determinants and health disparities, even in the presence of programs aimed to help improve these disparities. Despite care and evidence-based practice, health care disparities still exist among minorities (Lee,
Fitzpatrick, Sung-Yi, 2013). This pattern continues in Hawai’i. According to a 2013 reportpublished by the University of Hawai’i at Mānoa JABSOM Department of Native Hawaiian Health, Kanaka Maoli (the Hawaiian word for Native Hawaiian) and Pacific Islanders have the worst health and lowest income among all ethnic groups in Hawai’i. Over 40% of Kanaka Maoli and Pacific Islanders are living at or under the poverty rate (Look, 2013). The life expectancy for
Kanaka Maoli has been consistently lower in the state of Hawaii, with a lifespan of 74.3 years.  Kanaka Maoli has a disproportionately higher prevalence and mortality rate from chronic conditions such as heart disease, cancer, stroke, and diabetes (Look 2013).
Health promotion programs too often focus on either improving outcomes or on ways of
improving healthcare access. What is lacking from these programs is the formation of trusting relationships between client and provider. The trust built within these relationships helps to create expectations and cooperation that is mutually beneficial for both parties.

There are many efforts made to address the health disparities of Kanaka Maoli. Programs
include: Ke Ola Mamo, part of the Native Hawaiian Health system provides access and
educational services to Kanaka Maoli. Community centers such as The Waianae Coast Comprehensive Health Center and Waimanalo Health Center are community clinics located in
areas with high populations of Kanaka Maoli. These Centers also offer primary health care and special programs to remove access barriers for Kanaka Maoli. Although these programs are very beneficial and provided much-needed care and access to Kanaka Maoli, there is still a great need to improve health outcomes.According to the Department of Health and Human Services website, Healthy People (HP) 2020 (2017), determinants of health are factors that contribute to the overall health of a person.
Such factors include economic, personal, social, and environmental. Social determinants are multi-factorial and interconnected. H.P. 2020 breaks down social determinants into fivecategories: policymaking, social factors, health services, individual behavior and biology, and
genetics. Social factors include barriers such as discrimination and interactions. Health services include obstacles such as limited language assistance. All the obstacles result in unmet health needs or delays in receiving care How Cultural Harm Happens
Kanaka Maoli first experienced the effects of foreign contact by contracting and succumbing to diseases they had no immunity. Later, European missionaries imposed their religion and social
practices upon Kanaka Maoli with the intent of improving their physical and spiritual lives. As
the European and later American settlers continued to impose their culture and dominance over the Kanaka Maoli, they became more marginalized. Historical trauma is a result of acts and events such as genocide, loss of culture, and other events inflicted on a particular group of
people. This trauma results in traumatic stress disorder and deep-rooted anger that
perpetuated through generations (Clark 2017). This concept can apply to why some Kanaka
Maoli finds it challenging to break familial patterns and stereotypes, resulting in low self-
esteem and self-care. Stoil (2006) found in his study that when the native population speaks the predominant language (English), the assumption is that they (Kanaka Maoli) accept and have assimilated intothe dominant culture. Language is more than just the lexicon used to communicate.
Communication is also a way of connecting with others and includes words, body language, actions, and customs. This assumption leads to judgments upon the Kanaka Maoli as to why
they may not be complying or conforming to the expectations of the predominant culture.
Health care providers may become frustrated with Kanaka Maoli, who does not comply with
the prescribed care plan. In the health care setting, increasing the comfort level and
communication between the provider and the client would result in higher health literacy,
increased engagement with effective health care planning and goal making, which ultimately leads to greater compliance with the agreed-upon plan. Although strategies on client involvement in care planning are not new, cultural humility was not part of that strategy. Cultural Competency VS Cultural Humility Cultural competence is a common strategy used to train staff. However, it is overwhelming and impossible to achieve cultural competence in a world of multi-ethnicities as well as variations
within the culture. Another downside of cultural competence training is those who believe they are culturally competent may still hold on to negative stereotypes. Cultural humility and cultural awareness training focus on bringing awareness of the participant’s own cultural bias and provides communication skills to elicit understanding by the provider. This skill applies to a variety of situations and social groups such as LGBT, veterans, and disabled groups (Hook, 2013).

Health disparities include chronic diseases such as diabetes and hypertension and are prevalent in the primary care setting. Therefore, if primary care settings improve their communication with Kanaka Maoli, trusting relationships may result. It is within these relationships that mutually agreed upon care plans are crafted, resulting in compliance with the care plan increases. There may be times that the client may not be ready to address their health issues due to socioeconomic barriers. A trusting relationship between provider and client facilitates
safe and open communication to discuss the matter and find potential solutions for the
problem. A client will more likely address the more significant concerns of health when
fundamental issues such as food security and safety.

Cultural safety issues among other native populations such as those in New Zealand and Canada have been identified. Kanaka Maoli experiences a parallel history and experiences as these native populations with similar concerns of cultural safety in healthcare. It would be easy
to assume that the interventions to promote cultural safety among native populations outside of the United States can be adopted here.

Cultural Safety and Cultural Humility
The terms of cultural safety, cultural humility, and cultural competency are often mistakenly
used interchangeably. The term cultural competency refers to training regarding the values and practices of a specific culture to gain understanding. Cultural competency intends to work together with the client by understanding their culture. (Martin, 2016). This concept is described in the Transcultural Nursing Theory (also known as the Culture Care Theory) by Madeline Leininger (1991). According to Leininger, culture influences health, perception, and coping skills. Cultural knowledge is an essential component of nursing care. In developing
cultural competency, one develops understanding and respect for the beliefs and values of others. Dudas (2012) echoes this same understanding that cultural competence is a process of understanding and awareness of different attitudes and beliefs. However, there are concerns that this type of training can lead to miscommunication and stereotyping. Someone trained in
cultural competency may have a false sense of confidence in their ability to work with a person of a different culture from them. It is this stage that is the most dangerous for
misunderstandings and for cultural jeopardy to occur (Isaacson, 2014).
Cultural safety recognizes and respects the cultural identity of the client and the provider.
Cultural safety acknowledges that cultures can still have variances within them and allows a person to express their values and beliefs about how they wish to do so. It also recognizes that the provider has their own beliefs and values. Cultural safety is a practice that also shares
power in the client-provider relationship (Polaschek, 1998). Providing culturally safe care recognizes a person’s membership in a cultural group and its position in society. Cultural safety respects and nurtures the cultural identity of the client (Polaschek, 1998).

Social Determinants
Health care is more than just medical care received in a clinic or hospital. The influence of social-economic factors plays a much more significant role in health (Lee, Fitzpatrick, Sung-Yi,2013). Cultural differences, lack of minimal health care access, poverty, and care from professionals that are not culturally safe are a significant contribution to health disparities (Lee,
2013; De, 2008).

There are many programs in existence to reduce disparities. These programs intend to educate Kanaka Maoli on the importance of diet and exercise and other self-care behaviors. Programs also exist to help with access to health care. However, efforts to improve disparities need to go
beyond these actions. Health is a lifelong adaptive process that addresses the needs of the person (Halfon, 2002). Despite the recognition that health disparities among native people are widespread and significant, the literature on preventative care is sparse (Capell, 2008).

Inequities in the health care workforce are also present. According to Isaacson (2014), only 16% of all nurses in the U.S. are from a minority group. Only 11% of nurses in Hawai’i identifyas Native Hawaiian (Hawaii State Center for Nursing, 2019). With a workforce that does not represent the changing racial demographics of the United States and Hawai’i, it is essential for health care providers to have better training in working with a culture other than their own
(Dudas, 2012).

Health Care Ethnocentrism
With the emphasis on evidence-based practice in providing quality health care, ethnocentrismexists in the studies used to provide the evidence. Many studies either do not include or do notidentify the ethnicities of participants. Research studies also contain a bias of western view on health, the body, and what health behaviors are (Lee, Fitzpatrick, Sung-Yi, 2013).

Ethnocentrism is blind. Many people with the best intentions and desires to help others may
not realize how their own cultural bias is creating harm. Issacson (2014) described a group of nursing students who participated in a cultural immersion activity with Native Americans. Thestudents were instructed to write their reflections on the experiences before, during, and afterthe activity. The reflections were analyzed and found that many of the students held unrealized prejudice and stereotypes. Another typical response from the students was how
uncomfortable they felt being a minority for the first time in their lives. Had the students not
have that cultural interaction, they would not have realized their own bias.
The unknown bias that exists in health care providers results in a lack of awareness, skill, and support in providing appropriate care for native peoples. As a result, patients-treatment
nonadherence, reduced patient satisfaction, diagnostic errors, recovery complications, and
poor outcomes continue to occur (Delgado, 2013). The best way to address personal bias is with an awareness of one’s thoughts and values. Having the desire to understand personal bias
and values is necessary to understand the needs of others. It is also essential to recognize that people can identify with more than one group. A person may belong to a cultural group, a social, and an occupational group. Each of these factors
influences one’s overall values and behaviors (Dollarhide, 2016). The lack of this
acknowledgment can result in discord between the provider’s belief that they are providing the best and most unbiased care and the patient’s understanding of health and priorities resulting in health inequality and disparities (White, et al., 2017).

Benefits of Cultural Safety Training
The culturally diverse population that exists today calls for better communication and
relationship building between provider and client. There is overwhelming evidence of
disparities among native peoples despite the many programs and services created to address it.
As a result, there are many missed opportunities to positively affect health and decrease disparities (Delagdo, 2013). With increased cultural safety comes earlier interventions resulting in earlier diagnosis and treatment plans, which are culturally congruent with the values of the patient, family, and community. Supporting the patient’s health practices, along with western
medicine, improves opportunities for health promotion and disease prevention and promotes
the quality of care initiatives (Dudas, 2012). Cultural humility among the health care provider increases communication and fosters mutual trust—a trusting relationship results in improved overall health for individuals and community resiliency (Danaher, 2011). A provider who places value in understanding and seeking to provide cultural safety will foster a shared understandingof a client’s needs. Increasing indigenous staff also aids in a supportive environment and
fosters better communication and understanding (Gomersall, 2017).

Think cultural health.
The U.S. Department of Health & Human Services created a website called Think Cultural Health. It was launched in 2004 to improve health equity by providing
continuing education opportunities and educational resources for health care professionals.  The website includes information on the National CLAS standards, educational modules specific
to various health care disciplines, educational resources. The site offers educational modules designed specifically for behavioral health professionals, disaster personnel, nurses, oral health
providers, and physicians. There is also a module provided in the Spanish language. The modules are cost-free and provide accredited continuing education credit for completion of the modules. The module fits well with the aims of this project. The nurse specific courses specifically cover how to deliver culturally and linguistically competent nursing care, self-awareness tool, strategies for providing patient-centered care, communication techniques,
language assistance tools, and reviews the CLAS standards. The Physician (Nurse Practitioner) modules cover the CLAS standards and strategies for delivering patient-centered care, communication, and language assistance, and reviews CLAS related activities, includingstrategic planning and community assessment.

An example of how culture shapes the perception of health Malama kou piko. In her book Nānā I Ke Kumu, Pukui, Haertig, and Lee (1972) describe theHawaiian concept of the piko. By definition, the piko (Image 1) is the umbilical cord, the genital organs, the posterior fontanel, or the crown of the head. These points represent an attachment or a relationship with one’s ancestors, health, and descendants; it is now known as
the Triple Piko. The Piko Po’o (head) is the connection to ancestors and gods. Specifically, it is the area where
the hair whorl or cowlick is located. This area is where the spirit enters or leaves the body
during dreams or excursions and is the symbolic umbilical cord between mortal man and his ancestors. The umbilical cord is the link between the infant and its mother. The Piko Kino (belly button) is
the symbolic link to all blood-kin. Close relatives may poetically refer to a child as “my piko.”

This piko is the connection to the earth, to family here on earth. It is also the symbolic
connection to health, food, and the ‘āina (land). There are many customs and ceremonies
around the cutting of the umbilical cord. The technique depended on the rank or gender of the
child, where, and who severed the umbilical piko. Even the storing of the piko and the placenta
held many instructions necessary for the health of the child.
The Genital Piko is said to be the source of creation, the progenitor. Kanaka Maoli both revered and enjoyed the Genital Piko. Songs and hula were written and danced in honor of the Genital Piko. The Hawaiian mindset never considered this to be vulgar. They felt that without this piko, there would be no children, no descendants. This piko represents the future and all it holds.

Even in modern times, this concept of mālama kou piko (take care of your piko) exists. This
concept of mālama kou piko has passed down through generations. However, for some
families, this concept may have been passed down incompletely, with some of the concepts are present with other parts missing. This passing of an incomplete health concept may contributeto the ill health of the Kanaka Maoli, without them even knowing it. Many young Kanaka Maolitoday are re-learning and reviving these concepts.

For more information, please visit
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https://www.healthypeople.gov/2020/about/foundation-health-
measures/Determinants-of-Health

https://www.hawaiicenterfornursing.org/wp-content/uploads/2019/12/2019-

http://www.hpoe.org/becoming-culturally-competent

http://www.nursing-
theory.org/theories-and-models/leininger-culture-care-theory.php.

https://health.hawaii.gov/opcrh/files/2014/11/Assessment-Priorities-for-NH-OPP-Mele-
Look.pdf

http://www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-
nurses
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http://cletus.uhh.hawaii.edu:2059/login.aspx?direct=true&db=cmedm&AN=17135109&site=ehost-live

http://files.hawaii.gov/dbedt/census/popestimate/2018_county_char_hi_file/Pop_char
_hi_ 2018_final.pdf

https://cletus.uhh.hawaii.edu:4796/10.1007/s40615-017-0340-6