Tag Archive for: cultural safety

Why write/read book chapters? Community, connection, and creativity.

“…the neo-liberal academy has compelled me to compete and compare, to work on my own, to overwork, and to count narrowly. At various times, neoliberal ideologies have crept into my mind/writing/body, breaking me down. The academy’s “finite games” of winners and losers, the demands to prove I am a “credible academic”, the narrow counting and the changing and hardening rules of entry have kept me running on the production treadmill, frequently distracting me from what matters most” (Harré et al., 2017, pp. 5, 9).

I am a serial book chapter reader and writer. If you check out this link, you’ll see I have written a fair few. Writing a book chapter seems less daunting than trying to write a whole book, and less prescriptive and intimidating than journal articles because I can more easily imagine the reader. It may be a student or someone from my academic or professional community, but I have a sense of their ethical and political commitments. In quantified academia, research activity and impact are crucial to academic promotion/tenure and research funding. In my field of health, peer-reviewed journal articles are the gold standard. When I think like a ‘professional’ academic I sometimes wonder if book chapters are ‘worth’ writing. So much of “successful” knowledge production depends on your discipline, your structural location (not only whether you are tenured or precarious, but also whether you have a marginalised identity/ies or work in a marginalised field), your preferences for dissemination or contribution in terms of who you write for, and how ambitious you are, so it’s political as well. None of this is helped by the ways in which academia is still predicated on being an exceptional competitive individual which can preclude more contemplative kinds of collaboration (Black, 2022). In the Gigiversity, there’s also what Mark Carrigan calls temporal budgeting which can be a barrier to writing as a creative process. Writing becomes calculated, something that has to be accounted for, and made time for.

I am not immune from living a calculated life. I recently said no to an invitation to write an academic book chapter (and I am still ambivalent about this) because of the opportunity cost, not because of wanting it published in a journal where it would “count” more, but because my career is now based on consulting, so the time I spend writing without payment means not getting paid. You can read more about the reasons not to write book chapters in this blog by Adam Chapnick. I have also co-edited a book Researching with Communities: Grounded perspectives on engaging communities in research, supposedly a huge no-no, but that’s for another blog. Rasmus Nielsen’s conceptualization of the value of the book chapter genre is helpful (1) argumentative chapters, (2) trailer chapters, and (3) review chapters. In the first category, a book chapter can help to think through an argument in an interpretive and personal way; and the second category where you operationalize the underlying concerns for another project is where my work has typically landed. I save the third for journal articles. So why even write book chapters? Here are some of my reasons.

As a reader and scholar, anthologies have saved me as a person of color. This Bridge called my Back and later Black British Feminism edited by Heidi Mirza, which I devoured avidly in a largely monocultural academic New Zealand are just two examples. As an author Sara Ahmed, says that the Mirza book was pivotal to a broader political identity and that being part of “a collection can be to become a collective” (Ahmed, 2012, p.13). Younger me would have been so thrilled to get my hands on Towards a Grammar of Race In Aotearoa New Zealand edited by Arcia Tecun, Lana Lopesi and Anisha Sankar. Covering all the things younger me was living through but had no vocabulary for, things like racial capitalism, colonialism, white supremacy, and anti-Blackness.

More elegantly and evocatively, my friend and podcast guest extraordinaire Alice Te Punga Somerville writing from Musqueam whenua, offers many metaphors for the collectivity of edited books, as food, as gathering, as connected across time and space, tantalising and replenishing. She adds (in discussing a new edited book by Kiri Piahana-Wong and Vaughan Rapatahana) “Māori have always been collective with our writing: so many anthologies, collections, joint readings, festivals, hui, organisations, writing groups, one-off collectives, roopu… this one draws consciously on the Into the World of Light/ Te Ao Mārama anthologies called into being by Ihimaera and others… but all of these Māori literary awa are part of a massive network of tributaries and streams and gorges and brooks and braided rivers and underwater culverts and, yes, all the way out to open ocean…she concludes “slurping down this awa which is replenishing and exciting me… and loving this hui with writers known by my heart, writers I have long admired from afar, and writers I have yet to meet.”

These relationships and collaborations are such a good reason for writing book chapters. Helen Kara who I enjoy for their interest in creative methods values the sense of community or social network that can accompany an edited book when there is a clear theme and the authors richly complement each other, which cannot be achieved with a single or co-authored book. It’s what Debra Brian says is a plus for the reader — “they often capture an important moment in the history of the discipline, or an opportunity to bring together multidisciplinary takes on a central theme.” I have recently had a chapter on racism and care published in No longer silent: Voices of 21st Century Nurses edited by Lesley Potter with support from the Australian College of Nursing. It is envisioned as a snapshot of contemporary nursing in Australia. Here’s a short excerpt:

There is trepidation and vulnerability that accompanies naming racism, rather than the more palatable good feeling word diversity (De Souza, 2018). Discourses of diversity and inclusion are what Ahmed (2012) describes as ‘non-performative institutional speech acts’ meaning that just their use as words do not necessarily change what it is they are naming Ahmed, 2012, p. 119). Racism is so direct, so harsh in the text as opposed to toned down with my good humor or the self-effacing charm I have cultivated as a bolster. I am a nurse who migrated to Australia post PhD for work in academia. As a person of color or brown settler, I occupy a position of unease and anxiety, uninvited living on stolen land, in a country where relationships between Indigenous people, settlers and migrants are contested. I am also privileged to be a mobile, highly educated researcher working in the prestigious context of a University. As (Moreton-Robinson, 2007, 2015) quips, the White nation-space of so-called Australia, excludes both Indigenous people and non-British people. However, I invoke this process of critical reflexivity and locate my own positionality to account for myself and for my writing. A person with ancestral heritage in Goa, India but whose personal and familiar multiple migrations, have been shaped by colonization. I provide these histories and geographies to account for how I write, they provide me with a specific set of ethical and political commitments that aim to contribute to making nursing a profession that is less discriminatory and more equitable for both those who follow me and those we purport to serve. I care about nurses and nursing and am troubled by the paradox that a profession that claims to care could be implicated in perpetuating inequities for some populations. This stance of critique and the desire for accountability may make what I write seem particularly critical, however, it also reflects a deep investment in the nursing profession.

Changes in models of publishing have also made writing book chapters more worthwhile Patrick Dunleavy says in an LSE blog. Dorothy Bishop admits her best writing is in book chapters where she has had the freedom to integrate broad perspectives, but argued in the past that writing a book chapter was like burying your work because of difficulties in trying to access and cite work. However, now that e-book chapters are becoming as discoverable, and more affordable, the reader or potential citer no longer has to pay massive prices for books that are just as easy to find as journal articles. Individual chapters have become easier to use in teaching, as they can be added to reading lists on learning management systems (LMS). I have added a book chapter on Cultural Safety I co-wrote for the book The Relationship is the Project for a lovely intensive course I’ve been teaching in the School of Art with Alan Hill and Jody Haines at RMIT University called Creative Practice in Place: Working on Unceded Lands. Interestingly the chapter has been reprinted online in two different contexts, in Arts Hub as Taking action for Cultural Safety and republished in Spotlight, the Arts Wellbeing Collective magazine which makes it more accessible. However, access does not equal citations, so even if they are used in essays or theses, they may not show up in citation metrics.

Book chapters open up different formats and creative options compared to journal articles, which is why one of my favorite academic bloggers Pat Thomson who blogs at Patter writes them. Another favorite blogger Agnes Bosanquet writes In defence of book chapters that book chapters let you publish “something experimental, fun and adventurous” and you can take more “risks with style, structure and method”. Concluding that “when I want to write in the company of others, flex my writing muscles in new ways, and find pleasure in the craft of writing, then book chapters are a gift”. Historian Zora Simic says “I find them a more liberating form than a journal article and some of that is because of the way I think – journal articles typically demand an argument that is pursued in coherent fashion whereas I prefer ambiguity, open and loose ends, experimentation, and exploration for the sake of it.” This desire to write playfully and creatively resonates with me. There’s also a pragmatic freedom that Thomson identifies. Firstly, because your chapter is part of a collection, you do not have to do as much prefacing and situating as you would in a journal article. and secondly, you do not have to convince people to read the chapter because the editors have already done that work for you.

Viewing a field through a different lens is another reason to write a book chapter, providing a way in which students or practitioners can get a feel for a topic, its scope and debates. Elaine Swan adds “I recommend them to students as they can see how a topic can be understood through different concepts and methods.” Scholars like Carol D’Cruz find the breadth of the approaches to tackling the same issue appealing: “I love variety in the perspective and approach in edited collections, especially when all answering the same/similar problem.” Some writers also appreciate the opportunity to learn, to use their experience in another context, like Zora Simic who says “Once I responded to a call for contributions to a book called Fat Sex. I’d always wanted to know more about the history of fat activism/feminism and this was the perfect opportunity. It had nothing whatsoever to do with my other research, apart from being about feminism. But I loved writing and researching it.”

Leaving your mark in a field is another drawcard. Debra Brian contends saying yes to a book chapter “can signal your commitment and standing in the field, your academic social capital, etc — and it can bring other opportunities. Sometimes it is worth doing for the sake of collaboration and relationships and the opportunity to find a home for something that needs to be said but doesn’t really ‘fit’ in another format.” This really rang true for me in my contribution to Jessica Dillard-Wright’s book Nursing a Radical Imagination: Moving from Theory and History to Action and Alternate Futures co-edited with Jane Hopkins-Walsh and Brandon Brown where I wrote about creative methods in nursing education. We’ve subsequently collaborated on a number of other projects, Jess (and Jane) contributed an artwork for our exhibition and course for The Big Anxiety Festival, and did a Zoom guest lecture to art students. We have also just cowritten No as an act of care A glossary for kinship, care praxis, and nursing’s radical imagination Jessica Dillard-Wright, Favorite Iradukunda, Ruth De Souza, and Claire Valderama-Wallace in the tome Routledge Handbook of Philosophy and Nursing Edited By Martin Lipscomb. I feel deep gratitude for the friendship that has evolved between us in the process of talking and writing (a non-academic benefit (Tom Pepinsky) of writing book chapters)! Here’s the abstract:

Radical imagination and the transformations that ensue are fundamentally collaborative, connected, and conscious. In an effort to first imagine and then co-create a more just, equitable present/future for nursing and those with whom we care in the spirit of radical imagination, this chapter examines nursing care as praxis and the shifts that occur in embracing kinship as a reciprocal model for nursing. In so doing, we challenge embedded power structures within the healthcare-industrial complex – and thus nursing – as we currently know it. Using feminist, queer, anti-colonial, anti-imperialist, and abolitionist insights, we imagine a present/future for nursing liberated from the capitalist political economy entrenched in a boundless society of control. This speculative vision is urgent, encompassing, and material, bursting open the boundaries of nursing as we consider with whom we align and how we build toward a future on a deteriorating planet.

Obviously, academics have to be strategic about writing but I also write because writing helps me make sense of things. I write to think, just as I speak to think. The former is far more laborious for me but I am getting better at it. Book chapters allow me to play, to experiment, and to feel part of a community, a collective and that is hard to beat.

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Teaching into a headwind and Nursing a Radical Imagination

So, this incredible book Nursing a Radical Imagination: Moving from Theory and History to Action and Alternate Futures, Edited by Jess Dillard-Wright, Jane Hopkins-Walsh, Brandon Brown has been published, and what a thrill to have a chapter in it!

The book is described as “Examining the historical context of healthcare whilst focusing on building a more just, equitable world, this book proposes a radical imagination for nursing and presents possibilities for speculative futures embracing queer, feminist, posthuman, and abolitionist frames”.

Cover of my copy of the book

My chapter: Using Arts-Based Participatory Methods to Teach Cultural Safety details my efforts to introduce Cultural Safety into a Bachelor of Nursing program through collaborations with artist friends. There’s a section on engaging teaching colleagues in Possum skin bracelet making with Dr Vicki Couzens, a Gunditjmara woman from the Western Districts of Victoria who is a Senior Knowledge Custodian for possum skin cloak story and language reclamation and revival in her Keerray Woorroong Mother Tongue.

Me with Dr Vicki Couzens (taken in 2015).

Then the story of developing a unit for nursing students where a workshop was offered at the start of the semester drawing on Forum theatre developed by Augusto Boal co-facilitated with two experienced practitioners Azja Kulpińska and Dr Tania Cañas (action shot of us below).

Tania, Azja and I in action

In my chapter I set the scene of trying to teach Cultural Safety in Australia by talking about: whiteness in the “lucky country”; how Cultural Safety was introduced into nursing curricula; the University as both a colonial site and place of transformation; and how nursing degree programs experience the strictures of the neoliberal University while reproducing colonial legacy inequalities in the curriculum factory. I suggest the barriers to a culturally safe and transformative curriculum in nursing include: conservatism, multiple stakeholder demands, technomanagerialism, surveillance, precarity, conservatism, a lack of skills, and unexamined whiteness. I include a reflexive section which I call Teaching Cultural Safety while being unsafe. I conclude the chapter by describing teaching as a marginalised subject while a minoritised scholar as being like teaching into a headwind (see Anderson, et al., 2020) and drawing on Mukandi and Bond (2019) suggest that trying to “out-teach” the imposition of racialised ideas is impossible, but creating pockets where reparative and healing work can happen is something I am proud of doing.

I share my last words below:

So how do we make sure that the future of nursing is collectively “ours” when the responsibility for the work of Cultural Safety is unevenly distributed, devalued, and displaced onto those who are fighting with both armory and weapons to survive in whiteness? Those who are struggling with the work of fitting in or disappearing, who are tasked with being there without really being there? (Mukandi & Bond, 2019). High-quality academic work including teaching is slow work, time is needed to try things, to engage and innovate, to facilitate curiosity and creativity in students (Mountz et al., 2015). None of which can happen effectively in accelerated and precarious work contexts. If we want to deliberately teach students to not only be capable and competent but to fight for equity, anti-racism, and social justice, we must make time to challenge or experiment, otherwise we risk reproducing a depoliticised “what’s already there” future workforce, fixated on the useful, the commodified and utilitarian. A workforce that reproduces structural violence, joining generations who have done much the same. As Cultural Safety becomes tamed and domesticated, into University curricula, we must ensure it does not lose its critical edge. I am unconvinced that we can shift whiteness in nursing. But maybe, just maybe by making this contribution, “being part of a collection [in this book] can be to become a collective”(Ahmed, 2012, p. 13). This is my hope.

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An interview with nurse and multi-disciplinary researcher Dr Ruth De Souza

I had a chat with Ben Rodin from The Australian Nursing and Midwifery Journal . I said a few things. You can read more

“All bodies are not treated the same and we’re not affected by the virus in the same way… how we do healthcare actually matters… There’s some arguments that the failure to care, and poor quality [of care], are actually embedded in the structures and processes of the healthcare system.”

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Cultural safety in the arts

Robyn Higgins and I wrote a chapter about cultural safety in the arts in an exciting new book about community engaged arts practice The Relationship is the Project edited by Jade Lillie with Kate Larsen, Cara Kirkwood and Jax Jacki Brown.

Image from the cover of the book The Relationship is the Project. The book is on a wooden table.

It is exciting to be in such a fabulous line up with folks like Genevieve Grieves about working in First Nations contexts; Caroline Bowditch on access and disability; Dianne Jones, Odette Kelada and Lilly Brown on racial literacy; and other contributors including: Esther Anatolitis, Adolfo Aranjuez, Paschal Berry, Lenine Bourke, Tania Cañas, Rosie Dennis, Alia Gabres, Eleanor Jackson, Samuel Kanaan-Oringo, Fotis Kapetopoulos, Kate Larsen, Lia Pa’apa’a, Anna Reece, Daniel Santangeli, and Jade Lillie.

Table of contents from the book The Relationship is the Project

Here’s a tiny excerpt from our chapter to whet your appetite.

Why do we need cultural safety?
Australia is a white settler colony in which British invasion and colonisation have institutionalised whiteness. Like other sectors, this history is strongly reflected in the arts, including the ways our practitioners, organisations and institutions develop and deliver projects in collaboration with artists and communities.
Arts organisations often prioritise and centre whiteness. For people and communities who are not white, these organisations may not be seen as appropriate, accessible or acceptable, which can prevent participation and engagement.

Since I wrote this post the chapter has been edited and reprinted twice:

Artshub: Taking action for cultural safety and in The Arts Wellbeing Collective in their publication: Spotlight: The Arts Wellbeing Collective magazine – Edition 2 

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Cultural safety: On healing the health system through partnership

Cultural safety in health is the radical idea that people who use health services should be treated with competence, care and respect, so that their dignity and sovereignty are maintained, and not compromised by the system of health care. Both an ethical framework for negotiating relationship and an outcome of care, cultural safety rests on transforming power relations and disrupting universal factory models of care premised on an ideal implicit service user, who is typically able bodied, straight, cis gendered, white and middle class. Cultural safety provides a counter to the reductionism and individualism of episodic care in medicine, to demand that the health of recipients of care whether as individuals, families or communities is holistic and seen in the context of historical and geographical determinants.

There’s an extensive bibliography on the genesis of cultural safety, but briefly it’s a concept developed in Aotearoa, New Zealand by Māori nurses that’s travelled to other white settler nations like Canada, and contexts including the arts. It is a really exciting time for the concept of cultural safety in Australia as it gains momentum among Indigenous health advocates but more broadly in health contexts, challenging inter-changeably used terms like cultural awareness and cultural competence. Mark Lock has beautifully outlined developments in his article on How to Embed Cultural Safety in Healthcare Governance – Better Boards. These developments include:

  • The Medical Board of Australia, public consultation on a draft revised code of conduct including a revised section on culturally safe and sensitive practice  with Aboriginal and Torres Strait Islander peoples (June 2018).
  • The Nursing and Midwifery Board of Australia–care is ‘culturally safe and respectful’ (2018).
  • The Australian Health Practitioner Regulation Authority (AHPRA) committing to embedding cultural safety in the 15 national health practitioner boards (July 2018).
  • The Council of Australian Governments’ (COAG) Health Council public consultation on reforms of the Health Practitioner Regulation National Law (July 2018).
  • The National Safety and Quality Health Service Standards now contain six new actions for implementation in 2019, where achieving these actions means ‘provide culturally safe care’ for Aboriginal and Torres Strait Islander peoples (2019).
  • $350,000 for Australian-first online cultural safety training course for nurses and midwives delivering care to Aboriginal and Torres Strait Islander peoples (January 2019).

Recently, The Australian Health Practitioner Regulation Agency (AHPRA) asked for feedback on the definition of ‘cultural safety’ both from the public and specifically from Aboriginal and Torres Strait Islander individuals and organisations. The public consultation which closes next week (May 24th 2019) is led by the National Registration and Accreditation Scheme’s Aboriginal and Torres Strait Islander Health Strategy Group (Strategy Group) and the National Health Leadership Forum (NHLF), with the aim being to develop a definition that can be embedded more broadly. This is the proposed definition they want feedback on

‘Cultural safety is the individual and institutional knowledge, skills, attitudes and competencies needed to deliver optimal health care for Aboriginal and Torres Strait slander Peoples as determined by Aboriginal and Torres Strait Islander individuals, families and communities.

I really recommend reading the incisive and comprehensive critique of AHPRA’s definition of cultural safety in Croakey. Dr Leonie Cox (Queensland University of Technology) and Associate Professor Odette Best (University of Southern Queensland) argue that changing the definition from Māori scholar Dr Irihapeti Merenia Ramsden’s critical work replaces a political imperative with an individualised, ethnographic and idealised version which places the burden for health system transformation to the consumer in the guise of partnership. Cox and Best (2019) observe:

Let us be clear, cultural safety is about the cultures of systems, professions and practitioners. It is about an ongoing individual and organisational self-reflective exercise. It addresses the impact that mainstream cultures, ways of doing business and social positions have on practice and on health outcomes for service users.

I am pleased to have been involved in related initiatives happening in Victoria. In November 2018 I was invited to speak at the Victorian Clinical Council meeting, an independent group, which provides leadership and independent advice to the Department of Health and Human Services and Safer Care Victoria (SCV) on how to make the health system safer. The council had chosen the theme of diversity and cultural safety. In my presentation, I provided an overview of cultural safety. I also suggested a shift in focus from the language of diversity, to one that addresses power and privilege using critical tools like intersectionality and cultural safety. I shared the five facts about cultural safety and encouraged the council to ask disruptive questions and explore alternative ideas and perspectives. You can read more hereCommunique meeting 4 2018 (PDF, 130.27 KB). You can see the recommendations which will be presented to SCV and the department Secretary to endorse and action.

In April 2019, I was invited to be a keynote at Safer Care Victoria’s first
Partnering in healthcare forum. The theme ‘Together is better’ is a reflection of a genuine commitment to ensure consumers are at the centre of care. Three hundred attendees attended the sold out event over two days to focus on how to best respond to the needs and expectations of consumers and deliver care that is person centred, equitable and caring. What impressed me ever so much is that Safer Care Victoria worked hard to support consumers to take part and over a hundred participants identified as having a consumer background. SCV have also developed a Partnering in healthcare framework. I have had a long interest in power relations in health and in examining how concepts like choice, partnership and empowerment can transfer responsibility to service users but without the access to infrastructure, resources and support. I loved David Gilbert’s presentation. David is a Consumer Director in the National Health Service, UK and he spoke about the role of consumers and patients and how the notion of ‘patient leadership’ in the UK is transforming roles, opportunities, and models of patient partnership. In a fabulous article in the BMJ, David says:

Meanwhile, I watch the failure of the engagement industry—reliant on child-parent feedback mechanisms and adolescent-parent institutional arrangements that pit representatives against professionals (or co-opt them) in tedious sub-sub-committees. And yields… not much to be honest. Everywhere I look, power is neutralised and buffered. We are patted on the head, told to play with broken toys rather than join in with the big boys. The passion and wisdom gained through suffering and resilience is not valued. This is a caricature, but I believe it largely represents recent reality.

I really appreciated what David said about what we call people who try to change the system rather than healing in peace. occupy what do we call idiots like me who, instead of just wanting to heal in peace, return to the NHS in a different guise?

There were so many other highlights at the Partnering Forum which gave me great heart. One of the standouts (and I know I should mention every single one) was by Clinical Lead and Facilitator for the Rounds, Associate Professor Leeroy William, Chief Experience Officer Anne Marie Hadley and Anjali Dhulia from the Schwartz Round team who provide palliative care at Monash Health. This team were highly commended in the Safer Care Victoria compassionate care award category for the ‘Rounds’ which are a structured forum for all clinical and non-clinical staff. It provides a safe and nurturing space for people to regularly come together to talk about the emotional and psychological aspects of working in health care. The idea comes from work at the Schwartz Centre for Compassionate Care in Boston. What I loved about it, is the recognition of trauma and compassion fatigue for people who work in health care which includes staff like cleaners or kitchen staff who do not get seen as part of the health care team, but often have very intimate conversations and connections with people. I think that having the space to talk about things that matter in the factory system of health care can transform burnout, negativity and cynicism, by providing a sense of community and care and mostly reconnecting people to their purpose in working in health.

Which brings me to my own presentations at the conference. I did a keynote presentation and a workshop. Rather than attempt to summarise, I’ll leave the last words and images to the most fabulous Zahra Zainal, a Melbourne-based graphic recorder and illustrator, who has so much talent and was able to simplify and amplify my words into stunning illustrations. Please feel share to use and share with appropriate acknowledgement of Zahra and I.

Finally, I’d like to thank the team at Safer Care Victoria especially Lidia Horvath, Belinda MacLeod-Smith, Hayley Hellinger, Louise McKinlay, and Erin Pelly. Also many thanks to sponsors Bang the Table and The Victorian Agency for Health Information.

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We need more than diversity in nursing.

I wrote a piece for the Spring 2018 edition (Issue 23) of the Hive (the Australian College of Nursing’s quarterly publication). Cite as:DeSouza, R. (2018). Is it enough? :Why we need more than diversity in nursing. The Hive (23, 14-15). You can also download a pdf of the article for your own personal use.

Diversity is a hopeful, positive and celebratory idea, it generates more happiness than words like inequity, racism and privilege. It feels good for a large number of people precisely because it is depoliticized (Hall & Fields, 2013). It does not demand accountability. It does not demand transformational change of our minds or our environment, but requests that we continue to put up with difference or to tolerate it (Bell & Hartmann, 2007). What does it mean for our profession to be diverse? And is it enough?

Is it enough, when we have a yawning chasm of health inequity and disparity, of deaths in custody, of punitive policy aimed at Aboriginal Australians? Is it enough, in an era of devastating Islamophobia and racism enabled by nationalist right wing xenophobia? Is it enough, when politicians challenge group-based rights and argue that they undermine social cohesion and “our way of life”, maligning and scapegoating already vulnerable groups like African youth. Is it enough, when media only catapult the spectacular and exceptional into our view. Is it enough, when the entire world is condemning Australia’s abhorrent offshore policy of deterrence and detention. Yes, we need to recognise difference, but we must also understand how differences are connected to inequalities. As Mohanty observes: “diversity by passes power as well as history to suggest a harmonious and empty pluralism” (Mohanty, 2003, p. 193).

We might be ticking the diversity boxes and celebrating diversity — whether in University brochures and websites or on Harmony Day — but do our combined activities address health disparities? The problems of inequity and disparity are bigger than us but we can be accountable for the parts we play in larger political struggles. For a politics of equity, we also need to consider race, disability, ethnicity, class, gender, sexuality, and religion and integrate these into our analyses of our social world. We need to expand the frames we use to look beyond individual behaviour and to consider social and systemic issues, and call for systematic interventions to address inequity. ‘Celebrating’ cultural difference isn’t the same as action, as fighting for justice. As (Perron, 2013) notes, nurses can be both caring for individuals and advocating for the collective rights to equitable care, they aren’t mutually exclusive.

Diversity assumes that care is still a neutral technical activity
As nursing emerged from being a class of handmaidens to the medical system to the dynamic profession it is today, we have understood it to become an intellectual, cultural and contextual activity. This means it is also a political activity (De Souza, 2014). Nursing is connected to systems of power and privilege. Nurses and clients bring multiple ways of being in the world into the world of care and yet we only privilege some of these ways of being. Iris Marion Young describes oppression as being “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, 1990, p. 41). There continue to be clear links between institutional bias in health care systems and health disparities (Hall & Fields, 2013). Let’s ask ourselves what practices we enact every day that contribute to inequity?

Diversity maintains whiteness at its core
In diversity talk in nursing there’s an assumed white centre with difference added. White people are conceived as the hosts and people of color viewed as guests and the perspectives of Indigenous people are erased. Allen (2006, pp. 1–2) calls this the ‘white supremacy’ of nursing education: an assimilationist agenda that converts diverse groups people into a singular kind of nurse, which can then add ‘others’ into the mainstream to create a multicultural environment. But, this addition reinforces rather than displaces whiteness from the centre of structures and processes of educational or clinical institutions (p.66). It’s important that we focus on whether nurses reflect the communities that they serve. But representation in the workforce doesn’t mean that the people who are culturally different have a voice in the corridors of power. There are questions also about “who’s at the decision-making table and who’s not. And what’s on the agenda and what’s not” (Brian Raymond, 2016).

Diversity focuses on sensitivity and respect rather than on the social and historical
Race and racism are determinants of health inequities (Krieger, 2014) therefore it follows that a key area where nurses could intervene is to address discrimination. It is inadequate for us to provide individualised sensitive and respectful care while ignoring the historical and structural conditions that shape health and healthcare. As nurses, we understand more than most that life is an uneven playing field – we need to bring this knowledge to the way we work as a profession. Cultural sensitivity and awareness tend to assume that racism is “out there”, rather than something that is also enacted within healthcare systems. Our claims to colorblindness reinforce the problem, as” treating people the same” doesn’t take into account their differing needs, which is one definition of what care is.

Spotted at my local market

Creating a meaningful diverse and multicultural nursing profession
in an era where both patient populations and the nursing workforce are becoming more diverse, where are the spaces for nurses to talk about both institutional and societal racism and how they impact on care? How can nurses broaden their focus from the micro-level to see the big picture, especially when they labor in unstable and under-resourced working environments (Allan, 2017)? Nurse educators must confront our own resistance to teaching about race and racism (Bond & Others, 2017) – the recent debates about the inclusion of cultural safety into the Nursing and Midwifery Codes of Conduct reflect now far we have to go. Our curricula must more explicitly embed anticolonial and intersectional perspectives into learning experiences in order to prepare nurses for not only understanding how structural inequities affect health but also for the skills to counter them (Blanchet Garneau, Browne, & Varcoe, 2016; Thorne, 2017; Varcoe, Browne, & Cender, 2014). In Australia, the Indigenous Health Curriculum Framework developed by the Committee of Deans of Australian Medical Schools, recognised the critical need to teach students about racism. In particular, it asks us to see the connection between history and current health outcomes; to be able to identify features of overt, subtle and structural racism or discrimination and to be able to address and help resolve these occurrences.

Viewing nursing as a neutral, universal activity where appreciation, sensitivity and respect are adequate, prevents us from considering nursing as a political activity where power is at play. Conversely, embedding an understanding of the historical, structural and systemic factors that shape health, into our practice will allow us to create a meaningfully inclusive – and more caring – profession. This however, requires courage, commitment and accountability. Do we have it?

References

Allan, H. (2017). Editorial: Ethnocentrism and racism in nursing: reflections on the Brexit vote. Journal of Clinical Nursing, 26(9-10), 1149–1151.
Allen, D. G. (2006). Whiteness and difference in nursing. Nursing Philosophy: An International Journal for Healthcare Professionals, 7(2), 65–78.
Bell, J. M., & Hartmann, D. (2007). Diversity in Everyday Discourse: The Cultural Ambiguities and Consequences of “Happy Talk.” American Sociological Review, 72(6), 895–914.
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Pregnant with possibility: Migrant motherhood in New Zealand

First published in Mindnet  Issue 6 – Winter 2006

When my family arrived in New Zealand in 1975 there were very few people from Goa living here. We quickly got know every Goan in the country and, in hindsight, this connection provided me with an early interest in and focus on both maternal mental health and migrant mental health. Two Goan women we knew developed mental health problems that were devastating for themselves and their families. For one, it led to suicide and for another a lifelong history of mental illness and loss. Hardly good outcomes! This was a time when it was hard to maintain our culture. Thankfully, the more recent shift in focus to encompass settlement rather than just immigration will further enhance the well-being of ethnic communities in New Zealand.

There are still large research, policy and practice gaps in the area of migrant motherhood, which I’d like to address in this article. I’d like to start by highlighting the significance of migrant motherhood, which has potentially long term and wide ranging impacts on members of a family. I’ll then talk about the changing demographics of New Zealand society and suggest that health workers need to broaden their focus for working with New Zealand’s increasing diversity and develop culturally safe ways of working with migrants and their families. Lastly, I’ll share my experiences of research with migrant mothers from different ethno-cultural communities.

When migrants “cross borders they also cross emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. Boundaries are crossed when new identities and roles are incorporated into life” (Espín, 1997, p.445). Border crossing can involve trauma related to migration and a psychic split (Mohamed & Smith, 1999).

Migration policies favour women (and families) of childbearing age, so it is no surprise that having a baby is a common aspect of a woman’s settlement experience. Motherhood and migration are both major life events. They present opportunities but incur the risk of mental health problems, more so when they are combined. Many cultures and societies have developed special perinatal customs that can include diet, isolation, rest and household help. But these traditional and specific practices and beliefs that assist in the maintenance of mental health can be lost in migration (Kruckman, 1992). Women are separated from their social networks through migration and must find new ways to recreate these rituals or lose them (DeSouza, 2002). Research suggests that the loss of support, protective rituals and supportive networks compounded by a move to a nuclear family-model can result in isolation and postnatal depression (PND) (Barclay & Kent, 1998; Liamputtong, 1994).

Access to help and support can be impeded if the mother has language and communication problems.

Migrant mothers sometimes face additional cultural and social demands and losses that include the loss of lifestyle, control, sense of self and independence, family and friends, familiar birthing practices and care providers.

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

In a study of 119 pregnant immigrant women in Canada, Zelkowitz et al., (2004) found that the transitions associated with migration placed women at higher risk of depression. Forty-two percent of participants scored above the cut-off for depression. Depressive symptoms were associated with poorer functional status and more somatic symptoms. Depressed women reported a lack of social support, more stressful life events and poorer marital adjustment. In Australia, Liamputtong and Naksook (2003) found that Thai women who became mothers in Australia had several main concerns, including social isolation, different childrearing and child disciplinary practices, and the desire to preserve their culture. Findings of isolation, loneliness and negotiating between traditional and Western childbirth rituals are common in these studies and were significant issues in my own New Zealand research (DeSouza, 2006c). This research strongly suggests that migrant mothers, regardless of origin, benefit significantly from effective and familiar social support networks.

Psychiatric illness occurring at this time can have an adverse effect not only on the woman herself but also on her relationships, family, and the future development of her infant. The impact on a child of a mother’s depression can include behavioural problems, relationship problems and cognitive deficits. Research shows that infants who had a mother who was depressed in its first year of life are more likely to develop cognitive deficits and behavioural problems than infants whose mothers were not depressed in that first year (Beck, 1998).
A review by Goodman (2004) of literature from 1980 to 2002 found 20 research studies that included incidence rates of paternal depression during the first year postpartum. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.

Changing demographics

Many societies are grappling with issues of citizenship and participation in the context of globalisation, increased migration and increasing diversity. In Europe, one in every fifteen people was born overseas, in the US it rises to one in eight and in New Zealand it is one in five (DeSouza, 2006a). This presents unique challenges and opportunities for service providers to develop skills and competence for working with this diversity, especially as migration is going to be a key source of population increase. Census projections to 2021 suggest that Māori, Pacific and Asian populations will grow at faster rates than the European population but for different reasons. The Asian population is expected to more than double mainly due to net migration gains while Māori and Pacific people’s increases will be due to their higher fertility rates (Statistics New Zealand, 2005).

The Asian community has the highest proportion of women (54%), followed by Māori and Pacific (53% each) and European (52%) (Scragg & Maitra, 2005). Asian women are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups and to some degree this is a reflection of migration policy with Asian women using the opportunity to study or work. It is thought that 23% of New Zealand females were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands (Statistics New Zealand, 2005). The 2001 Census revealed growing numbers of Māori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), despite the dominance of the European/Pākehā who make up 79.6% of the population. In the period between 1991-2001, women originating from the Republic of Korea have increased 23 times from 408 to 9,354, women from China have quadrupled from 4,620 to 20,457 and women from South Asia have doubled in the same time period. Women from Africa (primarily South Africa, Zimbabwe and Somalia) have quadrupled in number (Statistics New Zealand, 2005). This has significant implications for the development and delivery of health services to women.

Cultural competence?

Working on a postnatal ward of a women’s hospital several years ago led me to question whether cultural safety had prepared the nursing and midwifery workforce for working with ethnic diversity1. Cultural safety, which refers to the experiences of the client, and cultural competence, which focuses on the practitioner and their capacity to improve health status by integrating culture into the clinical context, have been gaining prominence, but what do they actually mean?

The introduction of the Health Practitioners Competence Assurance Act 2003 has meant an additional responsibility to ensure the cultural competence of health practitioners. Cultural competence can be defined 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 (Betancourt, Green, & Carrillo, 2002). Cultural competence includes not only the interpersonal relationship (for example, training and client education) but also the organisational (for example, involving community representatives) and the systemic (for example, providing health information in the appropriate language, collecting ethnicity data).

The New Zealand Medical Council recently consulted its members on cultural competence (The New Zealand Medical Council, 2005). The consultation document includes a proposed framework and says that cross-cultural doctor-patient interactions are common, and doctors need to be competent in dealing with patients whose cultures differ from their own.

It cites the benefits of cultural competence as:

  • Developing a trusting relationship;
  • helping to get more information from patients;
  • improving communication with patients;
  • helping to resolve any differences;
  • increasing concordance with treatment and ensuring better patient outcomes; and
  • improved patient satisfaction.

For cultural competence to occur there is a need for the voices of ethnic communities to be considered in service development, policy and research. Despite the long histories of migration to New Zealand, ethnic communities have been absent from discussions of nation building and health care policy (DeSouza, 2006b). This has in part been due to the relatively small numbers of migrants from non-traditional source countries until the early 1990s, which meant that that the concerns of a relatively homogenous Pākehā people were reflected in policy (Bartley & Spoonley, 2004). This monoculturalism continues to be challenged by the increased prominence of Māori concerns since the 1970’s and increasing attention to biculturalism and health outcomes for Māori. Developments have also occurred with regard to Pacific peoples, largely around health disparities, but this concern has not been extended to ethnic communities despite their increasing visibility in long and short-term migration statistics. This is partly due to an assumption of a ‘health advantage’ of immigrants on the basis of current migration policy, which selects healthy people. However, evidence is growing that this advantage declines with increasing length of residence in a receiving country (Johnstone & Kanitsaki, 2005).

Cultural safety

When Britain assumed governance of its new colony in 1840, it signed a treaty with Māori tribes. Te Tiriti O Waitangi/The Treaty of Waitangi is today recognised as New Zealand’s founding document and its importance is strongly evident in health care and social policy. As an historical accord between the Crown and Māori, the treaty defines the relationship between Māori and Pākehā (non-Māori) and forms the basis for biculturalism.

Durie (1994) suggests that the contemporary application of the Treaty of Waitangi involves the concepts of biculturalism and cultural safety, which are at the forefront of delivery of mental health services. This means incorporating “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9) into the care that is delivered. There is an expectation that mental health staff in New Zealand ensure care is culturally safe for Māori (Mental Health Commission, 2001). Simply put, “unsafe practitioners diminish, demean or disempower those of other cultures, whilst safe practitioners recognise, respect and acknowledge the rights of others” (Cooney, 1994, p.6). The support and strengthening of identity are seen as crucial for recovery for Māori along with ensuring services meet Māori needs and expectations (Mental Health Commission, 2001). Cultural safety goes beyond learning about such things as the dietary or religious needs of different ethnic groups; it also involves engaging with the socio-political context (DeSouza, 2004; McPherson, Harwood, & McNaughton, 2003). However, critics suggest that cultural safety needs to encompass new and growing ethnic communities. Whilst in theory cultural safety has been expanded to apply to any person or group of people who may differ from the health professionals because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997), in practice the focus remains on the relationship between Pākehā and Māori, rather than migrants (DeSouza, 2004) and other communities (Giddings, 2005).

Expanding the bicultural to a multi-cultural framework is necessary without removing the special status of tangata whenua. New Zealand’s reluctance to encompass multiculturalism as a social policy framework has been shaped by two key factors, according to Bartley and Spoonley (2004). The first is the location of historical migration source countries such as the United Kingdom and Ireland, which shaped the development of activities and concerns (as they argue, racist and Anglo centric assumptions of a colonial New Zealand) and, secondly the rise in concerns over indigenous rights and the Treaty of Waitangi, which have precluded discussion around nation and nationality. Thus while countries such as Canada and Australia were developing multicultural policies, New Zealand was debating issues of indigeneity and the relationship with tangata whenua. As a result, New Zealand has yet to develop a locally relevant response to cultural diversity (multiculturalism) that complements or expands on bicultural and Treaty of Waitangi initiatives (Bartley & Spoonley, 2004).

Need for a migrant health agenda

It is, I hope, clear by now that there is a need to develop a migrant mental health agenda, yet much of the previous New Zealand research has omitted the experiences of migrant mothers. The Centre for Asian and Migrant Health Research at AUT University and Plunket have begun a collaborative project with funding from the Families Commission and Plunket volunteers to understand the experiences of migrant mothers from the United Kingdom, the United States, South Africa, Palestine, Iraq, China, India and Korea, which it is hoped will assist in the development of services and policy.

There is a misguided view that migrants do not experience compromises in their health status despite the changes in income and social support and the new stressors they encounter, which can lead to cumulative negative effects and the need to access mental health services. The neo-liberal trajectory that our society has taken has precluded an interest in the wellbeing of migrants who often face culture-related barriers in using mental health care services. Other than a literature review produced by the Mental Health Commission (Mental Health Commission, 2003), which recommended that mental health services become more responsive to Asian people, there has been little in the way of strategic or long term planning with most of the developments in this area coming from the community and voluntary sector.

Conclusion

Migrants face additional stressors that can increase their need for mental health services. Migration can be a traumatic life event. Becoming a mother in an unfamiliar country adds to this already traumatic event, leading migrant mothers to be more at risk of experiencing depression or other mental health issues. Yet, research on the migrant experience in New Zealand is limited and studies on postnatal depression have excluded migrants in the past.

As the number and diversity of migrants increase, their well-being becomes an increasingly important issue for policy makers and health professionals. The time is right to begin a dialogue about how mental health services can work effectively with this diversity. Migrant mothers hold the key to a family’s future well-being and so are an important group for us to understand and support. In the absence of policy there is a need to advocate for migrant mental health service development, building on the many grassroots initiatives that are already occurring. Beyond this, further discussion is needed as to how cultural competency and cultural safety can be applied to migrant populations.

1. ‘Ethnic’ is a term devised by the Department of Ethnic Affairs and refers to people who are neither Pakeha, Maori or Pacific).

References

Barclay, L., & Kent, D. (1998). Recent immigration and the misery of motherhood: a discussion of pertinent issues. Midwifery, 14, 4-9.

Bartley, A., & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi revisited: perspectives on the Treaty of Waitangi (2nd ed., pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beck, C. T. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27(1), 43-44.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Retrieved 27th April, 2005, from www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf

Cooney, C. (1994). A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.

DeSouza, R. (2002). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Massey University, Albany, New Zealand.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R. (2006a, May 26th). Cultural Diversity and Context: Responding to the needs of ‘This Child” in “This Family”. Paper presented at the 5th Annual Child Law Conference, Lexis Nexis, Auckland.

DeSouza, R. (2006b). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, In press.

DeSouza, R. (2006c). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Auckland, NZ: Muddy Creek Press.

Durie, M. (1994). Whaiora: Maori health development. Auckland; Oxford: Oxford University Press.

Espin, O. M. (1997). The role of gender and emotion in women’s experience of migration. Innovation: The European Journal of Social Sciences, 10(4), 445-455.

Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 2-35.

Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.

Kohen, D. (2001). Psychiatric services for women. Advances in Psychiatric Treatment, 7, 328-334.

Kruckman, L. D. (1992). Rituals and support: An anthropological view of postpartum depression. In J. A. Hamilton & P. N. Harberger (Eds.), Postpartum psychiatric illness: a picture puzzle (pp. 137-148). Philadelphia: University of Pennsylvania Press.

Liamputtong, P. (1994). Asian mothers, Australian birth: pregnancy, childbirth, and childrearing: the Asian experience in an English-speaking country. Melbourne: Ausmed Publications.

Liamputtong, P., & Naksook, C. (2003). Life as mothers in a new land: The experience of motherhood among Thai women in Australia. Health Care Women International, 24(7), 650-668.

McPherson, K. M., Harwood, M., & McNaughton, H. K. (2003). Ethnicity, equity and quality: Lessons from New Zealand. Quality & Safety in Health Care, 12(4), 237-238.

Mental Health Commission. (2001). Cultural Assessment Processes for Maori – Guidance for Mainstream Health Services. Wellington: Mental health commission.

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Mohamed, C., & Smith, R. (1999). Race in the therapy relationship. In M. Lawrence, M. Maguire & J. Campling (Eds.), Psychotherapy with women: feminist perspectives (pp. 134-159). New York: Routledge.

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Migrant Populations

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

The art of walking upright here

Is the art of using both feet.

One is for holding on.

One is for letting go. (Colquhoun, 1999, p.32)

Glenn Colquhoun’s poetry captures the challenge dislocation from home and family. The migrant or refugee has to somehow hold on to their legacy and their heritage whilst simultaneously letting go of those things that cannot be maintained in a new country. They must let go to create new lives, so they can stake a new claim of belonging; a new place to stand.

One in five New Zealanders was born overseas. This rises to one in three in Auckland. For many, migration is seen as a way of obtaining a better life, particular for ones children. Whilst many migrants make informed decisions, this needs to be seen as a continuum between full choice and no choice. This can been viewed as a ‘pull’ effect (migrants are drawn to a new country for the opportunities available) or a ‘push’ effect (the motivation is simply to leave where they are). Migrants can be defined as people who were born in one country and then move to another under an immigration programme. In New Zealand this consists of three main streams:

  •  Skilled/Business: Which relates to attracting migrants with qualifications and skills, or the potential to create business opportunities in New Zealand.
  • Family sponsored: Where New Zealand citizens or permanent residents can sponsor family members to the country.
  • Humanitarian: This includes refugees and allows for family members to be granted residence if there are serious humanitarian concerns.

Refugees that have resettled in New Zealand mostly originate from Africa, the Middle East, South East Asia and Eastern Europe. Refugees differ from voluntary migrants because they were forced to leave their home and have little if any choice in selecting their destination. They are at the extreme end of the ‘push’ effect, often having fled from situations of conflict and human right abuses. This has important implications for the provision of  health care, as they might not have had access to preventative and treatment services. Most refugees arriving in New Zealand will spend six weeks at the Mangere Refugee Reception Centre (MRRC) in South Auckland. There are estimated to be 20.6 million refugees and displaced people in need of protection and help (UNHCR, 2003). Currently New Zealand accepts a United Nations-mandated quota of 750 refugees per year, plus approximately the same number again of asylum seekers. Asylum seekers are people seeking refugee status without legal documentation. They often experience depression, hopelessness and helplessness related to stress and socio-economic deprivation. Even where migration is an informed choice, the result can still be isolation and loss of financial independence. Before migration, one often only considers the positives; it can be difficult to understand the adjustment that is required and to come to terms with the losses of family, friends, culture and familiarity.

In this chapter I present a view of cultural safety and how it is relevant to health from the perspective of a migrant with a view to informing those who will be caring for the needs of migrants and refugees. I will briefly review the history and tensions around migration and migrants. Anecdotes from my clinical experience are woven through the text to present multiple layers to reflect the complexity of the experience and reflective questions are posed to increase self-awareness. I conclude by offering a range of strategies for working with diversity.

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