How is cultural safety understood and translated into midwifery practice? A scoping review and thematic analysis

AimTo identify and understand the scope of the literature published since January 2008 that explored Australian midwives understanding of cultural safety and how this is translated into their practice when caring for First Nations women and families.BackgroundRecognition and understanding of First Nations peoples history and culture and the impact this has on the health and wellbeing of women and their families is essential if the midwife is to promote culturally safe and respectful maternity care. The role and responsibilities of the midwife in ensuring that their practice is culturally safe are now reflected in the Australian professional midwifery codes and standards. Whilst midwifery academics’ awareness of cultural safety and how it is taught within midwifery education programs have previously been explored, at present, little is known about midwives’ understanding of cultural safety, and how this translates into their clinical practice.MethodsA Scoping Review was undertaken following Arksey and O’Malley’s five step process. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses – Scoping Review extension checklist. Twelve studies met the criteria for inclusion. Thematic analysis was used to analyse the data and organise the results.ResultsThematic analysis, guided by two predetermined review questions led to the identification of six overarching themes: ‘Awareness of deficiencies’, ‘The importance of meeting women’s diverse needs’, ‘Understanding relationships as a foundation for culturally safe care’, ‘Working in partnership with others’, ‘Providing individualised care’ and ‘Fostering effective relationships and communication’. One sub-theme of the first theme was identified, this was named ‘Seeking an understanding of culture’.ConclusionAustralian midwives’ level of understanding of cultural safety and how it is translated into their midwifery practice when caring for First Nations women and their families differ widely. Midwives across Australia require increased and equitable access to appropriate opportunities to improve their knowledge and understanding of cultural safety. Whilst theoretical learning on cultural safety has a place in all midwives annual mandatory training requirements, this should ideally be supplemented, where possible, with opportunities for immersive practice in communities. Immersion was considered the optimal way to gain rich knowledge and understanding to strengthen culturally safe midwifery practice. Continuity models of midwifery care which incorporate the principles of cultural safety should be consistently implemented across Australia. These models enable midwives, women, families, communities, and Aboriginal Support Workers to work in collaboration towards achieving optimal outcomes for mothers and babies.Study registrationN/A     

Evolving beyond antiracism: Reflections on the experience of developing a cultural safety curriculum in a tertiary education setting

There is an inextricable link between cultural and clinical safety. In Australia high-profile Aboriginal deaths in custody, publicised institutional racism in health services and the international Black Lives Matter movement have cemented momentum to ensure culturally safe care. However, racism within health professionals and health professional students remains a barrier to increasing the number of Aboriginal and Torres Strait Islander Health professionals. The Australian Health Practitioner Regulation Agency's Aboriginal and Torres Strait Islander Health Strategy's objective to ‘eliminate racism from the health system’, and the recent adoption of the Aboriginal and Torres Strait Islander peoples led cultural safety definition, has instigated systems level reflections on decolonising practice. This article explores cultural safety as the conceptual antithesis to racism, examining its origins, and contemporary evolution led by Aboriginal and Torres Strait Islander peoples in Australia, including its development in curriculum innovation. The application of cultural safety is explored using in-depth reflection, and the crucial development of integrating critical consciousness theory, as a precursor to culturally safe practice, is discussed. Novel approaches to university curriculum development are needed to facilitate culturally safe and decolonised learning and working environments, including the key considerations of non-Indigenous allyship and collaborative curriculum innovations and initiatives.     

Providing culturally appropriate care: A literature review

Objectives

As part of a study that explored how midwives incorporate cultural sensitivity, into their practice, the literature was reviewed to ascertain how the concept of culture has been, defined and what recommendations have been made 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-file 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 satisfied the inclusion criteria.

Results

There are two main approaches to culture; the first focuses on the cognitive aspects of culture, the ‘values, beliefs and traditions’ of a particular group, identified 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 specific 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.     

Inequalities in health care provision: the relationship between contemporary policy and contemporary practice in maternity services in England

AIM: The project Addressing Inequalities in Health: new directions in midwifery education and practice (Hart et al. 2001) was commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB). Here, we draw on those research findings to consider current midwifery policy and practice in England. BACKGROUND: Little guidance on providing equality of care exists for midwives. The Code of Conduct [United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992] makes no specific requirement for midwives to address issues of inequalities of health in their practice. Recent policy documents emphasize the need to work towards reducing inequalities and to target practice to 'disadvantaged clients' without giving guidelines on how to identify and care for target groups. METHODS: In-depth studies of midwifery education and service provision were conducted in three very different parts of England. Three months of fieldwork were undertaken at each site, comprising a series of interviews with midwifery educators, managers, students, midwives and service users. Focus groups were also held and observation of classroom sessions and midwifery practice undertaken. Findings. A lack of clear and specific strategies concerning inequalities in health was evident at managerial level. Patchy knowledge of current policy was also evident amongst practising midwives. Specific projects with disadvantaged clients usually resulted from a particular midwife's personal interest or evident local need. All midwives emphasized the importance of 'equality of care'. How this was operationalized varied, and 'individualized' or 'woman-centred' care was assumed to encompass the concept. In the few examples where care was systematically targeted in accordance with policy directives, the midwife's public health role was increased. CONCLUSION: In the absence of a co-ordinated strategic vision driven by managers, practitioners find difficulty in prioritizing care and targeting resources to disadvantaged clients in line with policy directives. Tensions between policy and practice in the care of 'disadvantaged' women clearly exist. Successful implementation of policy at practice level needs: commitment from managers; clarity of purpose in documentation; and provision of specific targets for practitioners. However, the latter should remain flexible enough for the delivery of care to be appropriate and sensitive to individual needs.     

Anthropology, nursing and midwifery: a natural alliance?

Anthropology, and its supposed operationalisation within transcultural nursing, is becoming increasingly prominent in educational curricula in the U.K. This increase in interest is driven both by governmental pressure to provide more culturally appropriate care, and an intuitive notion that anthropology, nursing and other related professions such as midwifery have a common basis of mutually overlapping and re-enforcing theory and practice. This paper explores the question of whether there is a natural alliance between anthropology, and the applied aspects of health care disciplines such as nursing and midwifery, by examining some of the concepts underlying each discipline, and the ways in which these concepts are applied in practice. Anthropology is the study of culture, and it is suggested that a more complete understanding of this central concept is essential if it is to be utilised in the applied disciplines encompassed by the practice of nursing and midwifery.     

Cultural safety and the socioethical nurse

This article explores the social and ethical elements of cultural safety and combines them in a model of culturally safe practice that should be of interest and relevance for nurses, nurse educators and nurse ethicists in other cultures. To achieve this, the article briefly reviews and critiques the main underpinnings of the concept from its origins and development in New Zealand, describes its sociocultural and sociopolitical elements, and provides an in-depth exploration of the key socioethical elements. Finally, a model is presented to illustrate the strong connection between the social and ethical components of cultural safety that combine to produce culturally safe practice through the activities of a 'socioethical' nurse.     

Piloting of a nursing and midwifery competence framework in the cultural context of a middle eastern country

Clinical competence amongst nurses and midwives is vital for the delivery of safe and consistent patient care. However, worldwide there is a lack of agreement on definitions and notions about what constitutes competence and how it can be determined in everyday clinical practice. This situation poses professional dilemmas in situations where competing dialogues exist. This is particularly evident in countries that employ nurses and midwives from diverse national backgrounds with differing professional and educational experiences. To address potential misunderstandings, ensure a consistent approach to the confirmation of clinical competency and assure patient safety, a strategic decision was taken by the nursing and midwifery leadership of the country's major healthcare organisation to develop an organisationally and culturally sensitive competence framework model. This article reports on the design, development and piloting of an educationally led framework model. The model, referred to as ‘Q-PACE: Qatar's Practice, Appraisal, Competence and Education’, links previously fragmented activities regarding confirmation of clinical competence of staff into a unified holistic process that provides assurance regarding the competence of new and existing employees.     

Reflective education for professional practice: discovering knowledge from experience

To continually develop as a discipline, a profession needs to generate a knowledge base that can evolve from education and practice. Midwifery reflective practitioners have the potential to develop clinical expertise directed towards achieving desirable, safe and effective practice. Midwives are 'with woman', providing the family with supportive and helpful relationships as they share the deep and profound experiences of childbirth. To become skilled helpers students need to develop reflective skills and valid midwifery knowledge grounded in their personal experiences and practice. Midwife educators and practitioners can assist students and enhance their learning by expanding the scope of practice, encouraging self-assessment and the development of reflective and professional skills. This paper explores journal writing as a learning strategy for the development of reflective skills within midwifery and explores its value for midwifery education. It also examines, through the use of critical social theory and adult learning principles, how midwives can assist and thus enhance students learning through the development of professional and reflective skills for midwifery practice.     

How do new midwives’ early workforce experiences influence their career plans? An integrative review of the literature

AimTo explore how the early workforce experiences of new midwives influence their career plans.BackgroundEach year, thousands of new midwives graduate from entry-to-practice midwifery courses, gain professional registration, and enter the workforce. Despite this, the world continues to face a shortage of midwives. The first five years of clinical practice, commonly referred to as the early career period, can be highly stressful for new midwives, contributing to early attrition from the profession. Supporting the transition from midwifery student to registered midwife is vital if we are to grow the workforce. Whilst the early career experiences of new midwives have been more broadly explored; little is currently understood about how these can influence their career plans.MethodsFollowing Whittemore and Knafl’s (2005) five-stage process, an integrative review was conducted. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Nineteen studies met the criteria for inclusion. Thematic analysis was undertaken to organise and present the findings.FindingsThematic analysis, guided by the review question led to the identification of three overarching themes: ‘the need for support’, ‘sustaining health and wellbeing’, and ‘being able to provide safe and effective midwifery care’.ConclusionVery little research to date has specifically explored how the early career experiences of new midwives influence their career plans, particularly within the Australian context. Further research is required to better understand how the early workforce experiences of new midwives can either strengthen their commitment to the profession or contribute to the decision to leave midwifery prematurely. This knowledge would provide a basis for the development of appropriate strategies to minimise early attrition from the midwifery profession and promote career longevity.     

Assessment of Health Literacy in College-Age Females to Reduce Barriers to Human Papilloma Virus Vaccination

Assessing an individual’s healthy literacy and cultural background is important when discussing any health issue. This review explores specific concepts on HPV health literacy and how health disparities can influence college-age students’ knowledge about HPV-associated cancer and the importance of obtaining the 3 sequential doses of the Gardasil HPV vaccine. This information is relevant to practicing nurses, nurse practitioners, and midwives who provide direct individual care to adolescent and college-age students. Practical questions are asked to promote health literacy, provide culturally sensitive care, and reinforce health education on HPV, cervical cancer, and the HPV vaccine.     

Compliance with antihypertensive medication in Chinese immigrants: cultural specific issues and theoretical application

This paper presents a theoretical framework to study medication compliance in Chinese immigrants with hypertension (HTN). The framework was developed from (a) literature review of medication compliance and Chinese cultural belief/practices and (b) critique of major models of health behaviors in persons with chronic illness. Four constructs shape the model: motivation, cultural health perceptions, modifying factors, and cultural health care activities. Among these constructs, cultural health perceptions and health care activities are especially important because these address how Chinese immigrants perceive HTN and antihypertensive treatments and how they manage HTN. Using a culturally sensitive model is important to guide studies of medication compliance in this population and to assist health care providers to support compliance with antihypertensive treatments for Chinese immigrants.     

Review Article: Genetic competence of midwives in the UK and Japan

In the UK and Japan, midwives provide health services for women with concerns about a genetic condition or who are considering antenatal screening. In both countries, competences related to genetic health care have been devised but there is little evidence about midwifery competence in practice. A systematic literature review was undertaken to determine the extent to which midwives are achieving the genetic competences that are prescribed for their practice. English and Japanese literature from January 1999 to March 2009 was retrieved. Original studies or reviews, in which an aspect of midwifery practice was related to genetic competences, were eligible for inclusion. After a critical appraisal, six UK and five Japanese papers were eligible for inclusion. The findings indicated that midwives are not achieving the competences, nor are they confident about their genetics knowledge. Moreover, women are not being supported to make informed decisions regarding antenatal screening. We have confirmed that little research is being undertaken in both countries regarding competency achievement in practice. Changes to midwifery curricula and further continuing education are required to ensure that midwives are able to provide effective care regarding genetics.     

Cultural safety in New Zealand and the United States: looking at a way forward together

Cultural safety emerged in Aotearoa, New Zealand as a nursing response to bicultural interactions between indigenous Maori and other New Zealanders. The purpose of this research is to describe the meaning and experience of cultural safety as depicted by nurses in New Zealand and to illustrate the potential for this to inform U.S. nursing education and practice. This interpretive hermeneutic study explored cultural safety as described by 12 experienced nurses who were selected through snowball and purposive sampling. Audiotaped interviews were conducted after ethics approval. Interpretive analysis uncovered five themes that are described with data and paradigm cases. Cultural safety considers the perspective of the patient as the norm in contrast to the culture of health care. Understanding historical power differences and personal biases can help challenge victim-blaming responses by health care providers. Incorporating these understandings into reflective practice enhances the possibility of culturally safe learning for students and culturally safe care for patients.     

Globalization and the cultural safety of an immigrant Muslim community

AIM: This paper reports a study the aim of which was to further understanding of cultural safety by focusing on the social health of a small immigrant community of Muslims in a relatively homogeneous region of Canada following the terror attacks on 11 September 2001 (9/11). BACKGROUND: The aftermath of 9/11 negatively affected Muslims living in many centers of Western Europe and North America. Little is known about the social health of Muslims in smaller areas with little cultural diversity. Developed by Maori nurses, the cultural safety concept captures the negative health effects of inequities experienced by the indigenous people of New Zealand. Nurses in Canada have used the concept to understand the health of Aboriginal peoples. It has also been used to investigate the nursing care of immigrants in a Canadian metropolitan centre. Findings indicated, however, that the dichotomy between culturally safe and unsafe groups was blurred. METHOD: The methodology was qualitative, based on the constructivist paradigm. A purposive sample of 26 Muslims of Middle Eastern, Indian or Pakistani origin and residing in the province of New Brunswick, Canada were interviewed in 2002-2003. Findings. Participants experienced a sudden transition from cultural safety to cultural risk following 9/11. Their experience of cultural safety included a sense of social integration in the community and invisibility as a minority. Cultural risk stemmed from being in the spotlight of an international media and becoming a visible minority. CONCLUSION: Cultural risk is not necessarily rooted in historical events and may be generated by outside forces rather than by longstanding inequities in relationships between groups within the community. Nurses need to think about the cultural safety of their practices when caring for members of socially disadvantaged cultural minority groups as this may affect the health services delivered to them.     

'With woman' philosophy: examining the evidence, answering the questions

'With woman', 'woman centred' and 'in partnership with women' are new terms associated with midwifery care in Australia, and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women's experiences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women, those with 'high risk' pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to initiate a discussion of 'with woman' midwifery care as it applies to Australian practice.     

An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context.

Cultural safety has been promoted by its New Zealand proponents as an effective process for managing cultural risk in health care and improving the cultural responsiveness of mainstream health services when delivering care to culturally diverse populations. Its effectiveness in this regard has not, however, been comprehensively investigated. A key purpose of this study was to explore and describe what is known and understood about the notion of cultural safety and its possible application to and in Australian health care domains. Findings from the study indicate that the notion of cultural safety is conceptually problematic, poorly understood, and underresearched and, unless substantially revised, cannot be meaningfully applied to the cultural context of Australia.     

Mandatory continuing professional education: what is the prognosis?

Each year registered nurses apply for registration renewal. The Nursing and Midwifery Board of Australia stipulate all nurses and midwives are expected to take responsibility and accountability for participating in continuing professional development (CPD) as a declaration that their practice is current, safe and competent. The code of professional conduct and Australian Nursing and Midwifery Council (ANMC) competencies governing registered nurses and midwives, outline the professional and personal responsibility nurses hold in order to maintain clinical competence; which may be achieved through continuing nurse education and professional development. As the health care industry shifts focus to keep up with changes in technology, economics, demographics and culture, the nursing profession must respond accordingly.With the implementation of a national registration scheme in Australia, this paper provides a review of the literature relating to mandatory CPD and how CPD may assist nurses to respond to the changing needs of the health care system and its consumers, to ensure the best possible health outcomes. Suggestions of possible avenues of research into the concept of CPD are also offered.     

Culture and communication in ethically appropriate care

This article considers the difficulties with using Gillon's model for health care ethics in the context of clinical practice. Everyday difficulties can arise when caring for people from different ethnic and cultural backgrounds, especially when they speak little or no English. A case is presented that establishes, owing to language and cultural barriers, that midwives may have difficulty in providing ethically appropriate care to women of Pakistani Muslim origin in the UK. The use of interpreters is discussed; however, there are limitations and counter arguments to their use. Training is identified as needed to prepare service providers and midwives for meeting the needs of a culturally diverse maternity population.     

The health care needs of ethnic minority groups: are nurses and individuals playing their part?

The UKCC Code of Professional Conduct for nurses, midwives and health visitors stresses the need to have an understanding of the social and cultural determinants of health and illness There is as yet little evidence of what might constitute good practice in this area and it is difficult to ascertain why this basic philosophy is not translated into action Indeed, the nursing and midwifery professions' ability to deliver adequate and appropriate health care more generally to Britain's multiracial, multicultural population has been questioned This literature review presents evidence which strongly suggests that although we are living in a multicultural society patients from minority ethnic groups are additionally disadvantaged because the initiatives by nurses, and others working in the National Health Service, to meet their health care needs are inadequate and often inappropriate     

Cultural marginality: a concept analysis with implications for immigrant adolescents

Society in the United States is becoming increasingly culturally diverse. In 1996, almost 1 in 10 people living in the United States was a foreign-born immigrant and the number of foreign-born in the population exceeded 25 million. However, the lack of mutual understanding between health care providers and immigrants, particularly children and adolescents, has impeded progress in research and practice for this population. To facilitate nurses' understanding of immigrant adolescents' unique experiences, this article explores the concept of cultural marginality. Cultural margin ality is defined by the author as "situations and feelings of passive betweeness when people exist between two different cultures and do not yet perceive themselves as centrally belonging to either one." Using Walker and Avant's (1995) method as a framework, my article identifies attributes, antecedents, and consequences of cultural marginality in the context of immigrant adolescents' experiences. To clarify the abstract concept, cases are provided that distill meanings of the concept in life. A conceptual model has been synthesized to illustrate relationships among attributes, antecedents, and consequences and to highlight areas for further inquiry. Concept analysis is a critical step for the develop ment of nursing knowledge. The process of concept analysis is demonstrated through clarification of the concept of cultural marginality, which offers guidance for nursing research and practice within the immigrant adolescent population.