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Health Care And Indigenous Australians Cultural Safety In Practice 3rd Kerry Taylor

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KERRY TAYLOR & PAULINE THOMPSON GUERIN HEALTH CARE AND INDIGENOUS AUSTRALIANS Cultural safety in practice THIRD EDITION
HEALTH CARE AND INDIGENOUS AUSTRALIANS
HEALTH CARE AND INDIGENOUS AUSTRALIANS CULTURAL SAFETY IN PRACTICE Third edition Kerry Taylor and Pauline Thompson Guerin
© Kerry Taylor and Pauline Thompson Guerin, under exclusive licence to Springer Nature Limited 2010, 2014, 2019 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First edition published 2010 Second edition published 2014 Third edition published 2019 by RED GLOBE PRESS Previous editions published under the imprint PALGRAVE Red Globe Press in the UK is an imprint of Springer Nature Limited, registered in England, company number 785998, of 4 Crinan Street, London, N1 9XW. Red Globe Press® is a registered trademark in the United States, the United Kingdom, Europe and other countries. ISBN 978–1–352–00542–4 paperback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress.
v CONTENTS list of figures vi list of tables vii About the authors viii Preface ix Acknowledgements xii Introduction xiv 1 Talking about Indigenous health 1 2 Cultural frameworks for health 10 3 Cultural safety in practice 22 4 Taking a history 33 5 Determinants of health 56 6 Indigenous health today 79 7 Indigenous health priorities 98 8 Models of health 126 9 Capacity and resilience 149 10 Intercultural interactions 163 11 Health services and workforce issues 182 12 Indigenous health in a global context 197 13 Cultural safety: controversy and concerns 216 14 Reflection and practice 234 References 250 Index 265
vi LIST OF FIGURES 2.1 Queensland Health Organisational Cultural Competency Framework 15 3.1 Original stages towards cultural safety—as defined by Ramsden (2002)22 3.2 An aspirational model of cultural safety—as developed and defined by Taylor Guerin (2018) 23 4.1 Indigenous and non-Indigenous occupation of the land now called Australia35 5.1 Impact of educational disadvantage 61 5.2 A visual of the differences between equality, equity, reality and liberation 72 6.1 Proportion of Indigenous populations by remoteness categories 83 6.2 Indigenous and non-Indigenous population residence 83 6.3 Age and sex structure of Australia’s population by Indigenous status 88 7.1 Age specific death rates for intentional self-harm, by Indigenous status, 2012–2016 109 7.2 Child abuse substantiations (%) in 2016–2017 by type of abuse and state and territories for children aged 0–17 for (a) Indigenous children and (b) non-Indigenous children 113 11.1 Australian Government-funded organisations providing primary health care (PHC) services to Aboriginal and Torres Strait Islander people, by remoteness area, 2016–2017 188
vii LIST OF TABLES 2.1 Cultural frameworks, strengths and limitations 19 4.1 Brief summary of policy changes impacting Indigenous Australians 44 6.1 Indigenous and non-Indigenous population by state (ABS resident population)80 6.2 Proportion of population in selected age groups and Indigenous status 88 7.1 Children aged 0–16 years who were the subjects of substantiations: Number and rates per 1,000 children, by Indigenous status and state and territory, 2007–2008 110 7.2 Children aged 0–16 years who were the subjects of substantiations: Number and rates per 1000 children, by Indigenous status and state and territory, 2011–2012 111 7.3 Children aged 0–17 years who were the subjects of substantiations: Number and rates per 1000 children, by Indigenous status and state and territory, 2016–2017 112 10.1 Elements in communication 170 12.1 Comparison of Indigenous populations and treaty status in four countries202 14.1 Layers of reflection 235
viii About the authors Dr Kerry Taylor was Deputy Director and Associate Professor with the Poche Centre for Indigenous Health and Well-being, Flinders University, based in Alice Springs from 2013 to 2018. She has worked in Central Australia since 1988 in a range of roles and organisations, including in remote communities, as an adult educator, health educator and project officer for piloting Aboriginal Health Worker positions in a tertiary set- ting. She coordinated a program for student nurses to undertake remote and Indigenous health clinical experiences, which saw significant num- bers of graduates pursue these fields of practice. Kerry’s PhD thesis was on intercultural communication in Indigenous health care settings. Other research and teaching interests include cultural safety, health literacy and intercultural health care practice, disability and HTLV-1 research. She has been awarded individual and team Vice Chancellor’s Excellence in Teach- ing Awards. Kerry co-delivered the Aboriginal Cultural Awareness Program for NT Health workforces in Central Australia and remains affiliated with Flinders as an Associate Professor with the Poche Centre – College of Medicine and Public Health. Dr Pauline Thompson Guerin is affiliated with Flinders University of South Australia in the College of Nursing and Health Sciences and is an Associate Professor based at the Pennsylvania State University, Brandy- wine Campus, close to Philadelphia in the USA. Pauline has worked in the North Flinders Ranges in Nepabunna and in the Anangu ­ Pitjantjatjara Yankunytjatjara (APY) lands, particularly in Pukatja. She was a senior researcher for the Desert Knowledge Cooperative Research Centre (CRC) and was the manager of the Poche Centre for Indigenous Health in Adelaide. Her research interests include mental health and well-being; ­ residential mobility; teaching of cultural issues; and racism in health care.
ix Preface I was looking back over photographs taken when I first moved to the remote Aborigi- nal community of Ntaria (Hermannsburg) in 1988. I had a lot of photos of children and adults—all of them smiling and seemingly happy. When I first went to Ntaria, fresh from Sydney, it shocked me somewhat to learn that Tuesday was ‘Funeral Day’. ‘What do you mean, Funeral Day?’ I asked. ‘Funeral day—we usually have ­ funerals on Tuesday’, came the reply. It was said so matter-of-factly that it didn’t register with those around me that most people might not generally expect a funeral every week. But that was exactly what this community of several hundred went through just about every week during my relatively short stay there—a funeral nearly every Tuesday. (Taylor, 1999) The preface to our first edition sought to draw the link between the statis- tical picture of Indigenous health and what it meant on a personal level. Since 1988 too many of the people in those photos referred to above have either passed away or live with chronic illness or have had their lives impacted by loss, violence or economic hardship. We’d like to say much has changed since the first edition. However, while statistics point to improvement in some areas, Indigenous health remains Australia’s great- est health, medical and social challenge.1 ‘Insanity is to do the same thing over and over and expect different results’ (attributed often to Albert Einstein). This quote plays on my 1 In reviewing the materials for this edition, it became apparent that statistical informa- tion about the health and social contexts of Indigenous Australians is fraught with ­ difficulty as even current reports, including those from the Australian Bureau of Statis- tics, continue to source some data gathered prior to 2010. We acknowledge, however, the importance of statistical evidence to argue for more and improved conditions and to assist in knowing where to target resources to effectively address inequities. Although com- monly cited statistical information is again presented, we strongly encourage readers to check for the most current information available and check its sources. Why the same figures continue to be cited, and why it is difficult to gain an accurate picture of health and well-being today, is itself worthy of scrutiny. What we would like to stress is that whether a health issue is three, five or ten times more likely to affect a certain population compared to another, the reality is that every statistic cited is an individual. Cultural safety requires us to ensure that these figures alone do not become the drivers for health service delivery, but that care is delivered that is cognisant of the person each number represents.
Preface x mind as I reflect on the last now 30 years working in Indigenous health. Today I find myself working alongside Aboriginal colleagues who are now attending multiple funerals within a week. I feel more certain than ever that it is hardly time to congratulate ourselves for having stemmed the tide of Indigenous mortality and morbidity. I don’t believe we have seen the worst of this national crisis, and we may not in my lifetime. But that lifetime is still potentially 20 years longer than that of my Aborigi- nal colleagues. I am not trying to be bleak or express a hopelessness that nothing can change. In fact, the privilege of being able to do a second and third edition of this book offers a personal and professional oppor- tunity to do things differently—to not keep repeating mistakes of the past and expecting different results. As co-authors, Pauline and I believe small changes to practice can make big differences and that the greatest potential for change lies with the development of culturally safe health workforces. To date, much of the emphases in both health care and policy set- tings has expected Indigenous Peoples to change themselves in order to change the outcomes. Less attention has been given to the changes that dominant culture groups could and should make to provide more effec- tive care. Indigenous health in Australia is the result of a multiplicity of circumstances, histories, attitudes and beliefs and can only be considered within a multiplicity of contexts. As non-Indigenous authors of this book we do not present Indigenous knowledge or speak on behalf of Indigenous Peoples, other than where we have individually been asked to share certain information to help educate others. It has been suggested that non-Indigenous people have no place even writing a book on Indigenous Health. To those people, we respectfully disagree. Indigenous people alone will not improve indig- enous health; it is a shared responsibility and, as part of the dominant cultural groups, this book is our contribution to turning the lens on our- selves through reflection on practice. To guide this reflection, we have used the principles of cultural safety, as defined by the New Zealand Nursing Council and embraced by the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM). Culture in this context is not exclusively about ethnic- ity, but is more broadly defined. As a philosophy, cultural safety asks practitioners to consider issues of power, systemic racism, history and ­ colonisation. The majority of the workforces involved in Indigenous health in Australia are from non-Indigenous backgrounds. This book is our contribution to the reflection on practice that is inherent in cultur- ally safe health care. Where possible, we have sought contributions from Indigenous colleagues and community members and explicitly acknowl- edged their input. The overall text, the case studies and issues raised have
Preface xi also been informed by several decades of combined experience working with Indigenous Peoples in a variety of settings, including metropolitan and remote education and health in both Australia and New Zealand. Our hope is that this book will contribute to a better understanding of the application of cultural safety in practice that will ultimately lead to better outcomes for Indigenous health in Australia.
xii Acknowledgements This text has arisen from the authors’ shared teaching experiences in introducing Indigenous health issues to nursing, midwifery and medical students from Flinders University. It was originally adapted from the ‘Guide to Learning’, to which several academics within the School of Nursing Midwifery (now the College of Nursing and Health Sciences) initially contributed, but also informed by relationships with various Indigenous colleagues and friends and other professional experiences. Personal acknowledgements from Kerry Taylor As the primary author of the topic materials for NURS2723/24, Indig- enous Health Issues for Nurses and Midwives, at Flinders University, I would like to acknowledge the input of previous teaching team mem- bers and topic coordinators, who contributed various early content and refinements to the materials that prompted this work. The acknowledge- ments made of individuals in the first and second editions stand and are expanded on by subsequent experiences and learning. To Pauline Thompson Guerin, who’d have thought we would be here again? Thank you for continuing to encourage, support and motivate me to keep going. I’d like to also acknowledge the support of the Poche Centre for Indigenous Health Wellbeing and Flinders University for the ­ opportunity to continue working for better outcomes for Indigenous Australians and ­ better practice for health workforces. In particular, I want to thank my ­ current Poche Centre colleagues Colleen Hayes and Lorna Murakami-Gold for their generosity in sharing information, collaborating in our teaching and research efforts, and supporting my own efforts towards culturally safe practice. Personal acknowledgements from Pauline Thompson Guerin My deepest gratitude goes to the Indigenous and non-Indigenous friends and colleagues who shared their thoughts, feelings and experiences on the topic of Indigenous health, all of whom helped to shape this book.
Acknowledgements xiii Thanks to the hundreds of students in Indigenous health at Flinders Uni- versity who helped me to understand Indigenous health better, and to colleagues in the Desert Knowledge Cooperative Research Centre (CRC): Core Project 4 for discussions around remote Indigenous issues more generally. My dear friend, colleague and co-author, Kerry Taylor: as both of our lives have shifted and changed since we first met to teach Indigenous Health, we have grown in our compassion for ourselves and others. I trust that comes through in this edition. Thank you. And my most heartfelt thanks go to my children for being so patient and understanding while I spent nights and weekends writing and for embracing my work, wherever in the world it has taken us. Thank you for always challenging me to be better, and for making my world what it is. During the writing of the first edition of this book, I acknowledge sup- port from grants from the Australian Research Council (ARC DP0877901) and the Australian Institute of Aboriginal and Torres Strait Islander ­ Studies (AIATSIS G07/7290). Joint acknowledgements from the authors We would like to thank the team at Red Globe Press, now working with the London-based team led by Peter Hooper. We would especially like to acknowledge the reviewers of the second edition for their comprehensive feedback and suggestions for developing the third edition. We have grate- fully taken on board many of the suggestions for this third edition. Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
xiv INTRODUCTION Aboriginal and Torres Strait Islander health—why do we need this text? Aboriginal and Torres Strait Islander peoples account for only a relatively small proportion of the Australian population—approximately 2.8% nationally at the last census count (ABS, 2016a). For anyone involved in the health professions it might be reasonable then to ask, ‘why focus entire texts on such a small percentage of people?’ Although relatively small in percentage, this includes over half a million people; and it is the poor health outcomes of this population and their over-representation in the health care system that justifies—indeed demands—a greater focus for health professionals in training. But this anomaly alone should not be the only reason health professionals take an interest in this topic. There are other more significant reasons for turning our attention to Indigenous health issues in Australia—reasons we articulate in this book. For example, how Australia treats and regards Indigenous Peoples reflects the kind of society we are. As long as the health of Indigenous Australians remains so far below that of other Australians, we are dimin- ished as a nation. Health professionals, and those aspiring to be health professionals, have a rare and privileged opportunity to contribute to the promise of better outcomes for all Australians. This book is intended as a suggestive template for introducing the con- cept of cultural safety into Indigenous health issues. When learning about Indigenous health it is extremely important that the materials used are not only culturally appropriate, but also that they are locally appropriate. This requires you, the reader, to check the suitability of the materials in this book at the local level and adapt them accordingly. This text provides discussion points and activities for structuring teaching across a range of settings. The common purpose of the issues and case studies presented is to enhance the understanding and cultural safety of health professionals in relation to Indigenous populations. Throughout this book, you will be given the opportunity to explore personal and professional conceptualisations of health. You will be asked to compare, contrast and reflect on those ideas in relation to the ways
INTRODUCTION xv that different contexts—political, cultural, historical, environmental and socioeconomic—have affected health outcomes for Indigenous Australians. About this book Through case studies, discussions, reflections and critiques of health issues in Australia today, this book offers a starting point—for students at an undergraduate level or for health professionals who require an introduc- tion to the area—for learning about cultural safety as applied to Indigenous health issues. The material covered in this book has evolved from combined decades of both research and teaching Indigenous health. The authors have also worked closely with Indigenous health workers, academics and com- munities. The book takes the approach endorsed by the Australian Nursing Midwifery Accreditation Council (ANMAC) and the Australian College of Nursing (ACN) to provide stand-alone subjects on Indigenous health in nursing curricula. Other health disciplines may take differing approaches to educating students about Indigenous health but this book is written in a way such that students and professionals from a range of health and other disciplines should find it useful and beneficial to their practice. While this book is intended as an introduction, the issues and ideas can and should be adapted to suit local settings. We strongly advise if you are using this book for education purposes, that local Indigenous Peoples are consulted about the appropriateness of the content in your area. Local adaptation of the discussions and information is expected and required. What is new in this third edition? ➢ ➢ Updated references and resources. Because information on the inter- net is always changing, we have often provided key search terms and topics in addition to specific web pages. Where web pages are current at the time of printing, they have been included, but, in addition to specific hyperlinks, we have recommended to search, for example, the current CATSINaM web site or ABS statistics. ➢ ➢ Expanded content including a greater focus on urban health and pre- ventable health care. ➢ ➢ An additional chapter on controversies and concerns about cultural safety and what these responses might mean in terms of our relation- ships within the nation. ➢ ➢ More scenarios and critical thinking activities reflecting the diversity of Indigenous health nationally.
INTRODUCTION xvi Chapter outlines Chapter 1 Talking about Indigenous health provides a rationale for focusing on Indigenous health issues. We provide key definitions and terminol- ogy in context. Chapter 2 Frameworks for service delivery outlines a variety of approaches to understanding and addressing cultural issues in health care and the differing frameworks employed nationally. These include ­ cultural awareness, cultural sensitivity, cultural competence, cultural security, cultural respect, and also look at new frameworks to have emerged such as cultural capability and cultural humility, which illus- trate the adaption of cultural frameworks across Australia. Chapter 3 Cultural safety principles and practice discusses the main focus for this text, cultural safety. It presents an outline of, and an argu- ment for, the preferred use of ‘cultural safety’ as the underpinning phi- losophy and guiding principles for practice. Chapter 4 Taking a history looks at the crucial step in any good health professional’s encounter with a client—that of obtaining an adequate history. A client history in the Indigenous health care setting should include an understanding of the historical relationships, policies and events implicated in the health care status of people today. Chapter 5 Determinants of health explores the roles of matters sometimes seen as outside of the concern of health professionals. Education, poverty, incarceration, employment, housing, as well as racism, dis- crimination, ‘whiteness’ and cultural background, are all determinants of health. It requires readers to reflect on their own culture and its potential impact on others; to identify examples of systemic bias, insti- tutional and individual racism and discrimination; and to analyse and discuss determinants of health. Chapter 6 Indigenous health today examines the statistical picture, explor- ing some of the myths and stereotyped ideas that interfere with culturally safe health care. It also attempts to counter some of the mis- conceptions with an overview of the demographic and health profile of Indigenous Australians, including issues of identity and the impact on health. Chapter 7 Indigenous health priorities gives an overview of areas of special interest in Indigenous health in Australia. These include maternal and child health, chronic disease, mental health issues, disability and child protection.
INTRODUCTION xvii Chapter 8 Models of health provides a comparison of Indigenous and non- Indigenous approaches to health. The majority of health professionals in Australia subscribe to a non-Indigenous biomedical model. This sec- tion considers the various models and definitions of health and how they fit within the context of Indigenous client care. Readers are asked to articulate a personal definition of health, compare and contrast various models of health, and critically analyse the implications of competing or complementary models of health for practice. Scenarios are presented as a basis for discussion or analysis. Chapter 9 Capacity and resilience explores the capacity and resilience of Indigenous Peoples in contrast to the tendency of governments and others to take a deficits approach that has been evident throughout Australia’s history. This chapter calls for a reorientation away from problematising Indigenous Peoples to a focus on strengths, capacity and resilience in keeping with the philosophies of both cultural safety and primary health care. It explores the potential for success in health care outcomes that can be achieved from a simple change in view, while also maintaining the stance that improvement in Indigenous Peoples’ health is everyone’s responsibility. Chapter 10 Intercultural interactions presents a range of case studies related to health communications. Conflicting worldviews and miscom- munication are major challenges when health professionals differ in cultural and linguistic background from the clients in their care. This chapter provides an opportunity to examine intercultural interactions in various practice settings, as well as what it means to ‘de-colonise’ health care practice. Chapter 11 Health services and workforce issues explores current workforce issues, including the concept of Aboriginal-controlled health services and the associated benefits, challenges and complexities. We also explore the possibilities of creating a workforce of Indigenous health workers and liaison officers, along with other approaches to diversify- ing health care so that it is more appropriate and responsive to the needs of Indigenous clients. Chapter 12 Indigenous health in a global context compares and discusses Indigenous health from a global perspective. Australia continues to fall behind on all standard indicators of health for its Indigenous popula- tions. This chapter looks briefly at the experiences of colonisation on Indigenous health in other developed nations such as Canada, New Zealand and the USA. We compare the health status of Indigenous Peoples in a global context to illustrate the international relevance of the health of Indigenous Australians.
INTRODUCTION xviii Chapter 13 Cultural safety controversy and concerns looks at historical and recent responses to the teaching of cultural safety to our health work- forces and asks readers to examine what resistances might underlie such concerns. Chapter 14 Reflection on practice contemplates reflection as a key compo- nent of culturally safe practice. This section provides an opportunity for reflection on previously held assumptions, beliefs and attitudes. It examines the relevance of learning that is regardful of the practice setting, and offers an overall opportunity for reflection on the issues covered in this book. Frequently asked questions Relevance to practice ‘I don’t intend to work in Aboriginal or Torres Strait Islander health, so why do I need to learn about this?’ As you will learn throughout this book, no matter what your specific work area (specialty or location), your work is going to impact on Indigenous health, directly or indirectly. The majority of Indigenous Australians live in urban areas and have increased need for health ser- vices. Indigenous Australians, irrespective of where they live, can still be affected by a ‘culture’ of health services and staff that is not neces- sarily ‘Indigenous friendly’. ‘But Australia is a multicultural society: Why are we not learning about all the cultures in Australia?’ Focusing on this specific population does not imply that we do not recognise other groups and individuals worthy of similar analysis. Although the focus for this publication is on Indigenous health issues, with justification hopefully made explicit by the end of this text, the principles and knowledge that you acquire should be readily transfer- able to a range of cultural contexts—with ‘culture’ taken to include differences in gender, religion, age, sexual orientation, ethnicity, ­ disability and socioeconomic status (Ramsden, 2002). ‘Will this book tell me about particular diseases affecting Indigenous Peoples and how to treat those diseases and people?’ The short answer is ‘no’. This is not a disease-focused, biomedical text, although we do address some of these issues in Chapter 6. For a more detailed biomedical analysis, Aboriginal Primary Health Care: An Evidence-Based Approach (Couzos and Murray, 2008) provides extensive
INTRODUCTION xix and in-depth information about a range of health conditions affect- ing Indigenous Australians. We highly recommend it if you ever need to seek detailed information about specific conditions. Our book, however, takes a different approach to Indigenous health. The cul- tural safety model provides a firm foundation and takes a contextual approach to understanding Indigenous health. It focuses on what health professionals themselves can do to improve health outcomes. ‘Will this book tell me, step-by-step, how to care for or treat Indig- enous clients?’ Again, the short answer to this question is ‘no’. This book does not present a ‘recipe’ to caring for Indigenous Peoples. There is no step-by- step guide or checklist that can fulfil this purpose—nor should there be. This book requires the reader to examine their role in Indigenous health care from a contextual understanding of the social, political, historical, environmental and cultural perspectives. It is based on a belief that, prior to providing care across any of the health disciplines, a consideration of the contextual underpinnings of the client/patient/ community is essential for safe and effective practice. It is part of the preparation to enter the practice setting and engage with Indigenous Peoples, regardless of one’s level of experience.
1 1 Talking about Indigenous health With Indigenous Australians comprising less than 3% of the population there may be justifiable questions asked about exclusively focusing on Indigenous health. However, the health disparity experienced by less than 3% of Australians is unacceptable and poses one of the greatest challenges to health professionals in this country. Indeed, Tom Calma, the Aboriginal and Torres Strait Islander Social Justice Commissioner, has said: ‘It is not credible to suggest that one of the wealthiest nations of the world cannot solve a health crisis affecting less than 3% of its citizens’ (HREOC, 2005). Consider that if we, as a nation, could figure out how to improve Indigenous health in Australia, what might be the implications for health and Australian society as a whole? If we were to improve the health of, on the one hand, arguably Australia’s most valuable cultural resource and, concurrently, Australia’s most vulner- able and marginalised population, the skills, knowledge and experiences that would be developed to achieve this aim would benefit everyone. At an individual level, if we learned how to deliver health services so that outcomes mattered, this would improve health for everyone. Organisa- tionally, if we learned how to structure our systems so that no one was left behind, that everyone benefited, we would have an organisational structure coveted by all. And if our policies were such that they mat- tered, in real ways, and that they did not present barriers but facilitated culturally safe care, again, everyone would benefit. Apart from all the mutual benefit, health is a universal human right and while ever there is disparity within our nation we are diminished. We can and must do bet- ter. This chapter will explore the cultural relations between Indigenous and non-Indigenous people in the context of health and Australian soci- ety. In order to do so, it is necessary to first provide key definitions and terminologies.
Health Care and Indigenous Australians 2 Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Explain the reasoning for focusing on Indigenous health ➢ ➢ Define relevant terminology and rationales for their use ➢ ➢ Examine the relevance of Indigenous health issues to your own practice ➢ ➢ Apply transferrable cultural safety principles to other practice settings. Indigenous or Aboriginal and Torres Strait Islander health? Indigenous Australians are known to suffer the poorest health of any group within Australia. We have titled this text using the term Indig- enous, yet this is not always a widely accepted term by those who prefer to use Aboriginal and/or Torres Strait Islander People. Consensus is hard to find and rightly so, as we need to be mindful of the imposition of these labels through our history. As this text references diverse communities, individuals and circumstances, we have chosen to use the term Indig- enous with a strong encouragement that readers should check locally to find out the accepted terminology. So do health practitioners need a whole text or compulsory study on Indigenous health? Surely, caring for an Indigenous person should be the same as for any other person. Australia is a multicultural society. Why then focus on this particular group, who are also multicultural? One answer relates to the demographic makeup of health profession- als in Australia. Although Indigenous Australians have a greater need, this does not always translate to a greater uptake of or access to health services. We would expect that based on need, Indigenous Australians would access health services at about two or three times the rate of non- Indigenous Australians (AIHW, 2008). Given this higher consumer ratio, it would be reasonable to expect a comparable representation of Indig- enous health professionals. However, in 2011 Indigenous Australians only made up 1.6% of the health workforce (AHMAC, 2011), but comprised 2.8% of the population, with far greater health care needs than the non-Indigenous population. This imbalance requires a useful response. With the exception of Indige- nous Health Workers or Practitioners (IHWs or IHPs) and Indigenous liaison officers (ILOs), Indigenous nurses, doctors and allied health profession- als are few in Australia. Although there was a doubling to more than 200
Talking about Indigenous health 3 Indigenous medical practitioners in Australia since the last edition, this still only comprises less than 0.5% of all the medical practitioners in Australia (AHMAC, 2011). While it is hoped that some readers using this text will identify as Aboriginal or Torres Strait Islanders, the reality is that the major- ity will have a non-Indigenous background and, more frequently today, come from overseas (see Chapter 11 for workforce issues). The question has also been asked whether it is possible for ­ non-Indigenous health professionals to provide care that is acceptable and accessible to people who suffer the worst health of any population in this country. It has to be possible, as Tom Calma’s quote at the begin- ning of this chapter suggests. If any impact is to be made in addressing the unacceptable state of Indigenous health in Australia today, then the majority workforce must accept this national responsibility and act on it. Indigenous health professionals have been identified as critical to addressing Indigenous concerns. However, it would be unfair to place this burden on any one group of people when the root causes of current health concerns are multifaceted and complex, as evidenced by successive govern- ments’ failures to adequately improve outcomes for Indigenous Australians. How we talk about this topic: Terminology and definitions Simply starting a conversation about this topic may already seem fraught with difficulty. Some students have suggested that the potential to offend is overwhelming and that there is too much ‘political correctness’. They therefore opt to avoid discussions of Indigenous health altogether. So why do we emphasise correct terminology so much when talking about Indigenous health? Is it ‘political correctness’ and what does that actually mean? Often when something is deemed an example of ‘political cor- rectness’ it is more likely to be a resistance to acknowledging that some language, attitudes and behaviours marginalise and demean others. Before proceeding further into this book, readers may have noticed the different terminology already present when referring to Indigenous Aus- tralians. ‘Aboriginal and Torres Strait Islander’ is currently a commonly accepted, but not unanimously accepted, way of referring to populations in Australia. ‘Indigenous’ is also commonly accepted but, again, not unanimously accepted, terminology. However, we have used the term ‘Indigenous’ throughout the text for readability and brevity with no dis- respect intended. Where we refer to specific populations we have tried to ensure that the accepted identifiers have been used. Another terminology used in writing is to abbreviate Aboriginal and Torres Strait Islander to the acronym ‘ATSI’. This is often the case in medical writings and may partly result from publishing requirements to
Health Care and Indigenous Australians 4 shorten any phrases frequently used so as to reduce costs. However, our experience and advice from Indigenous colleagues is that this abbre- viation is offensive to some people and should be avoided. Consider the impact of reducing to an acronym something that perhaps is the most important description of your identity. Terminology and definitions will be discussed further in this chapter. (See also Laurie May’s poem in Chap- ter 5, on the impact of such labels.) Before the colonisation of Australia, the terminologies ‘Aboriginal’ and ‘Torres Strait Islander’ did not exist as a form of self-identification for the country’s First Peoples. The colonising groups imposed these identifiers. Even today, people generally identify by their language or nation group. For example, some people from the Arnhem Land region identify as ‘Yolgnu’, others in the Adelaide region as ‘Kaurna’, and yet other peoples from the Alice Springs region as ‘Arrernte’ or ‘Aranda’. It is important to be aware that there may be multiple spellings for different language groupings, nations and community names. Throughout this text, when referring to particular language or nation groups, we have relied on spellings developed by lin- guists, unless specifically requested by local people to use specific forms. Think about what it would be like for you as an individual to be referred to by an imposed label. There will be more detailed discussion of this in later chapters. However, using Indigenous names is not always pre- cise and straightforward because of variations in spelling and preferences. This is why we will repeatedly remind readers to find out what is preferred locally from credible sources—ask people for the accepted terminology for any given region or person—and it is important to not make assumptions. As the authors of this text, we would like to state from the outset that the terminology used throughout cannot be done without acknowledge- ment of our colonising histories. Indigenous Peoples and cultures are inherently diverse and anything but static. Therefore we need to set some parameters for the use of terminology from this point. The first step: Defining the terms ‘Indigenous’, ‘Aboriginal’ and ‘Torres Strait Islander’ Indigenous Peoples have been defined and described by successive governments and non-Indigenous people since first encountering one another, often with negative consequences. In fact, ‘The legal historian, John McCorquodale, has reported that since the time of white settle- ment, governments have used no less than 67 classifications, descriptions or definitions to determine who is an Aboriginal person’ (ALRC, 2003a). This creates considerable difficulty in knowing how to appropriately discuss some issues. The term ‘Indigenous’, in an Australian context,
Talking about Indigenous health 5 encompasses both Aboriginal and Torres Strait Islander peoples. However, some even challenge this usage. For example, Aboriginal and Torres Strait Islander Peoples (with an ‘s’) differ from one another, in that Aboriginal people are the Indigenous Peoples of the mainland of Australia while Tor- res Strait Islander Peoples are originally, as the name suggests, from the Torres Strait Islands north of Cape York Peninsula. To lump these two groups together as ‘Indigenous’ can be offensive to some people because it does not acknowledge differences. Using the ­ plural of ‘people’ and writing or saying ‘peoples’ is one way of acknowledging the inherent diversity in these groups. Indigenous Peoples are not as homoge- neous as the term might imply. Consider the label ‘European’ for example. European people speak a variety of languages, live within generally clearly defined borders across a variety of geographical zones and have distinct customs, cultures and beliefs. There are also often certain physical commonalities that allow people to identify with different ethnic groups (hair or eye colour, facial characteristics, skin tone), and yet we know these variations are not the keys to an individual’s identity. Non-Indigenous Aus- tralians are at times referred to as ‘European’, and yet may never have been to Europe and have no actual links with Europe or people there. In fact, for many ‘European Australians’, their connection to Europe may stem back generations and have little relevance today. Using this as an example, you might see how terminology can be problematic. Using the term ‘Aborigi- nal’ can wrongly suggest that everyone who identifies as ‘Aboriginal’ is the same. But, as with ‘Europeans’, there is considerable diversity in language, customs, beliefs, locations and histories. There is, however, a common thread that allows the term to suit a particular purpose. ‘Aboriginal’ denotes a link with the original people, literally meaning ‘of the original’. ‘indigenous’, spelt with a lower case ‘i’, means ‘belonging to’ or ‘being first’. Although there are many countries around the world with their own indigenous peoples, ‘Aboriginal’ (using the upper case) is commonly used to denote the Indigenous Peoples of Australia. When reviewing literature, students might also find that ‘Aboriginal’ is com- monly used throughout Canada, along with terms such as First People or First Nations Peoples. In Australia, the phrase ‘First Nations’ or First Aus- tralians is also in use (Dodson, 2007). Throughout northern hemisphere countries, Indigenous Peoples may be referred to as ‘Natives’. In Australia, however, the use of the term ‘Native’ can have negative connotations in some regions and is rarely used, other than in legal issues such as in ‘Native Title’. The term ‘native’ can also be suggestive of categorising people in the same way as plants and animals. In this book we have ensured the capitalisation of ‘Aboriginal’ and ‘Indigenous’ when referring specifically to the Aboriginal and Indigenous Peoples of Australia. This is not just a matter of being pedantic or politically
Health Care and Indigenous Australians 6 correct but rather it is a matter of showing the same respect you would expect for yourself. As with the other terminology we discussed, it is impor- tant to understand that, at least for some people, it can be highly offensive, and even considered racist, when these terms are not capitalised. As pro- fessionals, it is our responsibility to be aware of these possibilities and to do our best to not ‘diminish, disempower or demean’ someone’s cultural identity, which includes the terminology we use to describe people. As may be already apparent, there is a diversity of terminology and respectful ways of talking with and about Indigenous Peoples. Many organisations have style guides regarding terminology. Please make sure you seek out and respect local expectations. One helpful example is found in the ACT Council of Social Service (2016) Good Gulanga Practice Guide, relevant to their specific areas of operation. Critical thinking What is your response to the issue of terminology? Do you think it really matters or is this merely political correctness? Why do you think some requests for change are labelled as political correctness? Think of an example where you have been referred to by a label imposed by someone else. How did you feel about it? What cultural groups are in your region? How do they identify themselves? We will further discuss terminology in Chapter 3 on the identity and defi- nitions of Indigenous and Aboriginality. For now, however, it is essential that every effort be made to find out and use the locally and culturally appropriate terminology in your discussions. Informal terminology Indigenous Peoples and non-Indigenous people frequently use informal terms to refer to themselves and others in daily life. Usage of these terms can vary regionally, and what is affectionate or acceptable in some areas could be regarded as highly offensive in others. For example, consider the following scenario: In an undergraduate class in Adelaide, a Northern Territory student was telling a story about people she knew in her local town and began by saying that her ‘boyfriend was a half-caste from …’. Many in the group immediately reacted
Talking about Indigenous health 7 to the description as offensive and forcefully told the student things like, ‘You can’t say that, … that’s racist!’ The young woman was genuinely stunned by the response and looked to the lecturer to explain what she had done to provoke such a reaction. Critical thinking In the absence of other information, how would you respond, if at all, to such a com- ment by another student? Do you think this was an example of racism or something else? Give some explanation for your view. Why might the young woman’s boyfriend use a colonial term to describe himself? Can you think of other examples where the target of a derogatory name has used it in relation to themselves and why? In this scenario, the lecturer acknowledged that it was still common usage to hear terms such as ‘half-caste’ in some regions, by both Indigenous and non-Indigenous people. It was explained that the course would be looking at the impact of policy, scientific racism and the impact of colonisation and that this might provide a context for how these terms arose. The fact that some people use such terms themselves is indicative of the colonisa- tion process, which disempowers some and privileges others. Those who are privileged could be unaware of how (or be unwilling to explore how) they have come to be in their positions. The lecturer then asked the group how many of them had been given a government-applied classification based on their percentage of blood from one ethnic group or another. She also asked them to consider what this might mean to them if such clas- sification could be used to deny them certain rights and privileges. Activity For this activity, you will need to form a small group, perhaps with others studying this book or maybe with your family or other people you live with. Each member of the group should identify to their group how they identify themselves and why. Before you get started, your group should establish some rules. They might include, for example, respecting others and their choice not to identify personal information about themselves. Individual anonymity should be maintained both inside and outside the group. ▼
Health Care and Indigenous Australians 8 Consider the following case scenario. How did people identify themselves? Reflect on the reasons people gave as to why their identity was important. Some of the common self-applied labels included marital status, mother, single mother, single father, religion, interests, employment background and ethnic heritage. Did anyone identify themselves by their cultural or ethnic background? For example, if someone identified themselves as ‘half Scottish’, ‘half Australian’ or ‘Lebanese Australian’, ask how they might feel if the government used that classification to restrict their travel, places of residence, rights and so on. Consider how a term such as ‘half-caste’ can be offensive and may cause harm when the origin and intent are not understood. If you cannot do the activity in a group, consider the last time you were in a social ­ situation with people you were not familiar with. How did people introduce themselves? What was the context of the social situation, and did that influence how people intro- duced themselves? For example, if you are at a work get-together, people introduce themselves through their job title (‘I’m the manager’), but, if you are in a family situation, people may introduce themselves through family connections (‘I’m John’s wife’). ▼ Scenario A mother with two adolescent children comes to the emergency department with one of the children having possibly broken their arm skateboarding. The mother completes the forms and has ticked the box ‘Aboriginal or Torres Strait Islander’. The nurse has looked at the form and is entering the data into the system. Based on the mother’s appearance, the nurse suggests that perhaps she has made a mistake on the form—that she has wrongly ticked ‘Aboriginal or Torres Strait Islander’. Critical thinking What impact might this have on this family’s experience of health care? How might this impact on this mother’s experience of the system? How likely is she to feel wel- come there and come back again? What assumptions has the nurse made about Indigenous identity? What message do the children get about their identities? Through critical reflection, health professionals and students can develop readily transferable skills to the care of any individual or group. If you do not work directly with Indigenous clients or co-workers, you may well work with others who have experienced similar impacts on health and well-being. The experiences of Indigenous Australians are, after all, human experiences that are not exclusive to or derived from being Indigenous. They are the shared experiences of loss, trauma, resilience, sur- vival, grief, pride, capacity, health and illness.
Talking about Indigenous health 9 Conclusion In this chapter, we have discussed rationales for studying Indigenous health, defined relevant terminology and asked the reader to investigate locally appropriate terminologies. We have also sought to examine the relevance of Indigenous health issues to individual practice and consider the transferability of these issues to other populations. Some key cultural safety principles have already emerged: 1. Engage in dialogue—simply ask how someone wants to be addressed, respect how they choose to identify without questioning, assuming or stereotyping. 2. Consider the influence of history and decolonise practice by not con- tinuing to impose and disempower individuals or make assumptions. 3. Reflect on your use of language and terminology. Identify their origins and acceptability in the local context. 4. Think about who has power when different terminology is used or when it is assumed, and who makes the assumptions? These principles are applicable to working with anyone of a different cul- tural background to yourself and, in later chapters, we will discuss culture in its broadest definitions as being more than ethnicity. Culture can be a generational, social, religious or other difference that exists between you and the client or recipient of care. The following chapter will present an argument for the use of cultural safety as an underlying philosophical approach to Indigenous health issues. Making it local y y What relevance does learning about Indigenous health have for your own practice or intended practice? Write down your expectations now so that you will have them to review when you reach the end of this text. What do you know about the local Indigenous populations in your region? What language groups are associated with your locality? y y If you believe there are no local Indigenous people in your specific location, please ensure you investigate your assertion thoroughly.
10 2 Cultural frameworks for health This chapter examines a variety of frameworks used to understand and address cultural issues in health care. These frameworks include cul- tural awareness, cultural sensitivity, cultural competence, cultural security, cultural respect and cultural safety, which are discussed in more detail throughout the rest of this text. Development in this field is ongoing and, in this edition, we include the concepts of cultural capability and cultural ­humility. A brief description of each will be provided as well as readings, activities and case studies. Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Describe various frameworks for intercultural health service ➢ ➢ Define and apply various frameworks to scenarios ➢ ➢ Compare and contrast cultural safety with other current approaches ➢ ➢ Examine the relevance of cultural safety to your own practice. Culture and health How we think about health, whether that is our ‘philosophy’, our ‘world- view’, our ‘framework’—whatever we want to call it—influences what we do as individuals in practice. However, it also influences service delivery more generally. We might not even be aware that there is a certain way we think about health or that others might think about it differently, espe- cially if most of the people we spend time with share similar views to our own. These shared views can be called our ‘culture’. There are numerous approaches to service delivery that incorporate a focus on culture. Cultural awareness, cultural respect, cultural competency and cultural safety are some of the more established frameworks to influence services and health
Cultural frameworks for health 11 professional education. However, as these concepts are applied and scru- tinised, there is, and should be, ongoing development and new modes of thinking. In this edition, we will also consider more recent frameworks such as cultural capability and cultural humility. What is important, as always, is to find out what local frameworks are used within health services. Some of the models or understandings of health will be discussed in more detail in Chapter 8. However, at this stage, it is important to acknowledge that not everyone shares the same views about health and what it means to be healthy. How then do we, as health professionals, deal with this? Health systems that privilege a certain way of thinking unfortunately do this at the expense of others’ ways of thinking and therefore at the expense of some people’s health. With increasing aware- ness of the rights of individuals, health care providers and systems need to recognise that there is more than one way to do things and more than one belief system—there are many ‘cultures’, models, concepts or frameworks for working. In the words of Richard Trudgen: ‘it is my con- viction that the crisis can be understood and programs can be developed to deal with it. But finding its real cause will require us to look at the subject from the other side of the cross-cultural/cross-language divide— the side where Yolgnu live’ (Trudgen, 2010, emphasis in original). In this chapter, we will explore a number of these concepts and set the tone for how the rest of the book will unfold—firmly based within the authors’ preferred framework of cultural safety. Firstly, cultural safety (from the New Zealand concept kawa whakaruruhau) is derived from the experiences of Indigenous people; it has been embedded into the nursing curricula of New Zealand’s universities and has had more than 20 years of implementation in health services. While acknowledging that the concept has come from the Māori experience in New Zealand, we are not suggesting that we simply transfer the approach in its entirety. That would not be possible or appropriate for reasons that should be clear. However, a key reason for choosing cul- tural safety as a preferred approach for the Australian context is that it puts the onus for change on the health service provider rather than on the client. It is an undertaking to think about the things that make us unique and to provide care that takes account of these differences. Before looking at the development of cultural safety and other rationales for its adoption/adaption, it may be useful to go back a little to one of the first major considerations of culture in health care—trans-cultural nursing. Trans-cultural nursing The influence of anthropology was prominent in the 1960s with the groundbreaking work of nurse-anthropologist Madeleine Leininger, who
Health Care and Indigenous Australians 12 pioneered the first real model of health care practice to incorporate cul- tural considerations. Trans-cultural nursing at that time focused on the importance for the health care professional to learn about cultural dif- ferences. Culture was a limited concept that related to ethnicity or race. Trans-cultural nursing practice involved developing the knowledge base of the nurse to incorporate certain cultural protocols towards clients of different ethnic or religious backgrounds. One problem with trans-cultural nursing theory, however, was the potential reliance on stereotyped notions of how an individual might behave based on ethnicity. This paid little attention to life experiences and diversity within cultures, let alone across cultures or importantly ­ cultures that have been impacted through colonisation. Imagine the ­ usefulness of having care based on stereotypes of so-called Australian culture. What is Australian culture? If an Australian were in a hospital overseas, could they expect perhaps to be greeted with ‘g’day’, and served a meat pie with sauce in keeping with anticipated cultural preferences? Trans-cultural theories have definitely been valuable in shifting from a homogenised mentality to one that is regardful of the individual needs of clients and communities. Trans-cultural nursing today, however, has grown and expanded, as evidenced by journals and professional societies related to this field. While this is how trans-cultural nursing originally developed, along with other concepts we will discuss, some proponents of trans-cultural nursing have adapted and modified the original concept. We now see work in the field of trans-cultural nursing that has many of the same elements or concepts as those in cultural competence or cultural safety frameworks. Cultural safety Cultural safety will be discussed in more detail in the following and sub- sequent chapters. However, to establish an early understanding of this concept in order to compare and contrast other frameworks for inter- cultural practice, the Nursing Council of New Zealand (2011, p. 7) has defined cultural safety, or kawa whakaruruhau, as: The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability. The nurse delivering the nursing service will have undertaken a process of reflection on his or her own cultural identity and will recognise the impact that his or her personal culture has on his or her professional practice. Unsafe
Cultural frameworks for health 13 cultural practice comprises any action, which diminishes, demeans or disem- powers the cultural identity and well-being of an individual. In short, the recipient of care determines cultural safety. It is not restricted to culture as indicated by ethnicity. It requires health professionals to reflect on their own cultural identity and on their relative power as a health care provider. Various approaches to Indigenous health have viewed culture as a key determinant that can be ‘managed’ with increased cultural awareness or cultural competence on the part of providers. Nurs- ing, for example, has developed numerous philosophical approaches to influence the way in which practice is enacted in cross-cultural or mul- ticultural contexts. Cultural safety is one concept that the authors believe holds the greatest opportunity for transforming Indigenous health prac- tice in Australia. This is mainly because cultural safety is one of the few frameworks that recognises the colonising context as significant. However, it seems Australia is still a long way from fully embracing the necessary elements of a cultural safety philosophy. We will discuss this further in later chapters that explore resistances that also occurred in New Zealand when cultural safety was first proposed. Other frameworks for considering culture in health care We will now explore other frameworks that have focused on the issue of culture in health care. Some of these overlap with cultural safety, and some have very different goals. Some of the frameworks are not well defined or have been defined differently by various writers. Overall, how- ever, it is important to recognise that there are different terms and frame- works. Consider the aims and foci of the various approaches and their implementation in practice. Cultural competence Cultural competence, originally developed in the USA, has wide-ranging application and understanding and has been defined in many ways. Some definitions make it difficult to tease out the difference between cultural competence and cultural safety. Cultural competence has been 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 et al., 2002, p. v). ­ Campinha-Bacote (1994) defined cultural competence as a ‘process, not an
Health Care and Indigenous Australians 14 endpoint, in which the nurse continuously strives to achieve the ability to work within the cultural context of an individual, family, or community from a diverse cultural/ethnic background’ (pp. 1–2). Cultural competence in some instances has been broken down to include clinical, organisa- tional and systemic cultural competence (as cited in DeSouza, 2008). While there seems to be widespread adoption of cultural competence as a framework it has also come under much scrutiny and critique. It is often defined as the ability to work effectively with clients who are cultur- ally different. The service provider is the focus in this definition. There is a focus on behaviour that can be assessed as competent. But who decides whether a service provider’s care or service has been ‘competent’? What would this look like in practice? Many of the social sciences in Australia have adopted the concept and terminology of cultural competence and expanded it to include elements which are, as you will see, very similar to those employed in cultural safety. For example, cultural competence training in some psy- chology programs in Australia includes the importance of understanding the implications of a colonial history, notions of power (and disempow- erment or empowerment), the consideration of how one’s own culture impacts on their provision of care and how the care is received by clients. Side by side, it would be difficult to see any major difference between some ideas of cultural competence and cultural safety. Cultural humility Culturally Connected is a Canadian website that provides information and resources about cultural humility for health professionals (https://cultural- lyconnected.ca/cultural-humility/, accessed June 2018). They define cul- tural humility using Tervalon and Murray-Garcia’s (1998) definition: Cultural humility is a stance toward understanding culture. It requires a com- mitment to lifelong learning, continuous self-reflection on one’s own assump- tions and practices, comfort with ‘not knowing’, and recognition of the power/ privilege imbalance that exists between clients and health professionals. A cultural humility approach is interactive: we approach another person with openness to learn; we ask questions rather than make assumptions; and we strive to understand rather than to inform. Embracing and learning about the similarities and differences between health professionals and clients, such as language, religious beliefs or values, age, gender, understandings of health and illness, or sexual orientation, can help providers to understand a client’s health concerns, experiences, and preferences for care.
Cultural frameworks for health 15 Cultural humility has arisen from the medical professions in North America, in response to what was seen as a limitation of cultural competence. How- ever, cultural safety philosophy differs in the critical aspect of recognising our colonising pasts as influential to current health and health care practice. Cultural capability Queensland Health defines cultural capability as ‘the skills, knowledge, behaviours and systems that are required to plan, support, improve and deliver services in a culturally respectful and appropriate manner’ (www. health.qld.gov.au/atsihealth/cultural_capability, accessed 15 April 2018). The Queensland Health Framework document provides a well-­ articulated explanation of the key principles of cultural capability and guidelines for implementation. According to Figure 2.1, cultural capabil- ity is part of the Cultural Competency Framework embedded within and aligned to the Aboriginal and Torres Strait Islander Cultural Capability Frame- work 2010–2033 (Queensland Health, 2009). The framework includes eight elements, including the principles of self-reflection, cultural understand- ing, context, communication and collaboration. Figure 2.1 Queensland Health Organisational Cultural Competency Framework Source: Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010–2033
Health Care and Indigenous Australians 16 Cultural respect For the period between 2004 and 2009, the Commonwealth provided health services with yet another framework that acknowledged the role culture plays in the health outcomes of individuals and groups. Accord- ing to the Australian Health Ministers’ Advisory Council (2004), cultural respect is defined as: the recognition, protection continued advancement of the inherent rights, cultures traditions of ATSI peoples [sic]. Cultural respect was developed as a guiding principle in policy con- struction and service delivery, which was in response to the continu- ing unacceptable health outcomes of Indigenous Australians. It was yet another government response to the disparity between Australia’s overall ­ populations being among the healthiest in the world, while Indigenous Australian health is among the poorest in the world. This is in contrast to countries with similar colonial histories, such as New Zealand, Canada and the USA (see Chapter 12). As with the cultural safety experience in New Zealand, barriers remain to the provision of an equitable, quality health system. According to the government’s stated intention, ‘embedding cultural respect into services and delivery’ will: ➢ ➢ improve outcomes and quality ➢ ➢ deliver more efficient and effective services ➢ ➢ reduce expenditure ➢ ➢ improve customer satisfaction. This suggests that culture, as a determinant of health, is widely accepted and something requiring attention. Multiple literature reviews and reports have identified certain factors that might hinder the achievement of positive health service delivery to clients whose cultural background differs from that of the service providers. These factors include: ➢ ➢ cultural barriers to the uptake and delivery of services ➢ ➢ provider attitudes and practice ➢ ➢ communication ➢ ➢ mistrust of system
Cultural frameworks for health 17 ➢ ➢ poor cultural understanding—although the policy does not specify who exactly had poor understanding ➢ ➢ racism ➢ ➢ worldview/beliefs—deemed problematic although the reason was not specified. Cultural respect is described as a ‘shared respect’ that is achieved when the health system is a safe environment. It is a commitment to the principle that the construct and provision of services ‘will not wittingly ­ compromise the legitimate cultural rights, practices, values and expecta- tions’ (AHMAC, 2004). In 2010, we said that it was likely that an entirely new set of poli- cies will have been rolled out for the next five to ten years, as cultural respect was meant to be nearing its implementation point. What has been achieved? Can you find evidence of a cultural respect or any other cul- tural framework operating in your local area or state? How influential are these in shaping the health service provided and/or your own practice? The government’s implementation plan for the cultural respect frame- work included the following statement: development of rewards and incentives (e.g., salary, promotion, bonuses) for Cultural Respect performance, as well as sanctions for culturally destruc- tive practices (e.g., discrimination). Cultural Respect performance shall be an integral part of the employee-provider performance evaluation system, and provider-organisation performance evaluation system. (AHMAC, 2004, p. 20) Cultural respect is discussed in detail in the Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health, published by the Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee and available online: ­ www.coaghealthcouncil.gov.au/Portals/0/National%20Cultural%20 Respect%20Framework%20for%20Aboriginal%20and%20Torres%20 Strait%20Islander%20Health%202016_2026_2.pdf (accessed 15 June 2018). Reading With many cultural frameworks, there is a strong desire to have a tool to measure outcomes. The following reading importantly identifies the development of a tool led by First Peoples. ▼
Health Care and Indigenous Australians 18 Summary of concepts DeSouza (2008) proposes that cultural safety and cultural competence can be used together to meet the needs of cultural issues in health care. We have looked at some of the facets of cultural awareness, cultural sensitiv- ity, cultural competence, cultural respect, trans-cultural nursing and cul- tural safety. There are even more concepts today, such as cultural humility, cultural ease, cultural capability or cultural competency, distinguished by its focus on the individual rather than the broader system approach implied by cultural competence. The framework used in Western Australia and the Northern Territory has been that of cultural security. This is ‘a commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people’ (Thomson, 2005). The limitation of all of these frameworks or models is that we don’t know very much about how they actually play out in practice. We don’t have much research to show what works best or what actually makes a difference. The terms get thrown about as if they mean something in par- ticular, but there are assumptions underlying what these concepts mean and major differences in how the concepts are defined, both within and between different groups. If staff or students undergo some ‘cultural’ training or workshops, what does that mean? What are they taught? How do we know it will make a positive difference? How do we know that what is taught is not harmful— perhaps creating more stereotypes or discrimination against certain groups? While certain concepts, in an academic understanding, might be seen as more or less effective, when delivered in a workshop or similar it might depend on who was delivering the workshop, and how the issues are managed or presented. This makes it very difficult to assess and under- stand exactly what is being taught and the impacts. We have therefore considered each of the different concepts or frameworks and some of the weaknesses and strengths. Through this discussion and analysis you should have a better understanding of how knowledge, values and under- standing influence practice. Table 2.1 is a synthesis of some of the strengths and limitations of cul- tural safety and other frameworks. West, R, Wrigley, S, Mills, K, Taylor, K, Rowland, D and Creedy D K (2017) ‘Develop- ment of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students’, Women and Birth, 30(3), 236–44, https://doi.org/10.1016/j. wombi.2017.01.004 ▼
Cultural frameworks for health 19 Table 2.1 Cultural frameworks, strengths and limitations Framework Key idea or elements Strengths Limitations Cultural safety Regardful of difference Decolonising: understanding of history Consideration of power Reflective practice Understanding own culture Safety is determined by recipient of care Conceptually addresses elements that theoretically should improve health outcomes Requires more research Has generally focused on application in interpersonal contexts and not as much in organisational or structural contexts Cultural awareness Focus on awareness of differences between groups Provides a starting point to understand difference Unachievable to be aware of or knowledgeable about all cultures Can lead to stereotyping Cultural sensitivity Sensitive to elements of difference between self and clients Extends awareness to a sensitivity Improvement of practice requires more than sensitivity to issues Cultural competence Awareness, knowledge and skills relating to culture Understand self as culture bearer Recognition of historical, social and political influences Relatively extensive literature base Potentially perpetuates colonising practices and power imbalances Can be deemed competent by other than recipients of care Cultural respect Australian Government initiative Shared respect in a safe health environment Consideration of impact of services on health outcomes Failed to result in meaningful actions despite intentions Cultural humility A commitment to lifelong learning, continuous self- reflection on one’s own assumptions and practices, comfort with ‘not knowing’, and recognition of the power/privilege imbalance that exists between clients and health professionals Addresses the individual practitioner’s potential power and privilege Lack of literature
Health Care and Indigenous Australians 20 Framework Key idea or elements Strengths Limitations Cultural capability Cultural capability refers to the skills, knowledge, behaviours and systems that are required to plan, support, improve and deliver services in a culturally respectful and appropriate manner (West et al., 2017) Framework provides a clear set of strategies for achieving cultural capability, including staff training, resources development translation, community engagement, leadership partnership, data collection analysis, inclusive recruitment retention interpreting Lack of literature Critical thinking Consider the wide range of terminology and concepts relating to working in cultural contexts. How can getting caught up in the current terminology present a barrier for health professionals to working well in cultural contexts? Go to the Australian Indigenous Psychology Education Project website to find the resource: ‘Finding common ground: Avoiding the terminology trap’ (www. indigenouspsyched.org.au/resource/finding-common-ground-avoiding-terminology- trap, accessed 29 July 2018). Activity Conduct a search of each state and territory in Australia to identify cultural frame- works currently meant to be in use in the government-controlled sectors. There are multiple Aboriginal or Torres Strait Islander controlled services in each state and territory as well. See if you can identify specific frameworks used in some of these settings. Are there any particular frameworks that seem to be gaining prominence? Table 2.1 Continued
Cultural frameworks for health 21 Conclusion No single approach is likely to have all the answers. If there were such an approach, the challenges of Indigenous health in Australia would have been met and dealt with long ago. Cultural safety has arrived at a set of principles for ensuring that dominance does not result in a lack of safety and accessibility for those who have a different cultural background to the providers. This chapter has briefly explored cultural safety as a concept along with other frameworks that have been developed and used in health and other disciplines. While it may be an individual choice as to which frame- work resonates with readers, cultural safety is offered as the preferred approach by the authors because of its transferability across disciplines, contexts and cultures and the essential element of recognising the role of colonisation in health outcomes today. Scenario A local health service wanted to assess how well it was doing providing care to Indigenous clients. The practice manager developed a written client satisfaction sur- vey that was left in the reception. What do you think of this approach to assessing care for this or any other population group? How appropriate would this be in your specific location? Explain your response—why or why not? How would you personally know if you were providing culturally safe care? Making it local y y Has anyone witnessed the rewards or sanctions associated with any of these frameworks in practice? y y How do we as health professionals ensure that policies and frameworks for prac- tice do not just linger in folders and on web pages of health services? What can you do as an individual to see policies in practice? y y Find your current service’s cultural framework. If you are a student, visit a health service in your local area.
22 3 Cultural safety in practice The previous chapter examined the various frameworks for looking at cul- ture within health care settings. This chapter will expand on this book’s preferred framework of cultural safety and explore the elements that make it a relevant approach for the Australian health care environment. Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Describe the pathways to cultural safety ➢ ➢ Identify the principles of culturally safe practice ➢ ➢ Define and apply cultural safety to scenarios. Pathways to cultural safety Some writers have considered cultural safety as the third level in a set of three levels of cultural understanding. We, on the other hand, view cultural safety less as a hierarchy and more like a continual process of reflection on practice. In this chapter, we will briefly describe the levels of cultural safety as articulated in the New Zealand concept, and will address more fully the application of cultural safety in practice (Figures 3.1 and 3.2). Figure 3.1 Original stages towards cultural safety—as defined by Ramsden (2002) Cultural Awareness (of differences) Cultural Sensitivity (acceptance of right to differences) Cultural Safety (defined by recipient)
Cultural safety in practice 23 Cultural awareness Cultural awareness is the first step in being aware that there are differ- ences between people. This can be more challenging than it seems. The obvious or exotic differences are perhaps easier to identify than the more subtle differences. These obvious differences might include the mode of dress, foods people eat or music preferences. However, cultural awareness also seeks to uncover the less obvious differences, including interpersonal behaviours, such as showing respect for authority by look- ing down, which may contrast with another culture that shows respect by looking directly at a person in authority. This is a stage that many people find very interesting and enjoyable, such as learning new words and protocols. These differences can be observed and enjoyed or visited for a period without requiring any fundamental change in practice. For some, it can be a little like going to a museum, but then you go home. Unfortunately many professional development workshops and educa- tional settings tend to limit their cultural training to this stage of aware- ness. However, cultural awareness also requires an understanding of one’s Figure 3.2 An aspirational model of cultural safety—as developed and defined by Taylor Guerin (2018) Self Awareness Cultural Awareness Cultural Sensitivity Cultural Safety and Reflective Practice
Health Care and Indigenous Australians 24 own culture and the commonalities across all cultures that allow people to relate to and interpret any perceived differences. Cultural awareness, simply put, is being aware that people are dif- ferent. We discuss it again here because it is a widely used terminology, both within the domain of cultural safety and more generally. Cultural awareness is not entirely natural—it is not something that you are born with; awareness of differences between people is social and develops over time. If you watch small children, for example, two- to four-year- olds, they would generally not ‘see’ differences between people—kids are kids, grown-ups are grown-ups, and that’s basically all they understand. Being aware that people are different is not problematic, but what is important is what you think of those differences and how you act on them. For a long time, health professions adopted a seemingly equitable and benevolent mode of practice of treating everyone the same. This was thought to be appropriate, fair and reasonable. ‘I treat everyone the same’ was intended to demonstrate a lack of prejudice on the part of the health service and practitioner. However, evidence has suggested that disparities in health outcomes of some populations can be attributed in part to cul- tural differences between clients and care providers. Increasingly, people began talking about the need to be ‘culturally aware’. Treating everyone the same suggests everyone belongs to a homogeneous base. Experi- encing the same treatment therefore may not necessarily mean equal outcomes. Cultural awareness approaches often focus on learning about the things that make cultural groups different from one another. While a use- ful first step, learning these sorts of details can also lead to stereotyping and inappropriate behaviour or interactions. It is not possible to learn everything there is to know about all the cultures that you encounter in your practice. Cultural safety principles, on the other hand, provide a more useful addition to your knowledge base. Cultural sensitivity Cultural sensitivity is intended as the next step up from cultural aware- ness. It means being sensitive to the differences that one might have learned about through cultural awareness. Sensitivity assumes that health care professionals can apply their awareness of cultural differences to their own practice. It validates the right to difference. Cultural sensitivity is also thinking about your own attitudes and values and how they might affect the person you are working with, as well as taking into account the cultural issues that might influence your clients.
Cultural safety in practice 25 In this step you might say, ‘OK, there are cultural differences, and now I can be sensitive to those differences’. As a health professional, I can consider different modes of operating for my clients. Difference is ­ legitimated—difference is OK—and it is about being sensitive to the possibility that my difference might impact on others. In this stage, the health professional reaches an understanding that individuals are entitled to hold differing worldviews, values, knowledge and beliefs. It should not be a matter of leaving these cultural foundations at the door in order to access health care. The health professional needs to be sensitive to differ- ing needs and expectations, and work to accommodate these where pos- sible. It is not, and should not, be the goal to ‘convert’ someone to your preferred culture. Cultural safety Although this is not a linear process, cultural safety is achieved when the recipients deem the care to be meeting their cultural needs. This requires the health professional to reflect on their interactions and the impact of their own cultural identity on the care they provide to someone from a different cultural background. Irihapeti Ramsden (2002), who spearheaded the original cultural safety movement in New Zealand, believed that it was not enough to focus on the ‘exotic’ aspects of an individual or group culture as was often done in cultural awareness, cultural sensitivity or trans-cultural nurs- ing approaches. In contrast to trans-cultural nursing, which originally sought to describe and respond to the cultural differences, cultural safety involves recognition of power balances and historical, political, social and economic structures. Cultural safety requires the health professional (or others) to understand their own culture and to acknowledge the power imbalance brought about by dominant systems. It requires them to actively seek to ensure no ‘cultural harm’ is done through actions that may impact on clients. Cultural safety has gained momentum in Australia, with a growing body of literature challenging existing approaches to Indigenous health care. It is important to acknowledge that the cultural safety framework itself came from Indigenous Peoples outside Australia. However, rather than suggest simply applying a foreign concept to an Australian context, it is obvious that without some adaptation and regard of local contexts, histories and worldviews, this act itself would be an unsafe one. While cultural safety is an Indigenous construct, it requires the dominant or colonising culture to engage in processes of self-reflection and decolonis- ing practice.
Health Care and Indigenous Australians 26 Examining the New Zealand experience suggests that clinical compe- tencies, technical expertise and theoretical knowledge form only part of the care equation when the recipients of care differ in some way from the health professional. Statistically, this is the situation in Australia where the majority of health professionals are non-Indigenous and those most in need of health care are Indigenous Peoples. Although cultural safety has arisen from the disciplines of midwifery and nursing, other health disciplines have found, or are finding, rel- evance for their practice. Sadly, Irihapeti Ramsden did not live long enough to see the transforming impact of this philosophy globally and across professions. Even where other philosophical frameworks have emerged, there can be no denying that the New Zealand experience has had a profound influence in focusing on culture and colonisation in health. There are numerous readings and resources that might be ­ examined for a deeper understanding of the development and conceptu- alisation of cultural safety. Readings For anyone interested in learning more, Irihapeti Merenia Ramsden’s PhD thesis, ‘Cultural safety and nursing education in A ˉotearoa and Te Waipounamu’ (2002) is available online through Massey University, New Zealand. Other readings of interest include: Browne, A, Varcoe, C et al. (2009) ‘Cultural safety and the challenges of translating critically oriented knowledge in practice’, Nursing Philosophy, 10(3): 167–179. Laverty, M, McDermott, D and Calma, T (2017) ‘Embedding cultural safety in ­ Australia’s main health care standards’, Medical Journal Australia, 207(1): 15–16. Molloy, L, Lakeman, R, Walker, K and Lees, D (2017) ‘Lip service: Public mental health services and the care of Aboriginal and Torres Strait Islander peoples’, International Journal of Mental Health Nursing, 27, 1118–1126. Smith, S (2012) ‘Cultural safety in nursing education: Increasing care for LGBT indi- viduals’, http://hdl.handle.net/2376/3442. (This master’s thesis from Washington State University shows the transferability of cultural safety to populations who may differ from the health professional in term of sexual orientation.) Williams, R (1999) ‘Cultural safety: What does it mean for our work practice?’, Aus- tralian and New Zealand Journal of Public Health, 23(2): 213–214.
Cultural safety in practice 27 Cultural safety principles The following is a brief summary of the principles of cultural safety, as identified by the Nursing Council of New Zealand (2011): 1. The need for health practitioners to reflect on their practice is a criti- cal aspect of culturally safe practice. Because most health professionals are members of dominant cultural groups, think about how this might impact on clients who are members of a minority ethnic group. We discuss reflection on practice in more detail in Chapter 14. 2. Talk, ask, engage in dialogue with the client. This might seem obvi- ous. However, there are countless examples of encounters where Indig- enous (and other) patients are spoken about, around and on behalf of, but often not talked to or with. (See Chapter 10, ‘Intercultural interactions’.) A culturally safe approach will require true engagement with the client to understand their unique needs, beliefs, understand- ings and preferred ways of doing things. Where there is a perceived or actual barrier to discourse (or conversation), clients can remain unengaged and unempowered in response to their own health care needs. Talking, asking and engaging with the client is not always easy to achieve so this topic will be considered further in later chapters. 3. Seek to minimise the power differentials between yourself and client. Western health care has traditionally been hierarchical in nature, although this is slowly changing. Health professionals may be ­ wittingly or unwittingly in positions of power over their clients. Consider what might shift the power balance in your practice ­ setting. Language is a very important indicator of power in health care. Think about the way in which clients are sometimes referred to as ­ ‘non-compliant’, ‘absconder’ or ‘frequent flyers’. These kinds of labels position the health professional as the one in power, whereas the cli- ents are reduced to simple labels. 4. Undertake a process of decolonisation. This was a somewhat contro- versial aspect of the New Zealand model that came in for some criti- cism in the press. It is this element, however, that separates cultural safety from all other approaches, acknowledging the key role of a colonising history in contemporary health outcomes for Indigenous Peoples. The colonising experience of New Zealand differs significantly from that of Australia (see Chapter 12, ‘Indigenous health in a global context’ for details). Therefore, we will consider what a decolonising process may mean in an Australian context.
Health Care and Indigenous Australians 28 5. Ensure that you do not diminish, demean or disempower others through your actions. Sometimes it is easier to identify culturally unsafe practice than it is to identify culturally safe approaches. Both, however, require a level of self-awareness and a willingness to critique practice and systems. Actions can include subtleties of body language, how you say things and what you say, as well as more overt behav- iours. Examples are discussed throughout the book. Critical thinking What are some fundamental differences between New Zealand and Australia that might make the transferability of cultural safety more challenging? The New Zealand state nursing exam has included questions focusing on cultural safety. y y What do you think of this idea for Australia? How would it be received locally? What are the arguments for and against? Critical thinking Think about the transferability of cultural safety principles to clients who differ from health professionals in other ways—either by religion, gender, socioeconomic status, sexuality or age. Do you have any particular groups within your local area that may also require care that is regardful of certain differences? Who are these groups? How might their ‘cultural difference’ need to be incorporated into their care? For example, is there a large ageing population or LGBTQI community in your region? Do some staff have unexamined, negative attitudes towards older or LGBTQI people that might impact on their care? What is the demographic makeup of your community and what might this mean for shaping practice or preparing for practice? Scenario An elderly Indigenous man was called to a clinic to collect his new hearing aid. On arrival the receptionist said to him, in front of a waiting room of other people: ‘Now George, how many is this? You can’t keep getting them replaced you know. You bet- ter look after this one!’ What elements of culturally unsafe practice can you identify? ▼ Scenario An elderly Indigenous man was called to a clinic to collect his new hearing aid. On arrival the receptionist said to him, in front of a waiting room of other people: ‘Now George, how many is this? You can’t keep getting them replaced you know. You bet- ter look after this one!’ What elements of culturally unsafe practice can you identify? ▼
Cultural safety in practice 29 There remains no single, standardised or universally accepted model of cultural education in Australia. In the absence of a fully articulated, locally relevant and universally accepted philosophy, cultural safety has been examined for its relevance to the Australian and other health care settings. It is a concept that is increasingly recognised for its appropriateness in the Australian context. The Congress of Aboriginal and Torres Strait Islander Nurses Midwives (CATSINaM) endorsed it as an approach, as have the Leaders of Indigenous Medical Education (LIME Network), and other peak professional bodies and many academics across Australia. As already stated, culture can be defined more broadly than by ethnic- ity alone. Health professionals may differ from their clients by socioeco- nomic status, religion, age, gender, sexuality and more. Cultural safety in the Indigenous health context can be distinguished by the key compo- nent that is often lacking from other frameworks—that of decolonisation. What might the New Zealand cultural safety principles mean in a prac- tical sense in an Australian setting? Consider the following scenarios: Not all of the receptionist’s responses could have been based on ethnicity. What other cultural differences might have influenced her response? The man, an elder from his community, was furious at the treatment. What role, if any, should the receptionist have in commenting on a patient’s reason for attending? Set in the context of a life of external non-Indigenous ‘control’ over this man’s life, this one incident caused him to leave the clinic without being seen. ▼ Scenario 1 A young Indigenous mother has been asked to sign consent for a major operation for her child. She is alone in the hospital and seems unwilling to sign anything. There is no Indigenous liaison officer available and some staff are suggesting obtaining a court order if the mother won’t sign. She is, after all, putting her child at risk by delay- ing surgery. The doctors have already spoken to the mother and have now requested nursing staff to do what they can to obtain consent. The mother signs the form but then leaves her child in the hospital and returns home. Using the principles, consider: 1. Reflection on practice. How would you feel about your practice if you were involved in the above scenario? 2. Who has the power in this scenario? What pressures are brought to bear to obtain consent? Even though consent has been obtained, has it been done in a culturally safe manner? If not, why not? ▼
Health Care and Indigenous Australians 30 3. What dialogue could have been engaged in with the mother? Would you have involved anyone else—if so, who and why? 4. What aspects of this encounter might be considered as colonising in nature? How might you decolonise this scenario? 5. What may have been behind the mother’s responses? Are there possible cultural issues resulting in the mother’s reluctance? You might need to investigate local cul- tural norms for childrearing roles and responsibilities. 6. How might this have been managed differently? What evidence is there that this mother may have been demeaned, disempowered or diminished? 7. Does the context make a difference in this scenario? If so, in what ways does it make a difference? What needs to be considered? Scenario 2 Two people are sitting at the triage desk of an emergency department. One is a ­ non-Indigenous person in casual clothes and the other is a registered Aboriginal Health Worker in uniform with ID badge. Every person who approaches the triage desk, both Indigenous and non-Indigenous, direct their communications to the non- Indigenous person. What assumptions have been made in this situation? Who is deemed to be in the position of authority or ‘in charge’? Why might Indigenous Peoples also defer to the non-Indigenous person at the desk? What impact might this experience have on the Indigenous worker? How might the non-Indigenous person exacerbate or mitigate this situation? Scenario 3 A young boy in the paediatric ward was asking for a toy from the ward collection using his local Indigenous language. The large male nurse stated at high volume that he would not give the boy any toys while he was speaking ‘language’. ‘No, when you stop talking in language and ask me properly in English, then I’ll give it to you.’ What lessons did the child learn about the world in this one small exchange? What underlying message does the young boy get about his own language and identity? ▼ ▼
Cultural safety in practice 31 Looking at the above scenarios, it is important not to apply the same expec- tations to everyone in order to be equal and reasonable. For the young Indigenous mother (or any mother), depending on her individual circum- stances, she may have been reluctant to sign a consent form because of cultural considerations, or simply because of past experience or any number of other possible explanations. Dominant culture Australians expect bio- logical parents to be the ones responsible for providing consent for their children. Biological parents are therefore naturally the first ones spoken to about their children and the first ones from whom information is sought. However, not all cultures construct parental responsibility in the same way. Some cultures, such as many Indigenous cultures, hold biological parents responsible for nurturing and care, but also share the responsibility with oth- ers in their kinship systems for major decision-making. Therefore, without consideration of the potential for a different set of needs, treating this young woman the same as everyone else might not in fact be equal. It could have put her in an untenable situation from which she felt compelled to leave. That is not to say that it is the case in every situation. However, it is some- thing that needs to be examined in context. Rather than ask the mother to hold the child, a simple change in question format to ask who the mother would like to hold their child would provide choice rather than challenge. Health professionals may not know, and not need to know, what is behind the preferences and decisions of clients and communities in order to be culturally safe. They simply need to be aware of the right to be differ- ent, and to respect the right to one’s own worldview and cultural values. Cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation and an acknowledgement of whiteness and privilege. These actions are a means to challenge racism at personal and institutional levels and to establish trust in health care encounters. Activity Consider the various approaches discussed in this chapter and think about your own values and experiences. What would be your ­ personal/ professional philosophy of practice in an intercultural context and why? What did he learn about power? How might this scene be made more culturally safe for all participants? Who is in the best position to change practice? ▼
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Who knew the combination beside your uncle? Myself—he told me last month—when he had his last bad spell. Nobody else—that cousin, for instance? I don't believe Mr. Bulson knew it. Then that's what made it look black for you. The safe wasn't forced open, that's sure. Somebody opened it who knew the combination. The money might have been taken some time ago, said Gertrude. Anyway, it is gone, and you and I are supposed to be the thieves. She smiled bitterly. How strange! and we hardly know each other! And I don't see any way of clearing ourselves, said the newsboy, with equal bitterness. But let that drop. What are you going to do? Going to some friend's house? I have no friends here. You see, we came from Philadelphia, and I am not much acquainted as yet. Then you'll go to Philadelphia? If you wish, I'll carry that bag and see you to the train. No, I'm not going to Philadelphia. I would rather remain in New York, near my uncle. He may need me some day. He's a hard-hearted man! burst out the newsboy. I don't see how he could treat you so mean! It is his sickness makes him so, Nelson; he was never so before. Gertrude heaved a long sigh. I must say I really do not know what to do. I know a hotel on Third Avenue, but it's not a very nice place. No, I don't wish to go there. If I could think of some friend—— Did your uncle send you away without any money?
I took only the clothing I needed, nothing more. Then I'll give you what I've got, answered Nelson promptly, and drew out what little money he possessed. No; I won't rob you, Nelson. But you are very, very kind. It aint any robbery, he answered. Come, you must take it. And he forced it into her hand. I know an old lady who'll take you in, he continued suddenly. Her name is Mrs. Kennedy. She's only a fruit and candy woman, but she's got a heart as big as a balloon. She's a nice, neat woman, too. The matter was talked over for a few minutes, and Gertrude consented to go to the two rooms which Mrs. Kennedy called her home. These were close to Third Avenue, and late as it was, they boarded a train and rode down. The building was dark, and Nelson had some trouble in rousing the old woman. To be sure I'll take the lady in, Nelson, said Mrs. Kennedy, when the situation was partly explained. Come in, miss, and welcome. Gertrude was glad enough to enter and drop into a chair, and here our hero left her, and at once hurried down to the lunch-room with all speed. Not wishing to arouse Sam Pepper if he was asleep, he went around to the rear window, opened that, and crawled through. To his surprise Pepper was not there. I'm lucky, after all, he thought, and undressed with all speed. Hardly had he crawled into bed when Pepper came in. He lit the gas and looked at our hero, but Nelson snored and pretended to be fast asleep. Sam appeared relieved at this, and soon retired. His bag, which he had brought with him, he placed under his bed, in a corner next to the wall.
The newsboy could not sleep, and from the time he lay down until daylight appeared he turned and tossed on his cot, reviewing in a hundred ways all that had occurred. But he could reach no satisfactory conclusion. The one thing, however, which remained fixed in his mind was that Gertrude Horton was now homeless, and he felt that he must, in some measure at least, look out for her. I don't suppose I can do much, he thought dismally. But what I can do I will, that's certain. Long before Sam Pepper was stirring Nelson was up and dressed. As he was going out Pepper roused up. Where are you bound? he asked. Going to sell papers. You're starting early to-day. I've got to hustle, if I want to make any money. And so speaking, Nelson left the place. He was soon down at Newspaper Row, as it is commonly called, that part of Park Row and Nassau Street where are congregated the offices of nearly all of the metropolitan dailies. He had not a cent in his pocket, but this did not bother him. He soon found Paul Randall, who was being shoved right and left in the big crowd of boys who all wanted to get papers at once. What papers do you want, Paul? he asked. The little newsboy told him, and Nelson said he would get them for him. And I'd like to borrow a dollar, Paul, he went on. I had to give up every cent I had. That's too bad, Nelson, replied Paul. I can't loan you a dollar. All I've got extra is sixty-five cents. You can have that.
Then I'll make that do, said our hero. He took all of Paul's money and started into the crowd, to get papers for his friend and himself. He was struggling to get to the front when, on chancing to look to one side, he caught sight of Billy Darnley, the newsboy bully who had robbed him of the five dollars.
CHAPTER XII. NELSON RECOVERS SOME MONEY. Billy Darnley! gasped our hero, in astonishment. The bully saw Nelson and instantly ducked his head. He, too, was after newspapers, but now thought it best to quit the scene. I didn't t'ink he'd be here so early, he muttered, and pushed to the rear of the crowd. Once in the open, he took to his heels and dashed down Frankfort Street in the direction of the Brooklyn Bridge arches. But Nelson was not to be lost so readily, and he was out of the crowd almost as soon as the bully. I'm after Billy Darnley! he shouted to Paul. Come on! There now ensued a race which was highly exciting, even if not of long duration. Darnley was swift of foot, and the fear of what might follow lent speed to his flying feet. But Nelson was also a good runner. At the corner of Rose Street were a number of heavy trucks. Darnley managed to pass these, but it took time. When our hero came up, the trucks blocked the street completely. In and out Nelson dodged among the trucks, between the wheels and under the very hoofs of the heavy horses. In a twinkle he was clear of the mass and again making after Darnley, who was now flying toward Vandewater Street. At this point there is a large archway under the approach to the Brooklyn Bridge, and toward this archway the bully directed his footsteps. But Nelson was now close at hand, and underneath the
archway he succeeded in reaching the big newsboy, catching him firmly by the arm. Lemme go! growled Billy Darnley. Lemme go, Nelse, or I'll hammer yer good. Maybe I'll do the hammering, retorted Nelson. Where's my five dollars? I aint got no money of yours. You have, and I want you to hand it over. Aint got it, I say. Lemme go! Instead of complying our hero grasped the bully by the throat and ran him up against the stonework of the arch. I want my money, he said sternly. If you don't give it to me—— Let up—yer—yer chokin' me! gasped Billy Darnley. Will you give me the money? No. The bully struggled fiercely, and so did Nelson. Down went both on the pavement and rolled over and over. But our hero's blood was up, and he put forth every ounce of strength he possessed. At last he had Darnley flat on his back, and then he sat astride of the bully. Now will you give up? he panted. Or must I hammer you some more? Oh, Nelson! have you got him? asked Paul, running up. Yes, and he's got to give me my money. A fight! a fight! cried some of the boys who began to collect. This aint a fight, said Nelson loudly. He's a thief, and stole five dollars from me. He's got to give it up.
He caught Darnley by the throat again, and now the bully was only too glad to give in. Let—let up! he gasped. Let up! Will you give me my money? I've only got two dollars and ten cents. Hand it over. Let me up first. Not much! With something like a groan Darnley brought out the money and passed it over. Now I'm going to search you, went on Nelson, in as determined a voice as ever. No, no! pleaded Darnley in alarm. He did not like the crowd that was gathering. Yes, search him, Nelse, said a boy named Marks. That's right, search him, put in another newsboy, named Wilson. I think he stole something from me last week. In spite of his protestations Billy Darnley's pockets were turned inside out. There were brought to light another dollar, which our hero also pocketed, a pearl-handled pocket-knife, a silver badge, and half a dozen other articles. My knife! shouted Nat Marks. Boys, you all know it. So it is, Nat, said Frank Wilson. And this is my badge—the one I won in the newsboys' competition last month.
The boys took the things, and then gathered around Billy Darnley with clenched fists. Nelson slipped outside of the crowd, and Paul went with him. In vain Billy Darnley tried to clear himself of the other lads. He struck one boy down, but the others pounced upon him front and rear, and soon had him again on his back. It looked like a football scrimmage, but the ball in this case seemed to be the bully's head. For ten minutes the tussle went on, and when at last the cry of Cop! cop! run for it! arose, Darnley found himself with his nose bleeding, two teeth loose, and his left eye all but closed. Moreover, his coat was torn to shreds. What is the meaning of this? demanded the policeman. They all piled on top of me! whined Darnley, looking the picture of misery. He's a thief! exclaimed one of the other boys, but from a safe distance. He stole something from three of the boys, he did. He didn't git nuthin' but what was comin' to him, officer. That's right; he ought to be locked up, put in another boy, also from a safe distance. Begone with you! said the policeman sternly, and gave Darnley a shove. If I see any more fighting I'll run you all in, and he walked away, twirling his club as he did so. Oh, me eye! groaned Darnley, and limped away, a sadder if not a wiser youth. It was many a day before he dared to show himself in Newspaper Row again. Well, I got back three dollars and ten cents, remarked Nelson, as he and Paul walked up Frankfort Street, so I won't need your loan. But, just the same, I am much obliged. And he passed over the money.
I wish you had gotten it all, Nelson, said Paul earnestly. Oh, but didn't they just pitch into Billy! And it served him right, too. Yes, I showed him up in his true colors, returned our hero. He soon had the papers he and Paul wanted, and then the pair separated, and our hero hurried over to his old stand on Broadway. His clothing had suffered considerably from the encounter with the bully and, though he brushed himself off as best he could, he felt that he made far from a handsome appearance. I must look better than this before I call on Miss Horton, he mused. If I don't, she'll take me for a regular tramp. He wondered if there would be anything in the newspapers about the robbery in Fifth Avenue, and snatched a few moments to scan several sheets. But not a word appeared. I guess they are too high-toned to let it get into print, he reasoned. Well, it's a good thing. I guess it would almost kill Miss Gertrude to see it in the papers. When Nelson got back to the lunch-room he found business was poor, and he expected to see Sam Pepper ill-humored in consequence. On the contrary, however, Pepper was all smiles, and even hummed a tune to himself as he waited on his customers. Something has happened to tickle him, thought the boy. Or else he's got a new plan on hand. How is the sick friend—any better? he asked Pepper. Much better, Nelson. And what do you think? He's loaned me money to turn this place into a first-class café. Don't you think that will pay better than a common lunch-room? I don't know. I'd rather be in the lunch business than running a saloon.
I wouldn't. I want to make money, responded Pepper. What are you going to do? Rip out that old show window and put in a new and elegant glass front, and put in a new bar and buffet. It will be as fine as anything around here when it's finished. I wish I had a friend to loan me money. What would you do with it? I'd buy out a good news stand. There's money in that. So there is. Sam Pepper mused for a moment. Maybe my friend will advance enough for that, too. Thank you, but you needn't bother him, said Nelson coldly. And why not, if I can get the rocks? I'd rather get the money myself. Won't the money be good enough? demanded Pepper, his face darkening. I'd rather know where it came from, returned the boy. The two were in the kitchen at the time, and Sam Pepper had a frying pan in his hand. See here, Nelson, I'll whack you over the head with this, if you talk like that! exclaimed the man, flying into a rage. You won't whack me more than once, Sam Pepper. Won't I? No, you won't. Who is master around here, I'd like to know?
You are, but I'm not your slave. You talk as if you knew something, went on Pepper, growing suddenly suspicious. Perhaps I do know something, replied the newsboy, and then hurried into the dining room to wait on a customer who had just entered. I'll have it out with you later, muttered Pepper savagely. If you know too much, I'll find a way to keep your mouth closed.
CHAPTER XIII. A QUESTION OF BUSINESS. Sam Pepper got no chance to talk to Nelson further that day. As soon as the noon trade was over, our hero hurried off to sell afternoon papers. This time he went up the Bowery, to where Mrs. Kennedy kept her fruit-and-candy stand. It was a small stand, and the entire stock was not worth over ten dollars, but the old woman made enough to keep the wolf from the door, and she was content. I was after thinking you'd come, she said, smiling broadly. I knew you'd want to know about the young lady. How is she? I left her this morning, sorrowful enough, I can tell ye that, Nelson. She don't know how to turn. She thinks she might take in sewing, or something like that, but, bless ye! how much would she make at that? Why, thim Jews that work night and day hardly make enough to keep 'em from starving! Yes, I know it, and it's a shame, said the boy. They get about five cents for a pair of pants and ten cents for a coat, and some of 'em make shirts for three and four cents apiece. I don't see how they stand it. No, she wouldn't earn anything at that. I was a-telling her of Gladys Summers, who sells flowers up on Fourteenth Street and at the theater doors, but she said she didn't want to go out on the street. She's afraid some of her friends would see her, I suppose. She hasn't any friends—'cepting you and me, Mrs. Kennedy. We've got to do for her.
It's little I can offer, Nelson; ye know that well enough. She can stay under my roof, but to board her—— I'll pay her board, until she finds something to do. I'll give you three dollars a week for keeping her. Will ye now? Nelson, you're more than kind-hearted. But where will ye be after getting the money? I'll earn it, he answered resolutely. I earn a dollar and over a day now, and I know I can make it more, if I try real hard. He soon left the fruit-and-candy stand and started in to sell papers. He felt that he had a new responsibility on his shoulders, and he determined to do his best. Soon his efforts began to tell, and by five o'clock he was sold out, and the day's earnings amounted to a dollar and thirty-two cents. Half for Miss Horton and half for myself, he murmured. That's the way it's got to be, after this. He was soon on his way to the tenement house in which Mrs. Kennedy's rooms were located. Ascending two flights of stairs, he knocked on one of the doors. Who is it? came from Gertrude Horton. It's Nelson. Oh! And instantly the door was unlocked. A glance at the girl's face told the boy that she had been crying. More than this he saw she was far from well, and the hand she gave him was as hot as fire. Oh, Miss Horton, you're sick! he exclaimed. What's the matter? I have a severe headache, she answered. I think it will pass away soon.
She sank down on a dilapidated lounge, and he took a kitchen chair. He saw that she trembled from head to foot, and that she had been worrying ever since he had left her. You mustn't worry too much, he said, as kindly as he could. Mrs. Kennedy says you can stay here as long as you feel like it. But she is poor, Nelson, and I—I haven't any money, excepting what you gave me, and you must take that back—you need it. No, I don't need it, Miss Gertrude. See, I've got a lot of money now. I collared that thief and made him give up what he had left, over three dollars—and I've earned the rest selling papers. That's why I didn't come before. I've fixed it up with Mrs. Kennedy, and you can stay just as long as you please. And you are going to pay her? cried the girl warmly. Oh, Nelson! you are indeed good-hearted. But, no; I must support myself. Well, you needn't hurry about it. I can earn enough for both of us just now—and that's what I am going to do. Why shouldn't I? It was my fault that your uncle put you out. No, Nelson; the fault, if it was a fault, was my own. The matter was of long standing. Homer Bulson had wished to marry me for a long time, but I have constantly refused him. Now he has gotten my uncle to side with him. They expect to bring me to terms, I suppose. More than likely my uncle thought I would come back to-day, to do as he wishes. I wouldn't go back. I shall not. I have made up my mind fully. I will support myself, and Homer Bulson can have Uncle Mark's whole estate, if he wishes it. Surely, in such a big city as this there is something I can do. I wouldn't go at sewing—it don't pay. What does pay—that I can do?
You might get a position in a store. Or maybe you know how to play the piano? went on our hero suddenly. I do know how to play. I took instructions for several years, and have played at private concerts, in Philadelphia. Then you can give piano lessons. But where can I get pupils? We'll advertise in the papers, went on the newsboy, with some importance. I know an advertising man down on the Row. He says anybody can do business by advertising. I'll ask him about it. Of course you'll want to give lessons at folks' houses—being as you haven't a piano of your own. Yes, answered Gertrude, and her face brightened greatly. I could do that, and I would go cheaply first, to get a start. Do you want to put your name in the advertisement? No, have the letters sent to the newspaper offices, and sign the advertisement—— Gertrude paused in thought. Weber, finished Nelson. That's the name of a swell piano, isn't it? It might be too grand for the folks we wish to reach, said Gertrude. Sign it 'Earnest.' And how much will the lessons be? I ought to get at least fifty cents. Then I'll tell the advertising man that. Oh, he's a dandy to write the ads up—makes 'em look like regular bargains! added the boy enthusiastically. Nelson remained at the rooms a while longer, and then hurried to Sam Pepper's place. To his surprise Pepper had locked up, and on the window was the sign:
Closed for repairs. Will open as a first-class café in about two weeks. He hasn't lost any time in going ahead, thought our hero. I wonder where he is? Sam's out of town, called out a bootblack who had some chairs close by. Told me to give you this. And he passed over an envelope, containing a sheet of paper and the store key. On the sheet was written: Am going away for two or three days on business. A man will be here at ten o'clock to-morrow morning to measure the place for new fixtures. You stay around while he is here. Then you keep the place locked up until I get back. Gone away for two or three days, thought Nelson. I wonder what he is up to now? He went inside, and saw at once that many of the old fixtures had been removed, and that the little kitchen in the rear had been turned almost inside out. The living apartment, however, was as it had been, excepting that Sam Pepper had used it for packing purposes, and the floor was strewn with bits of paper and some excelsior. If I'm to stay here, I might as well clean up, thought our hero, and set to work with a broom. And then I'll take an hour off and clean and mend my clothes. In cleaning up Nelson came across several letters, which were old and mussed. Whether Sam Pepper had thought to throw them away or not, he did not know. To make sure, he picked the letters up and looked them over. Hullo! he cried. Here's more of a mystery.
The letters were addressed to Pepperill Sampson and were signed Mark Horton. The majority of them concerned some orders for dry goods to be shipped to various Western cities, but there was one which was not of that nature. This ran in part as follows: I have watched your doings closely for three weeks, and I am now satisfied that you are no longer working for my interest, but in the interest of rival concerns. More than that, I find that you are putting down sums to your expense account which do not belong there. The books for the past month show that you are behind over a hundred and fifty dollars. At this rate I cannot help but wonder how far behind you must be on the year and two months you have been with our house. You can consider yourself discharged from this date. Our Mr. Smith will come on immediately and take charge of your samples. Should you attempt to make any trouble for him or for us, I will immediately take steps to prosecute you. You need never apply to our house for a recommendation, for it will not be a satisfactory one. The letter was dated twelve years back, and had been sent to Pepperill Sampson while he was stopping in Cleveland. Nelson read the communication twice before he put it away. Who was Pepperill Sampson? The name sounded as if it might belong to Sam Pepper. Were the two one and the same person? They must be the same, thought Nelson. Sam was once a commercial traveler after he gave up the sea, and I've heard him speak of Cleveland and other Western towns. But to think he once worked for Mark Horton! He scratched his head reflectively. Let me see, what did Sam say about the man he wanted me to rob? That he had helped the man who had shot my father. Is there really something in this? And if there is, what can Mark Horton know about the past?
CHAPTER XIV. BULSON RECEIVES A SETBACK. The mystery was too much for Nelson, and at last he put the letters on a shelf and finished the cleaning. Then he sat down to mend his clothing, and never did a seamstress work more faithfully than did this newsboy. The garments mended, he brushed them carefully. There, they look a little better, anyway, he told himself. And sooner or later I'll have a new suit. Having finished his toilet, he walked down to Newspaper Row. The tall buildings were now a blaze of lights, and many men of business were departing for their homes. But the newsboy found his friend in his office, a little box of a place on an upper floor of the World building. The advertising man had always taken an interest in our hero, and he readily consented to transact the business gratis. The advertisements were written out to the boy's satisfaction, and Nelson paid two dollars to have them inserted in several papers the next day and that following. If the young lady is a good teacher, I might get her to give my little girl lessons, said Mr. Lamson, as Nelson was leaving. I know she's all right, sir, answered the boy. Just give her a trial and see. She's a real lady, too, even if she is down on her luck. Then let her call on my wife to-morrow morning. I'll speak to my wife about it to-night. I will, sir, and thank you very much, Mr. Lamson. And our hero went off, greatly pleased. Late as it was, he walked up to Mrs.
Kennedy's rooms again. This time the old Irishwoman herself let him in. Sure and it's Nelson, she said. I've got good news, Miss Gertrude, he said, on entering. I put the advertisements in the papers through Mr. Lamson, and he told me that you might call on his wife to-morrow morning about giving his little girl lessons. Hear that now! exclaimed Mrs. Kennedy proudly. Sure, and it takes Nelson to do things, so it does! It meself wishes I had such a b'y. I am very thankful, said the girl. Have you the address? Yes, here it is, on the back of his business card. I know you'll like the place, and maybe they can put you in the way of other places. Av course, said Mrs. Kennedy. Before I had rheumatism I wint out washing, and wan place always brought me another, from some rilative or friend of the family. I will go directly after breakfast, said Gertrude. And I hope I shall prove satisfactory. Knowing the girl must be tired, Nelson did not stay long, and as soon as he had departed Mrs. Kennedy made Gertrude retire. Happily for the girl her headache was now much better, and she slept soundly. In the morning she helped Mrs. Kennedy prepare their frugal repast. As the old Irishwoman had said, she was troubled with rheumatism, and could not get around very well. So Gertrude insisted upon clearing the table and washing the dishes. But, sure, and a lady like you aint used to this work, remonstrated Mrs. Kennedy.
I mean to get used to it, answered Gertrude. I mean to fight my way through and put up with what comes. Mr. Lamson's home was over a mile away, but not wishing to spend the carfare Gertrude walked the distance. She was expected, and found Mrs. Lamson a nice lady, who occupied a flat of half a dozen rooms on a quiet and respectable side street. She played several selections, two from sight, which the lady of the house produced. That is very good indeed, Miss Horton, said Mrs. Lamson. You read music well. Little Ruth can begin at once, and you can give her a lesson once a week. Ruth, this is Miss Horton, your new music- teacher. A girl of nine came shyly forward and shook hands. Soon Gertrude was giving her first lesson in music. It was rather long, but Ruth did not mind it. Then Mrs. Lamson paid the fifty cents, and Gertrude went away. She's awfully nice, said Ruth to her mamma. I know I shall like her. She is certainly a lady, was Mrs. Lamson's comment. It is easy to see that by her breeding. A new look shone in Gertrude's eyes as she hurried down the street. In her pocket was the first money she had ever earned in her life. She felt a spirit of independence that was as delightful as it was novel. She had already seen her advertisements in two of the papers, and she trusted they would bring her enough pupils to fill her time. She felt that she could easily give five or six lessons a day. If she could get ten or twelve pupils, that would mean five or six dollars per week, and if she could get twenty pupils it would mean ten dollars.
I wish I could get the twenty. Then I could help Nelson. He is so very kind, I would like to do something in return for him, was her thought. The weather was so pleasant she decided to take a little walk. She did not know much about the lower portion of the city, and walked westward until she reached Broadway, not far from where our hero was in the habit of selling morning papers. Gertrude was looking into the show window of a store, admiring some pretty pictures, when she felt a tap on her shoulder, and turning, found herself face to face with Homer Bulson. Gertrude! exclaimed the young man. I have been looking high and low for you! Where have you been keeping yourself? That is my business, Mr. Bulson, she answered stiffly. Why, Gertrude, you are not going to be angry at me, are you? Why shouldn't I be angry? Haven't you made enough trouble for me? I haven't made any trouble—you made that yourself, he answered, somewhat ruffled by her tone. I do not think so. Uncle Mark is very much upset over your disappearance. Does he wish me to come back? she questioned eagerly. No, I can't say that, answered Homer Bulson smoothly. But he doesn't want you to suffer. He said, if I saw you, I should give you some money. Thank you, but I can take care of myself. Have you money? I can take care of myself; that is enough.
Why don't you let me take care of you, Gertrude? Because I do not like you, Mr. Bulson. How is Uncle Mark to-day? About as usual. You must have upset him very much. Of course I don't believe you took any money out of his safe, went on Bulson. I guess the guilty party was that young rascal who called on you. Nelson is no rascal. He is an honest boy. Nelson! ejaculated the young man. Is his name Nelson? Yes. You act as if you had met him. I—er—no—but I have—have heard of him, stammered the young man. He called on you once, I believe, with somebody who sold you some books. I don't remember that. But he must be the thief. I tell you Nelson is no thief. Thank you for that, Miss Gertrude, came from behind the pair, and our hero stepped up. Mr. Bulson, you haven't any right to call me a thief, he went on, confronting the fashionable young man. Go away, boy; I want nothing to do with you, answered Bulson. Nevertheless, he looked curiously at our hero. I am no thief, but you are pretty close to being one, went on Nelson. Me! Yes, you. You tried to swindle a friend of mine out of the sale of some books you had ordered from him. I call that downright mean. Boy, don't dare to talk to me in this fashion! stormed the young man. If you do, I'll—I'll hand you over to the police.
No, you won't. You just leave me alone and I'll leave you alone, answered the newsboy. And you leave Miss Gertrude alone, too, he added warmly. Gertrude, have you taken up with this common fellow? asked Bulson. Nelson has been my friend, answered the girl. He has a heart of gold. I can't agree with you. He is but a common boy of the streets, and —— Homer Bulson went no further, for Nelson came closer and clenched his fists. Stop, or I'll make you take it back, big as you are, said the boy. Then you won't accept my protection? said Bulson, turning his back on our hero. No. If Uncle Mark wishes to write to me he can address me in care of the General Post Office, answered Gertrude. All right; then I'll bid you good-day, said Homer Bulson, and tipping his silk hat, he hurried on and was soon lost to sight on the crowded thoroughfare. I hate that man! murmured Nelson, when he had disappeared. I both hate and fear him, answered Gertrude. I am afraid he intends to cause me a great deal of trouble.
CHAPTER XV. BUYING OUT A NEWS STAND. After the above incident several weeks slipped by without anything out of the ordinary happening. In the meantime Sam Pepper's place was thoroughly remodeled and became a leading café on the East Side—a resort for many characters whose careers would not stand investigation. The man seemed wrapped up in his business, but his head was busy with schemes of far greater importance. He had said but little to Nelson, who spent a good part of his time at Mrs. Kennedy's rooms with Gertrude. Sam had found the letters and put them in a safe place without a word, and the boy had not dared to question him about them. Nor had Pepper questioned Nelson concerning what the lad knew or suspected. The results of Gertrude's advertising were not as gratifying as anticipated; still the girl obtained seven pupils, which brought her in three dollars and a half weekly. Most of the lessons had to be given on Saturdays, when her pupils were home from school, and this made it necessary that she ride from house to house, so that thirty- five cents of the money went for carfare. Never mind, said the newsboy; it's better than nothing, and you'll get more pupils, sooner or later. The boy himself worked as never before, getting up before sunrise and keeping at it with sporting extras until almost midnight. In this manner he managed to earn sometimes as high as ten dollars per week. He no longer helped Pepper around his resort, and the pair compromised on three dollars per week board money from Nelson. The rest of the money our hero either saved or offered to Gertrude.
All he spent on himself was for the suit, shoes, and hat he had had so long in his mind. I declare, you look like another person! cried the girl, when he presented himself in his new outfit, and with his hair neatly trimmed, and his face and hands thoroughly scrubbed. Nelson, I am proud of you! And she said this so heartily that he blushed furiously. Her gentle influence was beginning to have its effect, and our hero was resolved to make a man of himself in the best meaning of that term. One day Nelson was at work, when George Van Pelt came along. How goes it, George? asked the boy. Nothing to brag about, returned Van Pelt. How goes it with you? I am doing very well. Made ten dollars and fifteen cents last week. Phew! That's more than I made. How much did you make? Eight dollars. I wish we could buy out that news stand. I am sick of tramping around trying to sell books, went on George Van Pelt. Last week I was over in Jersey City, and one woman set her dog on me. I hope you didn't get bit, said Nelson with a laugh. No, but the dog kept a sample of my pants. Have you heard anything more of the stand? The owner says he's going to sell out sure by next week. He told me he would take ninety dollars cash. He's going away and don't want a mortgage now. Ninety dollars. How much have you got? I can scrape up forty dollars on a pinch.
I've got fifteen dollars. That makes fifty-five dollars. We'll want thirty-five more. How can we get that amount? I reckon we can save it up—inside of a few weeks, if we both work hard. The man won't wait. There's a party will give him seventy-five dollars cash right away. He's going to take that if he can't get ninety. At that moment Nelson caught sight of the familiar figure of a stout gentleman crossing the street toward him, and ran out to meet the party. Good-morning, sir! he said. Have some papers this morning? Hullo! you're the boy that saved me from being run over a few weeks ago, returned the stout gentleman. Yes, sir. I'll have a Sun and a Journal, and you can give me a Times, too. How is business? Good, sir. I was in a hurry that day, or I would have stopped to reward you, went on the gentleman. You did reward me, sir. Did I? I had forgotten. You see, that fire in Harlem was in a house of mine. I was terribly upset. But the matter is all straightened out now. I hope you didn't lose much. No, the loss went to the insurance companies. The stout gentleman paused. My lad, I would like to do something for you,
he went on seriously. Have you got a job for me? I don't know as I have, just now. But if you need help—— I do need help, sir. Are you a capitalist? A capitalist? queried the man, puzzled. What do you mean by that? I mean one of those gentlemen that loan money out on business? I've heard of 'em, down in Wall Street. Well, I sometimes loan money out. Then I'd like to borrow thirty-five dollars. Nelson beckoned to George Van Pelt, who had moved off a short distance. You see, it's this way, he went on, and then told about the news stand that was for sale, and what he and the book agent wished to do. Mr. Amos Barrow, for such was the gentleman's name, listened attentively. And you think this would be a good investment? he questioned. Yes, it's a good stand, said Van Pelt. But you ought to have some money with which to stock up. We'll work hard and build it up, said our hero. I know that neighborhood well. Old Maxwell never 'tended to business. I'll go around and get twice as large a paper route as he ever had. And we can keep plenty of ten-cent paper-covered books, and all that. And we can keep things for school children, too, put in George Van Pelt. There is a school near by, and many of the children pass the stand four times a day. Well, I'll give you fifty dollars, Nelson, said Mr. Barrow. That will help you to buy the stand and give you fifteen dollars working
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Health Care And Indigenous Australians Cultural Safety In Practice 3rd Kerry Taylor

  • 1.
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  • 5.
    KERRY TAYLOR &PAULINE THOMPSON GUERIN HEALTH CARE AND INDIGENOUS AUSTRALIANS Cultural safety in practice THIRD EDITION
  • 6.
    HEALTH CARE ANDINDIGENOUS AUSTRALIANS
  • 7.
    HEALTH CARE AND INDIGENOUS AUSTRALIANS CULTURALSAFETY IN PRACTICE Third edition Kerry Taylor and Pauline Thompson Guerin
  • 8.
    © Kerry Taylorand Pauline Thompson Guerin, under exclusive licence to Springer Nature Limited 2010, 2014, 2019 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First edition published 2010 Second edition published 2014 Third edition published 2019 by RED GLOBE PRESS Previous editions published under the imprint PALGRAVE Red Globe Press in the UK is an imprint of Springer Nature Limited, registered in England, company number 785998, of 4 Crinan Street, London, N1 9XW. Red Globe Press® is a registered trademark in the United States, the United Kingdom, Europe and other countries. ISBN 978–1–352–00542–4 paperback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress.
  • 9.
    v CONTENTS list of figuresvi list of tables vii About the authors viii Preface ix Acknowledgements xii Introduction xiv 1 Talking about Indigenous health 1 2 Cultural frameworks for health 10 3 Cultural safety in practice 22 4 Taking a history 33 5 Determinants of health 56 6 Indigenous health today 79 7 Indigenous health priorities 98 8 Models of health 126 9 Capacity and resilience 149 10 Intercultural interactions 163 11 Health services and workforce issues 182 12 Indigenous health in a global context 197 13 Cultural safety: controversy and concerns 216 14 Reflection and practice 234 References 250 Index 265
  • 10.
    vi LIST OF FIGURES 2.1Queensland Health Organisational Cultural Competency Framework 15 3.1 Original stages towards cultural safety—as defined by Ramsden (2002)22 3.2 An aspirational model of cultural safety—as developed and defined by Taylor Guerin (2018) 23 4.1 Indigenous and non-Indigenous occupation of the land now called Australia35 5.1 Impact of educational disadvantage 61 5.2 A visual of the differences between equality, equity, reality and liberation 72 6.1 Proportion of Indigenous populations by remoteness categories 83 6.2 Indigenous and non-Indigenous population residence 83 6.3 Age and sex structure of Australia’s population by Indigenous status 88 7.1 Age specific death rates for intentional self-harm, by Indigenous status, 2012–2016 109 7.2 Child abuse substantiations (%) in 2016–2017 by type of abuse and state and territories for children aged 0–17 for (a) Indigenous children and (b) non-Indigenous children 113 11.1 Australian Government-funded organisations providing primary health care (PHC) services to Aboriginal and Torres Strait Islander people, by remoteness area, 2016–2017 188
  • 11.
    vii LIST OF TABLES 2.1Cultural frameworks, strengths and limitations 19 4.1 Brief summary of policy changes impacting Indigenous Australians 44 6.1 Indigenous and non-Indigenous population by state (ABS resident population)80 6.2 Proportion of population in selected age groups and Indigenous status 88 7.1 Children aged 0–16 years who were the subjects of substantiations: Number and rates per 1,000 children, by Indigenous status and state and territory, 2007–2008 110 7.2 Children aged 0–16 years who were the subjects of substantiations: Number and rates per 1000 children, by Indigenous status and state and territory, 2011–2012 111 7.3 Children aged 0–17 years who were the subjects of substantiations: Number and rates per 1000 children, by Indigenous status and state and territory, 2016–2017 112 10.1 Elements in communication 170 12.1 Comparison of Indigenous populations and treaty status in four countries202 14.1 Layers of reflection 235
  • 12.
    viii About the authors DrKerry Taylor was Deputy Director and Associate Professor with the Poche Centre for Indigenous Health and Well-being, Flinders University, based in Alice Springs from 2013 to 2018. She has worked in Central Australia since 1988 in a range of roles and organisations, including in remote communities, as an adult educator, health educator and project officer for piloting Aboriginal Health Worker positions in a tertiary set- ting. She coordinated a program for student nurses to undertake remote and Indigenous health clinical experiences, which saw significant num- bers of graduates pursue these fields of practice. Kerry’s PhD thesis was on intercultural communication in Indigenous health care settings. Other research and teaching interests include cultural safety, health literacy and intercultural health care practice, disability and HTLV-1 research. She has been awarded individual and team Vice Chancellor’s Excellence in Teach- ing Awards. Kerry co-delivered the Aboriginal Cultural Awareness Program for NT Health workforces in Central Australia and remains affiliated with Flinders as an Associate Professor with the Poche Centre – College of Medicine and Public Health. Dr Pauline Thompson Guerin is affiliated with Flinders University of South Australia in the College of Nursing and Health Sciences and is an Associate Professor based at the Pennsylvania State University, Brandy- wine Campus, close to Philadelphia in the USA. Pauline has worked in the North Flinders Ranges in Nepabunna and in the Anangu ­ Pitjantjatjara Yankunytjatjara (APY) lands, particularly in Pukatja. She was a senior researcher for the Desert Knowledge Cooperative Research Centre (CRC) and was the manager of the Poche Centre for Indigenous Health in Adelaide. Her research interests include mental health and well-being; ­ residential mobility; teaching of cultural issues; and racism in health care.
  • 13.
    ix Preface I was lookingback over photographs taken when I first moved to the remote Aborigi- nal community of Ntaria (Hermannsburg) in 1988. I had a lot of photos of children and adults—all of them smiling and seemingly happy. When I first went to Ntaria, fresh from Sydney, it shocked me somewhat to learn that Tuesday was ‘Funeral Day’. ‘What do you mean, Funeral Day?’ I asked. ‘Funeral day—we usually have ­ funerals on Tuesday’, came the reply. It was said so matter-of-factly that it didn’t register with those around me that most people might not generally expect a funeral every week. But that was exactly what this community of several hundred went through just about every week during my relatively short stay there—a funeral nearly every Tuesday. (Taylor, 1999) The preface to our first edition sought to draw the link between the statis- tical picture of Indigenous health and what it meant on a personal level. Since 1988 too many of the people in those photos referred to above have either passed away or live with chronic illness or have had their lives impacted by loss, violence or economic hardship. We’d like to say much has changed since the first edition. However, while statistics point to improvement in some areas, Indigenous health remains Australia’s great- est health, medical and social challenge.1 ‘Insanity is to do the same thing over and over and expect different results’ (attributed often to Albert Einstein). This quote plays on my 1 In reviewing the materials for this edition, it became apparent that statistical informa- tion about the health and social contexts of Indigenous Australians is fraught with ­ difficulty as even current reports, including those from the Australian Bureau of Statis- tics, continue to source some data gathered prior to 2010. We acknowledge, however, the importance of statistical evidence to argue for more and improved conditions and to assist in knowing where to target resources to effectively address inequities. Although com- monly cited statistical information is again presented, we strongly encourage readers to check for the most current information available and check its sources. Why the same figures continue to be cited, and why it is difficult to gain an accurate picture of health and well-being today, is itself worthy of scrutiny. What we would like to stress is that whether a health issue is three, five or ten times more likely to affect a certain population compared to another, the reality is that every statistic cited is an individual. Cultural safety requires us to ensure that these figures alone do not become the drivers for health service delivery, but that care is delivered that is cognisant of the person each number represents.
  • 14.
    Preface x mind as Ireflect on the last now 30 years working in Indigenous health. Today I find myself working alongside Aboriginal colleagues who are now attending multiple funerals within a week. I feel more certain than ever that it is hardly time to congratulate ourselves for having stemmed the tide of Indigenous mortality and morbidity. I don’t believe we have seen the worst of this national crisis, and we may not in my lifetime. But that lifetime is still potentially 20 years longer than that of my Aborigi- nal colleagues. I am not trying to be bleak or express a hopelessness that nothing can change. In fact, the privilege of being able to do a second and third edition of this book offers a personal and professional oppor- tunity to do things differently—to not keep repeating mistakes of the past and expecting different results. As co-authors, Pauline and I believe small changes to practice can make big differences and that the greatest potential for change lies with the development of culturally safe health workforces. To date, much of the emphases in both health care and policy set- tings has expected Indigenous Peoples to change themselves in order to change the outcomes. Less attention has been given to the changes that dominant culture groups could and should make to provide more effec- tive care. Indigenous health in Australia is the result of a multiplicity of circumstances, histories, attitudes and beliefs and can only be considered within a multiplicity of contexts. As non-Indigenous authors of this book we do not present Indigenous knowledge or speak on behalf of Indigenous Peoples, other than where we have individually been asked to share certain information to help educate others. It has been suggested that non-Indigenous people have no place even writing a book on Indigenous Health. To those people, we respectfully disagree. Indigenous people alone will not improve indig- enous health; it is a shared responsibility and, as part of the dominant cultural groups, this book is our contribution to turning the lens on our- selves through reflection on practice. To guide this reflection, we have used the principles of cultural safety, as defined by the New Zealand Nursing Council and embraced by the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM). Culture in this context is not exclusively about ethnic- ity, but is more broadly defined. As a philosophy, cultural safety asks practitioners to consider issues of power, systemic racism, history and ­ colonisation. The majority of the workforces involved in Indigenous health in Australia are from non-Indigenous backgrounds. This book is our contribution to the reflection on practice that is inherent in cultur- ally safe health care. Where possible, we have sought contributions from Indigenous colleagues and community members and explicitly acknowl- edged their input. The overall text, the case studies and issues raised have
  • 15.
    Preface xi also beeninformed by several decades of combined experience working with Indigenous Peoples in a variety of settings, including metropolitan and remote education and health in both Australia and New Zealand. Our hope is that this book will contribute to a better understanding of the application of cultural safety in practice that will ultimately lead to better outcomes for Indigenous health in Australia.
  • 16.
    xii Acknowledgements This text hasarisen from the authors’ shared teaching experiences in introducing Indigenous health issues to nursing, midwifery and medical students from Flinders University. It was originally adapted from the ‘Guide to Learning’, to which several academics within the School of Nursing Midwifery (now the College of Nursing and Health Sciences) initially contributed, but also informed by relationships with various Indigenous colleagues and friends and other professional experiences. Personal acknowledgements from Kerry Taylor As the primary author of the topic materials for NURS2723/24, Indig- enous Health Issues for Nurses and Midwives, at Flinders University, I would like to acknowledge the input of previous teaching team mem- bers and topic coordinators, who contributed various early content and refinements to the materials that prompted this work. The acknowledge- ments made of individuals in the first and second editions stand and are expanded on by subsequent experiences and learning. To Pauline Thompson Guerin, who’d have thought we would be here again? Thank you for continuing to encourage, support and motivate me to keep going. I’d like to also acknowledge the support of the Poche Centre for Indigenous Health Wellbeing and Flinders University for the ­ opportunity to continue working for better outcomes for Indigenous Australians and ­ better practice for health workforces. In particular, I want to thank my ­ current Poche Centre colleagues Colleen Hayes and Lorna Murakami-Gold for their generosity in sharing information, collaborating in our teaching and research efforts, and supporting my own efforts towards culturally safe practice. Personal acknowledgements from Pauline Thompson Guerin My deepest gratitude goes to the Indigenous and non-Indigenous friends and colleagues who shared their thoughts, feelings and experiences on the topic of Indigenous health, all of whom helped to shape this book.
  • 17.
    Acknowledgements xiii Thanks tothe hundreds of students in Indigenous health at Flinders Uni- versity who helped me to understand Indigenous health better, and to colleagues in the Desert Knowledge Cooperative Research Centre (CRC): Core Project 4 for discussions around remote Indigenous issues more generally. My dear friend, colleague and co-author, Kerry Taylor: as both of our lives have shifted and changed since we first met to teach Indigenous Health, we have grown in our compassion for ourselves and others. I trust that comes through in this edition. Thank you. And my most heartfelt thanks go to my children for being so patient and understanding while I spent nights and weekends writing and for embracing my work, wherever in the world it has taken us. Thank you for always challenging me to be better, and for making my world what it is. During the writing of the first edition of this book, I acknowledge sup- port from grants from the Australian Research Council (ARC DP0877901) and the Australian Institute of Aboriginal and Torres Strait Islander ­ Studies (AIATSIS G07/7290). Joint acknowledgements from the authors We would like to thank the team at Red Globe Press, now working with the London-based team led by Peter Hooper. We would especially like to acknowledge the reviewers of the second edition for their comprehensive feedback and suggestions for developing the third edition. We have grate- fully taken on board many of the suggestions for this third edition. Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
  • 18.
    xiv INTRODUCTION Aboriginal and TorresStrait Islander health—why do we need this text? Aboriginal and Torres Strait Islander peoples account for only a relatively small proportion of the Australian population—approximately 2.8% nationally at the last census count (ABS, 2016a). For anyone involved in the health professions it might be reasonable then to ask, ‘why focus entire texts on such a small percentage of people?’ Although relatively small in percentage, this includes over half a million people; and it is the poor health outcomes of this population and their over-representation in the health care system that justifies—indeed demands—a greater focus for health professionals in training. But this anomaly alone should not be the only reason health professionals take an interest in this topic. There are other more significant reasons for turning our attention to Indigenous health issues in Australia—reasons we articulate in this book. For example, how Australia treats and regards Indigenous Peoples reflects the kind of society we are. As long as the health of Indigenous Australians remains so far below that of other Australians, we are dimin- ished as a nation. Health professionals, and those aspiring to be health professionals, have a rare and privileged opportunity to contribute to the promise of better outcomes for all Australians. This book is intended as a suggestive template for introducing the con- cept of cultural safety into Indigenous health issues. When learning about Indigenous health it is extremely important that the materials used are not only culturally appropriate, but also that they are locally appropriate. This requires you, the reader, to check the suitability of the materials in this book at the local level and adapt them accordingly. This text provides discussion points and activities for structuring teaching across a range of settings. The common purpose of the issues and case studies presented is to enhance the understanding and cultural safety of health professionals in relation to Indigenous populations. Throughout this book, you will be given the opportunity to explore personal and professional conceptualisations of health. You will be asked to compare, contrast and reflect on those ideas in relation to the ways
  • 19.
    INTRODUCTION xv that differentcontexts—political, cultural, historical, environmental and socioeconomic—have affected health outcomes for Indigenous Australians. About this book Through case studies, discussions, reflections and critiques of health issues in Australia today, this book offers a starting point—for students at an undergraduate level or for health professionals who require an introduc- tion to the area—for learning about cultural safety as applied to Indigenous health issues. The material covered in this book has evolved from combined decades of both research and teaching Indigenous health. The authors have also worked closely with Indigenous health workers, academics and com- munities. The book takes the approach endorsed by the Australian Nursing Midwifery Accreditation Council (ANMAC) and the Australian College of Nursing (ACN) to provide stand-alone subjects on Indigenous health in nursing curricula. Other health disciplines may take differing approaches to educating students about Indigenous health but this book is written in a way such that students and professionals from a range of health and other disciplines should find it useful and beneficial to their practice. While this book is intended as an introduction, the issues and ideas can and should be adapted to suit local settings. We strongly advise if you are using this book for education purposes, that local Indigenous Peoples are consulted about the appropriateness of the content in your area. Local adaptation of the discussions and information is expected and required. What is new in this third edition? ➢ ➢ Updated references and resources. Because information on the inter- net is always changing, we have often provided key search terms and topics in addition to specific web pages. Where web pages are current at the time of printing, they have been included, but, in addition to specific hyperlinks, we have recommended to search, for example, the current CATSINaM web site or ABS statistics. ➢ ➢ Expanded content including a greater focus on urban health and pre- ventable health care. ➢ ➢ An additional chapter on controversies and concerns about cultural safety and what these responses might mean in terms of our relation- ships within the nation. ➢ ➢ More scenarios and critical thinking activities reflecting the diversity of Indigenous health nationally.
  • 20.
    INTRODUCTION xvi Chapter outlines Chapter 1Talking about Indigenous health provides a rationale for focusing on Indigenous health issues. We provide key definitions and terminol- ogy in context. Chapter 2 Frameworks for service delivery outlines a variety of approaches to understanding and addressing cultural issues in health care and the differing frameworks employed nationally. These include ­ cultural awareness, cultural sensitivity, cultural competence, cultural security, cultural respect, and also look at new frameworks to have emerged such as cultural capability and cultural humility, which illus- trate the adaption of cultural frameworks across Australia. Chapter 3 Cultural safety principles and practice discusses the main focus for this text, cultural safety. It presents an outline of, and an argu- ment for, the preferred use of ‘cultural safety’ as the underpinning phi- losophy and guiding principles for practice. Chapter 4 Taking a history looks at the crucial step in any good health professional’s encounter with a client—that of obtaining an adequate history. A client history in the Indigenous health care setting should include an understanding of the historical relationships, policies and events implicated in the health care status of people today. Chapter 5 Determinants of health explores the roles of matters sometimes seen as outside of the concern of health professionals. Education, poverty, incarceration, employment, housing, as well as racism, dis- crimination, ‘whiteness’ and cultural background, are all determinants of health. It requires readers to reflect on their own culture and its potential impact on others; to identify examples of systemic bias, insti- tutional and individual racism and discrimination; and to analyse and discuss determinants of health. Chapter 6 Indigenous health today examines the statistical picture, explor- ing some of the myths and stereotyped ideas that interfere with culturally safe health care. It also attempts to counter some of the mis- conceptions with an overview of the demographic and health profile of Indigenous Australians, including issues of identity and the impact on health. Chapter 7 Indigenous health priorities gives an overview of areas of special interest in Indigenous health in Australia. These include maternal and child health, chronic disease, mental health issues, disability and child protection.
  • 21.
    INTRODUCTION xvii Chapter 8Models of health provides a comparison of Indigenous and non- Indigenous approaches to health. The majority of health professionals in Australia subscribe to a non-Indigenous biomedical model. This sec- tion considers the various models and definitions of health and how they fit within the context of Indigenous client care. Readers are asked to articulate a personal definition of health, compare and contrast various models of health, and critically analyse the implications of competing or complementary models of health for practice. Scenarios are presented as a basis for discussion or analysis. Chapter 9 Capacity and resilience explores the capacity and resilience of Indigenous Peoples in contrast to the tendency of governments and others to take a deficits approach that has been evident throughout Australia’s history. This chapter calls for a reorientation away from problematising Indigenous Peoples to a focus on strengths, capacity and resilience in keeping with the philosophies of both cultural safety and primary health care. It explores the potential for success in health care outcomes that can be achieved from a simple change in view, while also maintaining the stance that improvement in Indigenous Peoples’ health is everyone’s responsibility. Chapter 10 Intercultural interactions presents a range of case studies related to health communications. Conflicting worldviews and miscom- munication are major challenges when health professionals differ in cultural and linguistic background from the clients in their care. This chapter provides an opportunity to examine intercultural interactions in various practice settings, as well as what it means to ‘de-colonise’ health care practice. Chapter 11 Health services and workforce issues explores current workforce issues, including the concept of Aboriginal-controlled health services and the associated benefits, challenges and complexities. We also explore the possibilities of creating a workforce of Indigenous health workers and liaison officers, along with other approaches to diversify- ing health care so that it is more appropriate and responsive to the needs of Indigenous clients. Chapter 12 Indigenous health in a global context compares and discusses Indigenous health from a global perspective. Australia continues to fall behind on all standard indicators of health for its Indigenous popula- tions. This chapter looks briefly at the experiences of colonisation on Indigenous health in other developed nations such as Canada, New Zealand and the USA. We compare the health status of Indigenous Peoples in a global context to illustrate the international relevance of the health of Indigenous Australians.
  • 22.
    INTRODUCTION xviii Chapter 13 Culturalsafety controversy and concerns looks at historical and recent responses to the teaching of cultural safety to our health work- forces and asks readers to examine what resistances might underlie such concerns. Chapter 14 Reflection on practice contemplates reflection as a key compo- nent of culturally safe practice. This section provides an opportunity for reflection on previously held assumptions, beliefs and attitudes. It examines the relevance of learning that is regardful of the practice setting, and offers an overall opportunity for reflection on the issues covered in this book. Frequently asked questions Relevance to practice ‘I don’t intend to work in Aboriginal or Torres Strait Islander health, so why do I need to learn about this?’ As you will learn throughout this book, no matter what your specific work area (specialty or location), your work is going to impact on Indigenous health, directly or indirectly. The majority of Indigenous Australians live in urban areas and have increased need for health ser- vices. Indigenous Australians, irrespective of where they live, can still be affected by a ‘culture’ of health services and staff that is not neces- sarily ‘Indigenous friendly’. ‘But Australia is a multicultural society: Why are we not learning about all the cultures in Australia?’ Focusing on this specific population does not imply that we do not recognise other groups and individuals worthy of similar analysis. Although the focus for this publication is on Indigenous health issues, with justification hopefully made explicit by the end of this text, the principles and knowledge that you acquire should be readily transfer- able to a range of cultural contexts—with ‘culture’ taken to include differences in gender, religion, age, sexual orientation, ethnicity, ­ disability and socioeconomic status (Ramsden, 2002). ‘Will this book tell me about particular diseases affecting Indigenous Peoples and how to treat those diseases and people?’ The short answer is ‘no’. This is not a disease-focused, biomedical text, although we do address some of these issues in Chapter 6. For a more detailed biomedical analysis, Aboriginal Primary Health Care: An Evidence-Based Approach (Couzos and Murray, 2008) provides extensive
  • 23.
    INTRODUCTION xix and in-depthinformation about a range of health conditions affect- ing Indigenous Australians. We highly recommend it if you ever need to seek detailed information about specific conditions. Our book, however, takes a different approach to Indigenous health. The cul- tural safety model provides a firm foundation and takes a contextual approach to understanding Indigenous health. It focuses on what health professionals themselves can do to improve health outcomes. ‘Will this book tell me, step-by-step, how to care for or treat Indig- enous clients?’ Again, the short answer to this question is ‘no’. This book does not present a ‘recipe’ to caring for Indigenous Peoples. There is no step-by- step guide or checklist that can fulfil this purpose—nor should there be. This book requires the reader to examine their role in Indigenous health care from a contextual understanding of the social, political, historical, environmental and cultural perspectives. It is based on a belief that, prior to providing care across any of the health disciplines, a consideration of the contextual underpinnings of the client/patient/ community is essential for safe and effective practice. It is part of the preparation to enter the practice setting and engage with Indigenous Peoples, regardless of one’s level of experience.
  • 24.
    1 1 Talking about Indigenoushealth With Indigenous Australians comprising less than 3% of the population there may be justifiable questions asked about exclusively focusing on Indigenous health. However, the health disparity experienced by less than 3% of Australians is unacceptable and poses one of the greatest challenges to health professionals in this country. Indeed, Tom Calma, the Aboriginal and Torres Strait Islander Social Justice Commissioner, has said: ‘It is not credible to suggest that one of the wealthiest nations of the world cannot solve a health crisis affecting less than 3% of its citizens’ (HREOC, 2005). Consider that if we, as a nation, could figure out how to improve Indigenous health in Australia, what might be the implications for health and Australian society as a whole? If we were to improve the health of, on the one hand, arguably Australia’s most valuable cultural resource and, concurrently, Australia’s most vulner- able and marginalised population, the skills, knowledge and experiences that would be developed to achieve this aim would benefit everyone. At an individual level, if we learned how to deliver health services so that outcomes mattered, this would improve health for everyone. Organisa- tionally, if we learned how to structure our systems so that no one was left behind, that everyone benefited, we would have an organisational structure coveted by all. And if our policies were such that they mat- tered, in real ways, and that they did not present barriers but facilitated culturally safe care, again, everyone would benefit. Apart from all the mutual benefit, health is a universal human right and while ever there is disparity within our nation we are diminished. We can and must do bet- ter. This chapter will explore the cultural relations between Indigenous and non-Indigenous people in the context of health and Australian soci- ety. In order to do so, it is necessary to first provide key definitions and terminologies.
  • 25.
    Health Care andIndigenous Australians 2 Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Explain the reasoning for focusing on Indigenous health ➢ ➢ Define relevant terminology and rationales for their use ➢ ➢ Examine the relevance of Indigenous health issues to your own practice ➢ ➢ Apply transferrable cultural safety principles to other practice settings. Indigenous or Aboriginal and Torres Strait Islander health? Indigenous Australians are known to suffer the poorest health of any group within Australia. We have titled this text using the term Indig- enous, yet this is not always a widely accepted term by those who prefer to use Aboriginal and/or Torres Strait Islander People. Consensus is hard to find and rightly so, as we need to be mindful of the imposition of these labels through our history. As this text references diverse communities, individuals and circumstances, we have chosen to use the term Indig- enous with a strong encouragement that readers should check locally to find out the accepted terminology. So do health practitioners need a whole text or compulsory study on Indigenous health? Surely, caring for an Indigenous person should be the same as for any other person. Australia is a multicultural society. Why then focus on this particular group, who are also multicultural? One answer relates to the demographic makeup of health profession- als in Australia. Although Indigenous Australians have a greater need, this does not always translate to a greater uptake of or access to health services. We would expect that based on need, Indigenous Australians would access health services at about two or three times the rate of non- Indigenous Australians (AIHW, 2008). Given this higher consumer ratio, it would be reasonable to expect a comparable representation of Indig- enous health professionals. However, in 2011 Indigenous Australians only made up 1.6% of the health workforce (AHMAC, 2011), but comprised 2.8% of the population, with far greater health care needs than the non-Indigenous population. This imbalance requires a useful response. With the exception of Indige- nous Health Workers or Practitioners (IHWs or IHPs) and Indigenous liaison officers (ILOs), Indigenous nurses, doctors and allied health profession- als are few in Australia. Although there was a doubling to more than 200
  • 26.
    Talking about Indigenoushealth 3 Indigenous medical practitioners in Australia since the last edition, this still only comprises less than 0.5% of all the medical practitioners in Australia (AHMAC, 2011). While it is hoped that some readers using this text will identify as Aboriginal or Torres Strait Islanders, the reality is that the major- ity will have a non-Indigenous background and, more frequently today, come from overseas (see Chapter 11 for workforce issues). The question has also been asked whether it is possible for ­ non-Indigenous health professionals to provide care that is acceptable and accessible to people who suffer the worst health of any population in this country. It has to be possible, as Tom Calma’s quote at the begin- ning of this chapter suggests. If any impact is to be made in addressing the unacceptable state of Indigenous health in Australia today, then the majority workforce must accept this national responsibility and act on it. Indigenous health professionals have been identified as critical to addressing Indigenous concerns. However, it would be unfair to place this burden on any one group of people when the root causes of current health concerns are multifaceted and complex, as evidenced by successive govern- ments’ failures to adequately improve outcomes for Indigenous Australians. How we talk about this topic: Terminology and definitions Simply starting a conversation about this topic may already seem fraught with difficulty. Some students have suggested that the potential to offend is overwhelming and that there is too much ‘political correctness’. They therefore opt to avoid discussions of Indigenous health altogether. So why do we emphasise correct terminology so much when talking about Indigenous health? Is it ‘political correctness’ and what does that actually mean? Often when something is deemed an example of ‘political cor- rectness’ it is more likely to be a resistance to acknowledging that some language, attitudes and behaviours marginalise and demean others. Before proceeding further into this book, readers may have noticed the different terminology already present when referring to Indigenous Aus- tralians. ‘Aboriginal and Torres Strait Islander’ is currently a commonly accepted, but not unanimously accepted, way of referring to populations in Australia. ‘Indigenous’ is also commonly accepted but, again, not unanimously accepted, terminology. However, we have used the term ‘Indigenous’ throughout the text for readability and brevity with no dis- respect intended. Where we refer to specific populations we have tried to ensure that the accepted identifiers have been used. Another terminology used in writing is to abbreviate Aboriginal and Torres Strait Islander to the acronym ‘ATSI’. This is often the case in medical writings and may partly result from publishing requirements to
  • 27.
    Health Care andIndigenous Australians 4 shorten any phrases frequently used so as to reduce costs. However, our experience and advice from Indigenous colleagues is that this abbre- viation is offensive to some people and should be avoided. Consider the impact of reducing to an acronym something that perhaps is the most important description of your identity. Terminology and definitions will be discussed further in this chapter. (See also Laurie May’s poem in Chap- ter 5, on the impact of such labels.) Before the colonisation of Australia, the terminologies ‘Aboriginal’ and ‘Torres Strait Islander’ did not exist as a form of self-identification for the country’s First Peoples. The colonising groups imposed these identifiers. Even today, people generally identify by their language or nation group. For example, some people from the Arnhem Land region identify as ‘Yolgnu’, others in the Adelaide region as ‘Kaurna’, and yet other peoples from the Alice Springs region as ‘Arrernte’ or ‘Aranda’. It is important to be aware that there may be multiple spellings for different language groupings, nations and community names. Throughout this text, when referring to particular language or nation groups, we have relied on spellings developed by lin- guists, unless specifically requested by local people to use specific forms. Think about what it would be like for you as an individual to be referred to by an imposed label. There will be more detailed discussion of this in later chapters. However, using Indigenous names is not always pre- cise and straightforward because of variations in spelling and preferences. This is why we will repeatedly remind readers to find out what is preferred locally from credible sources—ask people for the accepted terminology for any given region or person—and it is important to not make assumptions. As the authors of this text, we would like to state from the outset that the terminology used throughout cannot be done without acknowledge- ment of our colonising histories. Indigenous Peoples and cultures are inherently diverse and anything but static. Therefore we need to set some parameters for the use of terminology from this point. The first step: Defining the terms ‘Indigenous’, ‘Aboriginal’ and ‘Torres Strait Islander’ Indigenous Peoples have been defined and described by successive governments and non-Indigenous people since first encountering one another, often with negative consequences. In fact, ‘The legal historian, John McCorquodale, has reported that since the time of white settle- ment, governments have used no less than 67 classifications, descriptions or definitions to determine who is an Aboriginal person’ (ALRC, 2003a). This creates considerable difficulty in knowing how to appropriately discuss some issues. The term ‘Indigenous’, in an Australian context,
  • 28.
    Talking about Indigenoushealth 5 encompasses both Aboriginal and Torres Strait Islander peoples. However, some even challenge this usage. For example, Aboriginal and Torres Strait Islander Peoples (with an ‘s’) differ from one another, in that Aboriginal people are the Indigenous Peoples of the mainland of Australia while Tor- res Strait Islander Peoples are originally, as the name suggests, from the Torres Strait Islands north of Cape York Peninsula. To lump these two groups together as ‘Indigenous’ can be offensive to some people because it does not acknowledge differences. Using the ­ plural of ‘people’ and writing or saying ‘peoples’ is one way of acknowledging the inherent diversity in these groups. Indigenous Peoples are not as homoge- neous as the term might imply. Consider the label ‘European’ for example. European people speak a variety of languages, live within generally clearly defined borders across a variety of geographical zones and have distinct customs, cultures and beliefs. There are also often certain physical commonalities that allow people to identify with different ethnic groups (hair or eye colour, facial characteristics, skin tone), and yet we know these variations are not the keys to an individual’s identity. Non-Indigenous Aus- tralians are at times referred to as ‘European’, and yet may never have been to Europe and have no actual links with Europe or people there. In fact, for many ‘European Australians’, their connection to Europe may stem back generations and have little relevance today. Using this as an example, you might see how terminology can be problematic. Using the term ‘Aborigi- nal’ can wrongly suggest that everyone who identifies as ‘Aboriginal’ is the same. But, as with ‘Europeans’, there is considerable diversity in language, customs, beliefs, locations and histories. There is, however, a common thread that allows the term to suit a particular purpose. ‘Aboriginal’ denotes a link with the original people, literally meaning ‘of the original’. ‘indigenous’, spelt with a lower case ‘i’, means ‘belonging to’ or ‘being first’. Although there are many countries around the world with their own indigenous peoples, ‘Aboriginal’ (using the upper case) is commonly used to denote the Indigenous Peoples of Australia. When reviewing literature, students might also find that ‘Aboriginal’ is com- monly used throughout Canada, along with terms such as First People or First Nations Peoples. In Australia, the phrase ‘First Nations’ or First Aus- tralians is also in use (Dodson, 2007). Throughout northern hemisphere countries, Indigenous Peoples may be referred to as ‘Natives’. In Australia, however, the use of the term ‘Native’ can have negative connotations in some regions and is rarely used, other than in legal issues such as in ‘Native Title’. The term ‘native’ can also be suggestive of categorising people in the same way as plants and animals. In this book we have ensured the capitalisation of ‘Aboriginal’ and ‘Indigenous’ when referring specifically to the Aboriginal and Indigenous Peoples of Australia. This is not just a matter of being pedantic or politically
  • 29.
    Health Care andIndigenous Australians 6 correct but rather it is a matter of showing the same respect you would expect for yourself. As with the other terminology we discussed, it is impor- tant to understand that, at least for some people, it can be highly offensive, and even considered racist, when these terms are not capitalised. As pro- fessionals, it is our responsibility to be aware of these possibilities and to do our best to not ‘diminish, disempower or demean’ someone’s cultural identity, which includes the terminology we use to describe people. As may be already apparent, there is a diversity of terminology and respectful ways of talking with and about Indigenous Peoples. Many organisations have style guides regarding terminology. Please make sure you seek out and respect local expectations. One helpful example is found in the ACT Council of Social Service (2016) Good Gulanga Practice Guide, relevant to their specific areas of operation. Critical thinking What is your response to the issue of terminology? Do you think it really matters or is this merely political correctness? Why do you think some requests for change are labelled as political correctness? Think of an example where you have been referred to by a label imposed by someone else. How did you feel about it? What cultural groups are in your region? How do they identify themselves? We will further discuss terminology in Chapter 3 on the identity and defi- nitions of Indigenous and Aboriginality. For now, however, it is essential that every effort be made to find out and use the locally and culturally appropriate terminology in your discussions. Informal terminology Indigenous Peoples and non-Indigenous people frequently use informal terms to refer to themselves and others in daily life. Usage of these terms can vary regionally, and what is affectionate or acceptable in some areas could be regarded as highly offensive in others. For example, consider the following scenario: In an undergraduate class in Adelaide, a Northern Territory student was telling a story about people she knew in her local town and began by saying that her ‘boyfriend was a half-caste from …’. Many in the group immediately reacted
  • 30.
    Talking about Indigenoushealth 7 to the description as offensive and forcefully told the student things like, ‘You can’t say that, … that’s racist!’ The young woman was genuinely stunned by the response and looked to the lecturer to explain what she had done to provoke such a reaction. Critical thinking In the absence of other information, how would you respond, if at all, to such a com- ment by another student? Do you think this was an example of racism or something else? Give some explanation for your view. Why might the young woman’s boyfriend use a colonial term to describe himself? Can you think of other examples where the target of a derogatory name has used it in relation to themselves and why? In this scenario, the lecturer acknowledged that it was still common usage to hear terms such as ‘half-caste’ in some regions, by both Indigenous and non-Indigenous people. It was explained that the course would be looking at the impact of policy, scientific racism and the impact of colonisation and that this might provide a context for how these terms arose. The fact that some people use such terms themselves is indicative of the colonisa- tion process, which disempowers some and privileges others. Those who are privileged could be unaware of how (or be unwilling to explore how) they have come to be in their positions. The lecturer then asked the group how many of them had been given a government-applied classification based on their percentage of blood from one ethnic group or another. She also asked them to consider what this might mean to them if such clas- sification could be used to deny them certain rights and privileges. Activity For this activity, you will need to form a small group, perhaps with others studying this book or maybe with your family or other people you live with. Each member of the group should identify to their group how they identify themselves and why. Before you get started, your group should establish some rules. They might include, for example, respecting others and their choice not to identify personal information about themselves. Individual anonymity should be maintained both inside and outside the group. ▼
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    Health Care andIndigenous Australians 8 Consider the following case scenario. How did people identify themselves? Reflect on the reasons people gave as to why their identity was important. Some of the common self-applied labels included marital status, mother, single mother, single father, religion, interests, employment background and ethnic heritage. Did anyone identify themselves by their cultural or ethnic background? For example, if someone identified themselves as ‘half Scottish’, ‘half Australian’ or ‘Lebanese Australian’, ask how they might feel if the government used that classification to restrict their travel, places of residence, rights and so on. Consider how a term such as ‘half-caste’ can be offensive and may cause harm when the origin and intent are not understood. If you cannot do the activity in a group, consider the last time you were in a social ­ situation with people you were not familiar with. How did people introduce themselves? What was the context of the social situation, and did that influence how people intro- duced themselves? For example, if you are at a work get-together, people introduce themselves through their job title (‘I’m the manager’), but, if you are in a family situation, people may introduce themselves through family connections (‘I’m John’s wife’). ▼ Scenario A mother with two adolescent children comes to the emergency department with one of the children having possibly broken their arm skateboarding. The mother completes the forms and has ticked the box ‘Aboriginal or Torres Strait Islander’. The nurse has looked at the form and is entering the data into the system. Based on the mother’s appearance, the nurse suggests that perhaps she has made a mistake on the form—that she has wrongly ticked ‘Aboriginal or Torres Strait Islander’. Critical thinking What impact might this have on this family’s experience of health care? How might this impact on this mother’s experience of the system? How likely is she to feel wel- come there and come back again? What assumptions has the nurse made about Indigenous identity? What message do the children get about their identities? Through critical reflection, health professionals and students can develop readily transferable skills to the care of any individual or group. If you do not work directly with Indigenous clients or co-workers, you may well work with others who have experienced similar impacts on health and well-being. The experiences of Indigenous Australians are, after all, human experiences that are not exclusive to or derived from being Indigenous. They are the shared experiences of loss, trauma, resilience, sur- vival, grief, pride, capacity, health and illness.
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    Talking about Indigenoushealth 9 Conclusion In this chapter, we have discussed rationales for studying Indigenous health, defined relevant terminology and asked the reader to investigate locally appropriate terminologies. We have also sought to examine the relevance of Indigenous health issues to individual practice and consider the transferability of these issues to other populations. Some key cultural safety principles have already emerged: 1. Engage in dialogue—simply ask how someone wants to be addressed, respect how they choose to identify without questioning, assuming or stereotyping. 2. Consider the influence of history and decolonise practice by not con- tinuing to impose and disempower individuals or make assumptions. 3. Reflect on your use of language and terminology. Identify their origins and acceptability in the local context. 4. Think about who has power when different terminology is used or when it is assumed, and who makes the assumptions? These principles are applicable to working with anyone of a different cul- tural background to yourself and, in later chapters, we will discuss culture in its broadest definitions as being more than ethnicity. Culture can be a generational, social, religious or other difference that exists between you and the client or recipient of care. The following chapter will present an argument for the use of cultural safety as an underlying philosophical approach to Indigenous health issues. Making it local y y What relevance does learning about Indigenous health have for your own practice or intended practice? Write down your expectations now so that you will have them to review when you reach the end of this text. What do you know about the local Indigenous populations in your region? What language groups are associated with your locality? y y If you believe there are no local Indigenous people in your specific location, please ensure you investigate your assertion thoroughly.
  • 33.
    10 2 Cultural frameworks forhealth This chapter examines a variety of frameworks used to understand and address cultural issues in health care. These frameworks include cul- tural awareness, cultural sensitivity, cultural competence, cultural security, cultural respect and cultural safety, which are discussed in more detail throughout the rest of this text. Development in this field is ongoing and, in this edition, we include the concepts of cultural capability and cultural ­humility. A brief description of each will be provided as well as readings, activities and case studies. Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Describe various frameworks for intercultural health service ➢ ➢ Define and apply various frameworks to scenarios ➢ ➢ Compare and contrast cultural safety with other current approaches ➢ ➢ Examine the relevance of cultural safety to your own practice. Culture and health How we think about health, whether that is our ‘philosophy’, our ‘world- view’, our ‘framework’—whatever we want to call it—influences what we do as individuals in practice. However, it also influences service delivery more generally. We might not even be aware that there is a certain way we think about health or that others might think about it differently, espe- cially if most of the people we spend time with share similar views to our own. These shared views can be called our ‘culture’. There are numerous approaches to service delivery that incorporate a focus on culture. Cultural awareness, cultural respect, cultural competency and cultural safety are some of the more established frameworks to influence services and health
  • 34.
    Cultural frameworks forhealth 11 professional education. However, as these concepts are applied and scru- tinised, there is, and should be, ongoing development and new modes of thinking. In this edition, we will also consider more recent frameworks such as cultural capability and cultural humility. What is important, as always, is to find out what local frameworks are used within health services. Some of the models or understandings of health will be discussed in more detail in Chapter 8. However, at this stage, it is important to acknowledge that not everyone shares the same views about health and what it means to be healthy. How then do we, as health professionals, deal with this? Health systems that privilege a certain way of thinking unfortunately do this at the expense of others’ ways of thinking and therefore at the expense of some people’s health. With increasing aware- ness of the rights of individuals, health care providers and systems need to recognise that there is more than one way to do things and more than one belief system—there are many ‘cultures’, models, concepts or frameworks for working. In the words of Richard Trudgen: ‘it is my con- viction that the crisis can be understood and programs can be developed to deal with it. But finding its real cause will require us to look at the subject from the other side of the cross-cultural/cross-language divide— the side where Yolgnu live’ (Trudgen, 2010, emphasis in original). In this chapter, we will explore a number of these concepts and set the tone for how the rest of the book will unfold—firmly based within the authors’ preferred framework of cultural safety. Firstly, cultural safety (from the New Zealand concept kawa whakaruruhau) is derived from the experiences of Indigenous people; it has been embedded into the nursing curricula of New Zealand’s universities and has had more than 20 years of implementation in health services. While acknowledging that the concept has come from the Māori experience in New Zealand, we are not suggesting that we simply transfer the approach in its entirety. That would not be possible or appropriate for reasons that should be clear. However, a key reason for choosing cul- tural safety as a preferred approach for the Australian context is that it puts the onus for change on the health service provider rather than on the client. It is an undertaking to think about the things that make us unique and to provide care that takes account of these differences. Before looking at the development of cultural safety and other rationales for its adoption/adaption, it may be useful to go back a little to one of the first major considerations of culture in health care—trans-cultural nursing. Trans-cultural nursing The influence of anthropology was prominent in the 1960s with the groundbreaking work of nurse-anthropologist Madeleine Leininger, who
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    Health Care andIndigenous Australians 12 pioneered the first real model of health care practice to incorporate cul- tural considerations. Trans-cultural nursing at that time focused on the importance for the health care professional to learn about cultural dif- ferences. Culture was a limited concept that related to ethnicity or race. Trans-cultural nursing practice involved developing the knowledge base of the nurse to incorporate certain cultural protocols towards clients of different ethnic or religious backgrounds. One problem with trans-cultural nursing theory, however, was the potential reliance on stereotyped notions of how an individual might behave based on ethnicity. This paid little attention to life experiences and diversity within cultures, let alone across cultures or importantly ­ cultures that have been impacted through colonisation. Imagine the ­ usefulness of having care based on stereotypes of so-called Australian culture. What is Australian culture? If an Australian were in a hospital overseas, could they expect perhaps to be greeted with ‘g’day’, and served a meat pie with sauce in keeping with anticipated cultural preferences? Trans-cultural theories have definitely been valuable in shifting from a homogenised mentality to one that is regardful of the individual needs of clients and communities. Trans-cultural nursing today, however, has grown and expanded, as evidenced by journals and professional societies related to this field. While this is how trans-cultural nursing originally developed, along with other concepts we will discuss, some proponents of trans-cultural nursing have adapted and modified the original concept. We now see work in the field of trans-cultural nursing that has many of the same elements or concepts as those in cultural competence or cultural safety frameworks. Cultural safety Cultural safety will be discussed in more detail in the following and sub- sequent chapters. However, to establish an early understanding of this concept in order to compare and contrast other frameworks for inter- cultural practice, the Nursing Council of New Zealand (2011, p. 7) has defined cultural safety, or kawa whakaruruhau, as: The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability. The nurse delivering the nursing service will have undertaken a process of reflection on his or her own cultural identity and will recognise the impact that his or her personal culture has on his or her professional practice. Unsafe
  • 36.
    Cultural frameworks forhealth 13 cultural practice comprises any action, which diminishes, demeans or disem- powers the cultural identity and well-being of an individual. In short, the recipient of care determines cultural safety. It is not restricted to culture as indicated by ethnicity. It requires health professionals to reflect on their own cultural identity and on their relative power as a health care provider. Various approaches to Indigenous health have viewed culture as a key determinant that can be ‘managed’ with increased cultural awareness or cultural competence on the part of providers. Nurs- ing, for example, has developed numerous philosophical approaches to influence the way in which practice is enacted in cross-cultural or mul- ticultural contexts. Cultural safety is one concept that the authors believe holds the greatest opportunity for transforming Indigenous health prac- tice in Australia. This is mainly because cultural safety is one of the few frameworks that recognises the colonising context as significant. However, it seems Australia is still a long way from fully embracing the necessary elements of a cultural safety philosophy. We will discuss this further in later chapters that explore resistances that also occurred in New Zealand when cultural safety was first proposed. Other frameworks for considering culture in health care We will now explore other frameworks that have focused on the issue of culture in health care. Some of these overlap with cultural safety, and some have very different goals. Some of the frameworks are not well defined or have been defined differently by various writers. Overall, how- ever, it is important to recognise that there are different terms and frame- works. Consider the aims and foci of the various approaches and their implementation in practice. Cultural competence Cultural competence, originally developed in the USA, has wide-ranging application and understanding and has been defined in many ways. Some definitions make it difficult to tease out the difference between cultural competence and cultural safety. Cultural competence has been 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 et al., 2002, p. v). ­ Campinha-Bacote (1994) defined cultural competence as a ‘process, not an
  • 37.
    Health Care andIndigenous Australians 14 endpoint, in which the nurse continuously strives to achieve the ability to work within the cultural context of an individual, family, or community from a diverse cultural/ethnic background’ (pp. 1–2). Cultural competence in some instances has been broken down to include clinical, organisa- tional and systemic cultural competence (as cited in DeSouza, 2008). While there seems to be widespread adoption of cultural competence as a framework it has also come under much scrutiny and critique. It is often defined as the ability to work effectively with clients who are cultur- ally different. The service provider is the focus in this definition. There is a focus on behaviour that can be assessed as competent. But who decides whether a service provider’s care or service has been ‘competent’? What would this look like in practice? Many of the social sciences in Australia have adopted the concept and terminology of cultural competence and expanded it to include elements which are, as you will see, very similar to those employed in cultural safety. For example, cultural competence training in some psy- chology programs in Australia includes the importance of understanding the implications of a colonial history, notions of power (and disempow- erment or empowerment), the consideration of how one’s own culture impacts on their provision of care and how the care is received by clients. Side by side, it would be difficult to see any major difference between some ideas of cultural competence and cultural safety. Cultural humility Culturally Connected is a Canadian website that provides information and resources about cultural humility for health professionals (https://cultural- lyconnected.ca/cultural-humility/, accessed June 2018). They define cul- tural humility using Tervalon and Murray-Garcia’s (1998) definition: Cultural humility is a stance toward understanding culture. It requires a com- mitment to lifelong learning, continuous self-reflection on one’s own assump- tions and practices, comfort with ‘not knowing’, and recognition of the power/ privilege imbalance that exists between clients and health professionals. A cultural humility approach is interactive: we approach another person with openness to learn; we ask questions rather than make assumptions; and we strive to understand rather than to inform. Embracing and learning about the similarities and differences between health professionals and clients, such as language, religious beliefs or values, age, gender, understandings of health and illness, or sexual orientation, can help providers to understand a client’s health concerns, experiences, and preferences for care.
  • 38.
    Cultural frameworks forhealth 15 Cultural humility has arisen from the medical professions in North America, in response to what was seen as a limitation of cultural competence. How- ever, cultural safety philosophy differs in the critical aspect of recognising our colonising pasts as influential to current health and health care practice. Cultural capability Queensland Health defines cultural capability as ‘the skills, knowledge, behaviours and systems that are required to plan, support, improve and deliver services in a culturally respectful and appropriate manner’ (www. health.qld.gov.au/atsihealth/cultural_capability, accessed 15 April 2018). The Queensland Health Framework document provides a well-­ articulated explanation of the key principles of cultural capability and guidelines for implementation. According to Figure 2.1, cultural capabil- ity is part of the Cultural Competency Framework embedded within and aligned to the Aboriginal and Torres Strait Islander Cultural Capability Frame- work 2010–2033 (Queensland Health, 2009). The framework includes eight elements, including the principles of self-reflection, cultural understand- ing, context, communication and collaboration. Figure 2.1 Queensland Health Organisational Cultural Competency Framework Source: Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010–2033
  • 39.
    Health Care andIndigenous Australians 16 Cultural respect For the period between 2004 and 2009, the Commonwealth provided health services with yet another framework that acknowledged the role culture plays in the health outcomes of individuals and groups. Accord- ing to the Australian Health Ministers’ Advisory Council (2004), cultural respect is defined as: the recognition, protection continued advancement of the inherent rights, cultures traditions of ATSI peoples [sic]. Cultural respect was developed as a guiding principle in policy con- struction and service delivery, which was in response to the continu- ing unacceptable health outcomes of Indigenous Australians. It was yet another government response to the disparity between Australia’s overall ­ populations being among the healthiest in the world, while Indigenous Australian health is among the poorest in the world. This is in contrast to countries with similar colonial histories, such as New Zealand, Canada and the USA (see Chapter 12). As with the cultural safety experience in New Zealand, barriers remain to the provision of an equitable, quality health system. According to the government’s stated intention, ‘embedding cultural respect into services and delivery’ will: ➢ ➢ improve outcomes and quality ➢ ➢ deliver more efficient and effective services ➢ ➢ reduce expenditure ➢ ➢ improve customer satisfaction. This suggests that culture, as a determinant of health, is widely accepted and something requiring attention. Multiple literature reviews and reports have identified certain factors that might hinder the achievement of positive health service delivery to clients whose cultural background differs from that of the service providers. These factors include: ➢ ➢ cultural barriers to the uptake and delivery of services ➢ ➢ provider attitudes and practice ➢ ➢ communication ➢ ➢ mistrust of system
  • 40.
    Cultural frameworks forhealth 17 ➢ ➢ poor cultural understanding—although the policy does not specify who exactly had poor understanding ➢ ➢ racism ➢ ➢ worldview/beliefs—deemed problematic although the reason was not specified. Cultural respect is described as a ‘shared respect’ that is achieved when the health system is a safe environment. It is a commitment to the principle that the construct and provision of services ‘will not wittingly ­ compromise the legitimate cultural rights, practices, values and expecta- tions’ (AHMAC, 2004). In 2010, we said that it was likely that an entirely new set of poli- cies will have been rolled out for the next five to ten years, as cultural respect was meant to be nearing its implementation point. What has been achieved? Can you find evidence of a cultural respect or any other cul- tural framework operating in your local area or state? How influential are these in shaping the health service provided and/or your own practice? The government’s implementation plan for the cultural respect frame- work included the following statement: development of rewards and incentives (e.g., salary, promotion, bonuses) for Cultural Respect performance, as well as sanctions for culturally destruc- tive practices (e.g., discrimination). Cultural Respect performance shall be an integral part of the employee-provider performance evaluation system, and provider-organisation performance evaluation system. (AHMAC, 2004, p. 20) Cultural respect is discussed in detail in the Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health, published by the Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee and available online: ­ www.coaghealthcouncil.gov.au/Portals/0/National%20Cultural%20 Respect%20Framework%20for%20Aboriginal%20and%20Torres%20 Strait%20Islander%20Health%202016_2026_2.pdf (accessed 15 June 2018). Reading With many cultural frameworks, there is a strong desire to have a tool to measure outcomes. The following reading importantly identifies the development of a tool led by First Peoples. ▼
  • 41.
    Health Care andIndigenous Australians 18 Summary of concepts DeSouza (2008) proposes that cultural safety and cultural competence can be used together to meet the needs of cultural issues in health care. We have looked at some of the facets of cultural awareness, cultural sensitiv- ity, cultural competence, cultural respect, trans-cultural nursing and cul- tural safety. There are even more concepts today, such as cultural humility, cultural ease, cultural capability or cultural competency, distinguished by its focus on the individual rather than the broader system approach implied by cultural competence. The framework used in Western Australia and the Northern Territory has been that of cultural security. This is ‘a commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people’ (Thomson, 2005). The limitation of all of these frameworks or models is that we don’t know very much about how they actually play out in practice. We don’t have much research to show what works best or what actually makes a difference. The terms get thrown about as if they mean something in par- ticular, but there are assumptions underlying what these concepts mean and major differences in how the concepts are defined, both within and between different groups. If staff or students undergo some ‘cultural’ training or workshops, what does that mean? What are they taught? How do we know it will make a positive difference? How do we know that what is taught is not harmful— perhaps creating more stereotypes or discrimination against certain groups? While certain concepts, in an academic understanding, might be seen as more or less effective, when delivered in a workshop or similar it might depend on who was delivering the workshop, and how the issues are managed or presented. This makes it very difficult to assess and under- stand exactly what is being taught and the impacts. We have therefore considered each of the different concepts or frameworks and some of the weaknesses and strengths. Through this discussion and analysis you should have a better understanding of how knowledge, values and under- standing influence practice. Table 2.1 is a synthesis of some of the strengths and limitations of cul- tural safety and other frameworks. West, R, Wrigley, S, Mills, K, Taylor, K, Rowland, D and Creedy D K (2017) ‘Develop- ment of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students’, Women and Birth, 30(3), 236–44, https://doi.org/10.1016/j. wombi.2017.01.004 ▼
  • 42.
    Cultural frameworks forhealth 19 Table 2.1 Cultural frameworks, strengths and limitations Framework Key idea or elements Strengths Limitations Cultural safety Regardful of difference Decolonising: understanding of history Consideration of power Reflective practice Understanding own culture Safety is determined by recipient of care Conceptually addresses elements that theoretically should improve health outcomes Requires more research Has generally focused on application in interpersonal contexts and not as much in organisational or structural contexts Cultural awareness Focus on awareness of differences between groups Provides a starting point to understand difference Unachievable to be aware of or knowledgeable about all cultures Can lead to stereotyping Cultural sensitivity Sensitive to elements of difference between self and clients Extends awareness to a sensitivity Improvement of practice requires more than sensitivity to issues Cultural competence Awareness, knowledge and skills relating to culture Understand self as culture bearer Recognition of historical, social and political influences Relatively extensive literature base Potentially perpetuates colonising practices and power imbalances Can be deemed competent by other than recipients of care Cultural respect Australian Government initiative Shared respect in a safe health environment Consideration of impact of services on health outcomes Failed to result in meaningful actions despite intentions Cultural humility A commitment to lifelong learning, continuous self- reflection on one’s own assumptions and practices, comfort with ‘not knowing’, and recognition of the power/privilege imbalance that exists between clients and health professionals Addresses the individual practitioner’s potential power and privilege Lack of literature
  • 43.
    Health Care andIndigenous Australians 20 Framework Key idea or elements Strengths Limitations Cultural capability Cultural capability refers to the skills, knowledge, behaviours and systems that are required to plan, support, improve and deliver services in a culturally respectful and appropriate manner (West et al., 2017) Framework provides a clear set of strategies for achieving cultural capability, including staff training, resources development translation, community engagement, leadership partnership, data collection analysis, inclusive recruitment retention interpreting Lack of literature Critical thinking Consider the wide range of terminology and concepts relating to working in cultural contexts. How can getting caught up in the current terminology present a barrier for health professionals to working well in cultural contexts? Go to the Australian Indigenous Psychology Education Project website to find the resource: ‘Finding common ground: Avoiding the terminology trap’ (www. indigenouspsyched.org.au/resource/finding-common-ground-avoiding-terminology- trap, accessed 29 July 2018). Activity Conduct a search of each state and territory in Australia to identify cultural frame- works currently meant to be in use in the government-controlled sectors. There are multiple Aboriginal or Torres Strait Islander controlled services in each state and territory as well. See if you can identify specific frameworks used in some of these settings. Are there any particular frameworks that seem to be gaining prominence? Table 2.1 Continued
  • 44.
    Cultural frameworks forhealth 21 Conclusion No single approach is likely to have all the answers. If there were such an approach, the challenges of Indigenous health in Australia would have been met and dealt with long ago. Cultural safety has arrived at a set of principles for ensuring that dominance does not result in a lack of safety and accessibility for those who have a different cultural background to the providers. This chapter has briefly explored cultural safety as a concept along with other frameworks that have been developed and used in health and other disciplines. While it may be an individual choice as to which frame- work resonates with readers, cultural safety is offered as the preferred approach by the authors because of its transferability across disciplines, contexts and cultures and the essential element of recognising the role of colonisation in health outcomes today. Scenario A local health service wanted to assess how well it was doing providing care to Indigenous clients. The practice manager developed a written client satisfaction sur- vey that was left in the reception. What do you think of this approach to assessing care for this or any other population group? How appropriate would this be in your specific location? Explain your response—why or why not? How would you personally know if you were providing culturally safe care? Making it local y y Has anyone witnessed the rewards or sanctions associated with any of these frameworks in practice? y y How do we as health professionals ensure that policies and frameworks for prac- tice do not just linger in folders and on web pages of health services? What can you do as an individual to see policies in practice? y y Find your current service’s cultural framework. If you are a student, visit a health service in your local area.
  • 45.
    22 3 Cultural safety inpractice The previous chapter examined the various frameworks for looking at cul- ture within health care settings. This chapter will expand on this book’s preferred framework of cultural safety and explore the elements that make it a relevant approach for the Australian health care environment. Chapter objectives After completing this chapter, you should be able to: ➢ ➢ Describe the pathways to cultural safety ➢ ➢ Identify the principles of culturally safe practice ➢ ➢ Define and apply cultural safety to scenarios. Pathways to cultural safety Some writers have considered cultural safety as the third level in a set of three levels of cultural understanding. We, on the other hand, view cultural safety less as a hierarchy and more like a continual process of reflection on practice. In this chapter, we will briefly describe the levels of cultural safety as articulated in the New Zealand concept, and will address more fully the application of cultural safety in practice (Figures 3.1 and 3.2). Figure 3.1 Original stages towards cultural safety—as defined by Ramsden (2002) Cultural Awareness (of differences) Cultural Sensitivity (acceptance of right to differences) Cultural Safety (defined by recipient)
  • 46.
    Cultural safety inpractice 23 Cultural awareness Cultural awareness is the first step in being aware that there are differ- ences between people. This can be more challenging than it seems. The obvious or exotic differences are perhaps easier to identify than the more subtle differences. These obvious differences might include the mode of dress, foods people eat or music preferences. However, cultural awareness also seeks to uncover the less obvious differences, including interpersonal behaviours, such as showing respect for authority by look- ing down, which may contrast with another culture that shows respect by looking directly at a person in authority. This is a stage that many people find very interesting and enjoyable, such as learning new words and protocols. These differences can be observed and enjoyed or visited for a period without requiring any fundamental change in practice. For some, it can be a little like going to a museum, but then you go home. Unfortunately many professional development workshops and educa- tional settings tend to limit their cultural training to this stage of aware- ness. However, cultural awareness also requires an understanding of one’s Figure 3.2 An aspirational model of cultural safety—as developed and defined by Taylor Guerin (2018) Self Awareness Cultural Awareness Cultural Sensitivity Cultural Safety and Reflective Practice
  • 47.
    Health Care andIndigenous Australians 24 own culture and the commonalities across all cultures that allow people to relate to and interpret any perceived differences. Cultural awareness, simply put, is being aware that people are dif- ferent. We discuss it again here because it is a widely used terminology, both within the domain of cultural safety and more generally. Cultural awareness is not entirely natural—it is not something that you are born with; awareness of differences between people is social and develops over time. If you watch small children, for example, two- to four-year- olds, they would generally not ‘see’ differences between people—kids are kids, grown-ups are grown-ups, and that’s basically all they understand. Being aware that people are different is not problematic, but what is important is what you think of those differences and how you act on them. For a long time, health professions adopted a seemingly equitable and benevolent mode of practice of treating everyone the same. This was thought to be appropriate, fair and reasonable. ‘I treat everyone the same’ was intended to demonstrate a lack of prejudice on the part of the health service and practitioner. However, evidence has suggested that disparities in health outcomes of some populations can be attributed in part to cul- tural differences between clients and care providers. Increasingly, people began talking about the need to be ‘culturally aware’. Treating everyone the same suggests everyone belongs to a homogeneous base. Experi- encing the same treatment therefore may not necessarily mean equal outcomes. Cultural awareness approaches often focus on learning about the things that make cultural groups different from one another. While a use- ful first step, learning these sorts of details can also lead to stereotyping and inappropriate behaviour or interactions. It is not possible to learn everything there is to know about all the cultures that you encounter in your practice. Cultural safety principles, on the other hand, provide a more useful addition to your knowledge base. Cultural sensitivity Cultural sensitivity is intended as the next step up from cultural aware- ness. It means being sensitive to the differences that one might have learned about through cultural awareness. Sensitivity assumes that health care professionals can apply their awareness of cultural differences to their own practice. It validates the right to difference. Cultural sensitivity is also thinking about your own attitudes and values and how they might affect the person you are working with, as well as taking into account the cultural issues that might influence your clients.
  • 48.
    Cultural safety inpractice 25 In this step you might say, ‘OK, there are cultural differences, and now I can be sensitive to those differences’. As a health professional, I can consider different modes of operating for my clients. Difference is ­ legitimated—difference is OK—and it is about being sensitive to the possibility that my difference might impact on others. In this stage, the health professional reaches an understanding that individuals are entitled to hold differing worldviews, values, knowledge and beliefs. It should not be a matter of leaving these cultural foundations at the door in order to access health care. The health professional needs to be sensitive to differ- ing needs and expectations, and work to accommodate these where pos- sible. It is not, and should not, be the goal to ‘convert’ someone to your preferred culture. Cultural safety Although this is not a linear process, cultural safety is achieved when the recipients deem the care to be meeting their cultural needs. This requires the health professional to reflect on their interactions and the impact of their own cultural identity on the care they provide to someone from a different cultural background. Irihapeti Ramsden (2002), who spearheaded the original cultural safety movement in New Zealand, believed that it was not enough to focus on the ‘exotic’ aspects of an individual or group culture as was often done in cultural awareness, cultural sensitivity or trans-cultural nurs- ing approaches. In contrast to trans-cultural nursing, which originally sought to describe and respond to the cultural differences, cultural safety involves recognition of power balances and historical, political, social and economic structures. Cultural safety requires the health professional (or others) to understand their own culture and to acknowledge the power imbalance brought about by dominant systems. It requires them to actively seek to ensure no ‘cultural harm’ is done through actions that may impact on clients. Cultural safety has gained momentum in Australia, with a growing body of literature challenging existing approaches to Indigenous health care. It is important to acknowledge that the cultural safety framework itself came from Indigenous Peoples outside Australia. However, rather than suggest simply applying a foreign concept to an Australian context, it is obvious that without some adaptation and regard of local contexts, histories and worldviews, this act itself would be an unsafe one. While cultural safety is an Indigenous construct, it requires the dominant or colonising culture to engage in processes of self-reflection and decolonis- ing practice.
  • 49.
    Health Care andIndigenous Australians 26 Examining the New Zealand experience suggests that clinical compe- tencies, technical expertise and theoretical knowledge form only part of the care equation when the recipients of care differ in some way from the health professional. Statistically, this is the situation in Australia where the majority of health professionals are non-Indigenous and those most in need of health care are Indigenous Peoples. Although cultural safety has arisen from the disciplines of midwifery and nursing, other health disciplines have found, or are finding, rel- evance for their practice. Sadly, Irihapeti Ramsden did not live long enough to see the transforming impact of this philosophy globally and across professions. Even where other philosophical frameworks have emerged, there can be no denying that the New Zealand experience has had a profound influence in focusing on culture and colonisation in health. There are numerous readings and resources that might be ­ examined for a deeper understanding of the development and conceptu- alisation of cultural safety. Readings For anyone interested in learning more, Irihapeti Merenia Ramsden’s PhD thesis, ‘Cultural safety and nursing education in A ˉotearoa and Te Waipounamu’ (2002) is available online through Massey University, New Zealand. Other readings of interest include: Browne, A, Varcoe, C et al. (2009) ‘Cultural safety and the challenges of translating critically oriented knowledge in practice’, Nursing Philosophy, 10(3): 167–179. Laverty, M, McDermott, D and Calma, T (2017) ‘Embedding cultural safety in ­ Australia’s main health care standards’, Medical Journal Australia, 207(1): 15–16. Molloy, L, Lakeman, R, Walker, K and Lees, D (2017) ‘Lip service: Public mental health services and the care of Aboriginal and Torres Strait Islander peoples’, International Journal of Mental Health Nursing, 27, 1118–1126. Smith, S (2012) ‘Cultural safety in nursing education: Increasing care for LGBT indi- viduals’, http://hdl.handle.net/2376/3442. (This master’s thesis from Washington State University shows the transferability of cultural safety to populations who may differ from the health professional in term of sexual orientation.) Williams, R (1999) ‘Cultural safety: What does it mean for our work practice?’, Aus- tralian and New Zealand Journal of Public Health, 23(2): 213–214.
  • 50.
    Cultural safety inpractice 27 Cultural safety principles The following is a brief summary of the principles of cultural safety, as identified by the Nursing Council of New Zealand (2011): 1. The need for health practitioners to reflect on their practice is a criti- cal aspect of culturally safe practice. Because most health professionals are members of dominant cultural groups, think about how this might impact on clients who are members of a minority ethnic group. We discuss reflection on practice in more detail in Chapter 14. 2. Talk, ask, engage in dialogue with the client. This might seem obvi- ous. However, there are countless examples of encounters where Indig- enous (and other) patients are spoken about, around and on behalf of, but often not talked to or with. (See Chapter 10, ‘Intercultural interactions’.) A culturally safe approach will require true engagement with the client to understand their unique needs, beliefs, understand- ings and preferred ways of doing things. Where there is a perceived or actual barrier to discourse (or conversation), clients can remain unengaged and unempowered in response to their own health care needs. Talking, asking and engaging with the client is not always easy to achieve so this topic will be considered further in later chapters. 3. Seek to minimise the power differentials between yourself and client. Western health care has traditionally been hierarchical in nature, although this is slowly changing. Health professionals may be ­ wittingly or unwittingly in positions of power over their clients. Consider what might shift the power balance in your practice ­ setting. Language is a very important indicator of power in health care. Think about the way in which clients are sometimes referred to as ­ ‘non-compliant’, ‘absconder’ or ‘frequent flyers’. These kinds of labels position the health professional as the one in power, whereas the cli- ents are reduced to simple labels. 4. Undertake a process of decolonisation. This was a somewhat contro- versial aspect of the New Zealand model that came in for some criti- cism in the press. It is this element, however, that separates cultural safety from all other approaches, acknowledging the key role of a colonising history in contemporary health outcomes for Indigenous Peoples. The colonising experience of New Zealand differs significantly from that of Australia (see Chapter 12, ‘Indigenous health in a global context’ for details). Therefore, we will consider what a decolonising process may mean in an Australian context.
  • 51.
    Health Care andIndigenous Australians 28 5. Ensure that you do not diminish, demean or disempower others through your actions. Sometimes it is easier to identify culturally unsafe practice than it is to identify culturally safe approaches. Both, however, require a level of self-awareness and a willingness to critique practice and systems. Actions can include subtleties of body language, how you say things and what you say, as well as more overt behav- iours. Examples are discussed throughout the book. Critical thinking What are some fundamental differences between New Zealand and Australia that might make the transferability of cultural safety more challenging? The New Zealand state nursing exam has included questions focusing on cultural safety. y y What do you think of this idea for Australia? How would it be received locally? What are the arguments for and against? Critical thinking Think about the transferability of cultural safety principles to clients who differ from health professionals in other ways—either by religion, gender, socioeconomic status, sexuality or age. Do you have any particular groups within your local area that may also require care that is regardful of certain differences? Who are these groups? How might their ‘cultural difference’ need to be incorporated into their care? For example, is there a large ageing population or LGBTQI community in your region? Do some staff have unexamined, negative attitudes towards older or LGBTQI people that might impact on their care? What is the demographic makeup of your community and what might this mean for shaping practice or preparing for practice? Scenario An elderly Indigenous man was called to a clinic to collect his new hearing aid. On arrival the receptionist said to him, in front of a waiting room of other people: ‘Now George, how many is this? You can’t keep getting them replaced you know. You bet- ter look after this one!’ What elements of culturally unsafe practice can you identify? ▼ Scenario An elderly Indigenous man was called to a clinic to collect his new hearing aid. On arrival the receptionist said to him, in front of a waiting room of other people: ‘Now George, how many is this? You can’t keep getting them replaced you know. You bet- ter look after this one!’ What elements of culturally unsafe practice can you identify? ▼
  • 52.
    Cultural safety inpractice 29 There remains no single, standardised or universally accepted model of cultural education in Australia. In the absence of a fully articulated, locally relevant and universally accepted philosophy, cultural safety has been examined for its relevance to the Australian and other health care settings. It is a concept that is increasingly recognised for its appropriateness in the Australian context. The Congress of Aboriginal and Torres Strait Islander Nurses Midwives (CATSINaM) endorsed it as an approach, as have the Leaders of Indigenous Medical Education (LIME Network), and other peak professional bodies and many academics across Australia. As already stated, culture can be defined more broadly than by ethnic- ity alone. Health professionals may differ from their clients by socioeco- nomic status, religion, age, gender, sexuality and more. Cultural safety in the Indigenous health context can be distinguished by the key compo- nent that is often lacking from other frameworks—that of decolonisation. What might the New Zealand cultural safety principles mean in a prac- tical sense in an Australian setting? Consider the following scenarios: Not all of the receptionist’s responses could have been based on ethnicity. What other cultural differences might have influenced her response? The man, an elder from his community, was furious at the treatment. What role, if any, should the receptionist have in commenting on a patient’s reason for attending? Set in the context of a life of external non-Indigenous ‘control’ over this man’s life, this one incident caused him to leave the clinic without being seen. ▼ Scenario 1 A young Indigenous mother has been asked to sign consent for a major operation for her child. She is alone in the hospital and seems unwilling to sign anything. There is no Indigenous liaison officer available and some staff are suggesting obtaining a court order if the mother won’t sign. She is, after all, putting her child at risk by delay- ing surgery. The doctors have already spoken to the mother and have now requested nursing staff to do what they can to obtain consent. The mother signs the form but then leaves her child in the hospital and returns home. Using the principles, consider: 1. Reflection on practice. How would you feel about your practice if you were involved in the above scenario? 2. Who has the power in this scenario? What pressures are brought to bear to obtain consent? Even though consent has been obtained, has it been done in a culturally safe manner? If not, why not? ▼
  • 53.
    Health Care andIndigenous Australians 30 3. What dialogue could have been engaged in with the mother? Would you have involved anyone else—if so, who and why? 4. What aspects of this encounter might be considered as colonising in nature? How might you decolonise this scenario? 5. What may have been behind the mother’s responses? Are there possible cultural issues resulting in the mother’s reluctance? You might need to investigate local cul- tural norms for childrearing roles and responsibilities. 6. How might this have been managed differently? What evidence is there that this mother may have been demeaned, disempowered or diminished? 7. Does the context make a difference in this scenario? If so, in what ways does it make a difference? What needs to be considered? Scenario 2 Two people are sitting at the triage desk of an emergency department. One is a ­ non-Indigenous person in casual clothes and the other is a registered Aboriginal Health Worker in uniform with ID badge. Every person who approaches the triage desk, both Indigenous and non-Indigenous, direct their communications to the non- Indigenous person. What assumptions have been made in this situation? Who is deemed to be in the position of authority or ‘in charge’? Why might Indigenous Peoples also defer to the non-Indigenous person at the desk? What impact might this experience have on the Indigenous worker? How might the non-Indigenous person exacerbate or mitigate this situation? Scenario 3 A young boy in the paediatric ward was asking for a toy from the ward collection using his local Indigenous language. The large male nurse stated at high volume that he would not give the boy any toys while he was speaking ‘language’. ‘No, when you stop talking in language and ask me properly in English, then I’ll give it to you.’ What lessons did the child learn about the world in this one small exchange? What underlying message does the young boy get about his own language and identity? ▼ ▼
  • 54.
    Cultural safety inpractice 31 Looking at the above scenarios, it is important not to apply the same expec- tations to everyone in order to be equal and reasonable. For the young Indigenous mother (or any mother), depending on her individual circum- stances, she may have been reluctant to sign a consent form because of cultural considerations, or simply because of past experience or any number of other possible explanations. Dominant culture Australians expect bio- logical parents to be the ones responsible for providing consent for their children. Biological parents are therefore naturally the first ones spoken to about their children and the first ones from whom information is sought. However, not all cultures construct parental responsibility in the same way. Some cultures, such as many Indigenous cultures, hold biological parents responsible for nurturing and care, but also share the responsibility with oth- ers in their kinship systems for major decision-making. Therefore, without consideration of the potential for a different set of needs, treating this young woman the same as everyone else might not in fact be equal. It could have put her in an untenable situation from which she felt compelled to leave. That is not to say that it is the case in every situation. However, it is some- thing that needs to be examined in context. Rather than ask the mother to hold the child, a simple change in question format to ask who the mother would like to hold their child would provide choice rather than challenge. Health professionals may not know, and not need to know, what is behind the preferences and decisions of clients and communities in order to be culturally safe. They simply need to be aware of the right to be differ- ent, and to respect the right to one’s own worldview and cultural values. Cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation and an acknowledgement of whiteness and privilege. These actions are a means to challenge racism at personal and institutional levels and to establish trust in health care encounters. Activity Consider the various approaches discussed in this chapter and think about your own values and experiences. What would be your ­ personal/ professional philosophy of practice in an intercultural context and why? What did he learn about power? How might this scene be made more culturally safe for all participants? Who is in the best position to change practice? ▼
  • 55.
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    Who knew thecombination beside your uncle? Myself—he told me last month—when he had his last bad spell. Nobody else—that cousin, for instance? I don't believe Mr. Bulson knew it. Then that's what made it look black for you. The safe wasn't forced open, that's sure. Somebody opened it who knew the combination. The money might have been taken some time ago, said Gertrude. Anyway, it is gone, and you and I are supposed to be the thieves. She smiled bitterly. How strange! and we hardly know each other! And I don't see any way of clearing ourselves, said the newsboy, with equal bitterness. But let that drop. What are you going to do? Going to some friend's house? I have no friends here. You see, we came from Philadelphia, and I am not much acquainted as yet. Then you'll go to Philadelphia? If you wish, I'll carry that bag and see you to the train. No, I'm not going to Philadelphia. I would rather remain in New York, near my uncle. He may need me some day. He's a hard-hearted man! burst out the newsboy. I don't see how he could treat you so mean! It is his sickness makes him so, Nelson; he was never so before. Gertrude heaved a long sigh. I must say I really do not know what to do. I know a hotel on Third Avenue, but it's not a very nice place. No, I don't wish to go there. If I could think of some friend—— Did your uncle send you away without any money?
  • 57.
    I took onlythe clothing I needed, nothing more. Then I'll give you what I've got, answered Nelson promptly, and drew out what little money he possessed. No; I won't rob you, Nelson. But you are very, very kind. It aint any robbery, he answered. Come, you must take it. And he forced it into her hand. I know an old lady who'll take you in, he continued suddenly. Her name is Mrs. Kennedy. She's only a fruit and candy woman, but she's got a heart as big as a balloon. She's a nice, neat woman, too. The matter was talked over for a few minutes, and Gertrude consented to go to the two rooms which Mrs. Kennedy called her home. These were close to Third Avenue, and late as it was, they boarded a train and rode down. The building was dark, and Nelson had some trouble in rousing the old woman. To be sure I'll take the lady in, Nelson, said Mrs. Kennedy, when the situation was partly explained. Come in, miss, and welcome. Gertrude was glad enough to enter and drop into a chair, and here our hero left her, and at once hurried down to the lunch-room with all speed. Not wishing to arouse Sam Pepper if he was asleep, he went around to the rear window, opened that, and crawled through. To his surprise Pepper was not there. I'm lucky, after all, he thought, and undressed with all speed. Hardly had he crawled into bed when Pepper came in. He lit the gas and looked at our hero, but Nelson snored and pretended to be fast asleep. Sam appeared relieved at this, and soon retired. His bag, which he had brought with him, he placed under his bed, in a corner next to the wall.
  • 58.
    The newsboy couldnot sleep, and from the time he lay down until daylight appeared he turned and tossed on his cot, reviewing in a hundred ways all that had occurred. But he could reach no satisfactory conclusion. The one thing, however, which remained fixed in his mind was that Gertrude Horton was now homeless, and he felt that he must, in some measure at least, look out for her. I don't suppose I can do much, he thought dismally. But what I can do I will, that's certain. Long before Sam Pepper was stirring Nelson was up and dressed. As he was going out Pepper roused up. Where are you bound? he asked. Going to sell papers. You're starting early to-day. I've got to hustle, if I want to make any money. And so speaking, Nelson left the place. He was soon down at Newspaper Row, as it is commonly called, that part of Park Row and Nassau Street where are congregated the offices of nearly all of the metropolitan dailies. He had not a cent in his pocket, but this did not bother him. He soon found Paul Randall, who was being shoved right and left in the big crowd of boys who all wanted to get papers at once. What papers do you want, Paul? he asked. The little newsboy told him, and Nelson said he would get them for him. And I'd like to borrow a dollar, Paul, he went on. I had to give up every cent I had. That's too bad, Nelson, replied Paul. I can't loan you a dollar. All I've got extra is sixty-five cents. You can have that.
  • 59.
    Then I'll makethat do, said our hero. He took all of Paul's money and started into the crowd, to get papers for his friend and himself. He was struggling to get to the front when, on chancing to look to one side, he caught sight of Billy Darnley, the newsboy bully who had robbed him of the five dollars.
  • 60.
    CHAPTER XII. NELSON RECOVERSSOME MONEY. Billy Darnley! gasped our hero, in astonishment. The bully saw Nelson and instantly ducked his head. He, too, was after newspapers, but now thought it best to quit the scene. I didn't t'ink he'd be here so early, he muttered, and pushed to the rear of the crowd. Once in the open, he took to his heels and dashed down Frankfort Street in the direction of the Brooklyn Bridge arches. But Nelson was not to be lost so readily, and he was out of the crowd almost as soon as the bully. I'm after Billy Darnley! he shouted to Paul. Come on! There now ensued a race which was highly exciting, even if not of long duration. Darnley was swift of foot, and the fear of what might follow lent speed to his flying feet. But Nelson was also a good runner. At the corner of Rose Street were a number of heavy trucks. Darnley managed to pass these, but it took time. When our hero came up, the trucks blocked the street completely. In and out Nelson dodged among the trucks, between the wheels and under the very hoofs of the heavy horses. In a twinkle he was clear of the mass and again making after Darnley, who was now flying toward Vandewater Street. At this point there is a large archway under the approach to the Brooklyn Bridge, and toward this archway the bully directed his footsteps. But Nelson was now close at hand, and underneath the
  • 61.
    archway he succeededin reaching the big newsboy, catching him firmly by the arm. Lemme go! growled Billy Darnley. Lemme go, Nelse, or I'll hammer yer good. Maybe I'll do the hammering, retorted Nelson. Where's my five dollars? I aint got no money of yours. You have, and I want you to hand it over. Aint got it, I say. Lemme go! Instead of complying our hero grasped the bully by the throat and ran him up against the stonework of the arch. I want my money, he said sternly. If you don't give it to me—— Let up—yer—yer chokin' me! gasped Billy Darnley. Will you give me the money? No. The bully struggled fiercely, and so did Nelson. Down went both on the pavement and rolled over and over. But our hero's blood was up, and he put forth every ounce of strength he possessed. At last he had Darnley flat on his back, and then he sat astride of the bully. Now will you give up? he panted. Or must I hammer you some more? Oh, Nelson! have you got him? asked Paul, running up. Yes, and he's got to give me my money. A fight! a fight! cried some of the boys who began to collect. This aint a fight, said Nelson loudly. He's a thief, and stole five dollars from me. He's got to give it up.
  • 62.
    He caught Darnleyby the throat again, and now the bully was only too glad to give in. Let—let up! he gasped. Let up! Will you give me my money? I've only got two dollars and ten cents. Hand it over. Let me up first. Not much! With something like a groan Darnley brought out the money and passed it over. Now I'm going to search you, went on Nelson, in as determined a voice as ever. No, no! pleaded Darnley in alarm. He did not like the crowd that was gathering. Yes, search him, Nelse, said a boy named Marks. That's right, search him, put in another newsboy, named Wilson. I think he stole something from me last week. In spite of his protestations Billy Darnley's pockets were turned inside out. There were brought to light another dollar, which our hero also pocketed, a pearl-handled pocket-knife, a silver badge, and half a dozen other articles. My knife! shouted Nat Marks. Boys, you all know it. So it is, Nat, said Frank Wilson. And this is my badge—the one I won in the newsboys' competition last month.
  • 63.
    The boys tookthe things, and then gathered around Billy Darnley with clenched fists. Nelson slipped outside of the crowd, and Paul went with him. In vain Billy Darnley tried to clear himself of the other lads. He struck one boy down, but the others pounced upon him front and rear, and soon had him again on his back. It looked like a football scrimmage, but the ball in this case seemed to be the bully's head. For ten minutes the tussle went on, and when at last the cry of Cop! cop! run for it! arose, Darnley found himself with his nose bleeding, two teeth loose, and his left eye all but closed. Moreover, his coat was torn to shreds. What is the meaning of this? demanded the policeman. They all piled on top of me! whined Darnley, looking the picture of misery. He's a thief! exclaimed one of the other boys, but from a safe distance. He stole something from three of the boys, he did. He didn't git nuthin' but what was comin' to him, officer. That's right; he ought to be locked up, put in another boy, also from a safe distance. Begone with you! said the policeman sternly, and gave Darnley a shove. If I see any more fighting I'll run you all in, and he walked away, twirling his club as he did so. Oh, me eye! groaned Darnley, and limped away, a sadder if not a wiser youth. It was many a day before he dared to show himself in Newspaper Row again. Well, I got back three dollars and ten cents, remarked Nelson, as he and Paul walked up Frankfort Street, so I won't need your loan. But, just the same, I am much obliged. And he passed over the money.
  • 64.
    I wish youhad gotten it all, Nelson, said Paul earnestly. Oh, but didn't they just pitch into Billy! And it served him right, too. Yes, I showed him up in his true colors, returned our hero. He soon had the papers he and Paul wanted, and then the pair separated, and our hero hurried over to his old stand on Broadway. His clothing had suffered considerably from the encounter with the bully and, though he brushed himself off as best he could, he felt that he made far from a handsome appearance. I must look better than this before I call on Miss Horton, he mused. If I don't, she'll take me for a regular tramp. He wondered if there would be anything in the newspapers about the robbery in Fifth Avenue, and snatched a few moments to scan several sheets. But not a word appeared. I guess they are too high-toned to let it get into print, he reasoned. Well, it's a good thing. I guess it would almost kill Miss Gertrude to see it in the papers. When Nelson got back to the lunch-room he found business was poor, and he expected to see Sam Pepper ill-humored in consequence. On the contrary, however, Pepper was all smiles, and even hummed a tune to himself as he waited on his customers. Something has happened to tickle him, thought the boy. Or else he's got a new plan on hand. How is the sick friend—any better? he asked Pepper. Much better, Nelson. And what do you think? He's loaned me money to turn this place into a first-class café. Don't you think that will pay better than a common lunch-room? I don't know. I'd rather be in the lunch business than running a saloon.
  • 65.
    I wouldn't. Iwant to make money, responded Pepper. What are you going to do? Rip out that old show window and put in a new and elegant glass front, and put in a new bar and buffet. It will be as fine as anything around here when it's finished. I wish I had a friend to loan me money. What would you do with it? I'd buy out a good news stand. There's money in that. So there is. Sam Pepper mused for a moment. Maybe my friend will advance enough for that, too. Thank you, but you needn't bother him, said Nelson coldly. And why not, if I can get the rocks? I'd rather get the money myself. Won't the money be good enough? demanded Pepper, his face darkening. I'd rather know where it came from, returned the boy. The two were in the kitchen at the time, and Sam Pepper had a frying pan in his hand. See here, Nelson, I'll whack you over the head with this, if you talk like that! exclaimed the man, flying into a rage. You won't whack me more than once, Sam Pepper. Won't I? No, you won't. Who is master around here, I'd like to know?
  • 66.
    You are, butI'm not your slave. You talk as if you knew something, went on Pepper, growing suddenly suspicious. Perhaps I do know something, replied the newsboy, and then hurried into the dining room to wait on a customer who had just entered. I'll have it out with you later, muttered Pepper savagely. If you know too much, I'll find a way to keep your mouth closed.
  • 67.
    CHAPTER XIII. A QUESTIONOF BUSINESS. Sam Pepper got no chance to talk to Nelson further that day. As soon as the noon trade was over, our hero hurried off to sell afternoon papers. This time he went up the Bowery, to where Mrs. Kennedy kept her fruit-and-candy stand. It was a small stand, and the entire stock was not worth over ten dollars, but the old woman made enough to keep the wolf from the door, and she was content. I was after thinking you'd come, she said, smiling broadly. I knew you'd want to know about the young lady. How is she? I left her this morning, sorrowful enough, I can tell ye that, Nelson. She don't know how to turn. She thinks she might take in sewing, or something like that, but, bless ye! how much would she make at that? Why, thim Jews that work night and day hardly make enough to keep 'em from starving! Yes, I know it, and it's a shame, said the boy. They get about five cents for a pair of pants and ten cents for a coat, and some of 'em make shirts for three and four cents apiece. I don't see how they stand it. No, she wouldn't earn anything at that. I was a-telling her of Gladys Summers, who sells flowers up on Fourteenth Street and at the theater doors, but she said she didn't want to go out on the street. She's afraid some of her friends would see her, I suppose. She hasn't any friends—'cepting you and me, Mrs. Kennedy. We've got to do for her.
  • 68.
    It's little Ican offer, Nelson; ye know that well enough. She can stay under my roof, but to board her—— I'll pay her board, until she finds something to do. I'll give you three dollars a week for keeping her. Will ye now? Nelson, you're more than kind-hearted. But where will ye be after getting the money? I'll earn it, he answered resolutely. I earn a dollar and over a day now, and I know I can make it more, if I try real hard. He soon left the fruit-and-candy stand and started in to sell papers. He felt that he had a new responsibility on his shoulders, and he determined to do his best. Soon his efforts began to tell, and by five o'clock he was sold out, and the day's earnings amounted to a dollar and thirty-two cents. Half for Miss Horton and half for myself, he murmured. That's the way it's got to be, after this. He was soon on his way to the tenement house in which Mrs. Kennedy's rooms were located. Ascending two flights of stairs, he knocked on one of the doors. Who is it? came from Gertrude Horton. It's Nelson. Oh! And instantly the door was unlocked. A glance at the girl's face told the boy that she had been crying. More than this he saw she was far from well, and the hand she gave him was as hot as fire. Oh, Miss Horton, you're sick! he exclaimed. What's the matter? I have a severe headache, she answered. I think it will pass away soon.
  • 69.
    She sank downon a dilapidated lounge, and he took a kitchen chair. He saw that she trembled from head to foot, and that she had been worrying ever since he had left her. You mustn't worry too much, he said, as kindly as he could. Mrs. Kennedy says you can stay here as long as you feel like it. But she is poor, Nelson, and I—I haven't any money, excepting what you gave me, and you must take that back—you need it. No, I don't need it, Miss Gertrude. See, I've got a lot of money now. I collared that thief and made him give up what he had left, over three dollars—and I've earned the rest selling papers. That's why I didn't come before. I've fixed it up with Mrs. Kennedy, and you can stay just as long as you please. And you are going to pay her? cried the girl warmly. Oh, Nelson! you are indeed good-hearted. But, no; I must support myself. Well, you needn't hurry about it. I can earn enough for both of us just now—and that's what I am going to do. Why shouldn't I? It was my fault that your uncle put you out. No, Nelson; the fault, if it was a fault, was my own. The matter was of long standing. Homer Bulson had wished to marry me for a long time, but I have constantly refused him. Now he has gotten my uncle to side with him. They expect to bring me to terms, I suppose. More than likely my uncle thought I would come back to-day, to do as he wishes. I wouldn't go back. I shall not. I have made up my mind fully. I will support myself, and Homer Bulson can have Uncle Mark's whole estate, if he wishes it. Surely, in such a big city as this there is something I can do. I wouldn't go at sewing—it don't pay. What does pay—that I can do?
  • 70.
    You might geta position in a store. Or maybe you know how to play the piano? went on our hero suddenly. I do know how to play. I took instructions for several years, and have played at private concerts, in Philadelphia. Then you can give piano lessons. But where can I get pupils? We'll advertise in the papers, went on the newsboy, with some importance. I know an advertising man down on the Row. He says anybody can do business by advertising. I'll ask him about it. Of course you'll want to give lessons at folks' houses—being as you haven't a piano of your own. Yes, answered Gertrude, and her face brightened greatly. I could do that, and I would go cheaply first, to get a start. Do you want to put your name in the advertisement? No, have the letters sent to the newspaper offices, and sign the advertisement—— Gertrude paused in thought. Weber, finished Nelson. That's the name of a swell piano, isn't it? It might be too grand for the folks we wish to reach, said Gertrude. Sign it 'Earnest.' And how much will the lessons be? I ought to get at least fifty cents. Then I'll tell the advertising man that. Oh, he's a dandy to write the ads up—makes 'em look like regular bargains! added the boy enthusiastically. Nelson remained at the rooms a while longer, and then hurried to Sam Pepper's place. To his surprise Pepper had locked up, and on the window was the sign:
  • 71.
    Closed for repairs.Will open as a first-class café in about two weeks. He hasn't lost any time in going ahead, thought our hero. I wonder where he is? Sam's out of town, called out a bootblack who had some chairs close by. Told me to give you this. And he passed over an envelope, containing a sheet of paper and the store key. On the sheet was written: Am going away for two or three days on business. A man will be here at ten o'clock to-morrow morning to measure the place for new fixtures. You stay around while he is here. Then you keep the place locked up until I get back. Gone away for two or three days, thought Nelson. I wonder what he is up to now? He went inside, and saw at once that many of the old fixtures had been removed, and that the little kitchen in the rear had been turned almost inside out. The living apartment, however, was as it had been, excepting that Sam Pepper had used it for packing purposes, and the floor was strewn with bits of paper and some excelsior. If I'm to stay here, I might as well clean up, thought our hero, and set to work with a broom. And then I'll take an hour off and clean and mend my clothes. In cleaning up Nelson came across several letters, which were old and mussed. Whether Sam Pepper had thought to throw them away or not, he did not know. To make sure, he picked the letters up and looked them over. Hullo! he cried. Here's more of a mystery.
  • 72.
    The letters wereaddressed to Pepperill Sampson and were signed Mark Horton. The majority of them concerned some orders for dry goods to be shipped to various Western cities, but there was one which was not of that nature. This ran in part as follows: I have watched your doings closely for three weeks, and I am now satisfied that you are no longer working for my interest, but in the interest of rival concerns. More than that, I find that you are putting down sums to your expense account which do not belong there. The books for the past month show that you are behind over a hundred and fifty dollars. At this rate I cannot help but wonder how far behind you must be on the year and two months you have been with our house. You can consider yourself discharged from this date. Our Mr. Smith will come on immediately and take charge of your samples. Should you attempt to make any trouble for him or for us, I will immediately take steps to prosecute you. You need never apply to our house for a recommendation, for it will not be a satisfactory one. The letter was dated twelve years back, and had been sent to Pepperill Sampson while he was stopping in Cleveland. Nelson read the communication twice before he put it away. Who was Pepperill Sampson? The name sounded as if it might belong to Sam Pepper. Were the two one and the same person? They must be the same, thought Nelson. Sam was once a commercial traveler after he gave up the sea, and I've heard him speak of Cleveland and other Western towns. But to think he once worked for Mark Horton! He scratched his head reflectively. Let me see, what did Sam say about the man he wanted me to rob? That he had helped the man who had shot my father. Is there really something in this? And if there is, what can Mark Horton know about the past?
  • 74.
    CHAPTER XIV. BULSON RECEIVESA SETBACK. The mystery was too much for Nelson, and at last he put the letters on a shelf and finished the cleaning. Then he sat down to mend his clothing, and never did a seamstress work more faithfully than did this newsboy. The garments mended, he brushed them carefully. There, they look a little better, anyway, he told himself. And sooner or later I'll have a new suit. Having finished his toilet, he walked down to Newspaper Row. The tall buildings were now a blaze of lights, and many men of business were departing for their homes. But the newsboy found his friend in his office, a little box of a place on an upper floor of the World building. The advertising man had always taken an interest in our hero, and he readily consented to transact the business gratis. The advertisements were written out to the boy's satisfaction, and Nelson paid two dollars to have them inserted in several papers the next day and that following. If the young lady is a good teacher, I might get her to give my little girl lessons, said Mr. Lamson, as Nelson was leaving. I know she's all right, sir, answered the boy. Just give her a trial and see. She's a real lady, too, even if she is down on her luck. Then let her call on my wife to-morrow morning. I'll speak to my wife about it to-night. I will, sir, and thank you very much, Mr. Lamson. And our hero went off, greatly pleased. Late as it was, he walked up to Mrs.
  • 75.
    Kennedy's rooms again.This time the old Irishwoman herself let him in. Sure and it's Nelson, she said. I've got good news, Miss Gertrude, he said, on entering. I put the advertisements in the papers through Mr. Lamson, and he told me that you might call on his wife to-morrow morning about giving his little girl lessons. Hear that now! exclaimed Mrs. Kennedy proudly. Sure, and it takes Nelson to do things, so it does! It meself wishes I had such a b'y. I am very thankful, said the girl. Have you the address? Yes, here it is, on the back of his business card. I know you'll like the place, and maybe they can put you in the way of other places. Av course, said Mrs. Kennedy. Before I had rheumatism I wint out washing, and wan place always brought me another, from some rilative or friend of the family. I will go directly after breakfast, said Gertrude. And I hope I shall prove satisfactory. Knowing the girl must be tired, Nelson did not stay long, and as soon as he had departed Mrs. Kennedy made Gertrude retire. Happily for the girl her headache was now much better, and she slept soundly. In the morning she helped Mrs. Kennedy prepare their frugal repast. As the old Irishwoman had said, she was troubled with rheumatism, and could not get around very well. So Gertrude insisted upon clearing the table and washing the dishes. But, sure, and a lady like you aint used to this work, remonstrated Mrs. Kennedy.
  • 76.
    I mean toget used to it, answered Gertrude. I mean to fight my way through and put up with what comes. Mr. Lamson's home was over a mile away, but not wishing to spend the carfare Gertrude walked the distance. She was expected, and found Mrs. Lamson a nice lady, who occupied a flat of half a dozen rooms on a quiet and respectable side street. She played several selections, two from sight, which the lady of the house produced. That is very good indeed, Miss Horton, said Mrs. Lamson. You read music well. Little Ruth can begin at once, and you can give her a lesson once a week. Ruth, this is Miss Horton, your new music- teacher. A girl of nine came shyly forward and shook hands. Soon Gertrude was giving her first lesson in music. It was rather long, but Ruth did not mind it. Then Mrs. Lamson paid the fifty cents, and Gertrude went away. She's awfully nice, said Ruth to her mamma. I know I shall like her. She is certainly a lady, was Mrs. Lamson's comment. It is easy to see that by her breeding. A new look shone in Gertrude's eyes as she hurried down the street. In her pocket was the first money she had ever earned in her life. She felt a spirit of independence that was as delightful as it was novel. She had already seen her advertisements in two of the papers, and she trusted they would bring her enough pupils to fill her time. She felt that she could easily give five or six lessons a day. If she could get ten or twelve pupils, that would mean five or six dollars per week, and if she could get twenty pupils it would mean ten dollars.
  • 77.
    I wish Icould get the twenty. Then I could help Nelson. He is so very kind, I would like to do something in return for him, was her thought. The weather was so pleasant she decided to take a little walk. She did not know much about the lower portion of the city, and walked westward until she reached Broadway, not far from where our hero was in the habit of selling morning papers. Gertrude was looking into the show window of a store, admiring some pretty pictures, when she felt a tap on her shoulder, and turning, found herself face to face with Homer Bulson. Gertrude! exclaimed the young man. I have been looking high and low for you! Where have you been keeping yourself? That is my business, Mr. Bulson, she answered stiffly. Why, Gertrude, you are not going to be angry at me, are you? Why shouldn't I be angry? Haven't you made enough trouble for me? I haven't made any trouble—you made that yourself, he answered, somewhat ruffled by her tone. I do not think so. Uncle Mark is very much upset over your disappearance. Does he wish me to come back? she questioned eagerly. No, I can't say that, answered Homer Bulson smoothly. But he doesn't want you to suffer. He said, if I saw you, I should give you some money. Thank you, but I can take care of myself. Have you money? I can take care of myself; that is enough.
  • 78.
    Why don't youlet me take care of you, Gertrude? Because I do not like you, Mr. Bulson. How is Uncle Mark to-day? About as usual. You must have upset him very much. Of course I don't believe you took any money out of his safe, went on Bulson. I guess the guilty party was that young rascal who called on you. Nelson is no rascal. He is an honest boy. Nelson! ejaculated the young man. Is his name Nelson? Yes. You act as if you had met him. I—er—no—but I have—have heard of him, stammered the young man. He called on you once, I believe, with somebody who sold you some books. I don't remember that. But he must be the thief. I tell you Nelson is no thief. Thank you for that, Miss Gertrude, came from behind the pair, and our hero stepped up. Mr. Bulson, you haven't any right to call me a thief, he went on, confronting the fashionable young man. Go away, boy; I want nothing to do with you, answered Bulson. Nevertheless, he looked curiously at our hero. I am no thief, but you are pretty close to being one, went on Nelson. Me! Yes, you. You tried to swindle a friend of mine out of the sale of some books you had ordered from him. I call that downright mean. Boy, don't dare to talk to me in this fashion! stormed the young man. If you do, I'll—I'll hand you over to the police.
  • 79.
    No, you won't.You just leave me alone and I'll leave you alone, answered the newsboy. And you leave Miss Gertrude alone, too, he added warmly. Gertrude, have you taken up with this common fellow? asked Bulson. Nelson has been my friend, answered the girl. He has a heart of gold. I can't agree with you. He is but a common boy of the streets, and —— Homer Bulson went no further, for Nelson came closer and clenched his fists. Stop, or I'll make you take it back, big as you are, said the boy. Then you won't accept my protection? said Bulson, turning his back on our hero. No. If Uncle Mark wishes to write to me he can address me in care of the General Post Office, answered Gertrude. All right; then I'll bid you good-day, said Homer Bulson, and tipping his silk hat, he hurried on and was soon lost to sight on the crowded thoroughfare. I hate that man! murmured Nelson, when he had disappeared. I both hate and fear him, answered Gertrude. I am afraid he intends to cause me a great deal of trouble.
  • 80.
    CHAPTER XV. BUYING OUTA NEWS STAND. After the above incident several weeks slipped by without anything out of the ordinary happening. In the meantime Sam Pepper's place was thoroughly remodeled and became a leading café on the East Side—a resort for many characters whose careers would not stand investigation. The man seemed wrapped up in his business, but his head was busy with schemes of far greater importance. He had said but little to Nelson, who spent a good part of his time at Mrs. Kennedy's rooms with Gertrude. Sam had found the letters and put them in a safe place without a word, and the boy had not dared to question him about them. Nor had Pepper questioned Nelson concerning what the lad knew or suspected. The results of Gertrude's advertising were not as gratifying as anticipated; still the girl obtained seven pupils, which brought her in three dollars and a half weekly. Most of the lessons had to be given on Saturdays, when her pupils were home from school, and this made it necessary that she ride from house to house, so that thirty- five cents of the money went for carfare. Never mind, said the newsboy; it's better than nothing, and you'll get more pupils, sooner or later. The boy himself worked as never before, getting up before sunrise and keeping at it with sporting extras until almost midnight. In this manner he managed to earn sometimes as high as ten dollars per week. He no longer helped Pepper around his resort, and the pair compromised on three dollars per week board money from Nelson. The rest of the money our hero either saved or offered to Gertrude.
  • 81.
    All he spenton himself was for the suit, shoes, and hat he had had so long in his mind. I declare, you look like another person! cried the girl, when he presented himself in his new outfit, and with his hair neatly trimmed, and his face and hands thoroughly scrubbed. Nelson, I am proud of you! And she said this so heartily that he blushed furiously. Her gentle influence was beginning to have its effect, and our hero was resolved to make a man of himself in the best meaning of that term. One day Nelson was at work, when George Van Pelt came along. How goes it, George? asked the boy. Nothing to brag about, returned Van Pelt. How goes it with you? I am doing very well. Made ten dollars and fifteen cents last week. Phew! That's more than I made. How much did you make? Eight dollars. I wish we could buy out that news stand. I am sick of tramping around trying to sell books, went on George Van Pelt. Last week I was over in Jersey City, and one woman set her dog on me. I hope you didn't get bit, said Nelson with a laugh. No, but the dog kept a sample of my pants. Have you heard anything more of the stand? The owner says he's going to sell out sure by next week. He told me he would take ninety dollars cash. He's going away and don't want a mortgage now. Ninety dollars. How much have you got? I can scrape up forty dollars on a pinch.
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    I've got fifteendollars. That makes fifty-five dollars. We'll want thirty-five more. How can we get that amount? I reckon we can save it up—inside of a few weeks, if we both work hard. The man won't wait. There's a party will give him seventy-five dollars cash right away. He's going to take that if he can't get ninety. At that moment Nelson caught sight of the familiar figure of a stout gentleman crossing the street toward him, and ran out to meet the party. Good-morning, sir! he said. Have some papers this morning? Hullo! you're the boy that saved me from being run over a few weeks ago, returned the stout gentleman. Yes, sir. I'll have a Sun and a Journal, and you can give me a Times, too. How is business? Good, sir. I was in a hurry that day, or I would have stopped to reward you, went on the gentleman. You did reward me, sir. Did I? I had forgotten. You see, that fire in Harlem was in a house of mine. I was terribly upset. But the matter is all straightened out now. I hope you didn't lose much. No, the loss went to the insurance companies. The stout gentleman paused. My lad, I would like to do something for you,
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    he went onseriously. Have you got a job for me? I don't know as I have, just now. But if you need help—— I do need help, sir. Are you a capitalist? A capitalist? queried the man, puzzled. What do you mean by that? I mean one of those gentlemen that loan money out on business? I've heard of 'em, down in Wall Street. Well, I sometimes loan money out. Then I'd like to borrow thirty-five dollars. Nelson beckoned to George Van Pelt, who had moved off a short distance. You see, it's this way, he went on, and then told about the news stand that was for sale, and what he and the book agent wished to do. Mr. Amos Barrow, for such was the gentleman's name, listened attentively. And you think this would be a good investment? he questioned. Yes, it's a good stand, said Van Pelt. But you ought to have some money with which to stock up. We'll work hard and build it up, said our hero. I know that neighborhood well. Old Maxwell never 'tended to business. I'll go around and get twice as large a paper route as he ever had. And we can keep plenty of ten-cent paper-covered books, and all that. And we can keep things for school children, too, put in George Van Pelt. There is a school near by, and many of the children pass the stand four times a day. Well, I'll give you fifty dollars, Nelson, said Mr. Barrow. That will help you to buy the stand and give you fifteen dollars working
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