Are Hospitalized Patients Culturally Safe?

Abstract

My personal and professional experiences as a practitioner nurse, and a lecturer unveil that, in the present environment, patients, along with the fear of death and illness, face stressors such as being stranger to the treatment team, being unaware of the treatment process, fear of questioning, the unfamiliar environment of the hospital and its governing culture. In most cases, not only the values, beliefs and identities of patients are not taken into account in decision making, but also the atmosphere governing medical centers is somehow trying to instill their thoughts and beliefs in them. This makes decision-making solely on the basis of disease recognition, not pertaining to the patient’s requirements. In such an atmosphere, the possibility of the patient’s participation, cooperation and protection in daycare is threatened, and in many cases, it prevents follow-up and adherence to treatment and prevents us from the goal of improving the quality of patient-centered services with a view to clinical excellence. The concept of cultural safety, along with encouraging the practitioners to rethink, opens the way for the implementation and attainment of the ideals of emancipatory theory in nursing, which have been for years restricted to the scope of theoretical knowledge.

1. Introduction

The advent of modernity and its values into the philosophy of medicine had begun years before I became a nurse. In fact, I entered this major during the period of positivist revision. Yet, like many of my colleagues, I became a nurse with a positivist viewpoint. Fully confiding in western medicines, treatments and their effectiveness for all patients, I entered the hospital as an emergency ward nurse. However, the more I worked on patients, the more I noticed the differences between people and their disease impressionability. As a nurse, I was more focused on the patient himself and found that each patient perceives the disease in his own way. Accordingly, the burden and severity of the disease were different from patient to patient, but what caught my attention the most was their negative feelings about the experience of being hospitalized. Something more than illness seemed to bother them. I had heard them saying many times: “Do not see me falling on this bed, I was someone for myself.” I do not know what was going on with them that they needed to remind us of their identity.

The turning point of all these thoughts was my hospitalization as a patient. I was admitted to the hospital where I worked. I had an independent identity there as a nurse, and I was in a friendly environment, so I thought it was the best place to get cured. But in a moment, after wearing the patients’ uniform and with my first encounter with nurses, I lost all my identity. The illness had devoured not only my health but also my identity. Although familiar with all the concepts of care and treatment, I was not involved in treatment decisions. I was just a patient and only the doctors’ and nurses’ decisions were given to me. At the end of the first day of hospitalization, I was so full of negative and disturbing feelings that the disease was thoroughly forgotten. The health care provider’s behaviors had a different story. They considered me someone who could not properly take care of herself and consequently got ill. While I was their colleague and knew all about the procedures and I was not afraid of them, I was blamed many times why I had not come earlier. I put myself in the shoes of patients who did not have my knowledge and realized what an unsafe and stressful place (hospital) they stepped in. Afterward, I reviewed that experience many times in my mind, and each time I felt the same sorrow. My feelings for myself as a nurse had changed.

With this concern and in search of a way to make the experience of hospitalization and illness lighter, I focused my studies on this area. Owing to my familiarity with philosophical concepts and philosophy of medicine, I realized how much I was entertained by the physiology of organism and body, and we are unaware of patients’ cultural beliefs and values and their effects on determining the level of health and the type of people’s experiences of health. Similarly, we have substituted the global standard treatment protocols for paying attention to patients’ social status and cultural-historical and identity characteristics. The result is considering patients’ identities based on their illness, such as epileptic patients or cancer patients. More painfully, the teachings are focused on the same principles [1].

However, in recent decades, the inefficiency of such an attitude has become more apparent and patients’ dissatisfaction with the way services are provided, its coincidence with the customer-oriented issues and competition among medical centers has been an inauguration to criticize the biomedical model more than ever [2].

2. Cultural safety

Today, the emergence of new perspectives in the face of disease has fundamentally changed the meaning of treatment and care. In many developed countries, the patient is now considered among a set of factors determining the level of individual and social health, and the disease is considered not as a single phenomenon but as a product of the patient’s Life-world [3]. In this case, Emami quotes Mardiros as saying, “When people look more deeply at their diseases, they realize that disease, illness and malnutrition are themselves symptoms of a deeper disease rooted in class differences, economic exploitation and political pressures” [4].

Nursing is no exception to these changes. Although holistic teachings were rooted in Florence Nightingale’s point of view, and Madeleine Leininger was the first to formally emphasize the relationship between patient culture and nursing care [5], the integration of nursing with reductionist biomedical model and the desire to specialize in the care of various organs of the body caused the perspective of nursing to change at the same way as the philosophy of medicine changed. Perhaps the origin of these changes, coinciding with the introduction of the holistic paradigm, can be seen in the 1970s. Thus, health is defined as a feeling of well-being experienced and approved by the patient [6]. In fact, it is the patient’s mental understanding that affects his or her satisfaction, and no one else but the patient himself can tell what matters to him [7].

Nowadays, the propagation of such attitudes has caused the patient to be seen with all his/her appurtenance and “culture” is considered as the framework of individual worldview and the factor shaping health behaviors [8]. Many international human rights treaties now recognize the “cultural right” as a principle based on respect for ethnic differences and acceptance devoid of judgment, and protecting these rights is the responsibility of health care providers’ members, including nurses [9]. The International Council of Nurses (ICN) considers respect for human rights, including the cultural right, right to life, choice, human dignity and respectful behavior, which are not influenced by nationality, race, skin color, age and sex, as an integral part of nursing [10]. On the other hand, globalization and the expansion of communication, diversity and multiplicity of cultures and identities have changed the structure of societies. Now in many areas, therapists and patients do not share a common culture, and caring for patients with different cultures is a matter of course in 21st-century nursing [11].

In order to fulfill their mission of providing the community with health by communicating effectively with patients, all this has caused the health care providers to need a view beyond biological knowledge. My studies in this field eventually made me familiar with the concept of Cultural Safety. Regarding the issues raised, this concept emphasizes how the healthcare providers will be held responsible and accountable. In 1990, Irihapeti Ramsden introduced the concept of cultural safety as a result of colonialism and health inequalities in Maoris, which were among New Zealand’s indigenous tribes [11]. New Zealand at that time was an independent country where, despite the end of the colonial era, the spirit of colonialism was still flowing in its interpersonal relationships, and this caused the country’s largest indigenous minority to be in poor condition in terms of health and hygiene facilities. This concern was raised in 1988 by a group of Mao tribal nurses who relied on the concept of “safety” and found that regarding the prevailing culture of immigrant groups in the community there was no security for the natives in the Western biomedical educational space and this severely affected their health status [12]. They believed that despite the claims in today’s society, care is not provided for individuals, but is planned for the groups or classes to which they belong, and because health care systems are influenced by the dominant culture and powerful groups of society and are planned according to their needs, there is no justice in this regard. On the other hand, health care providers are also trained to deal and communicate with the dominant groups of the society and recognize them as the “norm” [13]. Thus, cultural safety was born as a postcolonial concept. This concept is derived from clinical nursing, which focuses on the strength of nurses and other members of the health care providers to highlight the effects of power inequality on patients’ health. Cultural safety is actually a radical concept that brings political perspective into the body of health knowledge and challenges “power” as a concept with the essence of politics in a knowledge-based context [14]. Given the effects of socio-political conditions on the attitudes and beliefs of the healthcare providers, especially nurses, this concept draws their attention to the impact of their views on patients’ health [12].

Cultural safety means providing effective healthcare to a person with a different culture so that this care is approved by the individual and his family [15]. Emphasizing on “self-awareness,” this concept challenges members of the healthcare providers in their intellectual background about the “power” [14], and creates a critical insight into the inherent power difference between the healthcare providers and the client, the therapist becomes aware of the impact of his or her thoughts on patients’ health. In this regard, considering the patient’s beliefs, values, personal experiences and cultural identity is inevitable [14, 16].

The word “culture” in cultural safety does not simply refer to ethnicity or race. Rather, in its broadest sense, it includes the age, sex, race, religion, social class, and economic and political status of individuals [17], this definition warns of the atmosphere of Racism and Ethnocentrism in health care providers and patient interactions. “Safety” is also derived from the idea of security in nursing and refers to the minimum standards that must be met to prevent harm to a person. Of course, along with physical safety standards, the role of moral standards is more prominent [18], and the patient’s experience of illness shapes a sense of security or insecurity [19].

Cultural safety targets the therapist’s attitudes and beliefs and emphasizes that the awareness of therapists about the impact of social, political and cultural factors on their thinking changes their viewpoints and is effective in creating safe interaction with patients [20]. According to this view, care is considered safe if the patient does not feel diminish, demean, disempowering [15] and if deprivation of health facilities and the social and political conditions of particular groups are recognized [21]. In other words, the patient’s “identity” is not integrated into the disease and his/her individual needs are included in health planning [22]. Cultural safety is, in fact, the result of critics’ efforts to achieve Emancipatory Theory. Hence, this concept can be considered as a facilitator for the transition from a purely empirical perspective to scientific intellect and wisdom. It is noteworthy that the Emancipatory Theory does not deny the importance of the empirical view, but it opposes its monopolism [23]. Therefore, cultural safety is not an emerging goal in nursing. Rather, it is a means of implementing what has been proposed in the theoretical realm for many years. In addition, this concept, along with encouraging the healthcare providers to rethink, paves the way for the implementation and achievement of the ideals of nursing emancipatory theories, which have not been outside the scope of theoretical knowledge for many years [24].

By creating a new attitude in the healthcare providers, cultural safety helps them to understand their truth and change their attitudes toward other ethnicities. In addition, cultural safety encourages the healthcare providers to be open-minded and do not blame the victims of socio-historical processes for what they are today and to be flexible with people who are different from them since the lack of security and fear of humiliation are among the factors that make patients refuse to go to medical centers on time. These feelings put the patient in a passive position against the culture that governs medical centers and threaten his/her cultural safety and this affects the health of a large segment of society [17]. Cultural safety aims to create an atmosphere free of threats and judgments for the patients [25].

In fact, cultural safety can be used as a tool to identify and analyze the relationship between the patient and the therapist.

When we look at therapeutic relationships through the cultural safety lens, we realize that the basis of the relationship between patients and therapists is the power of knowledge. This relationship is one-sided in nature and is surprisingly formed to meet the needs of therapists, like when taking a history, filling out forms or completing procedures. Although these activities are all aimed at doing the patient’s work, they are imperative and the way they are done is as if the patient has to help the doctor to do her daily work. The healthcare providers and especially the doctors ask more questions. Choosing the topic of conversation, it’s starting and finishing is determined by them, and patients are merely responders. In fact, the same concept of “low value conversation” of Mishler [26], prevails in medical centers: One question, one answer and then the next question. In fact, the relationship between the healthcare providers and the patients has become so classified and framed that even facing non-co-speaking patients is not a challenge for the healthcare providers, because the dominant language is the language that the healthcare providers speak. In this case, non-co-speaking patients cannot express their Life-world to the healthcare providers, so their attitudes, beliefs and desires are ignored. In this case, “language” comes out of the passive form of a set of words that express the meaning of the speaker and becomes a tool of strength or superiority of the healthcare providers. Because it is not possible to talk and bargain about what the patient wants and what the doctor deems appropriate, and these conditions lead to medical hegemony.

Cultural safety tells us that, in fact, patients do not consider the healthcare providers, especially physicians to be their servants due to their needs or even by habit. Rather, they see them in a higher and superior position and transfer the same view to the healthcare providers. Thus, a hegemonic relationship is formed in patient relationships and healthcare providers. The term “hegemony” was first coined by Antonio Francesco Gramsci (1937–1891) and implies the domination of a class not only economically but also in all social, political and ideological aspects. Hegemony is a form of control that is primarily exercised through the macro structures of a society [27].

In this regard, paying attention to the position of health services in today’s world, Daniel Weber (2016) warns about the medicalization process of human societies and considers that it a product of medical hegemony (health care providers). He uses the term Medical Care Industry for this purpose. He believes that it is so due to the introduction of money and politics as two main factors symbolizing power in the medical field [28].

These conditions include the agency of the healthcare providers toward patients. This agency is present in all processes from diagnosis to treatment decisions. Accordingly, medical expression dominates the biological expression of patients because patients only answer doctors’ questions and do not have the opportunity to express themselves, and this is the condition that cultural safety has been protesting against and warning about its formation in medical centers. Another issue that threatens patients’ cultural safety is professional centrism. Claiming that the problems are specialized, the healthcare providers do not actually involve patients in making the decision. In many cases, they provide patients with information selectively. In other words, they convey to patients what they want (at their own discretion). I call this situation a “disease indemnity.” This means that patients at the time of hospitalization should remunerate for their getting sick by abandoning their values, beliefs and preferences and accept the culture that governs the hospital [29] , cultural safety has passed through mere participation in the process of being ill and emphasizes “effective participation.” The current situation in the field of patient participation is actually what cultural safety calls the product of colonialism and warns about it. In fact, the insistence of cultural safety on patient participation is ultimately the attainment of the right to self-determination [21] that the superior view of physicians, which is referred to as professional centrism, has practically negated. From a cultural safety perspective, the scientific superiority of the healthcare providers and specifically the physicians cannot be a valid reason for treatment decisions because these people do not know the patient’s preferences. In fact, they make decisions for illness and not for the patient [25].

Specialism, on the other hand, draws a glass wall between the patient and the healthcare providers and divides them into two categories: “insider” and “other,” in such a way that the “insider” is at the center, and “the other” is around. Thus, cultural colonization governing medical centers is not a suitable platform for the realization of cultural safety. The dominance of the biomedical paradigm in these centers leaves no room for attention to the individuality, culture and identity of the patient in the ideology of the healthcare providers. This bipolar view shifts the power toward the health care providers and does not allow the patient to express her/himself, and in such a case the patient is exposed to cultural risk and not cultural safety [29].

On the other hand, patients have an effective role in the formation of this culture. As Foucault recalls, this dominance has emerged with the patient’s own complicity. It is clear that patients’ perspectives are derived from the culture and social teachings. Today, the cultural institutions of society, of which the media is perhaps one of the most pervasive and effective ones, move to maintain and strengthen this dominance, willingly or unwillingly. Medicalization that Ivan Illich mentions [30] is widely advertised by the media. Making numerous medical programs and inviting medical staff to discuss and comment even on religious beliefs and rituals such as fasting, etc. contributes to accelerate this culture because people see all aspects of their lives from birth to death in their hands. In fact, influential organs in popular culture offer philosophies in which life is not possible without medical science, and in this way, they strengthen the hegemony of the healthcare providers.

Cultural safety can change totalitarian ideologies, and create critical insights into the members of the healthcare providers informing them the impact of their performance. Accordingly, while satisfying patients and promoting health services, it organizes and facilitates marginal movement to the center. As a converter tool to change the atmosphere of medical centers for the benefit of the patient, “cultural safety” can reduce the suffering of illness and hospitalization [14].

To achieve this goal, it is necessary for nurses and other members of the healthcare providers to have a view beyond the disease of the patient, and taking into account all the biological, psychological, social and cultural aspects to provide safe care that is approved by the patient. In the face of patients with chronic diseases, nurses and other members of the healthcare providers should pay special attention to the bio-world of the patient because these patients live with their disease and as a result, the disease can change the quality of their life for a long time. And this is exactly where understanding the patient’s bio-world can be effective in providing safe services. In addition, it should be noted that without knowing the patient, safe and approved care cannot be provided. Therefore, a suitable bed must be provided to hear the patient and understand his expectations. Nurses and other members of the healthcare providers should be aware that standardizing treatment of patients not only means justice but also endangering their cultural security, creates conditions of inequality and the exercise of power.

Cultural safety is the result of a process that begins with cultural awareness and leads to cultural safety by understanding cultural sensitivity and cultural competence [22]. Cultural awareness means understanding the impact of culture on the formation of one’s beliefs, values and political power and emphasizes that different cultures, subcultures and ethnicities have different values and views [31]. Cultural sensitivity means respecting and valuing different cultures. With such an attitude, one understands how culture affects one’s personal and professional identity, and this is essential for establishing an effective cultural interaction [32]. Cultural competence is also understanding the values, beliefs and functions of patients’ health that promote patients’ health and is considered as an essential part of holistic care [31].

Thus, cultural safety is the product of a movement that begins with cultural awareness and eventually reaches cultural competence [33]. But, in many cases, the current education has remained at the level of cultural awareness. As a result, only existing cultural diversity is accepted, but the place of culture in the treatment of the disease and patients’ views on the disease are not considered [14]. What is raised in cultural sensitivity is beyond mere recognition of differences.

According to this concept, even two people with a common culture can have different perceptions of the world [18], and understanding this can pave the way for cultural safety.

In other words, even in common contexts, nurses should not present care with their own pre-judgments and presuppositions, and this is the very emphasis on individualized care in nursing.

3. Conclusions

The healthcare providers behave as they are trained. What is taught in medical and nursing universities is the treatment of diseases based on the biomedical paradigm. This paradigm is knowledge-based and disease-oriented and does not take into account many individual and social factors. Therefore, a large group of factors affecting health is ignored. Neglecting things such as paying attention to individual and non-biological aspects of the disease causes inefficiency of the health system. Teaching these cases can make students be more effective people to maintain and promote health. Changing the viewpoints of nursing education custodians from the concept of “culture” is essential in this regard. It is necessary for nursing and other medical disciplines’ students to learn that specialized knowledge does not necessarily outperform empirical knowledge, and treating the disease without knowing the patient’s bio-world is just a mirage.

On the other hand, communicative inequality and information imbalance minimizes the possibility for the patient to participate in care procedure. Believing in supposed superiority due to their expertise, the healthcare providers unconsciously choose options that meet their own needs. The guided information neglects the patient’s agency. In so doing, participation in treatment as a fundamental cornerstone in cooperation between the patients and curers is replaced by obeying treatment. This elite-oriented perspective contrasts sharply with a humanitarian and democratic process which is a necessity for a patient-curer relationship. In this case, the cure team identifies itself as an elite group with a consistent organization which considers patients as a formless mass being affected; thereby, the cure team feels superior and tends to convey such superiority to patients. In an atmosphere like this, the possibility for the patient to affect the care team is almost trivial or improbable, and this is a threat to the cultural safety of the hospitalized patients.

Acknowledgments

This chapter is a part of my research study and extensive studies conducted by me and my colleagues. Hereby, I express my heartiest gratitude to Professor Reza Negarandeh, Professor Hamid Peyrovi, and Dr. AbouAli Vedadhir, who helped and guided me in performing the study.

Conflict of interest

The author declares no conflict of interest.