Optimising Cultural Safety and Comfort during Gynaecological Examinations: Accounts of Indigenous Maori Women

Procedures that disrupt women's usual boundaries of space and privacy are commonplace in clinical care. Clinicians' provision of culturally safe care requires awareness that 'every-day' interventions are often outside of the realms of'normal' for people physically, emotionally and spiritually (Cook, 2011; Cook & Brunton, 2014). The term, clinicians, is used in this article to signify nurses and doctors where they are referred to collectively. Clinicians' ability to engage in a culturally competent manner is described by Durie (2001) as a relational skill, which improves the performance of health professionals. The aim of this article is to provide Maori women's examples of such relational skills, to highlight how cultural competency can be expressed by Pakeha (non-indigenous) nurses and doctors in ostensibly routine, invasive clinical situations. In this article we report on the accounts of ten women identifying as Maori, who described experiences of examinations provided by Pakeha clinicians. This analysis is significant as there are considerable quantitative data about the marginalised position of Maori compared to other ethnicities within Aotearoa in relation to sexual, maternal and gynaecological health and cancer diagnoses (Brewer, Pearce, Jeffreys, Borman & Ellison-Loschmann, 2010; Lamb, Dawson, Gagan & Peddie, 2013; McKenzie, Ellison-Loschmann & Jeffreys, 2011; Morgan, Donnell & Bell, 2010). However, there are few studies of Maori accounts about clinical care by Pakeha (see for example Pitama et al., 2012; Wilson, 2003).The operational definitions of cultural safety and cultural competency are drawn from the Nursing Council of New Zealand (NCNZ) (2011), which evolved from the innovative work of Maori nurses, led by Irihapeti Ramsden (1992). Also pertinent are Papps' and Ramsden's (1996) rationale for cultural safety, and the imperative for Maori health initiatives and the Treaty of Waitangi to be upheld within social policy (Kingi, 2007; Lyford & Cook, 2005). Culturally safe health service delivery to Maori is determined by the recipients of care, including families. For clinicians to foster cultural safety requires an appreciation of people as whole beings. A holistic orientation acknowledges worldviews encompassing beliefs about morality, behaviour and rituals, and recognises that people are connected physically, emotionally, intellectually and spiritually to others (living and ancestral), and to the land. Cultural competency requires clinicians to reflect on the significance of their own cultural identity and its impact upon practice (NCNZ, 2011). This cognisance entails appreciation of historical, political and social influences on health, rather than a narrower awareness of rituals and practices. Clinicians committed to providing culturally safe care are mindful of power relations, and adapt care to meet diverse needs. Commitment to cultural competency is a politically active position (Giddings, 2005). Respect for difference requires that clinicians relate to people who identify as Maori beyond a bio-reductionist framework of an individual 'case' to diagnose and treat (Jeffery, 2005).Although primary health care providers including iwi (tribal) health organisations endeavour to make available indigenous nurses and doctors, Maori are under-represented in health professions and Maori commonly do not have a choice of providers ( McKimm, Wilkinson, Poole & Bagg, 2010; Wilson, McKinney & Rapata-Hanning, 2011). Within mainstream healthcare, Giddings (2005) notes that nurses who experience marginalisation are not necessarily able to advocate for marginalised patients and protocols; efforts to 'fit in' may silence protest. Giddings argues that is unjust to expect Maori nurses to carry sole responsibility for the cultural safety of Maori.Blaming vulnerable populations, including Maori, for their health status is commonplace (Reid & Robson, 2006; Wilson & Neville, 2008). …