Cultural safety: There is no turning back!

It is now over 20 years since Dr Irihapeti Ramsden and nursing colleagues conceptualized “cultural safety” and took the profession by storm (Papps & Ramsden, 1996). Cultural safety focuses on the social determinants of health and the impact of power relationships through social processes, such as colonization, that have benefited one group of people to the devastating detriment of others. This is starkly reflected in health inequities. Cultural safety requires reflecting on and responding to power dynamics. For those of us in positions of power, there is an inherent ethnocentric belief that our cultural way of being is natural, correct and superior to that of others. In mental health nursing, this bias intentionally and unintentionally filters into the therapeutic relationship and manifests in poor communication, erosion of autonomous decision-making and actions that are perceived as disrespectful, regardless of good intent (Curtis et al., 2019). Cultural responsivity requires a conscious commitment to the development of long-standing trust initially tainted by injustice and empowerment of those disadvantaged. It requires establishing collaborative relationships with those immersed in the culture to best serve those from that culture. For those of use from the dominant culture, it requires shifting the power imbalance in monocultural institutions that support bias, so that inequity is addressed. No easy feat, but therein lies our challenge. My passion is forensic mental health, the interface between mental health and the criminal justice system. The populations served internationally by forensic mental health services (FMHS) attest to the depth of inequity. In Australia, indigenous people (Aboriginal and Torres Strait Islanders) experience a relative risk of imprisonment 15.2 times that of the non-indigenous population. They constitute 3% of the population and 27% of the prison population, with a staggering imprisonment rate of 2,434 per 100,000 population versus 160 per 100,000 population for non-Aboriginal (Skipworth, 2018). In a representative sample of indigenous people incarcerated in Queensland, the 12-month prevalence of mental disorder was 73% amongst men and 86% amongst women (Heffernan, Andersen, Dev, & Kinner, 2012). In Canada, indigenous people (First Nations, Inuit and Métis) account for only 4.3% of the general population, yet 21% of the total federal prison population (Gutierrez, Helmus, & Hanson, 2017). They too have high rates of psychotic mental illness and major depression (Simpson, McMaster, & Cohen, 2013). In my own country, Māori (the indigenous people) experience 7.5 times the risk of imprisonment when compared to New Zealanders of European heritage, with an incarceration rate of 704 per 100,000 population (Skipworth, 2018). In prison, Māori have the highest frequency of psychotic symptoms compared to any other ethnic group (Indig, Gear, & Wilhelm, 2016). Non-indigenous migrant groups (ethnic minorities) experience similar socio-political dominance, and socio-economic and health disadvantage. For example, in prisons in England and Wales, 26% identified as being of a non-white ethnicity, compared with 13% in the general population (Sturge, 2018). There is growing concern regarding the unmet mental health needs of this incarcerated population (Lammy, 2017). So, do we perpetuate inequity by supporting the monocultural bias of custodial institutions, or adopt a departure from this pathway towards transformational change to address the root cause of inequity? In Aotearoa, New Zealand, the platform for the latter was laid with the signing of the Treaty of Waitangi in 1840 between the British colonizers and Māori tribes, which guaranteed Māori self-determination, viable partnership and equality. Despite a history which has negated this intent, this vision is promulgated in the blueprint for FMHS. The Mason Report (Mason, 1988) created the possibility of transformational change towards bicultural FMHS. Services in which standard evidence- based clinical approaches co-exist with cultural ways of being), in a mutually beneficial relationship. For over 20 years, I have held joint academic and clinical nursing appointments in FMHS. It has been my privilege to be part of an innovative service that has attempted to confront the challenges I have outlined. The Auckland Regional Forensic Psychiatry Services (ARFPS) serves a catchment population of 1.5 million people in the northern regions of Aotearoa, New Zealand. It provides integrated mental health services to a 113-bed secure hospital, to those exiting the hospital and transitioning to the community, and to the region's courts and prisons. The workforce is multidisciplinary employing approximately 260 mental health nursing staff including healthcare assistants. This workforce is expected to have some knowledge and appreciation of Māori culture (Mason, 1988). However, more important is the expectation that the workforce is culturally safe with the ability to recognize and act on the root causes of cultural and ethnic inequities. This clinical workforce is enriched by a number of Māori health professionals, despite the disproportionate representation of Māori and other ethnic minorities within these professions (Te Pou o Te Whakaaro Nui, 2015). The ARFPS also employs cultural experts (Taura Whiri) as multidisciplinary team members to assist in the assessment and management of service users; provide training for staff; assist in developing cultural services; and maintain close relationships with local iwi (tribes). Within the service as a whole, there is an evidence-based clinical model of care combining therapeutic security, rehabilitation and recovery-oriented care, which stands alongside a cultural model of care with core cultural values. We have clinical pathways, which align the recovery journey with levels of security and eventually of successful integration to the community. One pathway is mixed gender; one is a male only for men involved in sex offending or very violent offending; and the third is Kaupapa Māori (a Maori approach), whereby clinical need is integrated with daily life, which reflects a group-orientated cultural way of being. We have evidence-based clinical interventions targeting recovery needs focusing on physical health, mental health, drugs and alcohol use, problem behaviours, activities of daily living, vocation and social well-being. We also have culturally specific interventions to enable cultural understanding and growth. Even the physical environment reflects a bicultural approach: a traditional meeting house and various depictions of a Maori way of viewing and representing their world (e.g. carvings representing holistic Māori health, incorporating physical, mental, family and spiritual well-being). Such symbolism taps into deep cultural meaning. Innovative cultural responsivity is not without its challenges. As significant as the bicultural progress has been, it has taken over 30 years. It is not integrated completely in all parts of the service or with external agencies we interface with. Lack of such consistency risks interrupting the cultural continuity of care. Pacific Island peoples (primarily of Samoan, Tongan, Cook Island, Fijian, Nuien, Tokelauan and Tuvaluan descent) who immigrated to Aotearoa, New Zealand, to fill employment gaps, constitute 7% of the general population, but account for 12% of the prison population (Poutama, 2019). These people have the highest prevalence rate by ethnicity of any mental illness amongst prisoners (Indig et al., 2016) and are grossly over-represented at the ARFPS. There is a need for a cultural model of care and associated service delivery model for this group of service users. To truly transform monocultural institutions, cultural leadership needs to sit alongside clinical leadership and be involved in all facets of decision-making. This remains work in progress. Kua tawhiti kē tō haerenga mai, kia kore e haere tonu. He nui rawa ō mahi, kia kore e mahi tonu We have come too far not to go further. We have done too much, not to do more

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