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Issues
Managing the cross-
cultural consultation
The importance of cultural safety
Ben Gray
Correspondence to: ben.gray@otago.ac.nz
Ben Gray has been a GP at Newtown ABSTRACT
Union Health Service (NUHS) for the last ‘Cultural competence’ is in the spotlight with recent documents released by
the Medical Council and the RNZCGP. The RNZCGP document has a strong
15 years, prior to which he worked in focus on better care for Maori, but the omission of any reference to the use
Waitara Taranaki. NUHS serves a diverse of interpreters means that the needs of those who speak limited English are
multiethnic population. He also works as inadequately addressed. This article argues that we should separate out the
two issues of ‘The Treaty of Waitangi’ and ‘cultural safety’. The Nursing
Senior Lecturer and convenes the ‘Pro- Council has made this distinction, largely based on the writings of Irihapeti
fessional Skills Attitudes and Ethics’ Ramsden on cultural safety. It then describes what the author has learned
course for Wellington Medical Students. about managing the cross-cultural consultation in an approach that is con-
gruent with cultural safety.
Cross-cultural care is much more in ing for many patients with either no I believe that the Treaty of
the spotlight currently. The Medical or limited English, a document on Waitangi is an important document
Council of New Zealand (MCNZ) has ‘Cultural competence’ (the RNZCGP and provides the principal negotiat-
recently released two guidelines: document) that makes no mention ing basis for the relationship between
‘Cultural competence’ (CC) (MCNZ29) of the use of interpreters, has missed Maori and the Crown. Maori are the
and ‘Best practices when providing an important aspect of the skills indigenous people of New Zealand
care to Maori patients and their needed for effective cross-cultural and, as the Treaty partner, the Crown
whanau’ (BPPCMP) (MCNZ30). The consultations. is responsible for ensuring that
RNZCGP has recently released ‘Cul- Doctors in medicine are slow to health services are accessible and
tural competence’. One appropriate react to some issues. Our nursing col- acceptable to Maori.
focus of the MCNZ and RNZCGP leagues have been developing the While current literature 4 ad-
documents is the impact of cultural issues around cross-cultural care for dresses cultural responsiveness to
competence on improving care for more than 10 years. The writings of Maori, other cultural groups are not
Maori. Alongside this remains the Irihapeti Ramsden in relation to ‘Cul- as well served. A bicultural rather
very important issue of improving tural safety’2 were an important than a multicultural response is also
care for our increasingly diverse stimulus to this debate in nursing. The reflected in the Medical Council
multicultural population; diversity current Nursing Council clearly dis- document, ‘Cultural competence
both in the origin of the doctors (as tinguishes two related but separate standards’: ‘14(g). An awareness of
noted by the MCNZ, 41% of all prac- domains: the general beliefs, values, behaviours
tising doctors received their primary ‘Competency 1.2: Demonstrates and health practices of particular
qualification from an overseas coun- the ability to apply the Treaty of cultural groups most often encoun-
try) and of the patients. Wearn et al.,1 Waitangi/Te Tiriti oWaitangi to nurs- tered by the practitioner.’
in their survey of Auckland GPs, ing practice Ramsden is critical of this ap-
show that communication difficulties Competency 1.5: Practices nurs- proach to cross-cultural care:
are a common feature of Auckland ing in a manner that the client de- ‘Ethno nursing as used within the
practice. From my perspective, car- termines as being culturally safe’3 Transcultural Nursing programmes
124 Volume 35 Number 2, April 2008Issues Issues Issues Issues Issues
has developed from cultural anthro- practice where I am regularly in con- ‘The attitudes and behaviour charac-
pology and takes on an observational tact with many different ethnicities teristic of a particular social group.’
approach to other cultures. While care with their own cultures and many
remains focussed on the “cultural” with their own language. Is ‘culture’ the same as ‘ethnicity’?
activities of the patient, there remains The model of learning about the For many people these two concepts
the tendency to promote a stereotypi- culture of my patients, promoted in are congruent. The vast majority of
cal view of culture over time thus the Jansen and Sorrensen article,4 has ethnic Samoans living in Samoa ad-
making it difficult to respond to indi- prompted me to articulate a model that here closely to Samoan cultural
vidual diversity. This can lead to a is helpful in culturally diverse prac- practice.
static approach to culture where tice. In my day-to-day work I see peo- The problem is that there are in-
groups of people come to hold an un- ple from many cultures: Maori, Pakeha, creasing numbers of people for whom
changing and uniform set of beliefs: Pacific Peoples, Assyrian Christians ethnicity is not an accurate predic-
The problem of stereotyping cul- from Iraq, Somali Muslims, Ethiopi- tor of their cultural behaviour for two
tures is compounded by the assump- ans, Cambodians, Vietnamese and main reasons:
tion that the country of origin of a small numbers from many other places. • They are living or were born in a
person (or his/her parents) identifies It is possible with some effort to learn society away from their ethnic
the most significant dimension of his/ to pronounce names properly and to home
her experience. pick up greetings in the main lan- • They are of mixed ethnicity.
Cultural knowledge belongs to the guages, but I will never have a de- There are many ethnically Samoan
culture and as such, cultural iden- tailed understanding of all of these people who were born in New Zea-
tity and traditions should remain with cultures. In addition, we also care for land. How culturally Samoan they
the culture. Teaching nurses to be ex- a number of other groups who tradi- are depends on many factors: whether
perts in Maori culture leads to fur- tionally do not have good access to they speak the language, how many
ther disempowerment of Maori, given primary care; people with addictions, generations since they lived in Sa-
that there are significant numbers people with enduring mental illness, moa, whether there is a community
who have been deprived of knowledge people who live on the streets. They of Samoans nearby or whether they
of their own identity and traditions. also have a set of values and beliefs are isolated from other Samoans. In
Ethnographic information is only one markedly different from mine. short it is a matter of to what extent
facet of many Maori health issues, The ideal is for people to receive they are assimilated into the main-
albeit very significant. The question care from people of their own cul- stream culture. People of mixed eth-
could be asked, how does Trans- ture. For many, this is unlikely to nicity may define their ethnicity in
cultural Nursing theory educate happen in the medium term. The next different ways according to circum-
nurses to give service to culturally best option is for people to receive stances. My mother was born an
dislocated adolescents with perhaps care from a carer who has a deep American. I am eligible for an Ameri-
a serious self destructive urge? This understanding of their cultural back- can passport. I consider myself a New
age group comprises a significant ground. Doing this without being flu- Zealander. Part of my cultural back-
percentage of the current Maori ent in the language of that culture is ground is American but, for the most
population who are highly at risk of very difficult and, in New Zealand, part, I do not think of it as being very
self-harming behaviours and suicide. where the majority of citizens only significant; however, for the purposes
Cultural Safety is based in attitude speak one language (English), learn- of ease of travel to the US I am able
change. If nurse and midwife practi- ing a second (or third or fourth) lan- to be an American, travelling on an
tioners hold safe attitudes, they will guage is a considerable barrier. American passport.
be able to work with the continuum There is, however, much we can Until 1986 the Government de-
of Maori people, from traditional learn to provide care for those whose termined that a person was Maori if
practitioners of the culture to those cultural background is significantly they had greater than 50% Maori
who have been denied any informa- different from our own. blood. This was in considerable con-
tion about Maoritanga.’2 This is what I have learned. flict with the Maori concept based
I suggest that the RNZCGP ‘Cul- on ‘whakapapa’, those who have de-
tural competency’ document, while What is ‘culture’? scent from Maori.
including many concepts from ‘Cul- My Oxford Dictionary provides many The standard that we now use is:
tural safety’, is also partial in its re- definitions of this word but two are Ethnicity is the ethnic group or
sponsiveness to groups other than apposite: groups that people identify with or
Maori. ‘The customs, arts, social institu- feel they belong to. Ethnicity is a
The following is an approach that tions and achievements of a particular matter of cultural affiliation, as op-
I have developed in my own clinical nation, people or other social group’; posed to race, ancestry, nationality
Volume 35 Number 2, April 2008 125Issues
or citizenship. Ethnicity is self per- many it will give a guide to culture, been made an illegal practice in New
ceived and people can belong to it is not sufficient to ensure good care Zealand. Nonetheless, this is a deeply
more than one ethnic group. because of the inevitable assumptions embedded cultural practice. There is
The census question is now that are involved. a difference between respecting and
‘Which Ethnic Group do you belong agreeing. I disagree with this prac-
to?’ with multiple answers possible.5 What other ‘cultures’ are there? tice, but if I am unable to respect
Knowing which cultural group(s) There are many characteristics of a their position I will not be of much
a person belongs to means that some person, other than ethnicity, that con- use. The only people able to change
predictions can be made regarding tribute to their values, beliefs and this practice permanently are the
the beliefs of that person. On a popu- practices. The obvious ones are reli- Somalis themselves, if they choose
lation basis this can be essential for gious belief, sexual orientation and to do so. After the law banning geni-
planning. For example, most Soma- level of education. Less obvious, but tal mutilation was passed, some fund-
lis are Muslim, therefore if we have important, are things such as whether ing was set aside for ‘education’ of
a lot of Somali migrants there will they share the ‘Western Medical’ view those who traditionally practised this.
be a need for separate places of wor- of how bodies work. Age can be an Our service applied for that funding.
ship from the Christian population. important determinant; those who We consulted with the community
On an individual basis, knowledge of lived through the Depression have a leaders and offered to run a series of
a person’s origin is helpful but not different view on throwing things educational evenings on health top-
infallible. Not all Somalis are Mus- away (hence the cupboards full of old ics that they were interested in. They
lim and the degree of devotion to medicines?). Most doctors do not talked about nutrition in New Zea-
their religion varies, so if you man- have a great deal of knowledge of land, common childhood illnesses,
age your Somali patients on the as- the ‘criminal’ culture. I have found it childbirth and gynaecological prob-
sumption that they are all Muslim you challenging caring for a now released lems. Inevitably, as a part of this, the
will be right most of the time but may convicted murderer. As a parent I effect of genital mutilation was dis-
cause offence to the few who are not. have learned a number of lessons that cussed, with their job to present as
Mason Durie6 has written about I could not have learned any other clearly as possible what is known
Maori reality and broadly divided way, enabling me to ‘share’ a culture about the medical consequences.
Maori into three groups: with other parents, which I could not These evenings were very successful
1. Maori who actively participate do before I had children. with a larger attendance than ex-
within Maori cultural institutions, In brief there would be no per- pected and a lot of positive feedback.
who feel uncomfortable partici- son that you could summarise all their Had we been in any way disrespect-
pating in the ‘mainstream’ of views on the world by knowing their ful no one would have attended.
Pakeha New Zealand. ‘culture’.
2. Maori who actively participate 2. Know your own culture
within Maori cultural institutions, Principles of good cross-cultural This may sound simplistic, but in the
who are comfortable participat- care context of cross-cultural care it is
ing in the ‘mainstream’ of Pakeha about understanding your base as-
New Zealand. 1. Respect sumptions. For example, doctors
3. Maori who are alienated from This may seem obvious but it is the trained in New Zealand all have a
their Maori culture and also feel cornerstone of good cross-cultural shared, detailed understanding of
uncomfortable participating in care. If you are unable to respect your how the human body works. Every-
the ‘mainstream’ of Pakeha New patient and their values and accept that one in the world does not share this
Zealand. they may be different from yours, then understanding. For example if your
As a generalisation, those in the sec- you will not be able to care well for patient believes in homeopathy and
ond group have access to appropri- people with significantly different val- you do not uncover this difference,
ate care. Those in the first group will ues from you. This sounds a bit sanc- then there are likely to be conflicts
benefit from culturally competent timonious; of course we all respect our regarding the taking of allopathic
care as described a in the section of patients’ values don’t we? I think my medicine. An important element of
Jansen and Sorrensen’s paper ‘Maori meaning is clearest if we look at it knowing your own culture is to
views of cultural competence’, but the through an extreme example. know what ‘stereotypes’ you hold
third group may be further alienated Many of the Somali women we (e.g. all ‘junkies’ are liars.) This is
if they are treated with the expecta- care for have been genitally muti- not to say that stereotypes are not
tion that they behave culturally as lated. I personally find this practice useful (many ‘junkies’ are liars), but
Maori. While I agree that it is im- abhorrent and abusive. I wish I could if you are not aware of your own
portant to document ethnicity, as for just stop them doing it. It has in fact prejudices (pre-judgings) then you
126 Volume 35 Number 2, April 2008Issues
are likely to provide poor care for 4. Avoid the phrase ‘non-compliant’ usual circumstances in which sexual
some patients. This phrase needs to be deleted from activity is relevant is when the doc-
your vocabulary. What it means is tor is assessing the likelihood of preg-
3. Be non-judgmental that the patient is not doing what the nancy and the likelihood of sexually
It is simple to be non-judgmental in doctor told them to do. The clear transmitted disease. I once admitted
a consultation with a patient whose implication is that the doctor is right a woman to hospital to exclude ec-
values are congruent with your own. and the patient is wrong. This is topic pregnancy (late at night after a
The further those values diverge anathema to good patient-centred home visit). I had asked whether she
from your own, the harder it gets. medicine. It is, however, a very use- was sexually active and she answered
The reality is that there are many ful ‘red flag’. Any patient who has ever yes. As I drove her to the hospital
people you will consult with who been labelled ‘non-compliant’ has with her ‘flatmate’ (a woman) in the
hold views and beliefs that are dif- some important unresolved issue. It car it dawned on me that she was al-
ferent from yours. One way of ad- may be as straightforward as ambiva- most certainly a lesbian.
dressing this is to explicitly state lence about taking medication be- If knowing about sexual activity
your own views or beliefs and ask cause of an even balance between is important, then a proper assess-
them for theirs; ‘in my culture we benefits and side effects, or it may ment cannot be done without the
believe that…what do you believe in be an indicator of a major cultural detail of who did what to whom and
your culture?’ One of the difficul- clash requiring skilful consulting to when. As Bill Clinton has shown, ‘hav-
ties with this is that merely avoid- determine where the clash is. Non- ing sex’ can mean different things to
ing the subject of conflict can be adherent is better, but the phrase that different people.
interpreted as judgmental by a pa- I prefer is that there is a mismatch More difficult are circumstances
tient. Take the case of a woman who between the doctor’s and the patient’s when you are unaware of the patient’s
comes in and has a positive preg- agendas. This serves as a reminder assumptions. I have had several So-
nancy test and bursts into tears, say- that it may be that the doctor rather mali mothers ringing me for after
ing she does not want to be preg- than the patient is ‘wrong’ and avoids hours care of their babies because of
nant. If you make no mention of judgement. vomiting and diarrhoea. They invari-
abortion as an option for her (par- ably have said that the baby had not
ticularly if your appearance fits the 5. Beware of assumptions drunk for days and was very very
patient’s stereotype of the sort of I like to think of the issue of cross- sick. I would arrive and find a child
person who is opposed to abortion) cultural consultation as a continuum who did not seem very ill and felt
she will probably feel some discom- from one extreme where all relevant frustrated at being called out urgently
fort raising the topic. If, for exam- values and beliefs are congruent be- when I did not think it was neces-
ple, you are opposed to abortion tween carer and patient, to the other sary. After discussion I understood
then you need to raise the topic and extreme where all relevant values and that many babies died in the refugee
inform the patient of what you do beliefs are dissonant or conflicting. camps of this sort of illness and the
for patients requesting an abortion We all make assumptions all the time. extent of the mother’s concerns was
if that is what she wants. Situations As long as they are the same assump- a reflection of this.
in which this is most important are tions our patients make then all will A common assumption of doctors
those where sections of the commu- be well, but if they are not then prob- is to presume that physical symptoms
nity are quick to judge: sexual ori- lems will arise. are caused by physical illness (until
entation, criminal record, illicit drug A good example is the question proved otherwise) A colleague had a
use, working as a sex worker. used to find out whether someone is case of an Ethiopian man who had
There is a considerable art behind sexually active. Possible questions abdominal pain. The cause of this was
asking the ‘naïve’ question on sensi- are: eventually diagnosed as due to a
tive subjects in such a way as to not • ‘Are you married?’ curse put on him by a neighbour in
offend. Prefacing the question with • ‘Do you have a partner?’ Ethiopia, but only after he had had
information on why it is important • ‘Do you have a girlfriend (boy- multiple blood tests, two gastro-
to know is helpful. For example, friend, if talking to a woman)?’ scopes, a colonoscopy and abdomi-
when asking a man who presents with • ‘Do you have a girlfriend or a nal CT. He was ‘cured’ with
an STD about whether he has sex with boyfriend?’ paroxetine and holy water.
men; first explaining that in New • ‘When did you last have sex?’
Zealand HIV is more common in men There are assumptions behind all of 6. Use interpreters carefully
who have sex with men can make the these questions that could backfire This is a difficult area because there
question less likely to cause offence and, if asked bluntly, all have the is little or no funding for professional
to a patient who is homophobic. potential to offend someone. The interpreters to work in primary care.
Volume 35 Number 2, April 2008 127Issues
The ideal for consulting with a per- lar disease is, but this is not a de- as the elements of patient-centred
son who is not a confident/comfort- scribed concept in Somali. medicine:
able English speaker is to use a pro- 1. Exploring both the disease and the
fessional interpreter. Using family 7. Do a Well Health Check illness experience
members or friends is often better The regular consultation has an un- 2. Understanding the whole person
than nothing, but there are signifi- written agenda that the purpose is to 3. Finding common ground
cant dangers: respond to the patient’s concerns. In 4. Incorporating prevention and
• You do not know what the qual- that context it is sometimes difficult health promotion
ity of the interpreting is like to raise important, but to you rel- 5. Enhancing the patient–doctor re-
• The issue of confidentiality is dif- evant, issues without risking offence. lationship
ficult, often it is impossible to ask At our service all new patients 6. Being realistic.
sensitive questions using a fam- are booked for an appointment with The book does not explicitly address
ily member interpreter a nurse for a Well Health Check as the question of cross-cultural con-
• Using children to interpret for soon as possible after they register sultation. It is written to describe a
parents creates difficulties for the with us. This enables us to gather ‘new’ way of looking at the consul-
child–parent relationship all the usual past medical history, tation rather than the old ‘doctor-cen-
• There is a much greater risk of allergies, medicines and so on. We tred medicine’.
the interpreter speaking for them, describe the nature of the service Everything that I have written
rather than interpreting. we provide and what they can ex- above is a logical consequence of
A good interpreter can also act as a pect from us. We then go on to find pursuing this way of consulting.
cultural broker, warning the carer out about ethnicity, language and It provides the philosophical
when the questions they are asking relevant cultural practice. We ask framework within which I work.
might cause offence in their culture questions about who is at home with
and why. them, whether they have a partner, 2. Supervision
Useful tips for improving a con- whether there are any issues with Practising good patient-centred
sultation that uses an interpreter are: family violence, gambling, use of medicine requires all of these things
• Remember that you are consult- addictive drugs. We couch all of this but, in particular, to be good at it
ing with your patient, not the in- in terms of ‘in order to care for you you need self-awareness. If particu-
terpreter we need to understand who you are’. lar patients annoy you, then you will
• Face the patient and address ques- It is then much easier to ask many be unable to care for them well un-
tions to the patient in the first questions that in other circum- less you understand where that an-
person – ‘where do you get the stances are harder to ask, on the ba- noyance comes from. I have found
pain?’ sis that we ask this of all our clients an invaluable aid to achieving bet-
• Look for body language cues and because for some of them they are ter patient-centredness has been at-
listen for ‘anglicised’ words that important. tending ‘Supervision’. This is a con-
may be used, as this gives a small cept from the counselling and social
opportunity to judge the accuracy 8. Learn to pronounce names work disciplines. It involves seeing
of interpretation I get annoyed when people spell my a trained supervisor (usually some-
• Arrange seating in an equilateral name GREY rather than GRAY. It is one with a counselling background
triangle so that you and the pa- an incredibly small thing, but none- of some sort) to discuss things that
tient can easily relate with each theless that is how I feel. It is my are difficult in your work. This does
other and the interpreter experience that addressing people by not include ‘clinical supervision’ such
• Keep your sentences short the correct name properly pro- as discussing the detail of pharma-
• If you sense that direct interpret- nounced makes a big difference to ceutical choices. Nor does it include
ing is not happening, try to slow the tone of the consultation, espe- extended personal psychotherapy. It
the consultation down to very cially for people who are used to most is something in between. I have
short sentences, explicitly ask- New Zealanders mispronouncing found it particularly useful:
ing for interpretation after each their names. • Following the death of a baby of
sentence (I will often use hand meningitis nine hours after I had
movements from the interpreter More generic issues diagnosed a viral infection.
to the patient to signify this) and • Dealing with friction between
pay particular attention to ad- 1. Practice patient-centred myself and work colleagues.
dressing the questions directly to medicine • Monitoring my mood during a
the patient The book entitled ‘Patient-centred particularly stressful family time
• Not all concepts will be easily Medicine’ by Moira Stewart et al.7 to ensure I was not too stressed
translated. We know what bipo- describes six features that they see to practice safely.
128 Volume 35 Number 2, April 2008Issues
• Discussing ‘boundary issues’, for I felt a responsibility for my patients’ tural safety is something you con-
example, times when I have or problems and if things went badly tinue to work on. I think this sits
have not used a chaperone. (some of them even died) then I took better. In any clinical setting there
It has been immensely useful for me this personally. is a continuum from ‘culturally
to be aware that, similar to many I have gradually shifted the sense identical’ to ‘culturally completely
doctors, I have a need to be liked of my job and now see that I am ac- different.’ The competence of all of
and that I am scared of not knowing companying my patients on their us in any particular setting will vary.
enough. Discussing ‘heartsink’ pa- journeys. They have many problems, A less culturally competent practi-
tients has enabled me to stop taking some I can influence, some I cannot. tioner may well be fine if they work
responsibility for problems that are I try to understand closer to the ‘cul-
not mine and to be more effective how they see their turally identical’
with what I do. problems and apply Providing care for end of the spectrum,
all the skill I can to whereas the most
3. Practising community-centred see if I can help them
diverse cultures is easier culturally compe-
medicine find the best road for if those cultural groups tent practitioner
Providing care for diverse cultures their journey. Some- have input in to how the may still provide
is easier if those cultural groups have times I make a huge care is provided poor care at the
input in to how the care is provided. difference (e.g. the ‘culturally com-
There are things to be learnt about drowning toddler pletely different’
how a cultural group behaves that that I resuscitated) sometimes I can end of the spectrum. In either in-
affect how a service is offered. For only provide comfort. Like all hu- stance they can only do their best.
the more vulnerable groups in our mans I make mistakes and I try to The other vital difference between
community, health is affected by learn from them. All of my patients the concepts is that, from the Medi-
many more things than narrowly fo- will die. cal Council’s document, this compe-
cused health services. To be effec- It is like a dance, sometimes close, tence can be judged by other clini-
tive, health providers need to par- sometimes apart, sometimes synchro- cians. Ramsden and later the Nurs-
ticipate in a community development nised, sometimes stepping on each ing Council both make it very clear
model that includes attention to other’s toes. They choose whether that whether a consultation was cul-
housing, childcare, rehabilitation they want to dance with me. If I am turally safe is judged by the patient.8
services, English language classes too awful they will find someone else This makes ‘assessment’ of whether
and many other things. to dance with. If they are from a the standard has been met more com-
strange land there may be no one plex but in my view more real.
4. Learning about the cultures of who knows their dance. If they
your patients choose me to dance with then we both Conclusion
Of course it is useful to know as much have to learn each other’s steps and The increased focus on cross-cultural
as you can about the culture of the hopefully find a beat we can both care is welcome and needed. Our pro-
patients in your practice. Understand- dance to. fession has started to produce mate-
ing the detail of how people fast dur- rial to inform practitioners on this
ing Ramadan (and what variation Cultural safety or cultural subject. One of the most important
there is in adherence) is of course competence? ‘cross-cultural’ issues is about Maori
useful in caring for Muslim patients. By not separating out cultural safety patients being seen by non-Maori
The main point I am making is that and Treaty of Waitangi issues the practitioners and this has been an
knowledge of generalisations about Medical Council has created the pos- important driving force behind the
other cultures without an under- sibility that a doctor could be cul- development of materials. I believe
standing of cultural safety as de- turally competent, but not meet the that this has led to a slightly con-
scribed by Ramsden2 and interpreted standards in Best practice in the care fused approach to this issue. The
as I have described above, could of Maori patients (if, for example, nurses base their approach on the
make your cross-cultural consulta- they had few Maori patients). I think Treaty of Waitangi and cultural safety
tions worse. the separation that the Nursing and I believe that there is significant
Council suggests works much better benefit in approaching these issues
Enjoy the journey and the dance and is more explicit about achiev- in this way compared with the cur-
When I left medical school I was well ing both goals rather than the Treaty rent view of the Medical Council and
inculcated with the view that the job of Waitangi goals being under the Colleges.
of a doctor was to take a history, ex- guise of ‘cultural competence’. Cul-
amine, order investigations, make a tural competence also sounds like Competing interests
diagnosis, treat and cure the patient. something you reach, whereas cul- None declared.
Volume 35 Number 2, April 2008 129Issues
References 4. Jansen P and Sorrensen D. Culturally competent health care. NZ
1. Wearn A et al. Frequency and effects of non-English consulta- Fam Physician 2002; 29(5): 306-311.
tions in New Zealand general practice.[see comment]. New Zea- 5. Department of Statistics New Zealand. Statistical Standard for
land Medical Journal, 2007. 120(1264): p. U2771. Ethnicity, D.o. Statistics, Editor. 2005.
2. Ramsden I. Cultural safety Kawa Whakarurhau. In: Cultural safety 6. Durie M. Whaiora Maori health development. Second Edition
and nursing education in Aotearoa and Te Waipounamu. Victo- ed. Melbourne, Australia: Oxford University Press; 1998.
ria University of Wellington; 2002. 7. Stewart M. Patient centred medicine; Transforming the clinical
3. Nursing Council of New Zealand. Competencies for the regis- method. London: Sage Publishing; 1995.
tered nurse scope of practice. Nursing Council of New Zealand/ 8. Hughes M et al. Preparing for cultural safety assessment.[see com-
Te Kaunihera Tapui o Aotearoa; 2005. ment]. Nursing New Zealand (Wellington) 2006; 12(1): 12-4.
In response
Dr Ben Gray has provided his views Aotearoa/New Zealand where Maori failing to check the understanding of
of the guidance produced by the have been shown to have the great- patients and their families.
Medical Council of New Zealand in est health inequities. No doubt ad- We do not agree with Dr Gray in
the area of cultural competence. The ditional guidance relating to Pacific a number of areas. Firstly, we would
resource booklet Best health out- peoples, migrant populations and see the ideal as being for any health
comes for Maori: Practice implica- others will follow. provider to have the knowledge,
tions released in October 2006, com- These professional standards com- skills and attitudes to engage with
plements the two Medical Council plement the requirements of the Code any patient. Of course some patients
statements about cultural competence of Health and Disability Services may have a preference for a provider
and health outcomes for Maori, re- Consumers’ Rights. The Right to Ef- of a particular gender or ethnic
leased in August 2006, and all these fective Communication (Right 5) in- group at times.
are available from the MCNZ website cludes: ‘Where necessary and rea- Secondly, we abhor the practice
http://www.mcnz.org.nz/Publications/ sonably practicable, this includes the of genital mutilation. Like other aban-
tabid/62/Default.aspx . right to a competent interpreter’. doned practices this has no place in
Both the Medical Council and the Together the HDC Code, the any society. We suspect that Gray is
RNZCGP guidance were developed MCNZ and the RNZCGP documents advocating a respectful approach to-
because of the requirements of the provide a framework for addressing wards people rather than respect for
Health Practitioners Competence As- cultural competence within the gen- all points of view, however objection-
surance Act 2003. Section 118(i) of eral practitioner workforce. able. This is important because respect
the HPCA requires all health practi- We note that for the most part and trust are the foundation of all good
tioner registration bodies (including Gray is in agreement with the ap- doctor–patient relationships that then
the MCNZ) to set standards of clini- proach of the MCNZ and RNZCGP. allows us to discuss practices that
cal competence, cultural competence, Neither body advocates a one-di- harm the health of patients such as
and ethical conduct to be observed mensional approach to culture and smoking or even genital mutilation.
by health practitioners. ethnicity in keeping with the plain Lastly, we note that the MCNZ
Understandably the MCNZ and fact that most people have many cul- statements and the HDC Code are not
most health practitioner registration tural affiliations even if they iden- optional matters. Doctors cannot
authorities use that terminology tify with only one ethnic group. More choose to adhere to the statement
rather than the terms cultural safety, than that, doctors need to be aware about health outcomes for Maori
cultural sensitivity or cultural of smoking history, family connec- while ignoring the statement about
awareness. The terms cultural com- tions, medical history and a myriad cultural competence. Like Gray, we
petence and clinical competence of matters which can impact on pa- urge doctors to learn more about the
appear together, highlighting the tient responses to the recommended backgrounds of patients they see. We
need to address cultural, communi- treatment. Doctors should also con- also urge doctors to consider care-
cations and technical abilities to sider that patient preferences will fully how they will implement the
ensure public safety. vary over time and in response to MCNZ and RNZCGP guidance into
The MCNZ and the RNZCGP have things like the stage of illness. everyday practice.
gone further by developing guid- The documents from the MCNZ and
ance or standards that specifically the RNZCGP address these matters, and Dr Peter Jansen FRNZCGP,
address Maori issues. This is reason- advise doctors to take care to avoid on behalf of Mauri Ora Associates
able given the context of practice is generalising, making assumptions or www.mauriora.co.nz
130 Volume 35 Number 2, April 2008You can also read
