How is cultural safety understood and translated into midwifery practice? A scoping review and thematic analysis

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Abstract

Aim

To identify and understand the scope of the literature published since January 2008 that explored Australian midwives understanding of cultural safety and how this is translated into their practice when caring for First Nations women and families.

Background

Recognition and understanding of First Nations peoples history and culture and the impact this has on the health and wellbeing of women and their families is essential if the midwife is to promote culturally safe and respectful maternity care. The role and responsibilities of the midwife in ensuring that their practice is culturally safe are now reflected in the Australian professional midwifery codes and standards. Whilst midwifery academics’ awareness of cultural safety and how it is taught within midwifery education programs have previously been explored, at present, little is known about midwives’ understanding of cultural safety, and how this translates into their clinical practice.

Methods

A Scoping Review was undertaken following Arksey and O’Malley’s five step process. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses – Scoping Review extension checklist. Twelve studies met the criteria for inclusion. Thematic analysis was used to analyse the data and organise the results.

Results

Thematic analysis, guided by two predetermined review questions led to the identification of six overarching themes: ‘Awareness of deficiencies’, ‘The importance of meeting women’s diverse needs’, ‘Understanding relationships as a foundation for culturally safe care’, ‘Working in partnership with others’, ‘Providing individualised care’ and ‘Fostering effective relationships and communication’. One sub-theme of the first theme was identified, this was named ‘Seeking an understanding of culture’.

Conclusion

Australian midwives’ level of understanding of cultural safety and how it is translated into their midwifery practice when caring for First Nations women and their families differ widely. Midwives across Australia require increased and equitable access to appropriate opportunities to improve their knowledge and understanding of cultural safety. Whilst theoretical learning on cultural safety has a place in all midwives annual mandatory training requirements, this should ideally be supplemented, where possible, with opportunities for immersive practice in communities. Immersion was considered the optimal way to gain rich knowledge and understanding to strengthen culturally safe midwifery practice. Continuity models of midwifery care which incorporate the principles of cultural safety should be consistently implemented across Australia. These models enable midwives, women, families, communities, and Aboriginal Support Workers to work in collaboration towards achieving optimal outcomes for mothers and babies.

Study registration

N/A

Introduction

The promotion of culturally safe and respectful maternity care for First Nations1 women and their families are key elements of midwifery practice, and this is now identified in the International Confederation of Midwives (2014) and the Nursing and Midwifery Board of Australia (2018a) and the Nursing and Midwifery Board of Australia (2018b). Additionally, the Australian Nursing and Midwifery Accreditation Council (2021, p.15), state the requirement for all Australian entry to practice midwifery programmes to include a discrete subject, taught from a First Nations perspective, on ‘Aboriginal and Torres Strait Islander peoples’ history, culture, and health’, based on the Nursing and Midwifery Aboriginal and Torres Strait Islander Health Curriculum Framework (CATSINaM, 2017). Midwifery practice content, specific to First Nations people must also be embedded throughout the programme (ANMAC, 2021, p.15). Whilst the introduction of these requirements ensures that new graduate and early career midwives have knowledge and understanding of diversity, history, culture, health, inclusion, and cultural safety (ANMAC, 2021), it is important to recognise that over 66% of currently practising midwives in Australia are aged over 40 years (NMBA, 2022), and many others originally gained midwifery registration overseas. There is subsequent potential for these cohorts to have received little or no prior cultural safety education, and whilst it is recommended that mandatory cultural safety training is provided for all existing non-First Nations practising healthcare staff nationally (Clifford et al., 2015, Alford, 2015), there is continued debate however about how exactly this education should be provided (Curtis et al., 2019).

For midwives to provide culturally safe care, they first need to understand its theoretical and philosophical underpinnings. The concept of culturally safe care was derived from the work of Irihapeti Ramsden, who in 2002 completed her doctoral study exploring cultural safety within the New Zealand context. Cultural safety was described by Ramsden as providing a “safe service’ that is ”defined by those that receive the service” (Ramsden, 2002, p.117).

This requires those providing health care to be able to undertake ‘‘a critical analysis of existing social, political, and cultural structures and the physical, mental, spiritual, and social outcomes for people who are different’ (Ramsden, 2002, p.180).

Whilst the concept of cultural safety has since been widely adapted internationally (Doran et al., 2019), there remains an awareness that the original concept is unique to the context of New Zealand. This is due to the focus upon the “biculturalism” of the Māori and Pakeha populations in New Zealand (Cox and Best, 2022). The history of colonisation in New Zealand is different to other countries such as Australia. In New Zealand the Māori people were able to have their way of life protected and were also given full citizen rights under the Treaty of Waitangi which was enacted in 1804 (New Zealand Ministry of Justice, 2020). This was not the case in Australia where the First Nations people have been subjected to discrimination including forced removal from their land, loss of their languages, forced removal of their children, they experience health disparities, economic disadvantage and were not granted full citizenship until the 1967 referendum (Mazel, 2018).

This scoping review builds upon the previous work of Williamson (2008) whose doctoral research explored firstly how midwives provide culturally appropriate care for women from culturally and linguistically diverse backgrounds, and then how they provided culturally safe care for First Nations women. Whilst at that time, very little was known about how culturally appropriate care was incorporated into midwifery practice, the literature that was identified suggested that there were two main approaches to culture (Williamson and Harrison, 2010). The first focussed upon cognitive aspects; culture was viewed as static and identified by the values, beliefs, traditions, and languages of groups rather than understanding ‘the diversity within groups’ (Williamson and Harrison, 2010). The second approach did however take a much broader view, with culture being seen as part of a wider social structure of an individual and how this impacted upon their health and wellbeing. This included the impacts of colonisation and how power relationships are ‘detrimental’ to the health and wellbeing of First Nations people (Williamson and Harrison, 2010).

Notably, this review concluded that:

“None of the available approaches has been shown to overcome the problem of stereotyping the individual whose background differs from that of the health care provider or provides a clear way to provide culturally appropriate care” (Williamson and Harrison, 2010 p. 767).

Whilst research has since explored midwifery academics awareness of cultural safety (Fleming et al., 2017) and how this is taught within midwifery education programs (Biles et al., 2021), it is now important to know how registered midwives understand cultural safety and how they translate this into practice.

This current review aims to identify and understand the scope of the literature, published since 2008, that has explored Australian midwives understanding of cultural safety and how this translates into their practice when caring for First Nations women and their families.

It is anticipated that the findings of the review will provide insight into whether there has been any progress in this field over the last 14 years, reveal any ongoing knowledge gaps, and identify areas for future research.

Section snippets

Methods

This scoping review was undertaken in accordance with the Arksey and O'Malley (2005) five step process. The framework consists of Stage 1: identifying the research question, Stage 2: identifying relevant studies, Stage 3: study selection, Stage 4: charting the data, and Stage 5: collating, summarising, and reporting the results. Systematically following this clear five step process contributed to both the rigour and transparency of the literature review.

The scoping review approach was selected

Results

A total of twelve papers met the criteria for inclusion in the scoping review with eight studies taking a qualitative approach and four employing mixed methods. Geographically, all studies were undertaken in Australia, with the states of Western Australia (Marriott et al., 2020; Thackrah et al., 2020, Thackrah et al., 2021; Munns, 2021; Bertilone et al., 2017), Queensland (Thackrah et al., 2020, Hickey et al., 2019), South Australia (Brown et al., 2016, Withall et al., 2021, Middleton et al.,

Discussion

This scoping review has identified the literature, published since 2008, which discusses Australian midwives understanding of cultural safety and/or how it is translated into their practice when caring for First Nations women and their families. It demonstrates that whilst some Australian midwives perceive their understanding of culturally safe care for First Nations women to be good and are able to identify the ways in which they integrate this into their practice, others significantly lack

Conclusion

Australian midwives demonstrate differing levels of understanding of cultural safety, what constitutes cultural safety, and how this translates into their midwifery practice when caring for First Nations women and their families. Despite this disparity, at the present time, opportunities for midwives to improve their knowledge and understanding are inconsistently available nationally.

Given the key role that midwives play in ensuring that maternity care provision is culturally safe, as judged by

Funding

No external funding.

Ethical statement

Ethical approval was not required for this scoping review of the literature.

Authorship, contributors, and acknowledgements

(1) TC, MW, RC (2) TC, MW, RC (3) TC, MW, RC.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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