The field of biomedical engineering has expanded markedly in the past 15 years. This growth is supported by advances in biological science, which have created new opportunities for development of tools for diagnosis of and therapy for human disease. This book is designed as a textbook for an introductory course in biomedical engineering. The text was written to be accessible for most entering college students. In short, the book presents some of the basic science knowledge used by biomedical engineers and illustrates the first steps in applying this knowledge to solve problems in human medicine.

Biomedical engineering now encompasses a range of fields of specialization including bioinstrumentation, bioimaging, biomechanics, biomaterials, and biomolecular engineering. Most undergraduate students majoring in biomedical engineering are faced with a decision, early in their program of study, regarding the subfield in which they would like to specialize. Each subfield has a set of course requirements, which can be supplemented by wise selection of elective and supporting coursework. Also, many young students of biomedical engineering use independent research projects as a source of inspiration and preparation but have difficulty identifying research areas that are right for them. Therefore, a second goal of this book is to link knowledge of basic science and engineering to current research, and the accompanying opportunities to create new medical products, in each subfield.

As a general introduction, this textbook assembles foundational resources from molecular and cellular biology and physiology and relates this science to various subspecialties of biomedical engineering. The first two parts of the book present basic information in molecular/cellular biology and human physiology; quantitative concepts are stressed in these sections. Comprehension of these basic life science principles provides the context in which biomedical engineers interact and innovate. The third part of the book introduces the subspecialties in biomedical engineering and emphasizes – through examples and profiles of people in the field – the types of problems biomedical engineers solve.

Introduction

This chapter explores some of the traditional cultural concepts around pregnancy and childbirth for Māori. To set the scene, it begins with my journey towards becoming a registered nurse and midwife. An overview of traditional Māori birthing practices and the importance of whakapapa introduces the cultural reality for Māori in terms of whānau. The effect of colonisation is discussed in terms of the introduction of a hospitalised maternity system and the outlawing of traditional home birthing for Māori. Evidence now suggests that the logic, which underpinned the establishment of hospital-based maternity systems, is burdened with inconsistencies that have had a devastating impact on Māori. This chapter therefore focuses on the dominance of medical professionals in maternity care. The client-driven movement for choice, such as woman-centered practices, workforce development issues, and cultural safety, is then addressed in relation to major socio-political issues and influences.

Traditional Māori birthing

New Zealand’s history prior to the arrival of Europeans is constructed from oratory accounts. These accounts were subject to the imagination of the storyteller, which could often be inl uenced as a result of their personal belief. Elsden Best’s ( 1929 ) beliefs, for example, suggested that Māori were very religious and had a great fear of the supernatural. This was in keeping with his British view of the world where the Christian god was to be feared at all costs and nature was a commodity to be controlled by humankind.

Kia ora and welcome to the second edition of Cultural Safety in Aotearoa New Zealand. It has been almost 20 years since cultural safety education became an integral part of the nursing and midwifery curriculum. A testament to the longevity of cultural safety has been its ability to remain relevant within the 21st century. Such relevance has culminated into the Nursing Council of New Zealand’s (2011) Guidelines for Cultural Safety, the Treaty of Waitangi and Māori Health in Nursing Education and Practice.

This edition builds on the first edition of Cultural Safety in Aotearoa New Zealand whereby chapters have been reviewed due to feedback from the health and education sector. The end result has been the inclusion of chapters focused on whānau-centred practice, disability and competence. Chapter 2, written by professionals from the Nursing Council of New Zealand (‘the Nursing Council’) on competencies required for registered nurses’ scope of practice, is of significance within this second edition. Direct passages from the Nursing Council’s competencies are linked to real-life experiences so that students can become familiar with such requirements at an earlier stage within their respective programmes.

As with the first edition, the first three chapters set the scene with a discussion on the concepts within cultural safety and historical events that led to its inclusion by schools of nursing and midwifery. The foundations of cultural safety follow with six chapters focusing on concepts around culture, ethnicity, the Treaty of Waitangi, prejudice, ethics and research.

Introduction

In this chapter we explore the notions of competence, cultural safety and cultural competence, and analyse the way in which nurses in New Zealand are currently assessed to determine if they meet these requirements. As cultural safety had its origins in nursing education, this chapter has a primary focus on nursing. The introduction of cultural safety into nursing education curricula in New Zealand is well documented (Papps & Ramsden, 1996 ; Wepa, 2001 ; Papps, 2002a , Papps, 2005 ). The subsequent history of the journey of cultural safety has also recently been published (Nursing Council of New Zealand, 2013 ). Demonstration of competence is, however, a later requirement for all registered health practitioners, including nurses. We discuss this in relation to the requirements of the Health Practitioners Competence Assurance Act 2003 (‘the Act’).

In 1992 the Nursing Council of New Zealand (‘the Nursing Council’), the regulatory authority for nursing in New Zealand, developed and published guidelines for nursing education curricula. Providers of nursing education courses were subsequently required to utilise these guidelines to include cultural safety into nursing courses leading to registration. Individuals completing a nursing education programme for registration as a nurse were subsequently required to demonstrate that they met cultural safety criteria on order to become registered nurses (Papps, 2002b ). There was no requirement for registered nurses already practising to meet these criteria until the enactment of the Act. The Act requires regulatory authorities to ‘set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession’ (s 118(i)). This means that all registered health practitioners must now demonstrate that they are clinically competent and safe to practice, as well as meet a standard of cultural competence.

Introduction

There was a time in my life when I almost wished I had never heard of cultural safety, let alone have any part in its introduction into nursing and midwifery education curricula. Between October 1990 and May 1996, I chaired the Nursing Council of New Zealand (‘the Nursing Council’). During that time, cultural safety was a major and extraordinarily contentious issue. The Nursing Council’s resolution that cultural safety would be part of the requirements for nursing and midwifery education programmes might be considered as one of the greatest challenges to face the nursing profession in New Zealand.

My experiences at the time cultural safety was introduced were intensely personal and highly political, and at times, my professional values were compromised. However, my interest in issues of power and knowledge, particularly in relation to nursing in New Zealand society, enabled me to reflect on and analyse some of the reasons why cultural safety was subjected to aggressive questioning by journalists, politicians and members of the public. This chapter provides a personal analysis of why cultural safety was almost lost from the language of nursing. It begins with a brief historical perspective on nursing and cultural safety in New Zealand. The important differences between transcultural nursing and cultural safety are discussed, as well as the ensuing public debate that followed cultural safety’s early development.

Introduction

This chapter is concerned with sex and gender, the distinctions between them, and what is assumed about how a person expresses their sexuality. The intention of this chapter is to bring some of the unconscious assumptions about sex, gender and sexual orientation into focus, and to challenge some of the ideological beliefs that underpin them. Why these terms are important and what they have to do with cultural safety is explored.

What do people see when they look in the mirror or when they look at other people? Perhaps age and ethnicity, perhaps also gender. They may or may not see aspects of the sexed body. Inevitably assumptions are made - it is the way minds work in order to manage the volume of information that confronts people in everyday life and work. When meeting new people, aspects of their identity that are immediately visible are registered. It’s done unconsciously. It’s noticed if they are big or small, thin or fat, light or dark, male or female, old or young, and so on. Language situates these aspects as dualisms - they are this or that - which enables people to categorise things in a simple fashion. Yet, there is much more diversity in the world.

Introduction

This chapter explores the historical relationship between the health status of Maōri, the Treaty of Waitangi and health services in Aotearoa New Zealand at the time when cultural safety developed. The clarii cation of these issues was necessary to enable me to work effectively in the teaching environment and introduce what was essentially new and revolutionary material to nursing and midwifery students. A chronological overview to the evolution of cultural safety following the immediate period after my initial teaching experiences in 1988 through to 2001 is presented. I wish to convey to the reader some essence of the sheer speed, over this thirteen-year period, at which cultural safety development has taken place within New Zealand nursing and midwifery professions.

Practice examples are given to assist the reader to recognise and understand the powerlessness of patients and the power of nurses.

Historical analysis

The effects of colonisation and the growing awareness through the 1970s and 1980s of the ongoing and long-term impact of the colonisation process on Maōri health outcomes were a critical impetus for the development of cultural safety. As political awareness and activity among Maōri during this time began to increase, gatherings of Maōri people working in education, welfare and justice, and health were also meeting together, many for the first time, to discuss those areas of concern in relation to Maōri.

Introduction

The definition of cultural safety and the history of its development have been addressed elsewhere in this book. It has been established that cultural safety is about understanding the way power shapes and influences healthcare practices and healthcare outcomes for patients or clients using healthcare services. Central to the presence or absence of experiencing care as culturally safe is the degree of trust between the nurse and the patient (Ramsden, 2002 ). A culturally competent nurse builds a trusting environment through effective communication and considered actions.

Being competent requires the nurse to rel ect on and interpret professional and institutional practices and assess how these might enhance or limit a patient’s sense of safety. Culturally safe care is the subjective experience of care that is assessed as safe by the patient (Ramsden, 2002 ). Nurses care for people when they are at their most vulnerable and when their ability to be autonomous or in control may be compromised because of their illness or situation (Dinc & Gastmans, 2012 ). Trustworthiness of the nurse by the patients means that they can rely on the nurse to keep them safe from harm, hence cultural safety.

Drawing on the cultures of the nurse, the client and the setting, we provide a brief overview of mental health nursing in Aotearoa New Zealand. A practice example – Ruby’s story – is then presented, interpreted and critiqued within a mental health nursing context. At the end of the chapter rel ective questions are posed to guide exploration of events in the story.

The 1980s was a transformative decade, both in a positive and negative sense. The reforming Labour Government (1984–1989) dismantled the contract that had existed from the 1930s and which had underpinned community and national welfare. But simultaneously, they also recognised Maōri as tangata whenua in new ways and restored the Treaty of Waitangi as the (partial) basis of law and policy.

In this environment, how professional communities understood their own practice, the effects of that practice on client communities and the relationship with Maōri came in for new scrutiny. Nursing was to take a particular step in the late 1980s, which was to prove especially significant.

Irihapeti Ramsden was to be involved in a series of hui in the late 1980s from which emerged the notion of cultural safety. Her secondment to the Department of Education in 1988 and her authorship of Kawa Whakaruruhau in 1990 helped develop and rei ne the concept and to implement it in nursing education. Along with Karl Pulotu-Endermann, I worked alongside Irihapeti in a number of nursing programmes to develop the content and principles of cultural safety as did other nursing educators. Irihapeti was a force to be reckoned with and she developed a particular approach that required an understanding of a colonial history, a sense of how culture affects individuals and professional practice, and what principles were relevant to nursing practice. In all of this, Irihapeti was clear that, while Maōri should be beneficiaries of cultural safety, kawa whakaruruhau was to apply to any situation where the nurse and patient were of a different ethnicity. Her chapter in this book conveys something of her role and vision as one of the pioneers in transforming nursing education.

Introduction

Caring is an ethical activity with a deep moral commitment that relies on a trusting relationship (Holstein, 2001 ). Health professionals are expected to be caring, skilful, and knowledgeable providers of appropriate and effective care to vulnerable people. Through universal services they are expected to meet the needs of both individual clients and broader communities, which are activities requiring sensitivity and responsiveness. In an increasingly complex globalised world, ethical reflection is required so that practitioners can recognise plurality: in illness explanations; in treatment systems; in the varying roles of family/whānau or community in decision making; and in the range of values around interventions and outcomes. To work effectively in multiple contexts, practitioners must be able to morally locate their practice in both historical legacies of their institutional world and the diversifying community environment. This chapter examines the frameworks that health professionals can use for crosscultural interactions. I then explore how they can select the most appropriate one depending on the person or group being cared for.

Ethics

Ethics is a part of all our actions as humans and as nurses. Ethics is about how nurses talk to their clients, how they respond to difference and how they make decisions. The word originates from the Greek word ‘ethos’, which refers to habits and character. Ethics can be seen in all religions, philosophies and cultures, even in those language groups that do not use the term. In the context of health, having an ethical framework provides a shared means of collectively and systematically examining varying viewpoints related to moral questions of right and wrong. Ethics is also a generic term used to refer to the ways people can think about, understand and examine how best to live a ‘moral life’ (Beauchamp & Childress, 2001 ). Ethics involves critical thinking and asking questions to highlight the appropriate course of action. It requires health professionals to consider and reconsider the taken for granted (Beauchamp & Childress, 1983 ). When working with people, it is inevitable that health professionals will confront an ‘ethical problem’ – a situation that raises questions that cannot be answered with a simple rule or fact.

Introduction

This chapter focuses primarily on the relationship between cultural safety, the Treaty of Waitangi, Maōri health and the legislative requirements of the Nursing Council of New Zealand (‘the Nursing Council’). This includes the ongoing requirements for enrolled nurses, registered nurses and nurse practitioners to demonstrate competence against the competencies for their designated scope of practice. Through the use of practice examples from a registered nurse and student nurse, we consider how nurses demonstrate competence in relation to cultural safety and the Treaty of Waitangi (‘the Treaty’). The use of reflective questions at the end of each practice example enables you to consider your own practice and the examples that you may be able to draw from your practice to demonstrate competence.

Legislation and standards

Under the Health Practitioners Competence Assurance Act) 2003 (‘the Act’), the Nursing Council governs the practice of nurses by setting and monitoring standards and competencies for registration which ensures safe and competent care for the public of New Zealand (Nursing Council of New Zealand, 2011a ).

Cultural safety , the Treaty and Maōri health are aspects of nursing practice that are rel ected in the Nursing Council’s Education Programme Standards for the Registered Nurse Scope of Practice (‘the Standards’). The Standards for the registration of nurses require that the content of theory- and practice-related experience in nursing programmes include cultural safety, the Treaty and Maōri health. Competencies outlined in the scopes of practice for nurses (Nursing Council of New Zealand, 2009 , 2010 ) require the nurse to practise nursing in a manner that the client determines as being culturally safe and to demonstrate the ability to apply the principles of the Treaty to nursing practice. Additionally, the Nursing Council’s Code of Conduct for Nurses (Nursing Council of New Zealand, 2012 ), requires nurses to respect the cultural needs and values of clients, and practise in compliance with the Treaty. Nurses are assessed against the competencies on an ongoing basis. As the regulatory authority, the Nursing Council is committed to enabling nursing workforce excellence.

Introduction

The major focus of my nursing practice has been in child and family care in the acute hospital child health setting, adolescent and adult alcohol services and drug rehabilitation. Coupled with my research in the area of nurses’ understanding of parenting in hospital, and nurses’ and parents’ emotional communication in hospital, I have developed a i rm resolve that health professionals must have a working knowledge of culturally safe practice. Nowhere is this more critical than in the care of the child, youth and family. In this chapter, the concept of cultural safety as it relates to child, youth and family health is explored. As a Pākehā , I am aware of ways the health system in New Zealand has benefited my culture to the detriment of others’, in particular, Māori. With this in mind, the transfer of power from health professionals to families and children is contended as fundamental to this process. The ensuing discussion is from my experience and perspective, so it does not attempt to discuss another culture’s perspective. Relevant statistics are examined; appropriate care plans, assessments and interventions discussed; and a tool to evaluate care provided to child, youth and families in Aotearoa New Zealand is presented.

Introduction

In the 1800s New Zealand was a very different country to the British colony that emerged after February 1840. Although the Maōri world was changing, a decade before the signing of the Treaty of Waitangi (‘the Treaty’) Maōri retained their autonomy. At this time it was estimated that the Maōri population was approximately 150 000 (Kingi, 2005 ). Pre-1830 Maōri were a vibrant and healthy people. They were international traders within and outside of New Zealand, with their own bank. They had total guardianship of their 66 million acres, resources and other assets.

During the 1830s resident Europeans, however, were few - about 1400 in the North Island and 500 in the South Island. With increasing European settlement came the introduction of arms and what was known as the musket wars resulting in notable decreases in the populations of some iwi. Traders and settlers exploited resources, and while some missionaries and traders purchased smaller pieces of land, speculators acquired large amounts of land. Furthermore, missionaries introduced Christian beliefs and practices (Orange, 2004 ).

Nonetheless, in direct contrast to promising developments associated with international trade, the health of Māori visibly declined due to the harmful impacts of introduced diseases, warfare and social change. In addition to declining health, Māori had increasing concerns about the lawlessness of settlers in Aotearoa New Zealand. This led to Ma¯ ori leaders petitioning the British Government to address this matter. In 1832 James Busby was appointed the British ‘Resident’ in New Zealand, responsible for the law and order of British subjects, backed by periodic visits from a warship from Sydney Royal Navy squadron. Busby also encouraged Māori chiefs to organise themselves into an entity more recognisable to the British Government to make and enforce British style ‘laws’ (Orange, 2004 ). This approach was unusual, as in some countries that the British migrated to, the indigenous people were almost ignored or brushed aside because they lacked the military and social organisation to resist settlement (Sinclair, 1980).

Introduction

Disability identity is a difi cult concept because for some it is a personal decision and for others it is political. Māori are very clear that they do not identify as disabled or as people with disabilities. Māori preference to identify from a kaupapa Māori (primarily Māori) and a whakapapa (genealogical) cultural context is nothing new - what is new for many providers of health and disability services is the insistence by Māori that they be referred to as whānau hauā and not as having disabilities.

When I began my own journey into nursing in 1979, I do not recall ever having to understand any individual culturally or identify a person as having a disability. It was not until I returned to training in 1991 that I first began learning about cultural safety in nursing. It was also the first time I heard the term ‘disability’ which I came to understand as a political identity. In 1993 I could not complete my nursing due to early signs of primary progressive multiple sclerosis and chronic obstructive pulmonary disease from my mother who smoked around me as a child. I left nursing to undertake university study in a social science field and later completed a PhD. In the United States, nurses with disabilities are allowed to continue to practice nursing due to the American Disabilities Act (1990), after they fought for it. In New Zealand, however, this is not necessarily the case. While there are some nurses with disabilities practising, I am personally aware of several who, due to their diagnosis, have felt that they were bullied out of the profession. However, whether they can work or not depends on their nursing environment. Since my own journey in health and disability services as a client, student and practitioner, I have found that the nursing fraternity has a lot to learn about disability, in particular, to whānau hauā and other cultural identities, who are largely ignored by both the cultural and disability communities (Hickey, 2008).