Introduction

The world has turned into a global village. There is interconnection in almost all the spheres of
life. Adaptation to the future challenges of the world, therefore, requires a sound understanding of
the religion, heritage, and politics of different cultures. There is need to have a great sense of
cultural awareness. People must be able to stand back from themselves and become aware of their
cultural values, perceptions, and beliefs. Cultural understanding is important in communicating
with people from other cultures. People from a different culture, may see, interpret and evaluate
things in totally different ways. Things that are deemed appropriate in one culture may not be
appropriate in another culture (Ware, 2013). Cultural competence entails the knowledge of cultural
respect, safety, and cultural competence. It is defined as developing an awareness of ones own
existence, sensations, thoughts and environments without allowing it to have undue influence on
people from other backgrounds. It entails demonstrating knowledge and understanding of the
clients culture; accepting and respecting cultural differences and adapting care to conform with
the clients culture (Ware, 2013). The essay looks at cultural competence in nursing care with the
main focus on Aboriginal and Torres Islander people.

Downing and Kowal (2011) define cultural competence as a set of congruent attitudes, behaviors,
and policies which come together in a system, agency or even amongst professionals and guides
them to work effectively in cross-cultural situations. Culture, in this case, refers to the integrated
pattern of human behavior which encompasses thoughts, beliefs, values, customs, and institutions
of a racial, ethnic, social or religious group. Competence in this sense refers to the ability to
function effectively (Downing, Kowal, & Paradies, (2011). A culturally competent system of care
as Ware, (2013) asserts therefore incorporates the importance of culture, differences that result
from the dynamics of the different cultures, the broadening of cultural knowledge and the ability
to adapt services to meet the unique needs of different cultures at all levels.

Downing, Kowal, and Paradies (2011) observe that the inability to provide culturally appropriate
care and lack of cultural awareness can increase the stress levels of the critically ill patients thereby
aggravating their situations. It may also as Adams, (2010) asserts, result in inadequate care from
the healthcare professionals tasked with taking care of patients drawn from diverse cultural
backgrounds.
The gap in the health status between the indigenous and non-indigenous Australians is very wide
which according to Kruske, Kildea and Barclay (2006) maintain, calls for the health care providers
to establish the mechanisms for lessening the gap. Williamson and Harrison, 2010 maintain that
throughout the centuries nursing has been shaped by technological advancements, expectations,
norms of the society, the discovery of new medicine and breakthroughs in pharmaceutical
treatments However, nursing has been greatly influenced by the need for nursing that is culturally
competent. This is especially very vital for nurses who practice in highly stressful and high acuity
healthcare environments. Liaw, Lau, Pyett, Furler, Burchill, Rowley and Kelaher (2011) argue that
nurses must develop cultural competency to ensure that they can create rapport with their patients,
develop, assess and implement interventions designed to meet the meet the needs of their patients.
To offer culturally competent care to all patients, nurses are required to a good understanding of
different cultural backgrounds (Kelly, Dudgeon, Gee & Glaskin, 2009).

According to Kelly, Dudgeon, Gee and Glaskin (2009), the cultural differences between the
service providers and the indigenous Australians date back to 1989. The National Aboriginal
Health strategy working part had claimed that little attention had been given to the content of health
related education care in Australia. The education given was not relevant to the traditional,
political, cultural and socio-economic factors of the Aboriginal history (Kruske, Kildea, &
Barclay, 2006). A recommendation was therefore made for an adequate training of the health
professionals as they got ready to work with indigenous people. There was an emphasis on the
integration of cultural aspects in professional education (McMurray & Param, 2008).

Nurses can develop cultural competence by going through the model of cultural competence. This
can start by cultural awareness. Nurses must as Davidson, Abbott, Davison, and DiGiacomo,
(2010) hold, conduct a self-examination and do an in-depth exploration of their professional and
cultural backgrounds. This must start with one conducting an in depth analysis of their own cultural
health beliefs and values. Williamson and Harrison (2010) note that learners may not have cultural
awareness by simply learning about other peoples culture. They must comprehend their
background and have a good understanding of the origin of their own prejudice and biased view
people from other cultures.

The second component may entail cultural knowledge in which the nurses may seek and obtain
information on the different cultural and ethnic groups in their care. The Cultural base of nurses
can be expanded through information which can be obtained from a lot of sources including
journals, internet resources, seminars and workshops (Davidson, Abbott, Davison & DiGiacomo,
2010).

The third component as explained by Durey, Thompson and Wood (2012), entails the cultural skill
which requires the nurses to collect culturally relevant data about the patients presenting problem
and perform a culturally specific assessment accurately. Nurses must therefore be able to correctly
assess the racial, ethnic and cultural differences between their patients (McMurray & Param,
2008).

Nurses must also engage in a cross-cultural encounter in which case they must engage in cross-
cultural interactions with patients drawn from diverse cultural backgrounds. Direct interaction with
patients from different cultural backgrounds as Polaschek (1998) states can increase the cultural
competency. The process of developing cultural competency is an ongoing process throughout the
career of a nurse and cannot be mastered (Davidson, Abbott, Davison & DiGiacomo, 2010).

Nurses must also have the cultural desire. As Davidson, Abbott, Davison and DiGiacomo (2010)
argue, they must be motivated to be culturally aware and seek cultural encounter. Nurses must as
Durey, Thompson and Wood (2012) maintain be open to others and accept and respect cultural
differences. They must also be ready to learn from others.

Nurses should as McMurray and Param (2008) note, avoid unintentionally stereotyping a patient
into a particular ethnic group or even culture based on factors such as race, outward appearance or
their religious affiliation. Healthcare professionals must also be very careful about labeling
patients. Patients must not be labeled as indigenous or non-indigenous patients (McMurray &
Param, 2008, Stewart, 2006).

Culturally competent care needs to start with the physical environment and the infrastructure. As
Downing, Kowal and Paradies, (2011) assert, there must be a specific area where the patients and
their families are accommodated as they wait to be attended to. Space must be culturally
appropriate and must be suitable for men and women alike. Physical space gives a lot of
impressions about a facility and shows if the facility values the indigenous Australians. The flags
of the indegenous people must be displayed at the facility to show respect for them. There should
also be a display of a write up which recognises the traditional country (Ware, 2013, Williamson,
& Harrison, 2010). According to Kelly, Dudgeon, Gee and Glaskin (2009), the acknowledgment
of the traditional owners of the land sends a message of recognition and appreciation to the
Aboriginal Australians. Artworks and other visual representation of the indigenous Australians at
the facilities shows an environment which is not only respectful but also welcoming to the
indigenous Australians (Abbott, Gordon, & Davison, 2008).

Culturally competent nursing care can also be achieved by making sure that there are specific
programs that are tailored towards the indigenous Australians. For instance, as Davidson, Abbott,
Davison and DiGiacomo (2010) argue, the Aboriginal women are more likely to make use of
maternity services which they see other Aboriginal women using. Women report high attendance
in antenatal care in centers that are specifically made for the Aboriginal women. There should be
provision therefore to allow mainstream services to give services that are specifically tailored
towards the indigenous Australians (Abbott, Gordon, & Davison, 2008). The programs can be
offered within a community setting and advertised well to ensure that they are utilised (McMurray
& Param, 2008).

Culturally competent care can also be attained by ensuring that there is equality and fairness in
employment. The health care professionals must be drawn from both indigenous and non-
indigenous people. Aboriginal and Torres Islander people must also be trained to be health care
professionals (Williamson & Harrison, 2010). Their presence in the healthcare facilities as Stewart
(2006) maintains, can give the Aboriginal and Torres Island people the assurance that they are also
respected and recognised as part of the society which as Williamson and Harrison (2010) asserts,
can encourage them to seek care in the health care facilities.

There must be an effective use of interpretive services within healthcare settings. Proper use of
interpretive services as Stewart (2006) holds, helps the indigenous Australians to feel at ease and
ensures that they communicate effectively. Besides that, it increases their access to appropriate
health care services since they are able to give the medical providers fully informed consents.
Interpretive services also enable the indigenous patients to understand their illness more easily
which enables them to discuss their illness more freely with the health care professionals (Adams,
2010). As Durey, Thompson and Wood, (2012) state, the interpretive services also enable the
health care professionals to get the most accurate information from the indigenous people which
results in better clinical decisions.
The Australian Nursing and Midwifery Council (ANMC) has put in place certain guidelines
regarding cultural differences. ANMC seeks to develop a nationalistic approach to nursing and
midwifery in Australia (Kruske, Kildea, & Barclay, 2006). ANMC stipulates that a registered
nurse must recognise culture, spirituals values, gender, age, sexuality, disability and economic and
social factors that impact on the health status of individuals. It holds that the factors have an effect
on how an individual responds to health and illness. It holds that each [person is unique and what
satisfies another person may not satisfy the other (Adams, 2010).

Nurses must undergo continuous professional development to increase their cultural awareness,
knowledge, and skills. Nurses must take some time to understand the protocol of the indigenous
Australians. They must understand how to communicate with the indigenous Australians. They
must clearly understand that the indigenous Australians have different meanings for different
styles of communication (Durey, Thompson, & Wood, 2012). Certain modes of communication
that are considered normal by the non-indigenous Australians may be considered a taboo among
the indigenous people. Nurses must, therefore, understand how to communicate with them to
ensure that they get the best information from them (Adams, 2010). For instance, the Aboriginal
Australians do not like yes or no questions since they see that as a sign of intimidation (Downing
& Kowal, 2011). As Durey, Thompson, and Wood, (2012) advice, Nurses must quickly
understand this and frame questions in a manner that does not elicit yes no responses.

The indigenous Australians naturally believe that they are inferior compared to other people. They
consider themselves less educated and less informed compared to the non-indigenous Australians.
Asking them a question in public would, therefore, be intimidating since they may take that as a
test upon their intelligence (Durey, Thompson, & Wood, 2012). Nurses must, therefore, learn to
communicate with them in a culturally appropriate manner that is not embarrassing to them. Direct
eye contact is considered as a sign of disrespect especially when communication involves a young
and an older Aboriginal Australians (Kruske, Kildea, & Barclay, 2006). . In the Aboriginal culture,
young people are not supposed to maintain direct contact when talking to older people. Healthcare
practitioners must understand this and modify their communication technique appropriately
(Adams, 2010).

The health care practitioners are considered as a form of authority. From the historical accounts,
the relationship between the indigenous Australians and the authority has not always been so good.
Formal structures of authority remind them of the rule of the colonialists who took away their land,
mistreated them and killed their people (Durey, Thompson, & Wood, 2012). The healthcare
professionals must, therefore, adapt a practice which is devoid of the formal structures of
relationships to encourage the indigenous Australians to seek care. The feeling of authority may
make the indigenous Australians hesitant to ask certain questions. They could easily say no to a
question asking them if they have any more questions while in reality, they could be having
questions which easily go unanswered (Downing & Kowal, 2011).

The health practitioners must also learn to respect the traditional healing practices of the
indigenous Australians (Liaw, Lau, Pyett, Furler, Burchill, Rowley & Kelaher, 2011). Before the
arrival of the white people, the indigenous Australians depended purely on traditional medicine.
They believed in their traditional healers and their medicines and held a lot of respect for them to
date. The healthcare practitioners must, therefore, learn to ask questions about their traditional
medicine since it shows them that their traditional ways are still recognised and respected
(McMurray & Param, 2008). Asking them questions about their traditional medicine could open
doors for further communication which could enable the health practitioners to gather the best and
accurate information needed for proper diagnosis (Abbott, Gordon & Davison, 2008).

Nurses must also be careful to ensure that they respect the Aboriginal patients. Care must be taken
to ensure that top down approach to decision making is avoided at all costs. Taking a top down
approach to decision making as Ware (2013) warns could make the Aboriginal Australians feel
intimated and could lead to failure to seek further medical care. Health care practitioners must
always strive to ensure that the patients are involved by seeking their input before making any final
decision (McMurray & Param, 2008).

To ensure that health practitioners take good care of the Aboriginal patients, nurses must undertake
a self-analysis of themselves. They must as Ware (2013) asserts, study themselves and determine
if they hold any stereotypical images and viewpoints. This is very important since the provision of
competent nursing care cannot happen by simply learning the culture of the Aboriginal
Australians. One must understand themselves and then learn to overcome personal prejudices that
may interfere with competent nursing care Ware (2013. All nurses must consider undertaking a
cross cultural awareness course to understand the history, protocols, influences, and issues about
the Aboriginal Australians. This will enable the nurses to create confidence and knowledge which
is needed for a culturally competent environment (Downing, Kowal & Paradies, 2011).

According to Kruske, Kildea, and Barclay (2006), nurses must understand the Aboriginal cultures
in their regions of assignment. They must understand that people have unique cultures and
differences. Understanding the local culture of the Indigenous people in their areas of placement
will make it easier for them to overcome certain problems that make communication difficult.
Understanding the local culture will ensure that the health care practitioners become aware of the
issues surrounding the body language and cultural factors. They will understand the words that can
be used when speaking to the Aboriginal Australians and the words that cannot be mentioned.
Understanding the culture in their placement will also enable them to learn how to give their
patients the needed personal space and privacy to ensure that there is no conflict that results from
a cultural misunderstanding (Williamson & Harrison, 2010).

Conclusion

The issue of culturally competent care has drawn a lot of debate and attention in Australia. This
is majorly exacerbated by the poor health seeking behavior of the Aboriginal Australians. The poor
health seeking behavior of the indigenous Australians can be traced back to the historical injustices
that were meted upon them which resulted in the loss of trust in the non-indigenous Australians.
To restore this trust and offer culturally competent care, the health care practitioners must start by
understanding their own cultural beliefs and values. This will ensure that their deal with their
stereotypical view points before attempting to learn other culture.

Health care workers must then strive to understand the culture of the indigenous Australians
around them to ensure that they can provide competent care. Understanding of the culture of the
people around them will ensure that they provide care that is culturally appropriate by showing
respect to the culture of the indigenous people. They can do that by respecting the symbols of
respect of the indigenous people such as their flags and their cultural heritage or respecting and
acknowledging their mode of communication and traditional forms of medication. Health care
professionals can also tailor services to meet the needs of the indigenous Australians to improve
their health seeking behavior.
Reference

Abbott, P., Gordon, E., & Davison, J. (2008). Expanding roles of Aboriginal health workers in the
primary care setting: seeking recognition. Contemporary nurse, 27(2), 157-164.

Adams, K. (2010). Indigenous cultural competence in nursing and midwifery practice. Australian
Nursing and Midwifery Journal, 17(11), 35.

Davidson, P. M., Abbott, P., Davison, J., & DiGiacomo, M. (2010). Improving medication uptake
in Aboriginal and Torres Strait Islander peoples. Heart, Lung and Circulation, 19(5), 372-
377.

Downing, R., & Kowal, E. (2011). Putting Indigenous cultural training into nursing
practice. Contemporary nurse, 37(1), 10-20.

Downing, R., Kowal, E., & Paradies, Y. (2011). Indigenous cultural training for health workers in
Australia. International Journal for Quality in Health Care, 23(3), 247-257.

Durey, A., Thompson, S. C., & Wood, M. (2012). Time to bring down the twin towers in poor
Aboriginal hospital care: addressing institutional racism and misunderstandings in
communication. Internal medicine journal, 42(1), 17-22.

Kelly, K., Dudgeon, P., Gee, G., & Glaskin, B. (2009). Living on the edge: Social and emotional
wellbeing and risk and protective factors for serious psychological distress among
Aboriginal and Torres Strait Islander people. Darwin: Cooperative Research Centre for
Aboriginal Health.

Kruske, S., Kildea, S., & Barclay, L. (2006). Cultural safety and maternity care for Aboriginal and
Torres Strait Islander Australians. Women and Birth, 19(3), 73-77.

Liaw, S. T., Lau, P., Pyett, P., Furler, J., Burchill, M., Rowley, K., & Kelaher, M. (2011).
Successful chronic disease care for Aboriginal Australians requires cultural
competence. Australian and New Zealand Journal of Public Health, 35(3), 238-248.

McMurray, A., & Param, R. (2008). Culture-specific care for indigenous people: a primary health
care perspective. Contemporary Nurse, 28(1-2), 165-172.
Polaschek, N. R. (1998). Cultural safety: A new concept in nursing people of different
ethnicities. Journal of Advanced Nursing-Institutional Subscription, 27(3), 452-457.

Stewart, S. (2006). Cultural competence in health care. Sydney: Diversity Health Institute.

Ware, V. (2013). Improving the accessibility of health services in urban and regional settings for
Indigenous people (Vol. 27). Australian Institute of Health and Welfare.

Williamson, M., & Harrison, L. (2010). Providing culturally appropriate care: a literature
review. International journal of nursing studies, 47(6), 761-769.