POSTED BY CATH SEAVER 86SC ON MARCH 01, 2018

From 1st March the new Code of Conduct for nurses and midwives (nurses) introduces a new concept of “Cultural Safety” into the Code itself.

Nurses traditionally have offered care to their patients on an individual basis without fear or favour irrespective of colour, class or creed. Respecting cultural differences is part of the bond of trust between nurse and patient. But the NPAQ believes the Code has overstepped the mark of mutual respect which must underpin any regulatory instrument.

There is a lot of indignation that the Code is racist to the core. That ultimately is a matter of opinion but most people would think that the Code requirement to "acknowledge white privilege" is unambiguous. In its essence, racism is primarily bad mannered bigotry, and of itself should be of little importance to nurses trying to deliver clinically safe, competent and non-discriminatory care to their patients. Whilst acknowledging valid nurse concerns about how the Code is written, NPAQ's primary concern is for the practical consequences of the Code. We must therefore look at what the Code actually says as opposed to the emotive reaction to the bullying and racist elements of it.

What the Code of Conduct actually says for Nurses (midwives similar)

Principle 3.2 
Culturally safe and respectful practice requires having knowledge of how a nurse's own culture, values, attitudes, assumptions, and beliefs influence their interactions with people and their families, the communities and colleagues. To ensure culturally safe and respectful practices, nurses must:

(a) Understand that only the person and/or their family can determine whether or not care is culturally safe and respectful.

What is the problem with this?

This begs the following questions:

1. If only the person (in the context meaning ‘patient’) or their family can determine what is
   "cultural safety", then how is a nurse to know what the patient thinks so they can deliver
   "culturally safe" care or practice?
   
   
2. What is the consequence to the nurse of not delivering "culturally safe" care or practice to patients under this Code condition?

Answers

Q1: Nurses can read the Code provisions 3.2 (b-f) for guidance about what constitutes "culturally safe" practice. Additional elaboration and explanation of the words and concepts, including the controversial racist provision for nurses to "acknowledge their white privilege " can be found in the Glossary. But this is all academic. It doesn’t matter what the nurse thinks or even tries to do.

"Cultural Safety" or lack of, is entirely in the mind of the patient and/or their family and whether they lodge a complaint to AHPRA about a nurse is entirely up to the patient and/or their families and their lawyers.  For instance, if the patient, for whatever reason, required the nurse to “acknowledge their white privilege” (say) as a condition of ‘Cultural Safety’ then the nurse would have to do it.  To be clear, this is not a requirement of AHPRA. The Code says it can only be a requirement of the patient if the patient demands it. But this is in practice an unfettered licence for patients to bully nurses with impunity. “If you don’t do as I want nurse I will stuff up your career”.

The normal defense of an employee subject to a complaint about their performance (in any field not just nursing) is to argue that their employer did not train them sufficiently. That defence is not available to a nurse under the Code because as a matter of law you cannot train for something that you cannot know about. Even worse the nurse cannot use the defence that their actions were that of a reasonable person, an objective test that even criminals have the right to exercise. Everything rests on the nurse's shoulders about an unknowable and indefensible proposition entirely at the whim of the patient.

Q2: So what is the consequence of a nurse not delivering 'Culturally Safe' care or practice? 

Because the body of the Code is silent on this, we must go to the Glossary for guidance. This is where it gets serious. It says "cultural safety is as important to quality care as clinical safety". 
This establishes a mechanism for the scale of a potential offense. Because the creation of an offence is entirely the subjective right of the patient or their family, the seriousness of the alleged breach of cultural safety is also in their hands. So offences will either be minor or egregious again entirely at the whim or opinion of the patient.

So what will the punishment be?  If the culturally unsafe practice is regarded as mild by the patient, then because of the new equivalence of cultural and clinical practice then the sanction should be the same as for a mild breach of clinical practice. A caution and limited period of supervised practice is normal. But what happens if the patient is grievously offended? Code consistency demands that the penalty for the most grievous clinical safety breaches should apply. The nurse is in clear danger of losing their registration if the Code is enforced consistently.

Conclusion

Forget about the bullying racism if you can. That is an emotive side issue. The process is to be the punishment. AHPRA claims take 18 months on average to resolve. There is no defence to "cultural safety" complaints.  Nurses are in jeopardy.  Already our first AHPRA notification for an alleged "cultural safety" breach has been lodged. The only thing that can be resolved in this particular case is what the punishment will be.

What is going to solve this problem?

The Code must be changed and the Chair of the Nursing and Midwifery Board of Australia, Professor
Cusack must resign. But this can only be done by nurses exercising their democratic right to withdraw their financial support from the QNU and the ANMF who support this Code and join the NPAQ the only organisation in Australia which is fighting this and will continue fighting this until the new changes to the Code are overturned.