(After Nursing Council of New Zealand (2009) Guidelines for Cultural Safety, the Treaty of Waitangi, and Maori Health in Nursing Education and Practice. Wellington, New Zealand: Nursing Council of New Zealand.)

An individual, whether nurse or patient, may identify with more than one culture, and these can change in terms of priority and influence in response to internal and external forces. Nurses have traditionally sought to provide care ‘regardless’ of difference, assuming that the provision of a single standard of care, if set at an appropriate level, will result in ‘best practice’. Similarly, the old adage often given is to provide the treatment that ‘we would like to be given to our own relative/mother/child’. This assumes that the standard of care appropriate to one individual or within one culture is necessarily the best for all members of society. The presumption here is that, on one level, everyone is the same and that this sameness represents the ideal, which is usually the mainstream of society. For nurses, the assumption is often that the culture of healthcare is the most desirable, that patients should be compliant and responsive to directives, because they are presented in their best interests. When expressed bluntly like this, the paternalism is clear – the expert knowledge of healthcare is presumed to give the practitioner the ability to determine what is best for the patient, often overlooking the patient’s expert knowledge of ‘self’. The tendency is for nurses, and other health professionals, to integrate this approach at a subconscious level, rather than as a result of a deliberate decision-making process. Yet treating everyone the same does not guarantee an acceptable standard of practice. The care that one individual values may not be desirable or even acceptable within another culture. Rather than seeking to provide care ‘regardless’ of difference, it may be more appropriate to consider how to provide care ‘regardful’ of what makes people unique.

For emergency nurses, the benefits of recognizing and responding to cultural difference can be seen in improved ability to anticipate problems, recognize non-typical patient responses and become more responsive to individual needs. This has flow-on effects in terms of efficiency and effective use of time and the ability to defuse potential conflict. Patients who present to the ED do so for a variety of reasons, and their attitudes and expectations towards care are similarly varied. Many of these patients appear agitated, aggressive, uncooperative or actively disruptive. While physiological responses can account for some behaviours, others appear socially inappropriate and can trigger negative responses from nurses and others attempting to care for them. Many emergency nurses thrive on the excitement and adrenaline rush associated with managing trauma and other life-threatening occurrences; dealing with non-urgent patient presentations can at times seem less worthy of time and resources. Whether this is an acknowledged response, often evident in the use of pejorative terms to describe certain groups of patients, or a more subconscious reaction, this can impact on patient care.

Nurses are expected to be non-judgmental, to uphold universal standards and to do so in a calm and conscientious manner. Yet nurses are also expected to make judgements, to prioritize care and to ration the use of resources in all aspects of clinical practice. Rather than simply labelling a patient as ‘non-compliant’ or ‘difficult’, nurses can seek to identify the areas of difference between their own expectations and those of the individual receiving care. The patient who sits sullen and unresponsive may not intend to be obstructive; without knowing what their previous experiences with hospitals, the health system and figures of authority has been, it is difficult to know how this may have impacted their behaviour. It may be that a physical impairment such as deafness or difficulty with language or understanding has led to a sense of isolation and frustration. It may be that the patient is simply so focused on other things, such as the circumstances that led them to present, concern about family and friends or fear of disclosing information related to their health and personal circumstances that this has resulted in the appearance of non-cooperation or aggression. While the potential causative factors are many, the risk remains the same. Nurses need to ensure that commonly encountered factors such as workload, patient acuity and other pressures do not impact their ability to assess a given situation. Failure to do so risks introducing assumptions and treatment based on misconceptions. An effective way to understand what is happening in a given situation is by asking the patient, and doing so in a manner that encourages the individual to feel safe in sharing relevant information. In an increasingly busy workplace it is important to find the time to reflect on practice and identify the unspoken moral judgements that are made.

Stereotyping, stigma and discrimination

The Oxford English Dictionary defines stereotype as ‘a widely held but fixed and oversimplified image or idea of a particular type of person or thing’ and cites as examples the stereotypes of women as carers and other racial and gender stereotypes. Stereotypes act like codes that give audiences a quick, common understanding of a person or group of people – usually relating to their class, ethnicity or race, gender, sexual orientation, social role or occupation. They are based on assumptions and generalizations about individuals and groups, and can be either positive or negative. There are certainly stereotypes present within the health system, and specific examples within the ED setting. These can have a positive impact, and at times are actively used to aid in recognition of conditions and to influence diagnoses. The constellation of signs and symptoms typically associated with myocardial infarction, support emergency nurses in the recognition of the patient with chest pain. However stereotypes can also perpetuate inaccurate and often damaging assumptions. They typically rely on reductionist, simplistic categorizations and can be used to exert power over marginalized groups. Use of stereotypes can result in expressions of social prejudice and tacit endorsement of inequalities in access to and availability of healthcare.

Whereas stereotypes can be either favourable or unfavourable, stigma relates to negative labelling that identifies some individuals as being less worthy than others (Feeg 2009). Common examples of stigmatization within healthcare include attitudes expressed towards people experiencing mental health issues, infectious and sexually transmitted diseases and self-inflicted injuries. Within the emergency care setting, typical patient groups for whom stigma can develop include those patients who are perceived as time-wasters, who exhibit drug-seeking or self-harm behaviours, present with non-urgent conditions or who are frequent attenders. Many of these patient groups are presumed to use a disproportionate or inappropriate amount of the limited resources available within the ED and to impact negatively on the acute care needs of others. Presumptions are also made around health and self-care behaviours that are seen as contributing to disease states, such as smoking, alcohol-related illnesses, and non-compliance with recommended treatments and medication regimens.

Discrimination occurs when one person is treated differently to another in the same or similar circumstances. Discrimination is not always illegal and at times is deliberately implemented in an effort to address issues of equity. Oppression, discrimination and marginalization have been associated with increased health risk amongst populations rendered vulnerable because of social deprivation, prejudice and violence. These vulnerable populations are also over-represented in the ED patient mix. Specific health-related conditions have been associated with marginalization and discrimination, such as obesity, mental illness and disability (Joachim & Acorn 2000, Latner et al. 2007, Verhaeghe et al. 2007, Bejciy-Spring 2008). Discrimination can result from prejudice that is triggered by personal responses to patient characteristics and imposed stereotypes. This has significance for the emergency nurse in that it can influence practice in conscious and unconscious ways, and affect the quality of care given.

A number of studies have linked variation in assessment and treatment of pain to presumptions and cultural stereotypes (Epps et al. 2008, Naryan, 2010). Rather than relying on generic expectations of pain behaviour linked to ethnicity or socio-cultural identification, it is important to acknowledge the significance of the pain experience to the individual. Chen et al. (2008) examined gender disparity in relation to the tendency to under analgise ED patients presenting with acute abdominal pain. This study identified that even when patients presented with similar symptoms and gave similar pain scores, women were consistently less likely to receive opioid analgesia and to wait longer for pain relief to be administered. Other examples include studies showing links to longer waiting times in EDs associated with ethnicity (Pines 2009) and health disparities associated with religious affiliation (Laird et al. 2007). Bias and assumption regarding some patient conditions and disease processes have been associated with the likelihood of receiving timely care. Dutch et al. (2008) found that descriptions of presenting complaints given at triage can lead to identification and avoidance of less desirable patients by emergency physicians. Emergency nurses have an ethical and professional duty of care and need to recognize and react to evidence of discrimination, and to reflect on aspects of their own practice that may involve unconscious expressions of marginalization.

Stereotypes are not only applied to patients; a number of assumptions are also made about the role and personal characteristics of nurses. These impact on the way in which patients, relatives and other health professionals view nursing as a profession and nurses as individuals. Misconceptions about the role of the nurse within the wider healthcare team can affect collegial relationships and expectations relating to authority, independence and autonomy in practice. Hierarchical structures remain in many health services and the nursing voice can at times be marginalized and the ability to act as a patient advocate impeded.

The culture of nursing

The profession of nursing has its own culture and associated cultural values and beliefs that guide practice. Nursing culture has been described as ‘…the learned and transmitted lifeways, values, symbols, patterns, and normative practices of members of the nursing profession of a particular society’ (Leininger 1994). An understanding of nursing culture is important as it allows for the dissemination of core values, recognition of nursing assumptions and clarification of nursing ideologies and goals. Cultural values associated with nursing typically encompass concepts such as caring, respect for patient rights, autonomy and dignity alongside practice fundamentals such as quality improvement and use of an evidential base. More clinically orientated norms include beliefs around topics such as pain management and the patient role. Emergency nursing has its own specific values and clinical expectations. Personal and practice attributes that are valued include efficiency, flexibility, creativity and the ability to respond to rapidly changing and often stressful situations. Emergency nurses are expected to be leaders, to hold a range of knowledge, to show expert assessment and analytic skills and to act as a cohesive force in combining the input from a range of specialties. Cultural responses common in emergency nursing that might not be acceptable within wider society include the use of ‘black humour’ as a response to critical, traumatic or otherwise distressing incidents. While recognizing the value of this in debriefing and coping with stress, the ED nurse needs to reflect and recognize when this moves from being a defence mechanism to a genuine expression of bias or discrimination.

A number of different models of care seek to address issues of cultural and social difference. Many of these are influenced by understandings of power and draw on elements of Critical Social Theory, an approach that challenged the traditional assumptions around truth, power and knowledge. Recognition of the significance of knowledge formation and application is linked to notions of empowerment, enlightenment and emancipation. Applying these principles to emergency nursing encourages self-reflection and recognition of judgements based on unexamined beliefs, values and attitudes. There is emphasis on recognizing the significance of context and individual circumstances rather than relying on generic understandings of health and illness.

Models that address issues of culture in nursing include transcultural nursing, cultural sensitivity, cultural competence and cultural safety. Williamson (2010) suggests that these approaches follow two principal paths; the first of these focuses on learning about elements of culture such as values, beliefs, and traditions that are identified and categorized according to a specifically defined cultural group, often determined by language or location. However, assuming that a set of attributes apply to all members within a group risks perpetuating cultural stereotypes. These approaches are based on learning about other cultures, identifying key characteristics or preferred patterns of care associated with each specific, defined culture. This can result in a checklist approach to cultural knowledge that presumes that all members of a cultural group hold a similar intensity and range of beliefs and values. This presumes a degree of stasis within cultures and minimizes the ability to look for and respond to individual variation. In seeking to learn about the ‘other’, there is also a risk that the culture of the individual nurse becomes positioned as the norm, and those with different cultural identities by default are seen as deviating from the mainstream or social ideal.

A second approach looks to position cultural understanding within a wider framework, looking at issues such as the social construction of health, racism, power and oppression. These approaches are often linked to discussions around colonization, indigenous health needs and socio-political underpinnings. Criticisms of this approach focus on the difficulty of defining core features and evaluating its impact in practice (Johnstone & Kanitsaki 2007, Williamson & Harrison 2010).

Whichever type of approach is used, emergency nurses need to be consciously aware of the presumptions and judgements they and others are making. The use of techniques such as structured reflection, debriefing, case review and clinical supervision can all assist in identifying and where necessary altering patterns of response.

Expressions of power

The structure of nursing has been influenced by its historical origins that contributed to the development of formal role delineation and expression of status through use of uniforms and titles. Uniforms offer outward symbolism and are representative of the power underpinning nursing culture. The presence of uniforms can create an artificial barrier that has the potential to impact on personal, collegial and organizational relationships, whether this is acknowledged by the individual practitioner or not. The uniform can be seen as an intimidatory tool, sending a subconscious signal that has both positive and negative connotations in the healthcare setting. However, for many people, the uniform is easily identifiable, reassuring and recognizable. It signals authority, control and competence and as such can be seen as a clear representation of professionalism.

Emergency nurses hold considerable power, although this is often unrecognized and unacknowledged. Nurses have at times portrayed a victim mentality, describing themselves as an oppressed group. While stereotypes such as ‘doctor’s handmaiden’ do tend to support this view, emergency nurses exercise considerable power and control over the patient environment, physical interactions and access to knowledge. Emergency nurses act as gatekeepers, mediating access to medical staff, resources and at times restricting family access and freedom of movement. By taking the time to reassure, explain and involve patients and their families, emergency nurses can share their power and reduce the sense of cultural distress that often follows entry to the health system.

Power and empowerment are concepts familiar to most nurses. There is an assumption that nurses actively seek to advocate for patients, and theories focusing on the role of the nurse-patient relationship and the goal of empowering patients to maximize their health status are well recorded (Chambers & Thompson 2009). The suggestion has been made that before being able to empower others, nurses need to empower themselves and their profession, with subsequent benefit in terms of improved clinical practice, patient and staff satisfaction and professional development. Donahue et al. (2008) identified a correlation between a nurse’s own sense of empowerment in the work setting and patient satisfaction, suggesting that there are tangible benefits in terms of patient care from developing a context that values and empowers healthcare practitioners.

While patients can be seen as a potentially oppressed group, they can also be supported in gaining and expressing power (Dong & Temple 2011). This can be through acknowledgment of concepts such as the ‘expert patient’ that recognizes that while individuals may not have expertise in terms of nursing or medical knowledge they are often experts in their own right. This has been seen particularly in relation to the management of chronic conditions, with the expert patient defined as one who has ‘the confidence, skills, information and knowledge to play a central role in the management of life with chronic diseases’ (Department of Health 2001). While this may seem to embody the core concepts identified within healthcare, the practice reality can often see a less positive response. Despite the rhetoric of patient autonomy, it is often easier for nurses and other healthcare practitioners to act in a more directive, paternalistic manner and informed patients can be seen as less responsive and compliant. The reality of overcrowded EDs can see the emergence of a culture that values unquestioning acceptance of healthcare directives and the emergence of more limited interactions between nurses and patients. Power can be exerted as much through acts of omission as through concrete actions and nurses can generate and experience both active and passive expressions of power. Patients also express and utilize power in a number of ways. This can be passively through withdrawal of support, compliance or engagement with the healthcare process or actively through expressions of aggression, threats of complaint or demanding recognition of patient rights and care standards.