Alchemy and Morality in ‘Rappaccini’s Daughter’ and ‘The Birthmark’ - Literature Essay Samples

In the seventeenth century, genuine scientific breakthroughs were ideals of the future. The reality was alchemy, an extremely basic science in which procedures were practically guesswork. It is this sense of the unknown that induces both fear and questions of morality in Hawthorne’s science fiction. The short stories ‘The Birthmark’ and ‘Rappaccini’s Daughter’ both include alchemists, bringing a Frankenstein-esque horror as to the possibilities and lengths the scientists will go to in order to achieve progress. The two scientists, Rappaccini and Aylmer, are bound together in an almost religious, Promethean quest to reach a higher knowledge, a higher spiritual being than that of mere mortals. Through reaching for this spiritual ideal, concepts of morality are complicated further. It is here necessary to consider whether if one is dedicated to reaching a higher knowledge, he is therefore above mankind and exempt from mortal laws of morality. The practice of alchemy not only had no written definition, but its process and methodology were also unknown. The danger of exploring the unexplored is heightened by the use of people as subjects. Both endings for the heroines in ‘Rappaccini’s Daughter’ and ‘The Birthmark’ culminate in death, each death caused by a scientist’s inability to predict a chemical’s reaction within the human body. The only certainty present in the alchemy is the result. Rappaccini and Aylmer, the two alchemists in the mentioned short stories, are certain of the physical change they are striving to achieve and so continue until they reach this ideal conclusion, or until their subjects die. Perhaps these scientists are only labelled ‘scientists’ by the modern definition due to their experimentation with materials. The characters can, arguably, be categorized more accurately as pseudo-scientists. They have a claim to science in their knowledge, yet it is based on myth and the unknown, meaning their that method is not specifically scientific. Each scientist can also be described according to the myth of the ‘mad scientist’. In literature, this character was present before Hawthorne. Mary Shelley’s Frankenstein and Jonathon Swift’s Gulliver’s Travels present versions of the ‘mad scientist’, who strives towards Promethean knowledge that usually resides beyond knowledge discoverable on earth. The experiments and their physical results within Hawthorne’s short stories are important. However, the moral consequences of the procedures are more important than the scientific results, and the ‘mad scientists’ are presented as figures to judge according to a nineteenth century morality. There is also an alignment between nineteenth century context and Hawthorne’s fictional progression of science. The industrial revolution began in 1760; therefore, Hawthorne’s fiction published in the 1830s onwards encounters a world that is still attempting to emerge fr om the practices of medieval science. Accessibility, however slight, to scientific knowledge allows Hawthorne’s characters in his nineteenth century fiction to develop beyond the ‘mad scientist’ stereotype to attain a measure of reason. The ‘mad scientist’ therefore remains a character that belongs to the past, uneducated in modern, scientific techniques, but insatiable in a desire to progress towards the future. Is the ‘mad scientist’, therefore responsible for all sin in ‘Rappaccini’s Daughter? The creator, Rappaccini, and his creation, Beatrice, both arguably harbor evil. The creator remains the most obvious source of evil, as his mind imagines the experiment, and his hands conduct it. However, he cannot be wholly blamed when practicing alchemy, as the results are unknown. The Bible states ‘the way of the wicked is as darkness; he knoweth not at what he stumbleth.’ If one is blind to what ‘he stumbleth’ upon during the process, the obstacle cannot be decided as good or bad. Moral judgement can therefore only occur once the experiment emerges from the ‘darkness’ to a definitive result. This darkness is presented as multifaceted, while the plot focuses on the experiment’s process. It can either serve as a temporary blindness that will lead into to a progressive, unexplored territory, or exist as an omen of inevitable tra gedy. Rappaccini is only branded as a ‘mad’ and evil scientist because his experiment ends in death. If he had created an elixir beneficial to medicine, he would transcend the ‘mad scientist’ stereotype and emerge instead as a pioneer. Thus far, the responsibility of the scientists has been explored. Hawthorne also examines their capabilities as well. The scientist’s practice does not require love to succeed, and it is examined how this fact influences relationships that undoubtedly do require love. Hawthorne wrote in an 1840 letter to Sophia Peabody, his future wife: ‘we are but shadows [†¦] till the heart is touched.’ Hawthorne therefore saw a person without love as incomplete, a mere ‘shadow.’ The heart, representative of emotion, and the head, representative of measured and reasonable thought, are presented as different but not completely antithetical. A body needs both a heart and a brain to function, therefore a whole being is not a combination, but a balance of these two. Hawthorne’s scientists are imbalanced, as they focus on mind over emotion. In ‘The Birthmark’ Aylmer seeks love by washing the ‘stains of acids from his fingers and [persuading ] a beautiful woman to become his wife.’ A lack of science is required in the initial courtship, suggesting that emotion and the ‘heart’ must temporarily overpower the reasonable ‘mind’ to succeed. It is ominous that, as Aylmer ‘stains’ his fingers once more, this balance is again disturbed, and his heart loses the ability to love. Yet, in this initial courtship, love is only mentioned once. Instead, he must persuade a woman to marry him, an action that is performed by the mind, not the heart. Sherwood R. Price argues that Hawthorne explores the ‘consequences of divorcing either reason from emotion or emotion from reason’. [2] This is not wholly accurate, as Hawthorne never implies such an antithesis as that reason is completely divorced from emotion, or vice versa. At the beginning, Aylmer must temporarily forsake science for love, yet it leaves ‘stains’ on his fingers. This situation suggests an inability to e ngage with a natural instinct of love for another through being so deeply influenced by alchemy, so that moral consequences – even to those he loves – are irrelevant. However, lacking this natural instinct to love is perhaps necessary to scientific achievement in Hawthorne’s fiction. Dependent on physical chemistry, achievement in alchemy requires a human body as a subject. Rappaccini’s progress is only able to continue through the dedication of his life and the sacrifice of those around him. Edward H. Rosenberry suggests that ‘Rappaccini has no physical offspring, only spiritual or intellectual.’ This is accurate on a metaphorical level, as the poison in Beatrice’s blood represents his scientific achievement. Yet, he does possess her also as a ‘physical’ specimen, necessary to the experiment. He does not, however, regard her as ‘offspring,’ only allowing an end to her solitude at the price of Giovanni Guasconti, the naà ¯ve student captivated by Beatrice, also becoming a subject. In imprisoning Giovanni as the next generation, Rappaccini promotes the idea that science requires, literall y, a life to thrive. Aylmer and Rappaccini must see their kin as mere subjects in order to scientifically progress, yet this outlook is complicated by their drive, which is seemingly emotional. They wish to elevate their subjects to a higher position of eternal perfection. Hawthorne’s scientists are therefore punished for their choice to forsake emotion. While Hawthorne’s scientists are indeed guilty of feeling little emotion, he also presents characters such as the rash, young Giovanni in ‘The Birthmark’ who feel too intensely, and are equally guilty. A life without love is empty, yet an existence governed entirely by emotion leaves the person, arguably, vulnerable. In response to Beatrice, Giovanni feels ‘a wild offspring of both love and horror’. As a sensitive man with the ability to feel, Giovanni should exist as the antithesis to Rappaccini. Yet, he cannot love fully either. His emotion is indefinable, and is instead a ‘wild offspring,’ suggesting that a definition has not yet been developed in the English language. Perhaps this implies an inability to react to a phenomenon he has never yet encountered. As ‘both love and horror’ exist as emotions, they should be based entirely on how one feels. Giovanni’s love instead stems from a morbid fascination, a sensation that originates in the mind. Even in expressing admiration, Giovanni still does not possess a genuine motive to save Beatrice from her own Father. Giovanni is perhaps condemned further for not being able to control his ‘wild’ emotion. His scientific pursuit aligns him with the heartless Rappaccini, and begins to balance his excess of emotion. If he were able to control his emotions, he could have remained detached from Beatrice from the beginning. As Hawthorne accuses men of being too measured, or too emotional, he suggests that residing at either end of the spectrum is limiting and has negative consequences. Thus far, Hawthorne’s seventeenth-century scientists have been examined in terms of moral action and its consequence. Hawthorne also allows the reader to witness the motives behind their actions, allowing for a further examination of character without judging wholly their outward behavior. The scientist’s pursuit of science resembles a Faustian urge for knowledge. Whilst Faustus signs his soul to Mephistopheles in blood, Aylmer and Rappaccini agree to the same pact without symbolic ritual. In their pursuit for science, Hawthorne’s scientists perhaps reach beyond this Faustian urge. Rappaccini does not need a devil’s permission to motivate his cause, and would ‘sacrifice human life [†¦] for the sake of adding so much as a grain of mustard-seed’ of knowledge. Rappaccini is undoubtedly Faustian in what he is willing to ‘sacrifice’ for knowledge, suggesting that he holds scientific achievement in higher regard than human life. Th is fact is emphasized by placing a momentous concept – human life – syntactically close to a physical, extremely small concept, a mustard seed. Like Rappaccini’s garden, this idea creates walls around him so that his scientific pursuits are separated from human life. The value of the ‘mustard-seed’ as representative of knowledge depends on perspective. Baglioni, the philosopher who speaks this statement, disagrees. To him, sacrificing human life in pursuit of progress is pointless. To Rappaccini, this ‘grain’ could be the key to his experiment, and worth countless human lives. As established, Rappaccini and Aylmer are guilty of pursuing a Faustian, higher knowledge. Dr Faustus is granted knowledge by the devil, suggesting perhaps that to reach this level of knowledge, one must go beyond an earthly realm to either heaven or hell. In a letter to Sophia Peabody, Hawthorne asks: ‘What delusion can be more lamentable [†¦] than to mistake the physical and material for the spiritual?’ [1] The mistake of Hawthorne’s scientists is perhaps not in their actions, but in their motivational ‘delusion’ that dictates that they can ascend to a higher knowledge, and still remain in mortal form. Specifically, Rappaccini’s mistake is assuming a God-like position in deciding whom he can ‘sacrifice’ for his cause, when he has neither the power nor authority to maintain a celestial position as a mortal. Taylor Stoehr argues that Hawthorne’s characters are punished for remaining in their imaginations, and not the re al world. They are however, not completely punished for these delusions. Instead, they are punished for not translating these ‘delusions’ in to a more reasonable version in reality. Their imaginations stretch too far, and mistake a ‘physical’ reality as capable of realizing ‘spiritual’ delusions. In attempting to achieve their fantasies, the scientists reach to realms such as heaven and hell that cannot support physical human forms, and their experiments inevitably end in death. Hawthorne’s fiction explores alchemy and physical chemistry. These pursuits processes, results, and consequences all reside in the physical. However, the moral choices which his characters encounter are what subsequently affect the physical realm that he focuses on. The use of alchemy may be detrimental, but the root of evil he examines extends ‘monster-like, out of the caverns of [the] heart.’ Edward H. Rosenberry, ‘Allegory of Science’, American Literature (Duke University Press, 1960), JSTOR Selected Letters of Nathaniel Hawthorne ed. by Joel Myerson (Columbus: Ohio State University Press, 2002) Sherwood R. Price ‘The heart, the head, and ‘Rappaccini’s Daughter’, The New England Quarterly (The New England Quarterly Inc., 1954), JSTOR, Proverbs, 4:19 Taylor Stoehr, Hawthorne’s Mad Scientists: Pseudoscience and Social Science in Nineteenth Century Life and Letters (Hamden: Archon, 1978)

Exploring The Nativist Perspective And Cognitive Development

Nature and Nurture is a concept that has been widely debated over the impact it plays in children’s language development. Is it better to nurture a child through their environment or allow their inner clock and biology to take over and take its course? Discussing the Nativist perspective and Cognitive development and their varying theories that are arguably similar and have criticisms of their own and how this plays a key role in this topic. At the age of 3 months we see early signs of phonology; children will turn their heads, and stop crying once hearing parent’s voices. They indicate contentment and amusement by smiling, and repeating sounds (e.g. cooing). (Berk, 2003). In addition babies 4-7 months notice new sounds such as the telephone. They also respond to â€Å"no† and changes in tone of voice. Early sound discrimination skills are beginning to emerge. 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Cultural Competency Definitions free essay sample

A paper to inform development of Cultural Competency Framework for First Nations and Aboriginal Peoples of British Columbia, Canada Cultural Definitions in health care – what does it all mean? There are many definitions and iterations of culture in health care – all with different meanings but many with overlaps. In order to develop a Cultural competency framework, it will be important for stakeholders to agree on what ‘cultural competency’ means and the differences, similarities or connections between this term and others used in different contexts. Any agency or institution using the terms(s) needs to state their own definitions so it is clear to their own readers, users, students or staff – what they mean when they apply the terms. The mostly commonly used terms associated with cultural competency are: ? Cultural responsiveness ?Cultural appropriateness ?Cultural awareness ?Cultural sensitivity ?Cultural safety ?Cultural competency Often these terms have been used interchangeably for training purposes – when in fact the training content has sometimes been the same or very similar. Culture General Definitions of Culture It is important to define what is meant by culture. Definitions of culture are often confused by using terminology such as ‘race’ and ‘ethnicity’ but a basic definition of culture reveals a far broader understanding. One definition of culture is: The totality of socially transmitted behavior patterns, arts, beliefs, institutions, and all other products of human work and thought. These patterns, traits, and products considered as the expression of a particular period, class, community, or population and can be expressed in intellectual and artistic activity and in the works produced by the ‘culture’ or ‘culture group’ Culture is essentially a convenient way of describing the ways members of a group understand each other and communicate that understanding. More often than not, the nuances of meaning are generated by behavior rather than words, and much of the interaction between members is determined by shared values operating at an unconscious or ‘take for granted’ level. Many groups have their own distinctive culture: the elderly, the poor, professional groups, gangs, the army . Websters Third New International Unabridged Dictionary defines culture as the total pattern of human behavior and its products embodied in thought, speech, action, and artifacts and dependent upon mans capacity for learning and transmitting knowledge to succeeding generations through the use of tools, language, and systems of abstract thought. Culture is increasingly recognized as a crucial variable in the delivery of health care services. Diagnosis and treatment planning and implementation require special skills and sensitivities when the health care practitioner and the patient are from different cultures. In ‘Critical Cultural Perspectives and Health Care Involving Aboriginal Peoples (Browne Varcoe, UBC) the authors examine the complexities inherent in attempting to define culture. Specifically they examine the problems that can arise when culture is defined too narrowly or from a culturalist perspective and the implications of applying narrow definitions of culture in the area of Aboriginal health. To counter these tendencies toward narrow understandings of culture, they propose a ‘critical cultural perspective’ as one way of broadening nurses understandings about the complexities of culture and the many facets of culture that require critical consideration. The following is an abridged version of their article. Browne and Varcoe argue that the question for those involved in health care is: how do understandings of culture shape our attempts to respond to cultural issues or cultural needs and what are the implications for nursing practice with Aboriginal peoples? They note that in todays political context, the concept of democratic racism helps to explain how Canadians can hold negative, racialized views of Aboriginal peoples while at the same time espousing liberal principles of equality, tolerance, fairness and justice (Henry et al, 2000). Democratic racism refers to an ideology in which two sets of values coexist yet fundamentally conflict that is, members of the dominant society espouse outward commitments to democratic principles of egalitarianism, colour blindness and equal opportunity, and at the same time, operate on the basis of discriminatory attitudes (Henry et al 2000). This does not imply that members of society are intentionally discriminatory or are even aware of the biases they hold. As Henry et al (2000: 383) explains, organizations and institutions are: filled with individuals who are deeply committed to their professional work, who are regarded as highly skilled practitioners, who believe themselves to be liberal human beings and yet they unknowingly, unwittingly contribute to racial inequality. In Canada, the models of cultural sensitivity and cultural competence that continue to predominate are founded on the ideals of multiculturalism (Doane Varcoe 2005a). Cultural sensitivity thus emerges as one of the central practices of multiculturalism. Given the value placed on multiculturalism in countries such as Canada, the USA, Australia, and the UK, it is not surprising that cultural sensitivity has become the predominant model in nursing and health care. As Newhouse (2004: 12) explains: most non-Aboriginal people are still caught up in the stereotypical images they see in the media and overlook emerging Aboriginal modernity, viewing Aboriginal people in cultural terms while Aboriginal people see themselves in cultural and political terms. To illustrate his point, Newhouse refers to a recent Canadian survey, which suggests that most Canadians believe that it is beneficial to all Canadians that the distinctive cultures of Aboriginal peoples remain strong. In Newhouses words, this finding largely represents an endorsement of Aboriginal culture as all singing, all dancing, 24/7. By this, Newhouse means that although Canadians would agree that Aboriginal peoples have a right to practice and express their culture- through singing and dancing all they want t]ension arises when aboriginal people express a desire and act as more than just a cultural group, when we want to do more than just sing and dance, when we want to develop institutions of governance and when we want our institutions to be visible, respected and paid attention to. (Newhouse 2004: 12) Assumptions about Aboriginal peoples and Aboriginal culture organized quite narrowly around notions of singing and dancing as markers of Aboriginality can also be given expression in clinical settings. In a recent study conducted in a Canadian hospital where there is a high proportion of First Nations people, nurses discussed their experiences providing care to some of the First Nations patients they encountered (Browne 2003). A nurse in this study seemed to speak with reverence about patients spirituality: RN: I find I cannot think of a Native person I have ever looked after that was not a gentle person. I really cant. They are very gentle people.. I think my basic premise, especially with elderly Native people, is that they have a wisdom and a spirituality that many of us, I think, never achieve. They just know things. And I am very respectful of that and how that is viewed by the other members of their family. These descriptions could be interpreted as romanticizing or exoticizing First Nations culture; the cultural gaze could be interpreted as a colonial gaze. Fascination with Aboriginal elders and spirituality has the potential to reinforce representations of Aboriginal peoples as exotic. In the health care context, assumptions about Aboriginal peoples as dependent on the system or as incapable become linked to assumptions about Aboriginal patients as dependent on pain medications, or as necessarily struggling with addictions, or as less than capable of caring for themselves, or as irresponsible in relation to their families or children (Browne 2003; 2005). Despite the emphasis in health care on culturally sensitive approaches, or perhaps in part because of the ideas underlying such approaches, assumptions about Aboriginal peoples founded on popularized, narrow conceptualizations of Aboriginal culture make it ripe for health care providers to relate to Aboriginal peoples poorly. While at first glance cultural sensitivity seems a laudable approach, it leaves health care providers open to drawing upon stereotypes and generalized assumptions in their practice. Viewing culture from a critical cultural perspective helps to remind us that people enact their culture differently, depending on their situation or context. When we are called on as health professionals to deliver cultural programs, or culturally-sensitive services, we must first give critical consideration to how we are conceptualizing culture and become better attuned to the blind spots that may affect our perspectives when we are influenced by a narrow view of culture. Our arguments are intended to draw attention to the problems inherent in adopting the narrow definitions of culture embedded in cultural sensitivity models, and how these narrow understandings can perpetuate stereotypes about particular ethno-cultural groups in this case Aboriginal peoples. Unlike New Zealand, where nurses are required to learn about cultural safety, the historical roots of present day inequities, and marginalizing practices in health care (Nursing Council of New Zealand 2002; Papps Ramsden 1996; Remsen 1993; 2000), no such formal strategies exist in Canada, the USA, the UK, or Australia. Unfortunately, in the absence of competing frames of reference, nurses will continue to draw on established theories of culture underpinned as they are by culturalist discourses to interpret the presumed health and social needs of Aboriginal peoples. Cultural responsiveness extends beyond language to include a much larger set of professional attitudes, knowledge, behaviours and practices, and organizational policies, standards and performance management mechanisms to ensure responsiveness to the diversity of patients who walk through health services’ doors . Sasso / Stanger recommend three types of ‘enablers’ to improve accessibility to health care: †¢Enablers for access (e. g. interpreters, bi-lingual staff) †¢Enablers for cultural responsiveness (e. g. iverse staff; standards and guidelines for culturally responsive care; ethnic data collection) †¢Enablers for comprehensiveness (e. g. community profiles and needs assessments; community engagement and partnerships) These can be summarized into the following enablers of a responsive health care system: -Communication and Awareness -Public policies – external [factors] -Databases – data, key contacts -Community engagement -Policies and Standards -Community Development and Engagement -Reflective workforce -Outreach programs – bi-cultural / bi-lingual advocates Training for Service providers: Cultural Competency and Awareness -Language services – interpreting and translations [of paper-based information] Cultural responsiveness takes on an organizational focus – it focuses on the ability of the system or institution to be culturally competent. The National Respite Network (US) produced a fact sheet (October 1997) defining ‘cultural responsiveness’ in family services. In it, cultural responsiveness is defined as ‘being aware of, and capable of functioning in, the context of cultural difference’. It is an essential tool in moving personal and professional interactions beyond racial assessments to cultural relevancy. Cultural responsiveness can aid in differentiating the limitations in family functioning that may be caused by poverty, the environment, and/or culture from those due to unhealthy family conditions or behaviors. Culturally responsive approaches must include information, activities, and practice opportunities that interweave family centered practice are vital. The National Respite Networks has developed its own framework for cultural responsiveness in respite and crisis care which: †¢includes principles that support personal and organizational strategies that expand the knowledge base on culture and managing diversity †¢presents cultural sensitivity and the dynamics of diversity as not only best practice but also as a personal enrichment activity, and †¢highlights community-based resources as reliable contacts for culture specific information and services. The three main focal points of program design that can facilitate the development of culturally responsive services are organizational structure, policies, and procedures; the training curricula; and, supervisory and staff roles and responsibilities. These are summarized in the Appendices. In New Zealand’s Department of Corrections ‘Maori Cultural Responsiveness Policy’ (2005) the agency states that since indigenous] Maori make up a disproportionately high percentage of the offender base, there are specific milestones in the Departments business plans which address the development of interventions, targeted towards reducing re-offending by Maori. Further the policy states that ‘All employees need to recognise and respond appropriately to the needs, aims and aspirations of the diverse cultural and ethnic groups to whom we provide services, or whose members are in our custody. The Departments aim is to have a culturally responsive workforce that contribute to the achievement of the Departments overall goal of reducing re-offending and specific focus on reducing re-offending by Maori’. Cultural Appropriateness Culturally appropriate care is tangible, action oriented, and respectful of diverse cultural practices . It includes the physical structure and environment, how a program or service is delivered and by whom, and it provides choices relative to how each person experiences culture. A culturally competent doctor will have an awareness of cultural diversity and the ability to function effectively, and respectfully, when working with and treating people of different cultural background, They will acknowledge: †¢That British Columbia has a culturally diverse population †¢That a doctors culture and belief systems influence his or her interactions with patients and accepts this may impact on the doctor-patient relationship †¢That a positive patient outcome is achieved when a doctor and patient have mutual respect and understanding. The Australian Institute of Family Studies (Bromfield et al, 2003) defined cultural appropriateness as: ‘Behaviours, attitudes and policies that come together in a system, agency or among professionals to enable effective practice with members of a cultural or ethnic group† Professor David Thomas (2002) defines cultural appropriateness as: â€Å"the delivery of programmes and services so that they are consistent with the communication styles, meaning systems and social networks of clients, or program participants or other stakeholders’ In studying the cultural appropriateness of evaluation methods used in Australia he found little evidence over a 10 year period of ‘culturally appropriate’ activity being integrated into research projects – there were ‘cross-cultural’ and ‘international perspectives’ incorporated, but very little that was considered culturally appropriate or relevant for indigenous Australians. This was not the case in New Zealand however. Most evaluations addressed the Treaty of Waitangi; Maori health or other socio-economic needs; and incorporated other culturally appropriate mechanisms such as community consultation with Maori; incorporating Maori belief systems and values; ensuring Maori participation in evaluation design, implementation and dissemination. Cultural Awareness. The National Aboriginal Health Organisation (NAHO, 2006) states in its ‘Position Statement on Cultural Competency and Safety’, that currently the dominant discourse is on cultural awareness and cultural sensitivity. These concepts largely focus on increasing the health provider’s knowledge of various cultural beliefs or trends (Papps, 2005). While NAHO supports cultural awareness as an important part of cultural safety, it aims to emphasise that awareness is only a starting point of the learning continuum. Cultural safety is near the end point of this continuum. It is therefore important to note the distinctions between cultural awareness, cultural competence and cultural safety. The provision of culturally safe care involves lifelong learning and continuing competence. Cultural safety is the outcome of culturally competent care. The Indigenous Physicians Association of Canada and Association of Faculties of Medicine of Canada (IPAC-AFMC) state in their draft paper on core cultural competencies for under-graduate medical education that ‘cultural safety takes us beyond: †¢Cultural awareness – the acknowledgement of difference †¢Cultural sensitivity – the recognition of the importance of respecting difference, and †¢Cultural competence – which focuses on the skills, knowledge and attitudes of practitioners While these three approaches have contributed to IPAC-AFMC’s understanding of the need to attend to a patient’s culture, there are real limitations and concerned associated with them. A central tenet of cultural safety is that it is the patient who defines what ‘safe service’ means to them. Cultural safety is different from cultural competence in that the personal reflection space is added to address the attitudinal dimension of learning. The Millbrook First Nation Band (Nova Scotia) state, in conjunction with their online ‘Aboriginal Cultural Awareness’ program for CESO, that the goal of â€Å"Aboriginal cultural awareness is to help non-Aboriginal people work with Aboriginal people in ways that convey respect for Aboriginal cultures and understanding of the issues that are important to First Nations, Metis and Inuit peoples. It is about relationship-building. † The Centre for Diversity in Ageing in Australia noted that cultural awareness was an essential skill in the provision of culturally appropriate services. Cultural awareness entails ‘an understanding of how a person’s culture may inform their values, behaviour, beliefs and basic assumptions’. Cultural awareness recognises that ‘we are all shaped by our cultural background, which influences how we interpret the world around us, perceive ourselves and relate to other people. You don’t need to be an expert in every culture or have all the answers to be culturally aware; rather, cultural awareness helps you to explore cultural issues with your care recipients more sensitively’. Cultural Sensitivity Being culturally sensitive involves having an understanding and appreciation of the consequences of European contact on Aboriginal people. With loss of language and externally imposed denial of ancestry came a sense of confusion and loss of self-esteem, which resulted in alcoholism and traditions not being passed down . Despite the length of time Europeans have been here, there is still a lack of understanding about Aboriginal people and their circumstances. They still negatively judge Aboriginal people based on blanket assumptions and negative stereotypes rather than considering each person’s unique circumstances. The general public assumes that Aboriginal people have everything given to them and should be rich. However, these ‘gifts’ have had the negative impacts of loss of self-esteem, language and connections to land and tradition. The Healing Ways Aboriginal Health and Service Review, October 1999 gave an in-depth view of culturally appropriate and sensitive care. Sensitive health care for Aboriginal people is based on relationships that extend from a shared understating of the effects of history and respect for life ways that are different. Culturally appropriate health care is tangible, action oriented, and is founded on respect for diverse cultural practices. Focus groups were held to discuss this and according to the participants relationships between an Aboriginal person and service provider are critical. Connections based on mutual respect and a feeling of comfort and safety are important but often absent. A lack of respectful communication comes across as patronizing and is often based on stereotypes about Aboriginal people. Physical actions can also be intimidating. For example, standing over someone with arms folded, asking questions too quickly, and not waiting for an answer discourages communication. Aboriginal people tend to have a more reflective and deliberate speech pattern then non-Aboriginal people. In ‘Critical Cultural Perspectives and Health Care Involving Aboriginal Peoples’ (Browne Varcoe, UBC) state that ‘despite a growing body of critical scholarship in nursing, the concept of culture continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care’. The writers took a critical look at how assumptions and ideas underpinning conceptualizations of culture and cultural sensitivity can influence nurses perceptions of Aboriginal peoples and Aboriginal health. Their specific aims were to: a. consider some of the limitations of cultural sensitivity in relation to health care involving Aboriginal peoples; b. explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and c. xplore the relevance of a critical cultural approach in extending our understanding of culture in relation to Aboriginal peoples health. Browne and Varcoe note that the need for greater cultural sensitivity was endorsed in a national Commission on the Future of Health Care in Canada. The Commission also identified Aboriginal health as a particular priority, and specific mention was made about the need for training for non-Aboriginal health care providers to learn their [Aboriginal] particular needs and culture (Romanow 2002: 220). Calls for culturally sensitive programs and services continue to abound, and nurses working in Aboriginal communities or with Aboriginal patients and families are under increasing pressure to provide culturally sensitive care. In ‘Understanding Governance in Strong Aboriginal Communities: Phase One: Principles and Best Practices from the Literature: Institute of Governance in collaboration with York University CESA Aboriginal Services, Saskatchewan Federated Indian College, 1999 – the writers note several ‘best practices’ for agencies working in multi-cultural settings. They state that ‘culture training for Managers has been largely neglected in the past. Emphasis is increasingly being placed on this important aspect of cooperative venture management and that managers of cross-cultural partnerships should be sensitized to ‘the impact of culture on behavior, and have some background on the social, economic, political environment and history’ of the partner. They further state that is important for managers to understand their own culture and the implications it has on their behavior and relationships with others. Cultural Safety The term â€Å"Cultural Safety† was developed in the 1980s in New Zealand by a Maori nurse the late Irihapeti Ramsden as a topic of her thesis. The term was developed in response to the indigenous Maori peoples’ discontent with nursing care. Maori nursing students and Maori national organisations supported the theory of â€Å"cultural safety† which upheld political ideas of self determination and de-colonisation of Maori people. Cultural safety was controversial when it was first introduced to public health and academic communities in the late 1980’s and early 1990’s. Criticisms voiced in the media claimed that Nursing schools, by adopting mandatory cultural safety curriculum, were â€Å"force-feeding† culture and indoctrinating nursing students with specific political views. Despite the opposition, in 1990 the Nursing Council of New Zealand incorporated cultural safety in its curriculum assessment processes, and nursing school examinations began testing student comprehension of the concept. The Council’s current document outlining its position on Cultural Safety is entitled â€Å"Guidelines for Cultural Safety, the Treaty of Waitangi, and Maori Health in Nursing and Midwifery Education and Practice. Trans-cultural nursing is the most common theoretical approach to cultural skills in education in Canadian nursing schools. It differs in a number of ways, including in origin, from the newer concept of cultural safety. Trans-cultural nursing was developed from the perspective by dominant (European, white) culture, whereas cultural safe ty was developed by non-dominant Maori peoples reacting to negative experiences in the health and nursing system. The National Aboriginal Health Organisation (NAHO) of Canada, in its position statement on cultural competency and safety, defines cultural safety as ‘what is felt or experienced by a patient when a health care provider communicates with the patient in a respectful, inclusive way, empowers the patient in decision-making and builds a health-care relationship where the patient and provider work together as a team to ensure maximum effectiveness of care’. NAHO further states that the achievement of cultural safety requires twofold change: †¢Micro-level building of cultural competence in health care providers (workers) and systemic change in health education curriculum; and †¢adoption of cultural safety standards of care by national accreditation bodies at the macro-level NAHO has developed a Fact Sheet on Cultural Safety. While acknowledging the work of Ramsden and its application in New Zealand (particularly within the nursing profession), they have identified ‘transcultural’ nursing as the common theoretical approach to cultural skills education in Canadian nursing schools. NAHO states that ‘cultural safety is an evolving term and a definition has not been finalised’. However the Nursing Council of New Zealand has defined culturally unsafe practice as â€Å"any actions that diminish, demean or disempower the cultural identity and well-being of an individual†. NAHO’s fact sheet states that â€Å"Cultural safety moves beyond the concept of cultural sensitivity to analyzing power imbalances, institutional discrimination, colonization and relationships with colonizers, as they apply to health care. NAHO further states that there is â€Å"much confusion and ongoing debate about how cultural safety differs from other concepts like cultural competency, cultural awareness, cultural sensitivity and cultural appropriateness. Each of these terms has many definitions and it is difficult to gauge how they overlap. † The fact sheet highlights that Ramsden views the terms on a continuum – noting that cultural awareness is the beginning step in the learning process (understanding difference) and cultural sensitivity is an intermediate step (self exploration begins). Cultural safety is the final outcome of the process where a [nurse] practitioner can provide safe care when interacting with patients from other cultures. Ramsden further argues that ‘cultural safety requires that nurses become respectful of nationality, culture, age, sex, political and religious beliefs’ while transcultural / multicultural nursing care encourages nurses to deliver service irrespective of these aspects of a patient. Cultural safety recognizes the nurse as the bearer of their own culture and attitudes, and that nurses consciously or unconsciously exercise power over patients. NAHO’s fact sheet goes on to state that â€Å"many academics maintain that cultural safety in the mainstream health system cannot be achieved by individual interactions. Rather, it depends on meaningful participation of Aboriginal people in the decision-making processes that allow transfer of power to Aboriginal governments (Browne, Fisk, Thomas 2001). NAHO has also developed a document â€Å"Guidelines for Health Care Administrators, Providers and Educators: Cultural Competency and Safety: A First Nations, Inuit and Metis Context† document which has been widely promoted including through the internet. NAHO uses the US Department of Health and Human Services’ definition of cultural competency (cited elsewhere in this report). In NAHO’s guideline, the writers note that ‘cultural safety within an indigenous context, means the health professional / Administrator / educator – whether indigenous or not – can communicate competently with a patient in that patient’s social, political, linguistic, economic and spiritual realm’. Interestingly, NAHO’s guidelines are based upon the ‘Tikanga (Customs and Traditions) Best Practice Guidelines;’ developed by the Waikato District Health Board of New Zealand. In New Zealand, Professor Mason Durie, a well-known commentator, researcher and practitioner in Maori health, aimed to define the difference between cultural safety and cultural competency in as address to the Australian and New Zealand Medical Councils. He stated that â€Å"although the differences between cultural competence and cultural safety are probably outweighed by their similarities, they have quite distinct starting points, and in the New Zealand context, quite different histories. Both are about the relationship between the helper and the person being helped, but culturally safety centres of the experiences of the patient (or client) while cultural competence focuses on the capacity of the health worker to improve health status by integrating culture into the clinical context. The point of the exercise is not just to recognize culture – but to be able to maximize gains from a health intervention where the parties are from different cultures. † Durie states that Cultural safety education focuses on teaching students about: †¢Colonial history and impact on indigenous peoples (rather than focusing on customs and beliefs) and helping learners not to blame victims of historical processes for current plights †¢Self-discovery of the student â€Å"what they are bringing to the table in terms of culture, attitudes, values and beliefs† †¢Making themselves aware of how they may consciously or unconsciously display attitudes that reflect on their practice and care with people from other cultures. Teach students how to be more self-aware and open-minded Cultural Competency There is significant literature and published materials on the topic of cultural competency – more than any of the other dimensions mentioned in this paper. This is not surprising since most commentators include all of the other domains of culture outlined herein, when describing cultural competency. Health Canada commissioned and published the report â€Å"In Certain Circumstances† Issues in Equity and Responsiveness in Access to Health Care in Canada in 2000. In the section â€Å"Introduction to Cultural Competence in Pediatric Health Care’ the following is noted (the following is summarised from an abridged version of the original report). For years, Canadians have looked with pride to their health care system, as a national symbol of our collective values. There is room for improvement, however, in the provision of Canadian health care. For example, culture can play a significant role in the accessibility of health care and as a result it is essential for health care providers to demonstrate cultural competence. In order to fulfill the principles of the Canada Health Act and satisfy the health care requirements of a diverse nation, the meaning and relevance of cultural competence in health care must be addressed. The Canada Health Act is the framework for health care in Canada. This pivotal piece of legislation stresses the importance of access to health care for all citizens. As such, one of the five principles of the Canada Health Act is the principle of accessibility. Within the context of the Canada Health Act, this principle refers to financial barriers to health. However, the specific text does not fully embody the true meaning of accessibility to health care for Canadians. Other barriers such as the geographic distribution of the population, a lack of specialized health care providers and a lack of interpreters may also create a barrier to access. Further barriers are often the result of cultural differences that give rise to ineffective communication and misunderstandings. Limited communication often results in limited assessment and thus, limited treatment. Communication is an essential aspect of health care. In turn, cultural competence is an important aspect of communication. In order to receive appropriate treatment of the highest quality, it is necessary for clients from all cultural backgrounds and linguistic profiles to be able to voice their individual needs, within their specific context, to a health care provider. When information has been successfully communicated by the client and understood by the health care provider, there is greater likelihood that the client will be able to access and receive the necessary care. There are a number of other definitions from Canada and internationally that aim to describe â€Å"cultural competence†. T Cross et al (1989) defines cultural competence as: Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enable effective interactions in a cross-cultural framework. The Seattle King County Department of Public Health (1994) defines cultural competence as: Cultural Competency is the ability of individuals and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic backgrounds and religions in a manner that recognizes, affirms, and values the cultural differences and similarities and the worth of individuals, families, and communities and protects and preserves the dignity of each. † The University of California, San Francisco describes cultural competency as: A set of practice skills, knowledge and attitude that must encompass 5 elements: †¢awareness and acceptance of difference; awareness of ones own cultural values; †¢understanding of the dynamics of difference; †¢development of cultural knowledge; †¢ability to adapt practice skills to fit the cultural context of the client or patient In ‘Cultural Sensitivity in Mental Health Nursing’ (2006) cultural competence was defined as being: â€Å"Being associated with four areas – awareness, knowledge, relationships and skills. In order to work with people from diverse cultures who have a mental health disability, the nurse must have cultural competence. † In ‘Cultural Competency in Human Services’ (2007) cultural competence refers to: One’s ability to understand, interact and respond to individuals with different world views or cultures. It differs from cultural awareness or sensitivity in that it is a set of congruent behavior s, attitudes and policies, which come together in a system, agency or among professionals and enables them to work effectively in cross-cultural situations. It includes being sensitive to individuals of different races, ethnicities, ages, religions, sexual orientations, socio-economic status among others. It is reflected in the health professional’s attitude and communication style’. Melies (1999) provides a definition of: ‘Culturally competent care is care that is sensitive to the difference individuals may have in their own experiences and responses due to their heritage, sexual orientation, socioeconomic situation, ethnicity and cultural background. It is care based on understanding how those differences may inform the responses of people and the process of caring for them† Ranzijn (2005) states that ‘you can never achieve cultural competence – it is an ongoing thing because cultures change with time and so too must the approach of the health professional. Ranzijn suggested an approach to cultural competence is defined as a 6 stage process: 1. Cultural incompetence 2. Cultural knowledge 3. Cultural awareness – incorporates elements of self reflection and self awareness 4. Cultural sensitivity – being able to express knowledge and awareness in individual and institutional behaviors. Institutions develop cultural competence as well as individuals 5. Cultural competence – perform appropriate behaviors routinely 6. Cultural proficiency Wells – a past President of the Aboriginal Nurses Association (2000) argued for the extension of cultural competency into cultural proficiency. Wells claimed that cultural competency is not adequate and that cultural proficiency is a higher order concept for institutions in that proficiency indicates mastery of a complex set of skills. Wells would say that the most effective way to achieve cultural proficiency is to maintain an open attitude and interact with people who are different, allowing them to become teachers or coaches. Wells states in her journal article â€Å"Beyond Cultural Competence: A Model for Individual and Institutional Cultural Development† that nursings attention o cultural diversity has been influenced by the changing demographic composition of the U. S. population. She states that nursing must continue to increase awareness and promote attitudinal and behavioral changes that will result in the delivery of culturally appropriate nursing care. The nursing literature includes several models of cultural development to assist nurses and other health care professionals in conducting a cultural assessme nt and incorporating cultural data into nursing care plans. Wells’ article presents a synthesis model of cultural development that illustrates that cultural awareness, cultural sensitivity, and cultural competence do not achieve the level of cultural development necessary to meet the health care needs of a diverse population. Cultural proficiency is a concept that extends cultural competence into nursing practice, administration, education, and research. It is a philosophical and behavioral approach to cultural diversity that guides and prescribes individual and institutional behavior toward â€Å"cultural others. Campinha-Bacote (1994) presented a culturally competent model of care with four components on a continuum: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill and (4) cultural encounters. Cultural awareness is defined as having cultural sensitivity and avoiding cultural biases. Cultural knowledge is defined as the care provider understanding the cultural would view and theoretical/conceptual framework of the p atient. Cultural skill is defined as the provider having developed the skill-set to access an individual’s background and formulate a treatment plan that is culturally relevant. Cultural encounters are the processes which allow the health care provider to directly engage in cultural interaction with clients from culturally diverse backgrounds. Additionally the authors provide a checklist of the â€Å"Six A’s for Culturally Responsive Services† as a as keys to providing access of services to underserved and culturally/ ethnically diverse populations. The six A’s are: (1) available, (2) accessible, (3) affordable, (4) acceptable, (5) appropriate, and (6) adoptable. The New Zealand Medical Council opted for cultural competence rather than cultural safety as an area to be emphasized in medical training. Professor Mason Durie, a prominent Maori health researcher and advocate, suggested that ‘cultural competence is about the acquisition of skills to achieve a better understanding of members of other cultures. It is another dimension to the doctor patient relationship that can provide doctors with additional information necessary for better clinical results’. A doctor who is culturally competent can use cultural impacts to improve performance in at least four areas: Domains on Cultural ImpactProfessional Gains Health perspectivesconceptual understanding Valuesprofessional practice Symptom hierarchiesdiagnosis Community capacitytreatment and care Many methods and ideas for teaching and learning cultural competence are found in literature – but there is general agreement that cultural competence happens on affective, cognitive and behavioral levels and that self-awareness is a critical indicator of success. Simulation or role play activities provide a participants with a setting where they can practice communication and problem-solving as well as develop self-awareness (Meltzoff and Lenssen, 2000). Immersion programs are powerful learning experiences at all levels because they allow participants to experience different cultures outside of their usual safe context. Immersion programs are probably the best learning tool but they are expensive and time-consuming. The Society of Obstetricians and Gynaecologists of Canada and their Aboriginal Health Issues Committee (2000) produced their Guide for Health Professionals Working with Aboriginal peoples, and while they did not refer specifically to ‘cultural competency’ they did suggest some areas of learning that would be necessary for health professionals: 1. Socio-cultural and historical context e. g. learning names of key Aboriginal groups in Canada; basic understanding of Aboriginal demographics; traditional geographic territories of Aboriginal peoples in the areas they serve; basic understanding of colonization and its impacts; basic understanding of Government’s obligations and policies regarding Aboriginal peoples in Canada 2. Health Concerns e. g. appreciation of holistic definitions of health as defined by Aboriginal peoples (e. g. edicine wheel); recognition of key health issues and areas of morbidity and mortality 3. Cross-cultural understanding – building a foundation of mutual respect between Aboriginal peoples and health care providers; recognition and acknowledgement that the current health system has many gaps and barriers for Aboriginal peoples, and advocating for ways to overcome these barriers; providing care in appropriate language where possible; respecting the role of traditional medicines and healers 4. Aboriginal health resources – support community-created programs and services; support community-directed Aboriginal health research; encourage education of Aboriginal health care professionals; recognize the need for preventative programming in Aboriginal communities The Health Resources and Services Administration, a branch of the US Department of Health and Human Services, conducted a project to review cultural competence in health care delivery organisations.