Cultural safety in disaster nursing

March 1, 2021

Perspectives from the 2011 earthquake and tsunami in Japan and the earthquake in Christchurch featured at a forum on the importance of cultural safety in disaster nursing.

From a nursing perspective, a disaster can be defined as a phenomenon that interrupts life in communities, preventing people from doing their daily activities. Disaster nursing is about supporting the daily activities of affected communities as part of the disaster recovery process. This definition of disaster nursing is endorsed by the World Health Organization (WHO)1 and the United Nations for Disaster Risk Reduction.2

Culturally sensitive disaster nursing is nursing that bridges a gap between familiar daily activities and destroyed life, in collaboration with the affected people. A 2020 Japanese study argued the importance of culture for the recovery of disaster-affected people.3 The definition of culture used in this study was: the thoughts, attitudes and behaviours that are based on values, beliefs and norms commonly observed among people in a community. “A fish only discovers its need for water when it is no longer in it. Our own culture is like water to a fish. We live and breathe through it.”4 Being surrounded by daily cultural activities, like a familiar sleeping style or eating habits, helps people feel comfortable and gives them energy to lead their lives.

Various researchers have noted visible behaviour, such as eating habits, and invisible elements, such as values, as being important parts of culture.5, 6, 7, 8 Culture affects people’s health and quality of life.9, 10 The Nursing Council of New Zealand has set cultural safety standards (kawa whakaruruhau) for nursing registration and for the ongoing competence to practise that nurses must demonstrate. Cultural safety is underpinned by communication; it acknowledges the beliefs and practices of different communities and the diversity of their world views; and it emphasises positive health outcomes for the person at the centre of care. Therefore, nursing care at the time of disaster also requires incorporating cultural aspects of care.11

Pacific Ring of Fire

The Asia-Pacific region is the most disaster-prone area of the world. Almost two million people were killed in disasters between 1970 and 2011, representing 75 per cent of all disaster fatalities globally.12 Both Japan and New Zealand are situated in the Pacific Ring of Fire which increases their risk of and exposure to earthquakes. The Great East Japan Earthquake and Christchurch earthquake in 2011 caused massive damage and loss, both tangible and intangible, to the affected communities.

As part of a multi-country qualitative research project addressing culturally competent nursing practice in disasters, a one-day forum was planned by Miki Marutani, Nahoko Harada and Lev Zhuravsky, in collaboration with the nursing workforce development team at Canterbury District Health Board (CDHB). This article summarises the main lessons from the forum and emphasises the importance of sharing knowledge and collaborating, especially in the current climate of globalisation, cultural change and uncertainty.

Along with its focus on sharing research and knowledge, the forum also emphasised the importance of culture and cultural safety, and of empowering communities affected by disaster, based on the premise that disaster nursing should be provided according to culture. By being sensitive and aware of material and non-material culture, nurses can support and empower people in their recovery from a disaster.

The forum was held in November 2019 at the Manawa learning centre in Christchurch. Among the 25 participants were nurses, emergency management personnel from across Canterbury, nursing leaders, community leaders, along with a CDHB Māori health team and a Japanese research team. The forum started with a mihi whakatau (Māori welcome) and the Japanese national anthem, and was conducted in two parts. The first part included brief presentations from invited speakers, who described aspects of disaster response and recovery from the perspectives of disaster management and community resilience. The second part included facilitated group work.

The Japanese researchers shared research findings related to the 2011 Japan earthquake disaster, as well as outlining the mental health and psychosocial support (MHPSS) provided to victims, so New Zealand participants could grasp both the academic and the clinical practice of disaster response in Japan.

Miki Marutani presented a conceptual framework of culturally sensitive disaster nursing, derived from a Japanese study which qualitatively examined responses of public health nurses (PHNs) in past disasters.13 PHNs in Japan are a nationally licensed profession and the majority work for municipal or state health centres. Disaster response is a part of health crisis management, so PHNs are expected to work extensively for affected people throughout the disaster phases.

In Japan, public health nursing in disasters aims to help maintain and reconstruct a just and safe society, in cooperation with people and communities. This includes helping people improve their circumstances, reducing gaps in health services to help prevent disease and impairment, helping people maintain their health and helping those at the end of life towards a peaceful death, throughout the disaster period.13

Nahoko Harada outlined the four-year MHPSS project used to aid recovery from the March 2011 disaster. It included services ranging from providing basic needs through to specialised care.14 She described the cultural characteristics of people in the Tohoku area of northern Japan and how these characteristics shaped the MHPSS programme over time. These characteristics included shyness and communities gathering at tea breaks. Informal health consultations were introduced at the tea breaks, and use of local dialects in communication was also introduced to the programme.

Other speakers included CDHB acting executive director of nursing Becky Hickmott, who spoke on “cultures of command and control” in a disaster, and how these cultures affected both victims of disasters and those responding. Agencies and groups who used “command and control” cultures were found to have rigid communication pathways, and each group tended to speak a different language and use different codes. That meant there was a lack of shared language and understanding between responding groups.

Hickmott said such agencies were often poor adapters to highly complex and unstable environments,15, 16 and these cultural differences left evacuees and staff feeling powerless, bewildered and frustrated. They struggled to understand these groups – an example of this was when one “command and control” agency described frail elderly evacuees who had dementia as “hazardous cargo”.

CDHB emergency department nurse coordinator Polly Grainger spoke about the challenges of setting up a robust process for identifying disaster victims. Using national health index (NHI) numbers could be difficult, due to the high number of admissions and the status and nature of injuries. Nationally, it was agreed that during a disaster there was a need to assign a secondary identifier called a disaster number to help the process.

However, Grainger said that in one Christchurch disaster, when victims arrived at the emergency department they could not be easily identified because of the similar age and gender of those affected. Using the D-identification (disaster code) increased the chance of incorrectly identifying the victims. She said the process of disaster identification needed to be further reviewed to decrease the risk of misidentification, and to consider cultural safety principles.

Lev Zhuravsky, of Lazer Consulting which provides resilience training, spoke of the importance of collaborative leadership when coping with unexpected and evolving events. He said true collaboration grew out of grounded self-awareness and an understanding of the systems being managed. Leaders and managers needed to promote a culture of psychological safety to help staff perform outside their comfort zones. Zhuravsky said this approach could enable teams to look at unexpected events as an opportunity for organisational growth and development, promoting resilience, self-efficacy and job satisfaction.

Kathy Peri, a gerontology nurse specialist and senior lecturer at the University of Auckland, spoke about media representation of the elderly following the Christchurch earthquakes and presented interim results of a research project on this topic. While media played an important role in providing information and orientating people to a new post-disaster reality, they might not be entirely objective in describing elderly people, their struggles and strengths. She said sometimes the elderly could be portrayed as victims and their voice not always heard. Balanced and comprehensive media coverage without ageism could give elderly the opportunity to tell their stories and support their recovery.

CDHB emergency department (ED) researcher Sandy Richardson talked about the contribution of the Māori health workforce in the immediate response to the February 2011 earthquake. One of the main challenges related to negotiating new roles. This involved Māori health workers who worked in other areas, but came to the ED to help with the response and were not familiar with the ED. These workers discussed how they had to negotiate new roles and described their experiences and what they were exposed to and whether that changed their perceptions of their role. Making sense of that, alongside their cultural identity and their perceptions of what it was like to be a Māori health worker, enabled them to make this transition into a disaster response role.

Applying a cultural lens in disaster response

  • Be aware of and recognise community-based leaders as well as other leaders.
  • Culture is not just ethnicity; it includes age, socioeconomic status and disability.
  • Look at the cultural safety response, to make sure it can be replicated, and to make sure it is stable and can be retained over time.
  • Credibility comes from being open to other perspectives. Acknowledge lessons learned; have situational and self-awareness; focus on solutions.
  • A cultural response is more effective if set up ahead of time. Engage with local leaders and embed plans in preparation for disaster.
  • Recognising where we can engage more strongly with the community. People are more likely to recover if they feel they belong and are part of what is happening.
  • Be flexible and adaptable to people’s needs. The person at the centre of care defines what they need. We should be “doing with” people, not “doing to”.

Cultural safety toolkit

  • Keep a list of networks with key contacts, directories, interpreters, regional or geographical areas, and ensure it is a practical and ongoing register.
  • Look at the role of animals in cultural response.
  • Use proven tools and groups, eg schools and school systems, the family. Form “armies”, eg the different student armies.
  • Hold ongoing leaders’ events to set processes in place in non-disaster time so networks, personal experiences and community resources are already in place, eg United States medical reserve has a list of retired/semi-retired medical staff and helps them maintain their competence.
  • Specific solutions should be geared towards those with differing cultural needs.

Relationships

  • Develop good working relationships across all sectors.
  • Work with those in the community who have knowledge or who can help expand knowledge.
  • Make sure you know who you communicate with, what relevant information is required, and keep gathering information.
  • Central government should be working locally in each area now.
  • Look at how to reinforce roles and responsibilities, and how to support people to stand down or walk alongside them; have indicators of progress.
  • Conduct drills with multiple organisations participating. Share perspectives and roles and identify gaps.
  • Identify key leaders, eg from churches, non-governmental organisations. Get them together and develop disaster response framework, policy and manuals to get the processes underway. People on the ground know who to talk to.
  • Standardise language: all agencies should use the same language.
  • Do a stock take of staff skills, eg as well as psychologists, there may be others with counselling experience.

Mental health, innovation and supports

  • Mental health and psychosocial support – basic needs first, with family and community support; non-specialised individual care.
  • Focus on self-care and looking after others.
  • Mental health support needs to be multi layered; care for own mental health as well.
  • Innovative technologies are good but do not always connect; we should keep using our ears and eyes.

Nursing curriculum development

  • Undergraduate curriculum should include basic disaster training and resilience.
  • Hold workshops on resilience for students and new graduates.

Disaster recovery framework

Workshop discussions at the forum focused on topics ranging from culturally sensitive disaster nursing to setting up a collaborative and culturally safe disaster recovery framework. Learning points from the group work have been summarised above.

The purpose of the forum was to look at disaster nursing through the lens of cultural safety. Sharing the experiences of the 2011 earthquake and tsunami in Japan and the earthquake in Christchurch, brought deep understanding and knowledge of the importance of cultural safety in a disaster response. Presentations from Japan and New Zealand demonstrated the relevance of cultural safety for nurses in every setting, including the importance of ensuring mental health and psychosocial support for both basic needs through to specialised care. The forum recommended actions that nursing and other agencies should examine to determine whether these should be implemented in educational institutions, community organisations, emergency response processes, or wider clinical settings.

The importance of all organisations involved in disaster relief examining their own responses through a cultural lens will improve the way we work with people in future disasters or crises in our nations. Building relationships of trust and openness across organisations in non-disaster times will help strengthen future responses and enable teams to be adaptive and responsive to the cultural needs of those we serve and care for.

Nahoko Harada, RN, PHN, PhD, is a professor in the Department of Psychiatric and Mental Health, School of Nursing, University of Miyazaki, Miyazaki, Japan. Lev Zhuravsky, RN, PGDipHMgt, MHSc, PhD candidate, is a principal consultant at Lazer Consulting, Auckland. Miki Marutani, RN, PHN, PhD, is research management director at the National Institute of Public Health, Saitama, Japan. Becky Hickmott, RN, MHSci, is acting executive director of nursing, Canterbury District Health Board, Christchurch.

References

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