Sámi and Norwegian nurses' perspectives on nursing care of Sámi patients: a focus group study on culturally safe nursing.

Sámi people report less satisfaction with healthcare services than the majority population in Norway, and report that they seldom encounter culturally adapted health services. This study investigates Sámi and Norwegian nurses' perspectives on culturally respectful and appropriate caring for Sámi patients in northern Norway. Six focus groups were conducted: three with Sámi-speaking nurses (n = 13) and three with Norwegian-speaking nurses (n = 10). Data were collected and analysed in line with Thorne's interpretive descriptive methodology. Three overarching themes emerged from the interviews: (i) the importance nurses gave to establishing a connection and building trust with Sámi patients; (ii) nurses' perceptions that in comparison to Norwegian patients Sámi patients could be less confrontational and direct, but that differences weren't always apparent and (iii) the importance nurses described to understanding the cultural context of their Sámi patients. This study showed that Sámi and Norwegian nurses working in northern Norway were largely perceptive about and respectful of cultural differences between Sámi and Norwegian patients. Some emphasised, though, that Sámi patients were diverse and that interpersonal differences were as or more important than cultural differences. Some also felt that more understanding of Sámi culture would be helpful for enabling culturally respectful nursing care.

Introduction

The Sámi people in Norway have distinctive legal rights to receive healthcare services adapted to Sámi language and culture in healthcare interactions [1-5] yet lack of inclusion of both language and culture in healthcare services is reported [6-12].

The overall Sámi population is estimated at approximately 100,000, of whom 55,600 live in northern Norway [13], in multicultural municipalities alongside Norwegian, Swedish, Finnish, and Russian people, but also people from many other cultures [14,15]. Sápmi is the traditional term for the Sámi homelands; a historical area without formal borders. In Norway the area extends from mid Norway to Finnmark County in the north. The Sámi population is diverse, living in a variety of communities, in rural, remote and urban settings, with differing cultural traditions and beliefs [16].

The forced assimilation policy by the Norwegian government, called Norwegianisation (1840–1987), had a devastating effect on Sámi culture and language [15,17]. The period of this Norwegianisation policy for some Sámi patients resulted in lack of trust in the Norwegian health-care services [9,11,18]. Even though the government provides good quality health services to all, it is worth noting that healthcare provided and health personnel are mostly Norwegian-speaking, with Norwegian cultural understandings [15].

For Sámi people, the Norwegian healthcare can be a system with another worldview and a different language, based on Western medicine [19,20]. Studies from the northern Sámi area, based on Sámi patients’ perspectives indicates that culture and language understanding are important factors when communicating with Sámi patients [21,22], and that some Sámi patients feel culturally unsafe in encounters with Norwegian healthcare [19].

Healthcare in Norway, as in many other places, is aimed at mainstream populations and often marginalises Indigenous minority populations, such as the Sámi people [18-21]. In culturally diverse societies, the dominant cultural system determines which problems are recognised as important and worthy of attention [23]. The Sámi people have a lower life expectancy than Norwegian people by approximately one and a half years [24], cultural differences are one of several explanations for why Indigenous people have poorer overall health and are less satisfied with the healthcare services than majority populations [18,25-27]. Sámi patients should be able to access health services demonstrating Sámi cultural understanding, or services offering healthcare adapted to meet the specific needs of Sámi patients, clients and residents [19]. If not, one can question if Norway’s healthcare system can offer culturally safe healthcare services for their Sámi peoples.

Cultural safety

The concept of cultural safety arose in the colonial context of New Zealand. In response to the poor health status of Māori, the Indigenous people of New Zealand, nurses and midwives insisted on changes to service delivery [28], and that nursing practice reflect and incorporate the point of view of the Indigenous minority in the country [26,27].

Cultural safety is a concept that could be applicable to Sámi healthcare because of the shared history and similar context of assimilation of Indigenous people in a global context, such as the Māori in New Zealand, the Aboriginal and Torres Strait Islanders of Australia, and the First Nations people of Canada, amongst others [24,29,30]. With a similar history of colonisation and current struggle for social justice and cultural reclamation, the principles of cultural safety are equally applicable in a Sámi context [26-29]. Cultural safety in practice consists of health practitioners being self-reflective of their own bias and background, and how this impacts on patient interactions [23,28,30]. Kirmayer [23] has described cultural safety thus;

Cultural safety is a powerful means of conveying the idea that cultural factors

critically influence the relationship between carer and patient. Cultural safety focuses

on the potential differences between health providers and patients that have an impact

on care and aims to minimize any assault on the patient’s cultural identity.

Specifically, the objectives of cultural safety in nursing and midwifery training are

to educate students to examine their own realities and attitudes they bring to clinical

care, to educate them to be open-minded towards people who are different from

themselves, to educate them not to blame the victims of historical and social processes

for their current plight, and to produce a workforce of well-educated and self-aware

health professionals who are culturally safe to practice as defined by the people they

serve.(Kirmayer 2012, p 157).

Cultural safety was not included in nursing education in 2014 and nor a requirement for nursing practice in Norway [31]. However, a new framework for nursing and health professional education was released on 15 March 2019 [32]. This framework requires all nurses and other health professionals to acknowledge Sámi rights and have knowledge and understanding of the Sámi as an Indigenous people [33,34]. A recent Norwegian white paper has called for attention, knowledge and understanding for Sámi patients and culture in healthcare [9].

Aim

The aim of this research is to describe and interpret Sámi and Norwegian nurses’ perspectives on caring for Sámi patients in northern Norway.

Materials and methods

Study setting- Indigenous context

This study was undertaken in northern Sámi areas in Norway, in northern Sápmi. The researchers are experienced, privileged and educated Registered Nurses and University teachers who have worked rurally and with Indigenous peoples, patients, and communities, both in Sápmi, Norway and Aboriginal Australia. This intersectionality did influence the study approach [35]. Our understandings of Indigenous people come from either an Indigenous, mixed-Indigenous or southern settler context, and are based on recognition and acceptance of our common history of colonisation, assimilation, oppression and experiences of both institutional and personal violation of Indigenous people as described in the literature [17,36].

Study design

Methodologically this study is undertaken based on Thorne’s interpretive descriptive design [37]. This methodology was developed to explore and understand human health and to create changes in clinical practice and healthcare settings. Thorne’ interpretive descriptive methodology draws on principles grounded in the epistemological mandate of nursing and exists to better understand situations that occur in contexts of healthcare. This methodology was chosen because it is appropriate for developing new nursing knowledge around Sámi cultural understanding in nursing [37]. Following this interpretive descriptive approach, six semi-structured focus group interviews were conducted and analysed.

Recruitment and participants

Initially the heads of nine of 19 municipalities and the local hospitals in Finnmark County, northern Sápmi, were contacted by email with information about the study and a request for forwarding this as an invitation for nurses to participate. Two reminders were sent. Twenty-three female registered nurses responded and were recruited, by both purposive and snowball sampling [38]. The participants in this study happened to be nurses who were especially attentive to Sámi patients’ needs.

All Sámi and Norwegian nurses who participated in this study live and work in the northernmost part of Norway. The minimum criterion to participate was two years’ clinical practice with Sámi patients. The nurses’ areas of clinical experience varied from rural district nursing, including residential aged care (n = 20), to critical care nursing in hospitals (n = 3) (Table 1).

Table 1.

Descriptors of participants

Descriptors	Sámi nurses (n = 13)	Norwegian nurses (n = 10)
Bilingual:Sámi/NorwegianNorwegian/SámiOnly Norwegian	1300	028
Age:25–4041-5556–65	553	190
Experience as a nurse:2–4 years5–15 years16–35 years	445	136
Postgraduate education	4	5
Current occupationHospital/specialist servicesCommunity care/district nursing	112	28

Data collection

The focus group interviews were conducted by the third author in Sámi, and the first author in Norwegian. All interviews had two researchers present (interviewer and observer). Focus groups two, four and six had Sámi-speaking participants (n = 13), with a Norwegian speaking observer. The remainder had Norwegian-speaking participants (n = 10). Quotes referring to Sámi or Norwegian participants are respectively marked S1-13 and N1-10 (Table 2).

Table 2.

An overview of focus groups, languages, participants, and codes used for focus groups in quotations

Focus group interview	Norwegian = NSámi = S	Number of participants n = 23	Codes in quotes
FG1	N	4	N1, N2, N3, N4
FG2	S	6	S1, S2, S3, S4, S5, S6
FG3	N	3	N5, N6, N7
FG4	S	4	S7, S8, S9, S10
FG5	N	3	N8, N9, N10
FG6	S	3	S11, S12, S13
		Norwegian n = 10Sámi n = 13

All interviews were conducted from May 2017 until January 2018, lasted from 55 to 115 minutes, and were recorded in undisturbed locations away from the participants’ workplaces. The Norwegian focus group interviews were transcribed verbatim by the first author, the Sámi interviews were transcribed and translated in one process from Sámi to Norwegian by the second author. To ensure rigour in the process and validity of data in translating, the Sámi focus group interviews were quality assured by an external, professional interpreter, as recommended by Papadopoulos and Lees [39].

Using a semi-structured interview guide, participants were invited to give examples of both positive and negative patient interactions involving cultural safety in practice. Example questions were: “how do you establish trust with your Sámi patients”, “describe a positive patient interaction with a Sámi patient”, “how do you help to provide a culturally safe nurse-patient interaction?”, “how do you take care of the patients in a culturally safe way?”, “how does your workplace support culturally appropriate care for Sámi patients?”, “what did you learn at nursing school about Sámi culture?” and “how do you include culture in encounters with Sámi patients?”. Follow-up questions clarified participants’ responses and enabled the researchers to learn more about their experiences. Additionally, field notes were written after each interview.

Data analysis

The transcription of the Norwegian focus group interviews was done verbatim, and the Sámi interviews was translated and transcribed directly into Norwegian. All authors participated in the analysis and all cross-checked it. The automatic code search tools of NVivo have been used. According to Thorne [37] all data analysis consists of cognitive processing in four stages; comprehension, synthesis, theory generation and re-contextualisation. The first step was reading and re-reading the transcripts to enhance familiarisation with the data and coding through word frequency and text search. The next step consisted of categorising the codes into sub-themes and themes, defining the themes and sub-themes in relation to Thorne’s interpretive descriptive theory, and reviewing the themes and sub-themes based on the nursing context [37]. Following this, re-contextualisation took place with three key themes where each have three sub-themes based on the research question.

Ethical considerations

This study was approved by the Norwegian Centre for Research Data (No. 50,578) [40] and was conducted based on the Helsinki Declaration [41]. The participants were given verbal and written information about the study both in Sámi and Norwegian to enable informed consent and signed a written consent document. Participation was voluntary and participants were informed that they could withdraw from the interviews at any time without giving a reason. In order to guarantee confidentiality, data was anonymised, and place names deleted. All data are stored electronically, and password protected. Quotes have been anonymised, using the codes in (Table 2).

Findings

Both Norwegian and Sámi nurses were aware of the presence of Sámi patients in healthcare, and that they may have different needs than non-Sámi patients. Most nurses in the study described how they worked hard to build trust and connection with their Sámi patients by acknowledging their own background in or knowledge of Sámi culture.

Three overarching themes emerged from the interviews: (i) the importance nurses gave to establishing a connection and building trust with Sámi patients; (ii) nurses’ perceptions that in comparison to Norwegian patients Sámi patients could be less confrontational and direct, but that differences weren’t always apparent and (iii) the importance nurses described to understanding the cultural context of their Sámi patients (Table 3).

Table 3.

Themes from data and analysis

Research question	Key theme	Sub-themes
How do Sámi and Norwegian nurses in northern Norway describe perspectives of culturally respectful nursing in encounters with Sámi patients?	Establishing a connection and building trust with patients is important, whether Sámi or not	Connecting by common language and culture
		Connecting by showing respect and interest
		Connecting depends of enough time
	How nurses perceive Sámi patients	Sámi patients have a non-confrontational communication
		Important to use culturally appropriate communication methods
		Sámi patients can have different needs
	Nurses reflection on how to practice respectful and culturally appropriate nursing	Knowledge of Sámi culture is needed
		Wishing to learn about Sámi culture
		Lack of Sámi language, culture and knowledge

Establishing a connection and building trust with patients is important, whether Sámi or not

All participants told stories of what they considered good interactions with self-presentation and connection as keys to encounters with Sámi patients. They gave examples from their practice by sharing stories of how important knowledge on Sámi culture is in nursing care, and how this has a positive impact on communication during nurse-Sámi patient interaction.

These “good meetings” included simple strategies to foster connections and conversations:

… knock on the door and say the phrase ‘good morning’ in the Sámi language. Then I tell the patient who I am, what family background I have and where I come from. This often leads to the patient opening up about themselves and where they come from. By finding a mutual connection it creates common ground between us. (S10)

This Sámi name ritual is typical of polite nursing practice in general but adds two essential elements: 1) revealing one’s family name, and 2) revealing where one comes from. This information is connected to bilateral Sámi family connections back in time and is grounded in patients’ expectations of the nurse beyond the nurses’ professionalism, based on historical connections between the patient’s family and the Sámi nurse’s family.

The following example highlights the potential impact of possessing special knowledge about symbolic communication in Sámi culture such as insider knowledge:

One morning the patient had put two steel knives in a cross towards the entrance door … I asked the patient why the knives were placed in the entrance like that … the patient told me that there had been spiritual unrest in the house overnight and he had put out the steel knives to protect the house … then he took the knives away and said there was no need for them anymore … I told my colleagues what had happened. A Norwegian colleague exclaimed ‘didn’t you think you could get killed [if the patient was in psychosis]?’. I answered that I never thought about that. Then we discussed how that kind of experience can be interpreted … in Sámi culture steel [silver] protects people from evil. So, it’s important to have knowledge about this [Sámi] culture. (S7)

The concept of silver and knives in a cross for protection is common knowledge in Sámi culture, but may pose challenges if one is an outsider and does not understand the differences between Sámi and Norwegian worldviews.

Some nurses commented that a way to start a trustful relationship is to use a common language. All Sámi nurses said Sámi language is a good way to connect, as this bilingual Norwegian nurse:

It is a good way to connect, it results in good dialogue when the patients realise that I speak their language. (N4)

Even if Norwegian nurses do not speak Sámi or have much knowledge of the culture, good connections can be established:

Oh, your name is [NN] … when they see my name [Sámi sounding name] they start talking Sámi language to me. I say ‘sorry, I don’t speak Sámi, I wish I could, but I don’t know how to speak Sámi’, then … perhaps it’s my imagination, but I feel that a connection has been established, I feel we’ve made contact in a deeper way. (N10)

Using respect for and knowledge of Sámi culture is a way to create connection with Sámi patients, as with all patients, like in this dialogue:

My trick is … showing respect … for their background, in the first meeting. I think showing interest and asking a little. Get to know them … (N10)

This is what we all do, if they’re Sámi, Somali or Norwegian, or have psychiatric problems … (N8)

We must make sure that we don’t start glorifying Sámi patients in relation to … the respect you should treat all patients with … (N9)

One must respond to all … both Sámi and Norwegian speaking patients with … the same curiosity. I work by creating a relationship of trust to a patient, whatever they are. (N9)

The participants highlighted that trouble communicating with Sámi patients is often rooted in lack of trust and time to establish a safe relationship:

When we rush and don’t allocate enough time, the interaction isn’t good, not successful, we get nowhere. (N4)

The Sámi nurses stated that they understood what patients needed, but the Norwegian nurses did not feel comfortable if they could not meet the patient’s need:

When you feel you’ve given help for what they needed and understand each other. And nothing disappears, like important information … Leaving a patient with a feeling that we didn’t understand each other … isn’t good, it really isn’t [they agreed in the focus group]. (N3)

Establishing a connection with any patient can be challenging and difficult, especially during a time of illness. This becomes even more difficult when an added layer of differing cultures and worldviews are present. How to navigate these challenges is complex and nurses need support to achieve this.

How nurses perceive Sámi patients

A general opinion amongst participants was that Sámi patients have a non-confrontational manner of communication, unlike the Norwegian style of more direct communication. One Sámi nurse described a non-confrontational Sámi way of talking:

My experience with Sámi patients is not to behave in a too direct or confrontational way, not to ask too personal or too blunt questions. Sámi patients have a non-direct way of communicating, you have to be able to read between the lines. In regard to indirect communication, I think it’s important to use culturally appropriate communication methods. It’s important that all staff learn about this. If a nurse isn’t sure how to interact with a Sámi patient, one can … ask a Sámi nursing colleague for advice. (S7)

All nurses talked about the importance of understanding communication styles regardless of Sámi or Norwegian patient backgrounds, and that although it can take a long time before Sámi patients open up in conversations, elderly Norwegian patients often have similar traits. Finding similarities across cultures may enable or improve communication.

I do not really experience that Sámi patients are so very … different from Norwegians., in that way. I think many Norwegian elderly also behave like that, they don’t want to complain. And you have to be curious about their person and their disease ailments, to get it. They [Sámi] often give ambiguous answers … if you ask if they have pain. In such case I ask: You said that you used to chop wood, does it hurt? (N8)

The participants explained that in general nurses have to be aware that opening up can take time. In this example the nurses both recognised and acknowledged diversity:

I think the most important thing is to realise that you have to treat everyone as an individual … Sámi patients differ, they’re so diverse … (N6)

We have a responsibility to bear in mind and reflect on the fact that this is a Sámi patient who again has different needs … different ways … (N1)

This reveals how nurses reflect on person-centred care and that all patients have to be met as individuals, Sámi patients are diverse with differing cultural traits depending on geographical regions, places and spaces encompassed by the umbrella term Sámi.

Nurses’ reflections on how to practice cultural respectful and appropriate nursing

All participants described how important insider knowledge is, but also stated that anyone can learn and have some knowledge about Sámi culture.

One nurse used her cultural knowledge of reindeer herding when a patient with dementia, a former reindeer herder, was restless at night:

During the spring movement of reindeer, patients (from a reindeer-herding context) often become restless … during night shifts we often take part in “reindeer herding” with our Sámi patients. It’s natural to me and we all know why the patient got restless and wants to herd the reindeer. If we hadn’t had this cultural knowledge, the patient may have been even more restless. When we ‘herd reindeer’ alongside the patients, they calm down. [The job is done, and the reindeer are safe]. Healthcare professionals without this Sámi cultural knowledge and understanding would probably not have understood why the patient was running around [herding reindeer]. In these cases, the patient may be medicated or sedated to calm down. The non-Sámi nurse doesn’t always understand what is happening to Sámi patients. (S5)

This situation was interpreted within the Sámi nurse’s knowledge and understanding of the patient’s former work context, and his belonging to the culture of nomadic reindeer husbandry.

One of the nurses also revealed that a patient appreciated being cared for by a Sámi nurse because he felt better understood. This is an example of how belonging to the same culture and language can provide a feeling of good connections. The Norwegian nurses agreed that knowledge of Sámi culture would make them understand patients better, as this quote illustrates:

To be honest, I have to admit that I feel I don’t know enough about Sámi culture. I have a relative who’s married to a Sámi man. I’ve got some information about Sámi from her, and I notice how she behaves … And it’s another culture … (N2)

Many participants noted that knowledge of Sámi culture helped them to adapt care to Sámi patients, and this sometimes became easier as they gained more experience. Descriptions of how nurses navigate between these two worlds of Sámi and Norwegian culture revealed excellent nursing skills.

An older dying patient was being transported by ambulance back home. Most likely his last journey … he had two daughters with him, and the ambulance stretcher is not a comfortable place to lie on for 4 hours. So, I usually place a duvet on top of the mattress. And I wrapped him up in the blanket, wrapped him almost like a baby in a komse [Sámi baby carrier] … I told the daughter and she was very happy and said ‘I love how you see this [Sámi culture] … that it’s almost like he can have a safe journey home in a Sámi komse.(N10)

This nurse wanted to make the transport comfortable and realised during the wrapping up that she did it as a Sámi mother would have done it for her baby, making the journey safe and warm.

Only two of the 23 participants said they had had any lectures about Sámi health, patients, and cultural understanding in their bachelor’s degree nursing education. Most participants highlighted the lack of Sámi culture and how it is needed in nursing. The nurses agreed that more Sámi perspectives are needed in nursing education, and also opportunities to learn the Sámi language:

When I took the nursing degree, I learned to get knowledge and to be more aware of why a Sámi and a Norwegian think in different ways. We’re brought up in two different cultures. I also learned that Norwegians from the coast of Finnmark got very angry when we spoke Sámi. There was no literature about Sámi health perspectives included in my bachelor’s programme. (S6)

The nurses stated that there was nothing or very little to accommodate Sámi patients, or to make healthcare facilities more Sámi-friendly. Some suggested that the facilities needed to be reorganised or rebuilt:

Our nursing home is not practically set out and all the living areas are very small and too small for Sámi activities and Sámi dedicated spaces … .there should be more Sámi colours and the nursing home should be more like a Sámi home. (S11)

Other Sámi participants, however, pointed out that a previous action of having a dedicated Sámi area in hospitals or nursing homes had not been successful, and hence discontinued, because the other patients of different cultural backgrounds did not understand or use the services or activities in the Sámi area.

Discussion

Despite the fact that nurses participating in this study described many incidents where they have provided cultural sensitive nursing care and that almost all spoke in ways deeply respectful of Sámi culture, participants also called for more focus on cultural sensitivity and awareness towards Sámi culture, both in nursing education and clinical practice. Additionally, all Sámi nurses called for the presence of Sámi duodji (Sámi arts and crafts), colours and decorations in healthcare institutions.

Communication and connection with Sámi patients

The Norwegian nurses explained their approach in caring for Sámi patients as universal nursing skills providing equal care to all. Sometimes they described the challenge of an added layer of language barriers, but mostly cultural differences were the barrier. Spending more time on conversations and knowing the Sámi family name rituals and connections in greeting procedures were described as important steps in exhibiting cultural knowledge. These are some of the participants’ few suggestions that may provide a good start for the process towards cultural safety in the care of Sámi patients. When working with older patients’ in rural homecare the patients and the nurses often get a social connection and also have non-clinical chats [42]. Ness’ studies from the older people living alone in Sámi areas [43] claims the nurses and patients get trustful relationships and that culturally competent nurses need to understand both themselves and their patients’ worldviews to avoid stereotyping of the nursing care.

Having cultural awareness, sensitivity and reflective skills was exemplified by understanding the Sámi greeting ritual of presenting oneself, understanding the purpose of steel knives placed in the form of a cross outside of a home, and understanding that the restless dementia patient was “herding reindeer “ in his head. Sámi nurses with insider knowledge of Sámi culture intuitively understood the situations and provided appropriate action and care. As insiders they were able to navigate taboos, for example not speaking too directly and in a confrontational manner, and not being anonymous by concealing your family name, which is disrespectful in Sámi culture [21,22]. This shows that Sámi nurses had an easier time than ethnic Norwegian nurses, and suggest that cultural skills could be important to give and incorporate into appropriate care [18-23,28,30]. The Norwegian nurses suggested professional development courses to upgrade their knowledge of Sámi culture. This is supported by other research from Sámi areas where healthcare personnel have requested courses to increase cultural skills when working with Sámi patients [18,22].

Both groups of nurses were open-minded to other cultures and some talked about how they practice inclusive nursing, and described examples of what Sivertsen et al. [27] call “two-eyed seeing”. These nurses were working in multicultural areas and were skilled in working with diverse groups of patients. They included different worldviews into their care and highlighted the importance of building bridges between the Sámi and Norwegian people. The Sámi nurses seemed to be more aware of the cross-cultural bridge-building in interactions with patients, maybe because they themselves were living in two cultures, in a similar way to their Sámi patients.

Cultural respectful and appropriate nursing

The participants discussed their approach to Sámi patients without explicit mention of power imbalances, which is an important aspect of the concept of cultural safety [23,28,30]. However, during the interviews they expressed great interest in welcoming Sámi patients. Their perception of cultural needs and situations reveal that they paid attention to Sámi patients. They strived to make them comfortable in different contexts, such as when the Norwegian nurses stated that Sámi culture was different from their own Norwegian culture. This seems to indicate that cultural safety as a concept of reflection and recognition is not present in theory, but in practice. The many stories from their nursing practice demonstrated caregiving in both person-centred [44] and culturally competent ways [23,28,30].

Curtis et.al [30] discuss cultural safety as an alternative to cultural competence. Cultural competency has been criticised for its focus on acquiring knowledge, skills and attitudes without recognition that cultural sensitivity is a process and not a static level of achievement. Critical consciousness is needed in order not to take the cultural skills “for granted” or use it like a checklist. The concept of cultural safety includes both cultural sensitivity and awareness of other cultures, and self-reflection about one’s own culture and the power imbalances embedded in society [45]. However, analyses of power imbalance, institutional discrimination, colonisation and awareness of the power relationship as they apply to healthcare is important [23].

Cultural safety originated from Māori nursing and midwifery practice in New Zealand, where healthcare professionals were urged to reflect on their own culture and unconscious bias brought into nursing interactions in the healthcare system [46]. In New Zealand and Australia cultural safety is formally linked to health equity, registration and competency‐based practice certification [47-49].

The participants told of ways to dealing with difficult situations and nursing tasks. Many of the participants described care provision consistent with a culturally safe practice without even knowing about cultural safety as a theoretical concept. This may be a lesson learned for northern Norwegian healthcare personnel to recognise and use cultural safety strategies to provide guidance for clinical practice.

The power imbalance which is an important aspect of cultural safety was not discussed by the nurses in the interviews. Participants did, however, discuss their attempts to provide respectful and cultural appropriate care, and also noted that offering culturally appropriate care was not only an individual responsibility, but also a responsibility of the healthcare system and nursing education supported by legislation [1-4], white papers [9,10,14] and ILO convention 169 [5]. The aim of Norwegian healthcare is to be better equipped to deal with Indigenous patient interactions, provide quality care and thus improve health outcomes. Workplaces, hospitals, and institutions providing nursing education all have a responsibility to ensure that their health personnel and new nursing graduates can demonstrate knowledge of Sámi health and culture [1-5,9,10,14].

The reported lack of Sámi traditional duodji (Sámi arts and crafts), colours and decorations in healthcare institutions is an example of decision makers not giving enough consideration to the multicultural presence in northern Sápmi. Norwegian white papers and health curricula have encouraged the presence of knowledge of Sámi history and culture [9,33,34]. Cultural safety is not currently part of nursing curricula in Norway, nor is it required of graduates in order to practice nursing in Norway [31]. However, cultural competence, awareness and sensitivity, as our participants reported and required, are rapidly becoming recognised terms in the curricula [32].

To achieve culturally safe nursing means to be aware of the differences between people and cultures and understanding how we bring our own culture in to the care we provide as nurses. In this process, cultural safety is achieved when the care recipients consider the care to have met their cultural needs [23,30], as expressed by the daughter of the dying man; she appreciated the Norwegian nurse’s action when she wrapped the patient as in a Sámi komse during his long journey home. The nurses should be mindful to not define all Sámi patients as alike, as Sámi culture is diverse. To assume that all members from a certain group share certain cultural “traits”, values and fixed sets of characteristics is by Kirmayer [23] described as an old-fashioned view, now abandoned by anthropology. All patients have different needs, attitudes, background and culture and need to be meet as individuals, like person-centred care [44].

The findings of this study reveal that participants are aware of their Sámi patients’ cultural backgrounds and try their best to enable culturally safe care. They welcome an acknowledgement of the importance of culture and cultural understanding both in education and clinical practice, and that services should adapt to meet the unique needs of the Sámi patients.

Limitations

Four of the six focus groups interviews were conducted in the Sámi administrative area, where most inhabitants, local government, schools, workplaces, and language are Sámi. This may have influenced the findings, by reinforcing the Sámi language commitment and Sámi elements in this context and may not reflect views of other northern Sápmi areas of Norway. Nurses from other Sápmi areas in Norway may have brought other perspectives on culturally safe care to the table.

Being able to participate in a focus group and speak your mother tongue is a privilege and may have enhanced the validity of the data as it minimises risk of misunderstandings and ambiguous perceptions and translations. Data production in qualitative research is a process influenced by both the researcher and the participants and is not without power positions [50,51]. The participants who signed up in this study were engaged with their Sámi patients, which may have influenced the data.

Conclusion

This study documents northern Sámi and Norwegian nurses’ experiences of working with Sámi patients and highlights challenges they describe around caregiving across cultures. The findings reveal nurses’ approaches to establishing connections and communication, their perceptions of Sámi patients and their reflections on respectful and culturally appropriate nursing.

Findings of this study may contribute to the literature by providing insight into factors that may contribute or hinder appropriate care for Sámi patients and by offering a consideration of the alternative practice of culturally safe nursing. This study shows that nurses working in northern Sápmi areas of Norway are often practising culturally safe nursing without being familiar with the theoretical concept. They are interested in learning more about Sámi culture to offer appropriate care, and we suggest that cultural safety would be a valuable and welcome addition both into practice and the nurse curriculum of nursing education.