Cultural Safety in health disciplines
Kate Murray; Trish Obst; and Annabel Ahuriri-Driscoll
Cultural Safety in practice
As health practitioners and health educators our interactions occur within an institutional system, but we are each responsible for the interactions between us as a service provider and service users. From the previous section you now understand that culture is broad and can include age or generation, sexual orientation, socioeconomic status, disability, ethnic identity or migration experience, spiritual beliefs and much more. The health professional delivering a service from a perspective of Cultural Safety will have engaged in a process of reflection on their own personal complex cultural identities and the impact culture has on their professional practice. For example, how does the practitioner understand their role, consider their actions as helpful, and determine how this aligns (or not) to clients’ needs and perspectives? Any action, conscious or unconscious, that demeans or disempowers the identity and wellbeing of a service user, is not culturally safe practice (Taylor & Guerin, 2010).
Culturally unsafe practice would be a problem in any area, whether it is research, clinical practice, training and education, policy and governance, or other work in which the health practitioner is engaged. Culturally safe practice requires being attuned to how our own biases and culture, power imbalances, and structural inequality may impact on how service users experience services. Gaining insight into how we individually understand and acknowledge difference and how we respond to others is crucial. Ultimately, a key goal for Cultural Safety is for practitioners and institutions to respect, be open to, and to respond kindly to the cultural identity of others (Ramsden, 2002). Our responses to differences and our own social experiences shape our communication skills and the decisions we make in our personal and professional lives.
The importance of Cultural Safety as a key competency for all health professionals has been recognised by health registration boards across Australia and Aotearoa New Zealand as well as by local, state and regional health districts and governing bodies. In the Australian context, the Australian Health Practitioner’s Regulation Agency (AHPRA), oversees the registration of 15 key health and allied health disciplines. AHPRA developed the 2020-2025 National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy as an overarching guide to ensure Cultural Safety forms a part of the education and registration requirements of the health professions overseen by the agency. The key focus of this strategy is to build a culturally safe health practitioner workforce for Australia. The development of this strategy indicates that Cultural Safety is a major priority for the health workforce and a fundamental part of the training of the future health workforce. Specific requirements regarding Cultural Safety training, professional development, practice standards and code of conduct are set by each profession’s National Board. Australian Health Practitioner Regulation Agency – Home (ahpra.gov.au) has links to each of the National Boards and their registration standards.
In Aotearoa New Zealand, while Health New Zealand | Te Whatu Ora provides the overarching coordination and responsibility for day-to-day health service delivery, registration requirements and competencies are managed by the various health professional boards and councils. The importance of Cultural Safety is built into the specific professional practice codes, which are commonly written in both English and te reo Māori and detail the role of Cultural Safety for the profession. This aligns with recommendations to move away from cultural competence towards Cultural Safety (Curtis et al., 2019), which have been adopted by the Medical Council of New Zealand. In addition, there are detailed specific cultural guidelines available within many disciplines such as nursing, where the term kawa whakaruruhau (Cultural Safety) originated. Te Tiriti o Waitangi (the Treaty of Waitangi) is key to the application of Cultural Safety in the Aotearoa New Zealand context (Ramsden 2002); its principles of partnership (entailing the balancing of kāwanatanga/government and tino rangatiratanga/self-determination), active protection, equity and options (Waitangi Tribunal, 2023), align well with principles of Cultural Safety.
Critical Self-Reflection Exercise 1
- Depending on what you are studying and your geographic location, what are the guidelines and registration requirements for your future health profession for Cultural Safety? Investigate the stated policies and guidelines for your (federal) health professional body and relevant organisational, district, or state authorities that may have policies and legislation that guide your practice.
- Knowing what you know now, how would you respond to the interview question – ‘tell me about how your practice is culturally safe’?
- As a student how are you already practicing Cultural Safety as you engage in your learning?
Now that you have identified the specific guidelines and standards for Cultural Safety for your discipline and reflected on how you personally engage in culturally safe interactions, case studies are provided for you to consider and apply what you have learned.
Case study applications
Case 1
One of your first clients has been admitted with uterine perforation following a voluntary termination of pregnancy; a rare complication of this generally safe surgical procedure. She also has a history of heroin abuse and was an active user just prior to her termination. She is in opiate withdrawal, which is complicating her other medical and mental health issues.
Reflect on this situation and identify some ways that your personal culture in this situation might impact on your service provision:
- How might your personal beliefs and experiences influence your treatment for this service user? For example, what are your views on drug use, parenting, and the client’s decision to voluntarily terminate her pregnancy, and how might they influence your response?
- What steps could you take to manage your personal reaction and ensure culturally safe service provision?
Case 2
One of your first clients is from a large family and there are always many family members present when you are with the client. The family members are loud, and they continuously interrupt when your client is responding to your questions, with their opinions and questions. You ask your client if they would mind if the family members waited outside while you are with them, but the client states very clearly that they want their family to stay with them.
Reflect on this situation and identify some ways that your personal culture in this situation might impact on your service provision. How too might the culture of the profession and/or clinic influence the policies that are developed and implemented?
- What are some of the ways in which you might engage in culturally safe practice in this scenario?
- What expectations do you have about the ‘correct’ way for clients to act in sessions?
- What would inform your decision-making as to whether you would ask the family to leave, such as ethical guidelines on confidentiality, privacy, and multicultural practice?
- What responsibility do you have to adapt your personal style?
- What do you see as the important steps to take in this scenario to ensure that there is effective engagement with the service user?
Case 3
Imagine you are a student on placement at a busy inner city private practice. The private practice is in a wealthy suburb and your supervisor has been teaching you about the newest health supplies available for clients. You are surprised by the cost, with many of the recommended models exceeding $1000 per item. Your supervisor brings their next client into the consultation room and introduces you to the client as a student who is observing. The client hands you their health device (e.g. eyeglasses, hearing aids, heart monitor, etc) to adjust and clean. You explain that you can ask the retail staff to service their equipment, as you would like to stay in the room to observe and assist with the consultation. The client shrugs and makes a comment to the practitioner that it is probably better that way since students never know what they’re doing and can’t afford to pay for it if they break it.
Reflect on this situation and identify some ways that your personal culture in this situation might impact on your service provision:
- How might your personal beliefs and experiences influence your approach to treatment for this service user?
- What steps could you take to manage your personal reaction and ensure culturally safe service provision?
- What steps could your supervisor take to ensure a safe experience for both you and the client?
Case 4
You are on placement in a paediatric outpatient service. The service is extremely busy and there is a long wait list. One of the first families you work with at the service arrives 30 minutes late for their appointment. They are dishevelled and not at all prepared for the appointment. They have forgotten to bring their referral and the child’s school reports that they were requested to bring. The service would like to offer the family a 6-week treatment program, but you are concerned that there may be barriers that prevent them from attending regularly or on time.
Reflect on this situation and if you are making decisions about treatment plans for this family, identify what factors might influence your decision making, and some ways that your personal culture in this situation might impact on your service provision:
- What might be some of the reasons for them turning up late and unprepared? How might your own beliefs about punctuality or experiences with caregiving influence your response?
- What steps could you take to manage the interaction with this family and support them to get the most from the service?
- What if with questioning you learn that they live some distance from the service, have no car and the public transport where they live is infrequent. There are several other children that needed to be taken care of so the mother could attend the appointment. Does having this additional information change your perspective on the situation?
- What might your initial reactions tell you about how you interpret other people’s behaviours in the absence of information?
Case 5
You are a student who has only done placement in a metropolitan setting, in acute areas with busy practices. You have been taught in your degree about the importance of treatment compliance, and the significant role medication can play in addressing certain health conditions. Each morning of placement, you work with a Registered Nurse who is completing the medication rounds. You walk in to see the next client whose medications are due, but the client says they do not want the medications and refuses to take them. The Registered Nurse you are working with tells the client to ‘just takes the medications’. The client continues to refuse. You and a fellow placement student begin to leave the room and the Registered Nurse says, ‘they are just non-compliant’.
Reflect on this situation and identify some ways that your personal culture in this situation might impact on your service provision:
- What are the dominant messages in this scenario?
- What steps could you take to manage the interaction with this service user and support them to get the most from the service?
- Who has the power in this scenario and how could power be shared?
- What structures and systems was the nurse responding to that invited them to declare the client non-compliant?
Critical Self-Reflection Exercise 2
- Can you identify an interaction when your values or beliefs were in conflict with those of another person you interacted with?
- Did this make you uncomfortable and if so, how did you manage your experience?
- Did your reaction lead you to dismiss the other person’s values or beliefs, or how else might it have affected how you responded to the other person?
- Knowing what you know now, what would you do differently?
Summary of individual applications
There are many ways in which your cultural identities will influence your service provision, both in ways known and unknown to you. In the service provider-service user dynamic, you inherently hold power (e.g., informational and legitimate power by holding a health professional position) and ultimately have responsibility in ensuring that the healthcare service meets the user’s needs. In relation to other parts of a service provider’s identity they may or may not hold positions of privilege relative to their client (e.g., race, socioeconomic status, sexual orientation). Where practitioners hold privilege, they may not have lived experience of the barriers or discrimination faced by others and such institutional and societal privileges can blind individual service providers to recognising instances of oppression, exclusion, and discrimination (D’Ignazio & Klein, 2020). Health practitioners across every stage of their career must continue to embrace critical reflection, sound supervision and peer-support structures, and cultural humility to engage with the uncertainty, difference, and discord that continuously arise within health service delivery in both small and sizeable ways. Care and attention to the undercurrents of power and privilege are an essential component, together with professional knowledge, to ensure quality, equitable, and safe services. It can also be transformative for practitioners as they deepen their understanding of themselves and their practice.
Cultural Safety in institutional settings
It is not enough to consider power and privilege only within the interpersonal relationship of service provider and service user. Institutional and societal factors must also be considered when creating culturally safe health services, with ample evidence suggesting there are significant changes required to establish culturally safe healthcare systems in Australia and Aotearoa New Zealand. There are well documented inequities in people’s access to healthcare services and the quality of care they receive depending on their demographic characteristics and geographic locations. In nearly all instances, individuals from non-dominant groups (e.g., racial/ethnic and religious minority groups) are less likely to access healthcare services, due to a number of systemic barriers and hence have worse treatment outcomes, which further undermines trust and willingness to seek services. Issues of trust are founded on historical abuses and discrimination of healthcare services and require reparations by service organisations through purposeful outreach to work to repair community trust and faith in their services.
There are more barriers for non-dominant communities when trying to access care. Low-income communities frequently have lower quality and fewer services than high-income communities, with minority groups over-represented in low-income communities. The physical location of services may disadvantage communities where they are not near public transportation lines or in convenient neighbourhoods for all communities to access. The layout and aesthetics of physical facilities are often designed for the dominant group, including the languages in which signage is written, the physical décor (e.g., flags and artwork displayed), and the size of the physical spaces that preclude family consultations with a preference for individual consultation approaches. The staff may not be representative of the communities that they serve (e.g., languages spoken, physical appearance and dress, knowledge of cultures), which can reduce a sense of safety and familiarity within a service as a whole. By virtue of a clinic being designed for a particular purpose and group, we must consider what other purposes and groups might then be automatically excluded from that space? Being responsive to and acting upon the cultural needs of unique and diverse populations within health services is an essential aspect in beginning to address health disparities (Wilson et, al., 2022).
Cultural Safety at an institutional level requires planning, coordination and administrative support. This includes in-depth understanding of the communities served, the demographic characteristics of those accessing the service, and detailed consideration of the gaps and inequities for various groups in their ability to access and receive benefit from the health service. Ensuring that diverse voices are part of the design and review of services is paramount. As Cultural Safety exists from the perspective of the service user, ongoing engagement that captures the experiences of the varied cultural groups served by the health service is paramount. Co-design and co-governance of services, such as those shown in the Aboriginal and Torres Strait Islander community-controlled health services offered in Australia demonstrate how bottom-up co-design can create altered organisational structures that can lead to increased reports of Cultural Safety by service users. Such approaches demonstrate how culturally safe systems go beyond the training of individual practitioners and consider the systemic factors that also influence the likelihood of people engaging with and benefiting from health services. As members of those systems, each practitioner plays a role in reflecting upon and creating change that ensures more safe and equitable services.
Critical Self-Reflection Exercise 3
Reflect on the healthcare settings where you have practiced (or if not yet practicing that you have attended as a service user):
- Can you identify some ways that you think culture might impact on people’s experiences within the health service?
- Has there been an experience you have had where the organisation or institution you have been involved with has rules or systems that have made it difficult for you to act or do what aligned best with your own values?
- How did you manage this? Did you feel constrained and powerless, or did you try to change something about the system? What happened when you tried to do things differently?
- How easy/hard do you think it is to change systems and why?
Further reading
Jones, B., Heslop, D., & Harrison, R. (2020). Seldom heard voices: A meta-narrative systematic review of Aboriginal and Torres Strait Islander peoples healthcare experiences. International Journal for Equity in Health, 19(1), 1-11. https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01334-w
Brown, H., & Bryder, L. (2023). Universal healthcare for all? Māori health inequalities in Aotearoa New Zealand, 1975–2000. Social Science & Medicine, 319, 115315. https://www.sciencedirect.com/science/article/pii/ S0277953622006219
References
Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why Cultural Safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health, 18(1), 174. https://doi.org/10.1186/s12939-019-1082-3
D’Ignazio, C., & Klein, L. F. (2020). Data feminism. The MIT Press. https://ebookcentral.proquest.com
Waitangi Tribunal. (2023). Hauora : report on stage one of the Health Services and Outcomes Kaupapa Inquiry. https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_195476216/Hauora%202023%20W.pdf [PDF]
Wilson, L., Wilkinson, A., & Tikao, K. (2022). Health professional perspectives on translation of Cultural Safety concepts into practice: A scoping study. Frontiers in Rehabilitation Sciences, 3. https://doi.org/10.3389/fresc.2022.891571
