Why cultural safety rather than cultural competency is ... · health professional, physician,...
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RESEARCH Open Access Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition Elana Curtis 1* , Rhys Jones 1 , David Tipene-Leach 2 , Curtis Walker 3 , Belinda Loring 1 , Sarah-Jane Paine 1 and Papaarangi Reid 1 Abstract Background: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. Methods: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Results: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. Conclusions: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important. Keywords: Cultural safety, Cultural competency, Indigenous, Māori, Disparities, Inequity, Ethnic © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. * Correspondence: [email protected] 1 Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand Full list of author information is available at the end of the article Curtis et al. International Journal for Equity in Health (2019) 18:174 https://doi.org/10.1186/s12939-019-1082-3
Transcript of Why cultural safety rather than cultural competency is ... · health professional, physician,...
RESEARCH Open Access
Why cultural safety rather than culturalcompetency is required to achieve healthequity: a literature review andrecommended definitionElana Curtis1* , Rhys Jones1, David Tipene-Leach2, Curtis Walker3, Belinda Loring1, Sarah-Jane Paine1 andPapaarangi Reid1
Abstract
Background: Eliminating indigenous and ethnic health inequities requires addressing the determinants of healthinequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate andequitable care. There is growing recognition of the importance of cultural competency and cultural safety at bothindividual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions haveincluded cultural competency in health professional licensing legislation, health professional accreditation standards,and pre-service and in-service training programmes. However, there are mixed definitions and understandings ofcultural competency and cultural safety, and how best to achieve them.
Methods: A literature review of 59 international articles on the definitions of cultural competency and culturalsafety was undertaken. Findings were contextualised to the cultural competency legislation, statements andinitiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health,convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical PractitionersAssociation (Te ORA) and consultation with Māori medical practitioners via Te ORA.
Results: Health practitioners, healthcare organisations and health systems need to be engaged in working towardscultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’power structures and be prepared to challenge their own culture and cultural systems rather than prioritisebecoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearlylinked to achieving health equity. Healthcare organisations and authorities need to be held accountable forproviding culturally safe care, as defined by patients and their communities, and as measured through progresstowards achieving health equity.
Conclusions: A move to cultural safety rather than cultural competency is recommended. We propose a definitionfor cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essentialprinciples and practical steps to operationalise this approach in healthcare organisations and workforcedevelopment. The unintended consequences of a narrow or limited understanding of cultural competency arediscussed, along with recommendations for how a broader conceptualisation of these terms is important.
Keywords: Cultural safety, Cultural competency, Indigenous, Māori, Disparities, Inequity, Ethnic
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: [email protected] Kupenga Hauora Māori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New ZealandFull list of author information is available at the end of the article
Curtis et al. International Journal for Equity in Health (2019) 18:174 https://doi.org/10.1186/s12939-019-1082-3
IntroductionInternationally, Indigenous and minoritorised ethnicgroups experience inequities in their exposure to the de-terminants of health, access to and through healthcareand receipt of high quality healthcare [1]. The role ofhealth providers and health systems in creating and main-taining these inequities is increasingly under investigation[2]. As such, the cultural competency and cultural safetyof healthcare providers are now key areas of concern andissues around how to define these terms have becomeparamount, particularly within a Aotearoa New Zealand(NZ) context [3]. This article explores international litera-ture to clarify the concepts of cultural competency andcultural safety in order to better inform both local andinternational contexts.In NZ, Māori experience significant inequities in
health compared to the non-Indigenous population. In2010–2012, Māori life expectancy at birth was 7.3 yearsless than non-Māori [4] and Māori have on average thepoorest health status of any ethnic group in NZ [5, 6].Although Māori experience a high level of health careneed, Māori receive less access to, and poorer carethroughout, the full spectrum of health care servicesfrom preventative to tertiary care [7, 8]. This is reflectedin lower levels of investigations, interventions, and medi-cines prescriptions when adjusted for need [8, 9]. Māoriare consistently and significantly less likely to: get under-standable answers to important questions asked ofhealth professionals; have health conditions explained inunderstandable terms; or feel listened to by doctors ornurses [10]. The disturbing health and social context forMāori and significant inequities across multiple healthand social indicators described above provide the ‘needs-based’ rationale for addressing Māori health inequities[8]. There are equally important ‘rights-based’ impera-tives for addressing Indigenous health and health equity[11], that are reinforced by the United Nations Declar-ation on the Rights of Indigenous Peoples [12] and TeTiriti o Waitangi (Treaty of Waitangi) in NZ.There are multiple and complex factors that drive In-
digenous and ethnic health inequities including a vio-lent colonial history that resulted in decimation of theMāori population and the appropriation of Māoriwealth and power, which in turn has led to Māori nowhaving differential exposure to the determinants ofhealth [13] [14] and inequities in access to health ser-vices and the quality of the care received. Framing eth-nic health inequities as being predominantly driven bygenetic, cultural or biological differences provides alimited platform for in-depth understanding [15, 16]. Inaddition, whilst socio-economic deprivation is associ-ated with poorer health outcomes, inequities remaineven after adjusting for socio-economic deprivation orposition [17]. Health professionals and health care
organisations are important contributors to racial andethnic inequities in health care [2, 13]. The therapeuticrelationship between a health provider and a patient isespecially vulnerable to the influence of intentional orunintentional bias [18, 19] leading to the “paradox ofwell-intentioned physicians providing inequitable care[20]. Equitable care is further compromised by poorcommunication, a lack of partnership via participatoryor shared decision-making, a lack of respect, familiarityor affiliation and an overall lack of trust [18]. Health-care organisations can influence the structure of thehealthcare environment to be less likely to facilitate im-plicit (and explicit) bias for health providers. Import-antly, it is not lack of awareness about ‘the culture ofother groups’ that is driving health care inequities - in-equities are primarily due to unequal power relation-ships, unfair distribution of the social determinants ofhealth, marginalisation, biases, unexamined privilege,and institutional racism [13]. Health professional edu-cation and health institutions therefore need to addressthese factors through health professional education andtraining, organisational policies and practices, as well asbroader systemic and structural reform.Eliminating Indigenous and ethnic health inequities re-
quires addressing the social determinants of health in-equities including institutional racism, in addition toensuring a health care system that delivers appropriateand equitable care. There is growing recognition of theimportance of cultural competency and cultural safety atboth individual health practitioner and organisationallevels to achieve equitable health care delivery. Some ju-risdictions have included cultural competency in healthprofessional licensing legislation [21], health professionalaccreditation standards, and pre-service and in-servicetraining programmes [22–25]. However, there are mixeddefinitions and understandings of cultural competencyand cultural safety, and how best to achieve them. Thisarticle reviews how concepts of cultural competency andcultural safety (and related terms such as cultural sensi-tivity, cultural humility etc) have been interpreted. Theunintended consequences of a narrow or limited under-standing of cultural competency are discussed, alongwith recommendations for why broader conceptualisa-tion of these terms is needed to achieve health equity. Amove to cultural safety is recommended, with a rationalefor why this approach is necessary. We propose a defin-ition for cultural safety and clarify the essential princi-ples of this approach in healthcare organisations andworkforce development.
Methods and positioningThis review was originally conducted to inform theMedical Council of New Zealand, in reviewing and up-dating its approach to cultural competency requirements
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 2 of 17
for medical practitioners in New Zealand Aotearoa. Thereview and its recommendations are based on the fol-lowing methods:
� An international literature review on culturalcompetency and cultural safety.
� A review of cultural competency legislation,statements and initiatives in NZ, including of theMedical Council of New Zealand (MCNZ).
� Inputs from a national Symposium on CulturalCompetence and Māori Health, convened for thispurpose by the MCNZ and Te Ohu Rata o Aotearoa– Māori Medical Practitioners Association (TeORA) [26].
� Consultation with Māori medical practitioners(through Te ORA).
The authors reflect expertise that includes Te ORAmembership, membership of the Australasian Leaders inIndigenous Medical Education (LIME) (a network to en-sure the quality and effectiveness of teaching and learn-ing of Indigenous health in medical education), medicaleducationalist expertise and Indigenous medical practi-tioner and public health medicine expertise acrossAustralia and NZ. This experience has been at the fore-front of the development of cultural competency andcultural safety approaches within NZ. The analysis hasbeen informed by the framework of van Ryn and col-leagues [27] which frames health provider behaviourwithin a broader context of societal racism. They notethe importance of shifting “the framing of the problem,from ‘the impact of patient race’ to the more accurate‘impact of racism’….on clinician cognitions, behaviour,and clinical decision making” [27].This review and analysis has been conducted from
an Indigenous research positioning that draws fromKaupapa Māori theoretical and research approaches.Therefore, the positioning used to undertake thiswork aligns to effective Kaupapa Māori research prac-tice that has been described by Curtis (2016) as:transformative; beneficial to Māori; under Māori con-trol; informed by Māori knowledge; aligned with astructural determinants approach to critique issues ofpower, privilege and racism and promote social just-ice; non-victim-blaming and rejecting of cultural-deficit theories; emancipatory and supportive of decol-onisation; accepting of diverse Māori realities andrejecting of cultural essentialism; an exemplar of ex-cellence; and free to dream [28].The literature review searched international journal data-
bases and the grey literature. No year limits were applied tothe original searching. Databases searched included: Med-line, Psychinfo, Cochrane SR, ERIC, CINAHL, Scopus, Pro-quest, Google Scholar, EbscoHost and grey literature. Search
terms included MeSH terms of cultural competence (keywords: cultural safety, cultural awareness, cultural compe-tence, cultural diversity, cultural understanding, knowledge,expertise, skill, responsiveness, respect, transcultural, multi-cultural, cross-cultur*); education (key words: Educat*,Traini*, Program*, Curricul*, Profession*, Course*, Interven-tion, Session, Workshop, Skill*, Instruc*, program evalu-ation); Health Provider (key words: provider, practitioner,health professional, physician, doctor, clinician, primaryhealth care, health personnel, health provider, nurse); HealthServices Indigenous (key words: health services Indigenous,ethnic* Minorit*, Indigenous people*, native people). A totalof 51 articles were identified via the search above and anadditional 8 articles were identified via the authors’ oppor-tunistic searching. A total of 59 articles published between1989 and 2018 were used to inform this review. Articlesreviewed were sourced from the USA, Canada, Australia,NZ, Taiwan and Sweden (Additional file 1 Table S1).In addition to clarifying concepts of cultural compe-
tence and cultural safety, a clearer understanding is re-quired of how best to train and monitor for culturalsafety within health workforce contexts. An assessmentof the availability and effectiveness of tools and strategiesto enhance cultural safety is beyond the scope of this re-view, but is the subject of a subsequent review inprocess.
Reviewing cultural competencyCultural competency is a broad concept that has variousdefinitions drawing from multiple frameworks. Overall,this concept has varying interpretations within and be-tween countries (see Table 1 for specific examples). In-troduced in the 1980s, cultural competency has beendescribed as a recognised approach to improving theprovision of healthcare to ethnic minority groups withthe aim of reducing ethnic health disparities [31].One of the earliest [49] and most commonly cited def-
initions of cultural competency is sourced from a 1989report authored by Cross and colleagues in the UnitedStates of America [29] (p.13):
Cultural competence is a set of congruent behaviours,attitudes, and policies that come together in a system,agency, or among professionals and enable thatsystem, agency, or those professionals to workeffectively in cross-cultural situations.
Cross et al. [29] contextualized cultural competency aspart of a continuum ranging from the most negative endof cultural destructiveness (e.g. attitudes, policies, andpractices that are destructive to cultures and conse-quently to the individuals within the culture such as cul-tural genocide) to the most positive end of culturalproficiency (e.g. agencies that hold culture in high
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 3 of 17
Table
1Definition
sandCon
ceptsof
RelatedTerm
s
Term
sDefinition
/Con
cept
Exam
ples
Sources
Culture
Theintegrated
patternof
human
behaviou
rthat
includ
esthou
ghts,
commun
ications,actions,customs,be
liefs,values,andinstitu
tions
ofaracial,ethnic,religious,orsocialgrou
p.
[29]
Theaccumulated
sociallyacqu
iredresultof
shared
geog
raph
y,tim
e,ideasandhu
man
expe
rience.Culture
may
ormay
notinvolvekinship,
butmeaning
sandun
derstand
ings
arecollectivelyhe
ldby
grou
pmem
bers.C
ulture
isdynamicandmob
ileandchange
saccordingto
time,individu
alsandgrou
ps.
[30]
Thereisatend
ency
with
inhe
althcare
toeq
uate
cultu
rewith
essentialized
notio
nsof
race
andethn
icity,w
hich
canlead
topractices
that
separate
cultu
refro
mits
social,econo
micandpo
liticalcontext.
Narrow
concep
tualizations
ofcultu
reandiden
titymay
limitthe
effectiven
essof
particular
approaches,and
afocuson
specificcultu
ral
inform
ationmay
inadverten
tlyprom
otestereo
typing
.
[31]
CulturalA
waren
ess
abe
ginn
ingstep
towards
unde
rstand
ingthat
thereisdifference.Many
peop
leun
dergocoursesde
sign
edto
sensitise
them
toform
alritual
rather
than
theem
otional,social,econo
micandpo
liticalcontextin
which
peop
leexist
[30]
[is]concerne
dwith
having
know
ledg
eabou
tcultu
ralb
ut,m
ore
specifically,ethnicdiversity.
[32]
anindividu
al’saw
aren
essof
her/hisow
nview
ssuch
asethn
ocen
tric,
biased
andprejud
iced
beliefstowards
othe
rcultu
res(p.e120)
[33]
essentially
thebasicacknow
ledg
men
tof
differences
betw
eencultu
res
[34]
recogn
izingthat
therearedifferences
betw
eencultu
res
[35]
CulturalSen
sitivity
alertsstud
entsto
thelegitim
acyof
differenceandbe
gins
aprocess
ofself-explorationas
thepo
werfulb
earersof
theirow
nlifeexpe
rience
andrealities
andtheim
pact
thismay
have
onothe
rs.
[30]
buildingon
theaw
aren
essof
differencethroug
hcultu
ralaccep
tance,
respectandun
derstand
ing
[36]
buildson
cultu
ralawaren
ess’acknow
ledg
men
tof
differencewith
the
additio
nof
therequ
iremen
tof
respectin
gothe
rcultu
res
[34]
whe
restud
entsstartto
analysetheirow
nrealities
andtheim
pact
that
thismay
have
onothe
rs.
[35]
CulturalH
umility
incorporates
alifelon
gcommitm
entto
self-evaluatio
nandself-critiqu
e,to
redressing
thepo
wer
imbalances
inthepatient-physician
dynamic,
andto
developing
mutually
bene
ficialand
non-paternalistic
clinicaland
advocacy
partne
rships
with
commun
ities
onbe
halfof
individu
alsand
defined
popu
latio
ns.
[37]
entails
valuinglife-long
learning
andcriticalself-reflection,alon
gwith
arespectful
andinqu
isitive
approach
whe
reby
practitione
rsareexpe
cted
toseek
know
ledg
efro
mtheirclientsregardingtheircultu
raland
structural
influen
cesrather
than
assumingun
derstand
ingor
expe
rtiseabou
tacultu
reou
tsideof
theirow
n
[38]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 4 of 17
Table
1Definition
sandCon
ceptsof
RelatedTerm
s(Con
tinued)
Term
sDefinition
/Con
cept
Exam
ples
Sources
defined
ashaving
aninterpersonalstancethat
isothe
r-oriented
rather
than
self-focused,
characterized
byrespectandlack
ofsupe
rioritytowardan
individu
al’scultu
ralb
ackgroun
dandexpe
rience.
[39]
does
nothave
anen
dpoint
orgo
al;the
reisno
objectiveof
masterin
ganothe
rcultu
re.Rathe
ritisacontinualp
rocess
ofself-reflectionand
self-critiqu
ethat
overtly
addressespo
wer
ineq
uitiesbe
tweenproviders
andclients.Attaining
cultu
ralh
umility
becomes
notago
albu
tan
active
process,an
ongo
ingway
ofbe
ingin
theworld
andbe
ingin
relatio
nships
with
othe
rsandself.
[40]
CulturalSecurity
itlegitim
ises
andvalues
cultu
rald
ifferen
cesto
ensure
noharm
iscaused
andultim
atelylinks
unde
rstand
ings
andactio
ns[41]
seeksto
create
interactions
betw
eenhe
alth
workersandhe
alth
service
usersthat
do‘not
comprom
isethelegitim
atecultu
ralrights,view
s,values
andexpe
ctations
ofAbo
riginalpe
ople’
[42]
CulturalR
espe
ctThe‘CulturalR
espe
ctFram
eworkforAbo
riginalandTorres
StraitIsland
erHealth
2004–2009’iden
tifiesthego
alof
cultu
ralrespe
ctas
‘uph
old[ing]
the
rightsof
Abo
riginalandTorres
StraitIsland
erpe
oplesto
maintain,protect
andde
veloptheircultu
reandachieveeq
uitablehe
alth
outcom
es
[42]
Themod
elen
tails
four
basicelem
entshigh
lightingtheim
portance
of‘Kno
wledg
eandAwaren
ess’that
inform
s‘SkilledPracticeandBehaviou
rs’
aswellasthede
velopm
entof
‘Stron
gRelatio
nships’b
etween(health
)institu
tions,ind
ividualsandcommun
ities
inorde
rto
achievean
‘Equ
ityof
Outcomes’
[43]
CulturalA
daptation
allm
odificatio
nsmadeto
standard
servicemetho
dsin
orde
rto
make
services
moreacceptable,
relevant,useful,and/or
effectivefordiversepo
pulatio
ns
[44]
TransculturalC
ompe
tence
theability
tointeract
with
clientelewho
comefro
marang
eof
different
cultu
ralb
ackgroun
ds[43]
TransculturalEffectiven
ess
ability
oforganisatio
nsandsystem
s‘to
acknow
ledg
eandrespon
dto
unique
anddiversepe
rspe
ctives
andsupp
ortno
n-discrim
inatorypractice’
(p.S51).Theseauthorsmaintain,furthe
rmore,that
transculturally
compe
tent
practitione
rsshou
ldrecogn
iseorganisatio
naland
system
icob
staclesand
activelyseek
waysto
mod
ifythem
[43]
TransculturalN
ursing
Leininge
r(1994)
defined
transculturaln
ursing
asbe
ingasubfield
ofnu
rsing,
focusing
oncomparativestud
yandanalysisof
different
cultu
resandisthe
basison
which
thetheo
ryof
cultu
recare
diversity
andun
iversalitywas
form
ed.
Thego
alof
transculturaln
ursesbe
ingto
“iden
tify,test,und
erstandandusea
body
oftransculturaln
ursing
know
ledg
eandpractices
which
iscultu
rally
derived
inorde
rto
providecultu
rally
specificnu
rsingcare
tope
ople”
[45]
Culturally
Unsafe
“any
actio
nsthat
diminish,de
meanor
disempo
wer
thecultu
ralide
ntity
and
well-b
eing
ofan
individu
al’
[46,47]
anyactio
nthat
diminishe
s,de
means,ordisempo
wersthecultu
ralide
ntity
and
well-b
eing
ofan
individu
al[48]
CulturalD
estructiven
ess
attitud
es,p
olicies,andpractices
that
arede
structiveto
cultu
resandconseq
uently
[29]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 5 of 17
Table
1Definition
sandCon
ceptsof
RelatedTerm
s(Con
tinued)
Term
sDefinition
/Con
cept
Exam
ples
Sources
totheindividu
alswith
inthecultu
resuch
ascultu
ralg
enocide
CulturalIncapacity
system
oragen
cies
that
lack
thecapacity
tohe
lpminority
clientsor
commun
ities
dueto
extrem
ebias,p
aternalism
anda
beliefin
theracialsupe
riorityof
thedo
minantgrou
p
[29]
CulturalB
lindn
ess
system
oragen
cies
that
functio
nwith
thebe
liefthat
colour
orcultu
remakeno
differenceandthat
allp
eoplearethesame
[29]
CulturalP
re-com
petence
anagen
cythat
realises
itsweaknessesin
servingminorities
and
attemptsto
improvesomeaspe
ctof
theirservices
toaspecific
popu
latio
n
[29]
CulturalP
roficiency
agen
cies
that
hold
cultu
rein
high
esteem
,who
seek
toaddto
theknow
ledg
ebase
ofcultu
rally
compe
tent
practiceby
cond
uctin
gresearch
andde
veloping
new
therapeutic
approaches
basedon
cultu
re
[29]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 6 of 17
Table
2KeyDefinition
sandCon
ceptsof
CulturalC
ompe
tency
Term
Definition
/Con
cept
Exam
ples
Sources
CulturalC
ompe
tency
asetof
cong
ruen
tbe
haviou
rs,attitu
des,andpo
liciesthat
come
toge
ther
inasystem
,age
ncy,or
amon
gprofession
alsanden
able
that
system
,age
ncy,or
thoseprofession
alsto
workeffectivelyin
cross-cultu
ralsitu
ations.
[29]
acknow
ledg
esandincorporates
-at
alllevels-theim
portance
ofcultu
re,the
assessmen
tof
cross-cultu
ralrelations,vigilancetowards
thedynamicsthat
resultfro
mcultu
rald
ifferen
ces,theexpansionof
cultu
ralkno
wledg
e,andtheadaptatio
nof
services
tomeetcultu
rally-
unique
need
s.
[29]
acultu
rally
compe
tent
coun
sellormustacqu
ire‘awaren
ess,know
ledg
e,andskillsne
eded
tofunctio
neffectivelyin
apluralistic
democratic
society’,i.e.,de
velopthe‘abilityto
commun
icate,interact,neg
otiate,and
interven
eon
behalfof
clientsfro
mdiversebackgrou
nds
[43]
theability
ofindividu
alsto
establisheffectiveinterpersonaland
working
relatio
nships
that
supe
rsed
ecultu
rald
ifferen
cesby
recogn
izingthe
impo
rtance
ofsocialandcultu
ralinfluen
ceson
patients,consideringho
wthesefactorsinteract,and
devising
interven
tions
that
take
theseissues
into
accoun
t
[53]
theability
ofsystem
sto
providecare
topatientswith
diversevalues,
beliefsandbe
haviou
rs,including
tailorin
gde
liveryto
meetpatients’
social,cultural,andlingu
istic
need
s
[54]
amorecompreh
ensive,skill-basedconcep
tthat
purposefullyinvolves
the
system
inadditio
nto
thepatientsandhasbe
enconceivedof
asan
on-going
quality
improvem
entprocess,relevant
across
individu
al,
organisatio
nal,system
icandprofession
allevels
[50]
acomplex
know
-act
grou
nded
incriticalreflectionandactio
n,which
thehe
alth
care
profession
aldraw
sup
onto
providecultu
rally
safe,
cong
ruen
t,andeffectivecare
inpartne
rshipwith
individu
als,families,
andcommun
ities
livinghe
alth
expe
riences,and
which
takesinto
accoun
tthesocialandpo
liticaldimen
sion
sof
care
[55]
theability
toworkandcommun
icateeffectivelyandapprop
riately
with
peop
lefro
mcultu
rally
different
backgrou
nds.Whileapprop
riatene
ssim
pliesno
tviolatingthevalued
rules,effectiven
essmeans
achievingthe
valued
goalsandou
tcom
esin
interculturalinteractio
ns
[33]
theability
toacknow
ledg
e,appreciate,and
respectthevalues,p
references,
andexpressedne
edsof
clients.Culturalcom
petenceisalso
theability
toresolvedifferences
andiden
tifysolutio
nsthat
redu
ceinterfe
rencefro
mvario
uscultu
ralfactors…Thisarticlede
fines
cultu
ralcom
petencyas
encompassingop
en-m
inde
dnessandarespectforpe
ople,fam
ilies,and
societiesof
vario
uscultu
ralb
ackgroun
ds.Being
ableto
translatethiscultu
ral
know
ledg
eandtheseskillsinto
practicemay
help
enhancethecultu
ral
approp
riatene
ssof
healthcare.
[51]
thede
velopm
entof
askillsetformoreeffectiveprovider-patient
commun
ication.
They
stressed
theim
portance
ofproviders’un
derstand
ingtherelatio
nship
betw
eencultu
ralb
eliefsandbe
haviou
randde
veloping
skillsto
improvequ
ality
[56]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 7 of 17
Table
2KeyDefinition
sandCon
ceptsof
CulturalC
ompe
tency(Con
tinued)
Term
Definition
/Con
cept
Exam
ples
Sources
ofcare
todiversepo
pulatio
ns.Severalinform
antsexpressed
concernabou
tthepe
rsistenceof
stereo
typicteaching
strategies
(suchas
treatin
gHispanics
oneway
andAfricanAmericansanothe
r).They
men
tione
dadditio
nalcom
pone
ntsthat
wereun
deremph
asized
such
asem
pathy,exploringsocioe
cono
micissues,and
addressing
bias
intheclinicalen
coun
ter
Socialworkersde
scrib
ecultu
ralcom
petenceas
acontinualp
rocess
ofstrivingto
becomeincreasing
lyself-aw
are,to
valuediversity,and
tobe
comeknow
ledg
eableabou
tcultu
ralstren
gths
[57]
frequ
ently
approached
inwayswhich
limitits
goalsto
know
ledg
eof
characteristics,cultu
ralb
eliefs,and
practices
ofdifferent
non-majority
grou
ps,and
skillsandattitud
esof
empathyandcompassionin
interviewingandcommun
icatingwith
non-majority
grou
ps.A
chieving
cultu
ralcom
petenceisthus
oftenview
edas
astaticou
tcom
e:One
is“com
petent”in
interactingwith
patientsfro
mdiversebackgrou
ndsmuch
inthesameway
ason
eiscompe
tent
inpe
rform
ingaph
ysicalexam
orreadingan
EKG.
[58]
anaw
aren
essof
cultu
rald
iversity
andtheability
tofunctio
neffectively,
andrespectfully,w
henworking
with
andtreatin
gpe
opleof
different
cultu
ralb
ackgroun
ds.C
ulturalcom
petencemeans
ado
ctor
hasthe
attitud
es,skills
andknow
ledg
ene
eded
toachievethis.A
cultu
rally
compe
tent
doctor
willacknow
ledg
e:That
New
Zealandhasacultu
rally
diversepo
pulatio
n.That
ado
ctor’scultu
reandbe
liefsystem
sinfluen
cehisor
her
interactions
with
patientsandacceptsthismay
impact
onthe
doctor-patient
relatio
nship.
That
apo
sitivepatient
outcom
eisachieved
whe
nado
ctor
and
patient
have
mutualrespe
ctandun
derstand
ing
[23]
Atthelevelo
ftheindividu
alpractitione
r,cultu
ralcom
petenceen
ables
increasedaw
aren
essandun
derstand
ingof
thepe
rspe
ctives
andlived
realities
ofMāoriclients,which
inturn
facilitates
genu
ineen
gage
men
t,trust,andinform
ationsharingcontrib
utingto
enhanced
clinicalou
tcom
es.
[59]
OrganisationalC
ulturalC
ompe
tency
Toachieveorganizatio
nalculturalcom
petencewith
inthehe
alth
care
leadership
andworkforce,itisim
portantto
maxim
izediversity.Thismay
beaccomplishe
dthroug
h:Establishing
prog
ramsforminority
health
care
leadership
developm
ent
andstreng
then
ingexistin
gprog
rams.Thede
siredresultisacore
ofprofession
alswho
may
assumeinfluen
tialp
osition
sin
academ
ia,
governmen
t,andprivateindu
stry.
Hiring
andprom
otingminorities
inthehe
alth
care
workforce.
Involvingcommun
ityrepresen
tatives
inthehe
alth
care
organizatio
n’s
planning
andqu
ality
improvem
entmeetin
gs.
[54]
Organisationalculturalcom
petenceinvolves
strategies
that
maxim
ise
diversity
andincorporateleadership
andworkforce
issues.Spe
cifically,
ethn
icmatchingandworking
with
commun
ities.The
lack
ofdiversity
inhe
alth
care
leadership
andtheworkforce
hasbe
eniden
tifiedas
abarrier
tocultu
rally
compe
tent
care,and
stud
ieshave
show
nthat
health
care
[60]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 8 of 17
Table
2KeyDefinition
sandCon
ceptsof
CulturalC
ompe
tency(Con
tinued)
Term
Definition
/Con
cept
Exam
ples
Sources
quality
andracialandethn
icdiversity
arelinked
System
icCulturalC
ompe
tency
Toachievesystem
iccultu
ralcom
petence(e.g.,in
thestructures
ofthehe
alth
care
system
)itisessential
toaddresssuch
initiatives
ascond
uctin
gcommun
ityassessmen
ts,d
evelop
ingmechanism
sforcommun
ityandpatient
feed
back,implem
entin
gsystem
sforpatient
racial/ethnicandlang
uage
preferen
cedata
collection,
developing
quality
measuresfordiversepatient
popu
latio
ns,and
ensurin
gcultu
rally
andlingu
istically
approp
riate
health
educationmaterialsandhe
alth
prom
otionanddiseasepreven
tioninterven
tions.
[54]
Atthesystem
level,thestructures
ofthehe
alth
care
system
areattend
edto
andinclud
estrategies,such
asethn
icity
data
collectionandstrategicplanning
.Ethn
icity
data
collectioncanassistin
theplanning
ofim
provem
entsto
services
bycomparin
gaccess
toservices
andou
tcom
esof
care.
[60]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 9 of 17
Table
3KeyDefinition
sandCon
ceptsof
CulturalSafety
Term
Definition
/Con
cept
Exam
ples
Sources
CulturalSafety
isan
outcom
eof
nursingandmidwifery
educationthat
enablessafe
serviceto
bede
fined
bythosethat
receivetheservice
[30]
afocusforthede
liveryof
quality
care
throug
hchange
sin
thinking
abou
tpo
wer
relatio
nships
andpatients’rig
hts
[32]
Theskillfornu
rses
andmidwives
does
notlie
inknow
ingthecustom
sof
ethn
ospe
cific
cultu
res.Rather,culturalsafetyplaces
anob
ligationon
thenu
rseor
midwife
toprovidecare
with
intheframew
orkof
recogn
izingandrespectin
gthedifferenceof
anyindividu
al.But
itisno
tthenu
rseor
midwife
who
determ
ines
theissueof
safety.It
isconsum
ersor
patientswho
decide
whe
ther
they
feelsafe
with
thecare
that
hasbe
engiven
[32]
Thefocusof
cultu
ralsafetyteaching
isto
educatestud
entnu
rses
andstud
entmidwives:
-to
exam
inetheirow
nrealities
andtheattitud
esthey
bringto
each
new
person
they
encoun
terin
theirpractice;−to
beop
enminde
dandflexiblein
theirattitud
estowardpe
oplewho
aredifferent
from
them
selves,towho
mthey
offeror
delivers-no
tto
blam
ethevictim
sof
historicalandsocialprocessesfortheircurren
tplight;−
toprod
uceaworkforce
ofwelledu
cated,
self-aw
areregistered
nurses
andmidwives
who
arecultu
rally
safe
topractice
[32]
whe
rethereisno
inadverten
tdisempo
weringof
therecipien
t,inde
edwhe
rerecipien
tsareinvolved
inthede
cision
makingandbe
comepartof
ateam
effortto
maxim
isetheeffectiven
essof
thecare.The
mod
elpu
rsuesmoreeffectivepracticethroug
hbe
ingaw
areof
difference,de
colonising
,con
side
ringpo
wer
relatio
nships,
implem
entin
greflectivepractice,andby
allowingthepatient
tode
term
inewhatsafety
means.
[65]
anu
rsewho
couldob
jectivelyevaluate
hisor
herow
ncultu
reandbe
familiar
abou
tthetheo
ryof
power
structures,isalso
acultu
rally
safe
nursein
allcon
texts
[35]
places
anem
phasison
thehe
alth
workerun
derstand
ingtheirow
ncultu
reandiden
tity,andho
wthismanifestsin
theirpractice.Thus,culturalsafetyisconcerne
dwith
both
system
icandindividu
alchange
with
theaim
ofexam
iningprocessesof
iden
tityform
ationanden
hancinghe
alth
workers’awaren
essof
theirow
niden
tityandits
impact
onthecare
they
provideto
peop
lefro
mindige
nous
cultu
ralg
roup
s.
[42]
aimsto
directlyaddresstheeffectsof
colonialism
with
inthedo
minanthe
alth
system
byfocusing
onthelevelo
fcultu
ralsafetyfeltby
anindividu
alseekinghe
alth
care.
Therespon
sibilityto
recogn
izeandprotectape
rson
’scultu
ralide
ntity
(and
hencemaintaintheircultu
ralsafety)lieswith
thehe
alth
service.Em
phasisisplaced
onassistingthehe
alth
workerto
unde
rstand
processesof
iden
tityandcultu
re,and
how
power
imbalances
orrelatio
nships
canbe
cultu
rally
unsafe
(and
thus,d
etrim
entalto
ape
rson
’she
alth
andwellbeing
)
[42]
astrategicandintenselypracticalplan
tochange
theway
healthcare
isde
livered
toAbo
riginalpe
ople.Inparticular,the
concep
tisused
toexpressan
approach
tohe
althcare
that
recogn
izes
thecontem
porary
cond
ition
sof
Abo
riginalpe
oplewhich
resultfro
mtheirpo
st-con
tact
history.
[63]
themovem
entfro
mcultu
ralcom
petenceto
cultu
ralsafetyisno
tmerelyanothe
rstep
onalinearcontinuu
m,b
utrather
amoredram
aticchange
ofapproach.This
concep
tualizationof
cultu
ralsafetyrepresen
tsamoreradical,po
liticized
unde
rstand
ingof
cultu
ralcon
side
ratio
n,effectivelyrejectingthemorelim
itedcultu
rally
compe
tent
approach
foron
ebasedno
ton
know
ledg
ebu
trather
onpo
wer.
[63]
bestnu
rtured
inconjun
ctionwith
othe
rem
bedd
edph
ilosoph
iessuch
asde
colonizatio
n,symbo
licinteractionism
,und
erstanding
socialinteractionin
context,andthe
socialjusticeim
perativeto
avoidfurthe
rharm
from
dominationandop
pression
[47]
(
aconstant
self-evaluatio
nby
aprovider
toen
sure
they’re
focusing
ontheindividu
alandareno
tbe
inginfluen
cedby
assumptions
abou
tthat
individu
al’scultu
ralb
ack-
grou
ndor
socialor
econ
omicstatus…also
helpsalterthecolonialrelatio
nshipandmakes
safe
spaceforIndige
nous
peop
leswith
inthesystem
andthereb
yallowing
them
tohe
lpreshapethesystem
itself
[62]
provides
fortheform
alrecogn
ition
ofpo
wer
relatio
nswith
inhe
alth
care
(and
inparticular
nursing)
interactions.Byadop
tingcultu
ralsafetyitbe
comes
noton
lypo
ssible
butinevitablethat
anexplorationof
theassumptions
unde
rlyingpractice,brou
ghtby
both
individu
alsandtheprofession
willoccur.Thisreflectivemod
eliseffectiveon
theindividu
al,institutionaland
profession
allevels,and
encourages
iden
tificationof
theassumptions
andprecon
ceptions
that
structurepractice
[66]
apo
werfulm
eans
ofconveyingtheidea
that
cultu
ralfactorscritically
influen
cetherelatio
nshipbe
tweencarerandpatient.C
ulturalsafetyfocuseson
thepo
tential
differences
betw
eenhe
alth
providersandpatientsthat
have
anim
pact
oncare
andaimsto
minim
izeanyassaulton
thepatient’scultu
ralide
ntity.Spe
cifically,the
objectives
ofcultu
ralsafetyin
nursingandmidwifery
training
areto
educatestud
entsto
exam
inetheirow
nrealities
andattitud
esthey
bringto
clinicalcare,toed
ucate
them
tobe
open
-minde
dtowards
peop
lewho
aredifferent
from
them
selves,toed
ucatethem
notto
blam
ethevictim
sof
historicalandsocialprocessesfortheircurren
tplight,and
toprod
uceaworkforce
ofwell-edu
catedandself-aw
arehe
alth
profession
alswho
arecultu
rally
safe
topracticeas
defined
bythepe
oplethey
serve.
[46]
does
notem
phasizede
veloping
“com
petence”
throug
hknow
ledg
eabou
tthecultu
reswith
which
profession
alsareworking
.Instead,culturalsafetyem
phasizes
recogn
izingthesocial,historical,p
oliticaland
econ
omiccircum
stancesthat
create
power
differences
andineq
ualitiesin
health
andtheclinicalen
coun
ter
[46]
isun
derpinne
dby
asocialjusticeframew
orkandrequ
iresindividu
alsto
unde
rtakeaprocessof
person
alreflection.Culturalsafetyisthereforeaho
listic
andshared
approach,w
here
allind
ividualsfeelsafe,can
unde
rtakelearning
[36]
toge
ther
with
dign
ity,and
demon
strate
deep
listening
[36]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 10 of 17
Table
3KeyDefinition
sandCon
ceptsof
CulturalSafety(Con
tinued)
Term
Definition
/Con
cept
Exam
ples
Sources
isgrou
nded
incriticalthe
oreticalpe
rspe
ctives
anddraw
sattentionto
critically
oriented
know
ledg
e,such
asracialization,cultu
ralism,institutionalracism
and
discrim
ination,andhe
alth
andhe
alth
care
ineq
uities
[68]
extend
sbe
yond
cultu
ralawaren
ess,sensitivity,and
skills-basedcompe
tenciesandispred
icated
onun
derstand
ingthepo
wer
differentialsinhe
rent
inhe
alth
care
service
deliveryto
redresstheseineq
uitiesthroug
hed
ucationalp
rocesses,focusingon
reflexive
thinking
[70]
isinform
edph
ilosoph
icallyby
“emancipatory
orne
ocolon
isationtheo
reticalpe
rspe
ctives”andby
anem
phasison
socialjustice.Groun
dedin
criticalthe
ory,cultu
ralsafety
invitesthenu
rse
[71]
goes
beyond
describ
ingthepractices
ofothe
rethn
icgrou
ps,b
ecause
such
astrategy
canlead
toachecklistmen
talitythat
essentialises
grou
pmem
bers.Furthermore,a
nursehaving
know
ledg
eof
aclient’scultu
recouldbe
disempo
weringforaclient
who
isdisenfranchisedfro
mtheirow
ncultu
re,and
couldbe
seen
asthecontinuatio
nof
acolonising
processthat
isbo
thde
meaning
anddisempo
weringor
approp
riatin
g.Culturally
safe
nurses
focuson
self-un
derstand
ingandtheem
phasisison
whatatti-
tude
sandvalues
nurses
bringto
theirpractice.Akeytene
tisthat
‘anu
rseor
midwife
who
canun
derstand
hisor
herow
ncultu
reandthetheo
ryof
power
relatio
nscan
becultu
rally
safe
inanycontext’
[60]
advocatesthat
both
profession
alsandinstitu
tions
workto
establishasafe
placeforpatients,which
issensitive
andrespon
sive
totheirsocial,p
olitical,lingu
istic,
econ
omicandspiritualconcerns.C
ulturalsafetyismorethan
anun
derstand
ingof
apatient’sethn
icbackgrou
ndas
itrequ
iresthe‘health
profession
alto
reflect
ontheir
owncultu
ralide
ntity
andon
theirrelativepo
wer
asahe
alth
provider’
[72]
Thecurriculum
staircaseor
poutam
aassumes
that
stud
entsbe
gintheircultu
ralsafetyed
ucationat
thebo
ttom
ofthestaircasewhe
rethey
bringwith
them
their
person
alexpe
riences,kno
wledg
e,andbiases.O
verthene
xt3yearsof
theirtraining
,the
stud
entsareassessed
ontheirability
tomoveto
each
step
.Thistraining
focuses
onracism
awaren
ess,theTreaty
ofWaitang
i,ng
āmea
Māori(con
ceptsim
portantto
Māori),and
strategies
forinstitu
tionalchang
e.Hen
ce,the
educationalp
rocess
involves
movem
entfro
maw
aren
essto
sensitivity,and
ultim
atelyto
safety.
[48]
ween
vision
edthat
cultu
ralsafetymight
assistnu
rses
toexam
ineho
wpo
pularized
notio
nsof
cultu
reandcultu
rald
ifferen
cesaretakenup
;tode
velopgreateraw
aren
ess
ofho
windividu
alandsocietalassumptions
andstereo
type
sop
eratein
practice;andto
better
recogn
izeho
worganizatio
naland
structuralineq
uitiesandwider
social
discou
rses
–with
inhe
alth
care
andin
oursociety–inevitablyinfluen
cenu
rses’interpretivepe
rspe
ctives
andpractices.
[73]
Critical
Con
sciousne
ssIfwetryto
movebe
yond
cultu
ralcom
petencyandinsteadfocuson
thede
velopm
entof
thiscriticalcon
sciousne
ss,w
hatisits
object
ofknow
ledg
e?In
othe
rwords,
“Whatstuffshou
ldwelearn?”Theob
ject
ofknow
ledg
eisno
tjustaseriesof
listsof
cultu
ralattrib
utes
(which
canqu
icklyde
gradeinto
dehu
manizingstereo
type
s),nor
isitaskillsetof
questio
nsandde
meano
ursweshou
ldassumewhe
nen
coun
terin
gapatient
who
isno
tlikeus.W
eprop
osethat
theob
ject
ofknow
ledg
eof
these
educationaleffo
rtsisthede
velopm
entof
criticalcon
sciousne
ssitself,that
is,the
know
ledg
eandaw
aren
essto
carryou
tthesocialrolesandrespon
sibilitiesof
aph
ysician.Thisway
ofknow
ingisadifferent
type
ofknow
ledg
ethan
that
requ
iredwhe
nstud
ying
thebiom
edicalsciences—
complem
entary,b
utdifferent
allthe
same.
[58]
Culturalcom
petencyisno
tan
abdo
minalexam
.Itisno
tastaticrequ
iremen
tto
becheckedoffsomelistbu
tissomething
beyond
thesomew
hatrig
idcatego
riesof
know
ledg
e,skills,andattitud
es:the
continuo
uscriticalrefinem
entandfosteringof
atype
ofthinking
andknow
ing—
acriticalcon
sciousne
ss—
ofself,othe
rs,and
the
world.
[58]
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 11 of 17
esteem, who seek to add to the knowledge base of cul-turally competent practice by conducting research anddeveloping new therapeutic approaches based on cul-ture). Other points along this continuum include: cul-tural incapacity, cultural blindness and cultural pre-competence (Table 1).By the time that cultural competency became to be
better understood in the late 1990s, there had beensubstantial growth in the number of definitions, con-ceptual frameworks and related terms [31, 50–52].Table 1 provides a summary of the multiple, inter-changeable, terms such as: cultural awareness; cul-tural sensitivity; cultural humility; cultural security;cultural respect; cultural adaptation; and transculturalcompetence or effectiveness. Unfortunately, this rapidgrowth in terminology and theoretical positioning(s),further confused by variations in policy uptake acrossthe health sector, reduced the potential for a com-mon, shared understanding of what cultural compe-tency represents and therefore what interventions arerequired. Table 2 outlines the various definitions ofcultural competency from the literature.Cultural competence was often defined within an
individually-focused framework, for example, as:
the ability of individuals to establish effectiveinterpersonal and working relationships that supersedecultural differences by recognizing the importance ofsocial and cultural influences on patients, consideringhow these factors interact, and devising interventionsthat take these issues into account [53] (p.2).
Some positionings for cultural competency have beencritiqued for promoting the notion that health-care pro-fessionals should strive to (or even can) master a certainlevel of functioning, knowledge and understanding of In-digenous culture [61]. Cultural competency is limitedwhen it focuses on acquiring knowledge, skills and atti-tudes as this infers that it is a ‘static’ level of achieve-ment [58]:
“cultural competency” is frequently approached inways which limit its goals to knowledge ofcharacteristics, cultural beliefs, and practices ofdifferent nonmajority groups, and skills and attitudesof empathy and compassion in interviewing andcommunicating with nonmajority groups. Achievingcultural competence is thus often viewed as a staticoutcome: One is “competent” in interacting withpatients from diverse backgrounds much in the sameway as one is competent in performing a physicalexam or reading an EKG. Cultural competency is notan abdominal exam. It is not a static requirement tobe checked off some list but is something beyond the
somewhat rigid categories of knowledge, skills, andattitudes (p.783).
By the early 2000s, governmental policies and culturalcompetency experts [50, 54] had begun to articulate cul-tural competency in terms of both individual andorganizational interventions, and describe it with abroader, systems-level focus, e.g.:
the ability of systems to provide care to patients withdiverse values, beliefs and behaviours, includingtailoring delivery to meet patients’ social, cultural, andlinguistic needs [54] (p. v).
Moreover, some commentators began to articulate theimportance of critical reflection to cultural competency.For example, Garneau and Pepin [55] align themselvesmore closely to the notion of cultural safety when theydescribe cultural competency as:
a complex know-act grounded in critical reflection andaction, which the health care professional draws uponto provide culturally safe, congruent, and effective carein partnership with individuals, families, and commu-nities living health experiences, and which takes intoaccount the social and political dimensions of care[55] (p. 12).
Reviewing cultural safetyA key difference between the concepts of cultural com-petency and cultural safety is the notion of ‘power’.There is a large body of work, developed over manyyears, describing the nuances of the two terms [34, 36,38, 43, 46, 49, 59, 62–69]. Similar to cultural compe-tency, this concept has varying interpretations withinand between countries. Table 3 summarises the defini-tions and use of cultural safety from the literature. Cul-tural safety foregrounds power differentials withinsociety, the requirement for health professionals to re-flect on interpersonal power differences (their own andthat of the patient), and how the transfer of powerwithin multiple contexts can facilitate appropriate carefor Indigenous people and arguably for all patients [32].The term cultural safety first was first proposed by
Dr. Irihapeti Ramsden and Māori nurses in the1990s [74], and in 1992 the Nursing Council of NewZealand made cultural safety a requirement for nurs-ing and midwifery education [32]. Cultural safetywas described as providing:
a focus for the delivery of quality care through changesin thinking about power relationships and patients’rights [32]. (p.493).
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Cultural safety is about acknowledging the barriers toclinical effectiveness arising from the inherent power im-balance between provider and patient [65]. This conceptrejects the notion that health providers should focus onlearning cultural customs of different ethnic groups. In-stead, cultural safety seeks to achieve better care throughbeing aware of difference, decolonising, consideringpower relationships, implementing reflective practice,and by allowing the patient to determine whether a clin-ical encounter is safe [32, 65].Cultural safety requires health practitioners to examine
themselves and the potential impact of their own cultureon clinical interactions. This requires health providers toquestion their own biases, attitudes, assumptions, stereo-types and prejudices that may be contributing to a lowerquality of healthcare for some patients. In contrast to cul-tural competency, the focus of cultural safety moves to theculture of the clinician or the clinical environment ratherthan the culture of the ‘exotic other’ patient.There is debate over whether cultural safety reflects an
end point along a continuum of cultural competency de-velopment, or, whether cultural safety requires a para-digm shift associated with a transformational jump incultural awareness. Dr. Irihapeti Ramsden [75] originallydescribed the process towards achieving cultural safetyin nursing and midwifery practice as a step-wise pro-gression from cultural awareness through to culturalsensitivity and on to cultural safety. However, Ramsdenwas clear that the terms cultural awareness and culturalsensitivity were separate concepts and that they werenot interchangeable with cultural safety. Despite someauthors interpreting Ramsden’s original description ofcultural safety as involving three steps along a con-tinuum [35] other authors view a move to cultural safetyas more of a ‘paradigm shift’ [63]:
where the movement from cultural competence tocultural safety is not merely another step on a linearcontinuum, but rather a more dramatic change ofapproach. This conceptualization of cultural safetyrepresents a more radical, politicized understanding ofcultural consideration, effectively rejecting the morelimited culturally competent approach for one basednot on knowledge but rather on power [63]. (p.10).
Regardless of whether cultural safety represents move-ment along a continuum or a paradigm shift, commenta-tors are clear that the concept of cultural safety alignswith critical theory, where health providers are invitedto “examine sources of repression, social domination,and structural variables such as class and power” [71](p.144) and “social justice, equity and respect” [76] (p.1).This requires a movement to critical consciousness, in-volving critical self-reflection: “a stepping back to
understand one’s own assumptions, biases, and values,and a shifting of one’s gaze from self to others and condi-tions of injustice in the world.” [58] (p.783).
Why a narrow understanding of culturalcompetency may be harmfulUnfortunately, regulatory and educational health organisa-tions have tended to frame their understanding of culturalcompetency towards individualised rather than organisa-tional/systemic processes, and on the acquisition ofcultural-knowledge rather than reflective self-assessmentof power, priviledge and biases. There are a number ofreasons why this approach can be harmful and undermineprogress on reducing health inequities.Individual-level focused positionings for cultural compe-
tency perpetuate a process of “othering”, that identifies thosethat are thought to be different from oneself or the dominantculture. The consequences for persons who experienceothering include alienation, marginalization, decreased op-portunities, internalized oppression, and exclusion [77]. Tofoster safe and effective health care interactions, those inpower must actively seek to unmask othering practices [78].“Other-focused” approaches to cultural competency
promote oversimplified understandings of other culturesbased on cultural stereotypes, including a tendency tohomogenise Indigenous people into a collective ‘they’[79]. This type of cultural essentialism not only leads tohealth care providers making erroneous assumptionsabout individual patients which may undermine theprovision of good quality care [31, 53, 58, 63, 64], butalso reinforces a racialised, binary discourse, used to re-peatedly dislocate and destabilise Indigenous identityformations [80]. By ignoring power, narrow approachesto cultural competency perpetuate deficit discourses thatplace responsibility for problems with the affected indi-viduals or communities [81], overlooking the role of thehealth professional, the health care system and broadersocio-economic structures. Inequities in access to the so-cial determinants of health have their foundations in co-lonial histories and subsequent imbalances in power thathave consistently benefited some over others. Healthequity simply cannot be achieved without acknowledgingand addressing differential power, in the healthcareinteraction, and in the broader health system and socialstructures (including in decision making and resource al-location) [82].An approach to cultural competency that focuses on
acquiring knowledge, skills and attitudes is problematicbecause it suggests that competency can be fullyachieved through this static process [58]. Cultural com-petency does not have an endpoint, and a “tick-box” ap-proach may well lull practitioners into a falsely confidentspace. These dangers underscore the importance offraming cultural safety as an ongoing and reflective
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process, focused on ‘critical consciousness’. There willstill be a need for health professionals to have a degreeof knowledge and understanding of other cultures, butthis should not be confused with or presented as effortsto address cultural safety. Indeed, as discussed above,this information alone can be dangerous without deepself-reflection about how power and privilege have beenredistributed during those processes and the implica-tions for our systems and practice.By neglecting the organisational/systemic drivers of
health care inequities, individual-level focused posi-tionings for cultural competency are fundementallylimited in their ability to impact on health inequities.Healthcare organisations influence health providerbias through the structure of the healthcare environ-ment, including factors such as their commitment toworkforce training, accountability for equity, work-place stressors, and diversity in workforce and gov-ernance [27]. Working towards cultural safety shouldnot be viewed as an intervention purely at the levelof the health professional – although a critically con-scious and empathetic health professional is certainlyimportant. The evidence clearly emphasises the im-portant role that healthcare organisations (and societyat large) can have in the creation of culturally safeenvironments [31, 32, 46, 60, 69]. Cultural safety ini-tiatives therefore should target both individual healthprofessionals and health professional organisations tointervene positively towards achieving health equity.Perhaps not surprisingly, the concept of cultural safety
is often more confronting and challenging for health in-stitutions, professionals, and students than that of cul-tural competency. Regardless, it has become increasinglyclear that health practitioners, healthcare organisationsand health systems all need to be engaged in working to-wards cultural safety and critical consciousness. To dothis, they must be prepared to critique the ‘taken forgranted’ power structures and be prepared to challengetheir own culture, biases, privilege and power ratherthan attempt to become ‘competent’ in the cultures ofothers.
Redefining cultural safety to achieve healthequityIt is clear from reviewing the current evidence associatedwith cultural competency and cultural safety that a shift inapproach is required. We recommend an approach to cul-tural safety that encompasses the following core principles:
� Be clearly focused on achieving health equity, withmeasureable progress towards this endpoint;
� Be centred on clarified concepts of cultural safetyand critical consciousness rather than narrow basednotions of cultural competency;
� Be focused on the application of cultural safetywithin a healthcare systemic/organizational contextin addition to the individual health provider-patientinterface;
� Focus on cultural safety activities that extendbeyond acquiring knowledge about ‘other cultures’and developing appropriate skills and attitudes andmove to interventions that acknowledge and addressbiases and stereotypes;
� Promote the framing of cultural safety as requiring afocus on power relationships and inequities withinhealth care interactions that reflect historical andsocial dynamics.
� Not be limited to formal training curricula but bealigned across all training/practice environments,systems, structures, and policies.
We recommend that the following definition for cul-tural safety is adopted by healthcare organisations:
“Cultural safety requires healthcare professionals andtheir associated healthcare organisations to examinethemselves and the potential impact of their own cultureon clinical interactions and healthcare service delivery.This requires individual healthcare professionals andhealthcare organisations to acknowledge and addresstheir own biases, attitudes, assumptions, stereotypes,prejudices, structures and characteristics that may affectthe quality of care provided. In doing so, cultural safetyencompasses a critical consciousness wherehealthcare professionals and healthcareorganisations engage in ongoing self-reflection andself-awareness and hold themselves accountable forproviding culturally safe care, as defined by the pa-tient and their communities, and as measuredthrough progress towards acheiveing health equity.Cultural safety requires healthcare professionals andtheir associated healthcare organisations to influ-ence healthcare to reduce bias and achieve equitywithin the workforce and working environment”.
In operationalising this approach to cultural safety, or-ganisations (health professional training bodies, health-care organisations etc) should begin with a self-review ofthe extent to which they meet expectations of culturalsafety at a systemic and organizational level and identifyan action plan for development. The following stepsshould also be considered by healthcare organisationsand regulators to take a more comprehensive approachto cultural safety:
� Mandate evidence of engagement andtransformation in cultural safety activities as a partof vocational training and professional development;
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� Include evidence of cultural safety (of organisationsand practitioners) as a requirement for accreditationand ongoing certification;
� Ensure that cultural safety is assessed by thesystematic monitoring and assessment of inequities(in health workforce and health outcomes);
� Require cultural safety training and performancemonitoring for staff, supervisors and assessors;
� Acknowledge that cultural safety is an independentrequirement that relates to, but is not restricted to,expectations for competency in ethnic or Indigenoushealth.
ConclusionCultural competency, cultural safety and related termshave been variably defined and applied. Unfortunately,regulatory and educational health organisations havetended to frame their understanding of culturalcompetency towards individualised rather thanorganisational/systemic processes, and on the acquisi-tion of cultural-knowledge rather than reflective self-assessment of power, priviledge and biases. This posi-tioning has limited the impact on improving healthinequities. A shift is required to an approach basedon a transformative concept of cultural safety, whichinvolves a critique of power imbalances and criticalself-reflection.Health practitioners, healthcare organisations and
health systems need to be engaged in working to-wards cultural safety and critical consciousness. Todo this, they must be prepared to critique the ‘takenfor granted’ power structures and be prepared tochallenge their own culture and cultural systems ra-ther than prioritise becoming ‘competent’ in the cul-tures of others. The objective of cultural safetyactivities also needs to be clearly linked to achievinghealth equity. Healthcare organisations and authoritiesneed to be held accountable for providing culturallysafe care, as defined by patients and their communi-ties, and as measured through progress towardsachieving health equity.We propose principles and a definition for cultural
safety that addresses the key factors identified as be-ing responsible for ethnic inequities in health care,and which we therefore believe is fit for purpose inAotearoa New Zealand and internationally. We hopethis will be a useful starting point for users to furtherreflect on the work required for themselves, and theirorganisations, to contribute to the creation ofculturally safe environments and therefore to theelimination of Indigenous and ethnic health inequities.More work is needed on how best to train andmonitor for cultural safety within health workforcecontexts.
Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12939-019-1082-3.
Additional file 1: Table S1. Summary of evidence sources identifiedfrom the literature review.
AbbreviationsLIME: Leaders in Indigenous Medical Education network; MCNZ: MedicalCouncil of New Zealand; NZ: Aotearoa New Zealand; Te ORA: Te Ohu Rata oAotearoa – Māori Medical Practitioners Association
AcknowledgementsBJ Wilson (for undertaking the original literature searching), Matire Harwood(for early oversight of the literature review searching undertaken by BJWilson), Te ORA members who reviewed the original Te ORA contract report.
Authors’ contributionsEC led the overall manuscript design and development, reviewed andanalysed the literature on the concepts of cultural competency and culturalsafety and drafted the Introduction, Methods and Positioning, ReviewingCultural Competency, Reviewing Cultural Safety (and associated tables) andRedefining Cultural Safety to Achieving Health Equity sections within themanuscript. RJ provided background cultural safety expertise, reviewed theoriginal Te ORA contract work and reviewed the manuscript design/development and contributed to draft manuscripts. DTL providedbackground cultural safety expertise and leadership of the Te ORA contractwork that led to this manuscript, reviewed the manuscript design/development and contributed to draft manuscripts. CW providedbackground cultural safety expertise and leadership of the MCNZ and TeORA contract work that led to this manuscript, reviewed the manuscriptdesign/development and contributed to draft manuscripts. BL reviewed themanuscript design/development and contributed to draft manuscripts withspecific input provided for the Abstract, Why a Narrow Understanding ofCultural Competency May Be Harmful and Conclusion sections of themanuscript. SJP provided supervision of the literature review design andanalysis, reviewed the manuscript design/development and contributed todraft manuscripts. PR provided background cultural safety expertise,reviewed the original Te ORA contract work and reviewed the manuscriptdesign/development and contributed to draft manuscripts. All authors readand approved the final manuscript.
FundingSome of the data sources used to inform this article were funded via aMCNZ contract with Te ORA (i.e. literature review, symposium and review ofMCNZ resources). Both the MCNZ and Te ORA pre-agreed to allow thesubmission of internal contractual work outputs to peer-reviewed journals.
Availability of data and materialsNot applicable.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Author details1Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New Zealand. 2Faculty of Education,Humanities and Health Sciences, Eastern Institute of Technology, Napier,New Zealand. 3Te Kaunihera Rata of Aotearoa, Medical Council of NewZealand, Wellington, New Zealand.
Curtis et al. International Journal for Equity in Health (2019) 18:174 Page 15 of 17
Received: 21 June 2019 Accepted: 31 October 2019
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