Cultural Safety

Introduction

In Canada, Brian Sinclair’s tragic death in 2008 has been a turning point in the conversation on racism, discrimination, racial/cultural profiling and how they impact access to and delivery of care.

It’s been almost six years [in the fall of 2008] since Brian Sinclair wheeled himself into the emergency room at Winnipeg’s Health Sciences Centre seeking treatment for a blocked catheter. Thirty-four hours later staff checked on the Aboriginal amputee. Some had assumed Sinclair was just drunk or homeless. By that time, he was dead.

The final report of the inquest into Sinclair’s death is expected soon. But presenters at Canada’s first Indigenous Health Conference were dismayed that it will focus exclusively on patient flow.

“There was a level of profiling and stereotyping that had to happen in order for a physically disabled man to languish and die in full public view and surrounded by health professionals,” said Vanessa Ambtman-Smith, Aboriginal health lead for Ontario’s South West Local Health Integration Network (LHIN). “We won’t have an opportunity to further pursue some of that underlying racism.”

Too often in health care the r-word “gets couched in terms of stereotypes, bias, discrimination and health inequities,” she said. “This is what it looks like when the system is failing; this is an example of an environment that is not culturally safe.”

(Vogel, L., 2015; parentheses inserted, emphases added) 

What is cultural safety?

Cultural safety in providing care (in any helping/compassionate profession) involves an understanding of the inequities that can adversely affect access to care, such as, for example, the persistent effects of colonization and of systemic racism and discrimination[1] (Browne et al., 2016; Curtis et al., 2019; First Nations Health Authority, 2016, 2019; Hart-Wasekeesikaw, 2015; Ramsden, 2002; Vogel, 2015). The concept, which directs service providers to don an equity lens in their work, has emerged from the domain of nursing and Indigenous health care in New Zealand, from the work of Dr Irihapeti Ramsden (2002).

Cultural safety, one might aver, melds intersectionality with the provision of care. Dr Ramsden’s work called on healthcare providers to contemplate and respond to the reality that patient needs are shaped by  social positioning and by the effect of marginalization and discrimination (e.g. of their gender, class and cultural identities).

Culturally safe approaches are those that recognize and challenge unequal power relations between service providers and survivors. Cultural safety requires as a starting step cultural humility, which is based on humble self-reflexive acknowledgement of ongoing learning in understanding a person’s experience. For a service provider, cultural safety training is designed to help them to check their biases, understand how discrimination shapes service uptake, and address power imbalances in provider-client exchanges. This implies also that it is important to recognize and foster strengths, but not to valorize individual autonomy and the strength-based approach to the point that one loses sight of the challenges confronting those in need.

Cultural safety is not cultural competence/awareness/sensitivity 

Do service providers know the term ‘cultural safety’  – never mind understanding what it means? Do they get that cultural safety has nothing to do with cultural competence or awareness? That it means understanding the dynamics, mechanics and forensics of power in giving and receiving service? Do they understand  – or intuit – that culturally safe service means paying attention to the structural inequities that afflict distressed clients, and not dwelling on the superficial cosmetic detail of everyday cultural practice?

Yes and no. It’s complicated.

In a recently completed needs assessment of the home visitation sector, we found that very few home visitors (HVs) were familiar with the term ‘cultural safety’ (Curtis et al., 2019) although several observed its basic principles in practice. All too often, when we asked about their understanding of the term, the responses were couched in terms of ‘cultural competence’ or ‘cultural awareness’ along with requests for workshops pertaining to cultural competence.

The thing is: that last workshop on cultural sensitivity might have got us all up to speed (sort of) on cultural minutiae (which interest crisis-drowned clients not at all) – but, really, that’s sizzle, not substance.

There is a definite need for workshops, co-designed with diverse trainers, to address the lack of structured understanding of cultural safety (and of its focus on the factors that shape equity, privilege, and access to various forms of care and service). Even the attendance of some staff at a few workshops may well have a positive trickle-down effect at agencies via orientation, mentoring and on-the-job shadowing. Structured training in the meaning and applications of cultural safety would allow service providers to gain and share knowledge forward in their professional networks; in other words, these workshops should have a ‘train the trainer’ approach.

On the positive side, though, most of the service providers that my team-members and I spoke with in 2019 (and also earlier in 2016) evinced a practice-based (if hazy) sense of the spirit, meaning and import of cultural safety, even if they had never heard the term before. They might not know the terminology (admittedly confusing!) but they do understand that there is a radical difference between attention to surface detail and deep understanding of their client’s complex challenges.

HVs also emphasized the importance of active listening and simple, relatable language in creating and sustaining relationships. Communication (verbal and non-verbal) should mindfully avoid trauma triggers, stereotypes, condescension and complex grammar and vocabulary. Participants consistently emphasized the value of a non-judgmental and strength-based approach; the importance of discarding a ‘deficit’ based approach to screening or interacting with clients; their efforts to promote the self efficacy of clients. While they described the challenges (e.g. unemployment, emotional fragility, stress, lack of finances, isolation) of diverse women served by their agencies, they were emphatic about the need to be respectful to their clients and avoid framing their clients as needy or weak, as victims.

HVs recognized that seeking help against violence may be acutely uncomfortable, intimidating and shameful for women, especially those struggling with multiple barriers and intersectional challenges. In that context, they felt that it is important for them to enhance their clients’ sense of self efficacy and agency, and not to goad or lecture them in any way. They were aware that women’s sense of agency is often eroded by abusers. Command mode advice from the HV would only deepen the effect of abuse and immediately or eventually wreck the HV-client relationship.

As you mentioned that, we are to see what she is looking for. It’s not that I have to be like okay, this is a very difficult situation and you need to get rid of it. No, it’s not my point of view. It is her, the lady, the client, mom, what does she want. Being very mindful about that. [Focus Group, Calgary]

HVs serving diverse immigrant-refugee (IR) populations described their observance of cultural safety in connecting with clients in their residential locales. Many IR families live in small culturally cohesive and homogeneous enclaves where opinion and gossip are powerful social controls (to the extent that they impact arrangement of marriages, work and social relationships, both in Canada and overseas). Help seeking to meet economic need (e.g. food bank, welfare cheques) or to find support against family violence can attract stigma and censure (not to mention that the seeker faces fresh violence if detected in the effort). In these contexts, HVs have to be cognizant of the concerns of the mothers they visit, e.g. meeting them at a café or other public location.

Service provider (SP)4: Of course, there’s lot of stigma seeking any resources in the community. If you’re going to a food bank that means you’re poor, if you’re going to counseling that means you have mental health, if you’re going to our low income places that means – so there’s always stigma. There’s always stigma going to access resources, there’s always a stigma accessing these resources. So we have to refer to them these resources and make them comfortable and then make them realize they’re there for your help, they’re there for you to stand on your feet. Sometime now you can use them and then later on you can give it back to the community.

Interviewer: It’s especially important I think because many not everywhere but many immigrants tend to live in cultural islands so everyone knows everyone to some extent.

SP4: Yes, of course.

Interviewer: So literally who sees us, who hears us becomes a powerful presence, am I right?

SP4: Of course, it does. Because when I came to Canada 20 years ago and I used to take the bus and people used to stop, you know what, you’re standing at the bus station, is everything okay. Yes, everything is okay, what do you mean. I’m taking the bus. So they think this is accessing ETS [Edmonton Transit Service] what’s the big deal. Even I had the car at that point. Oh, you have a car but you’re still standing here, yes, I can use ETS, what’s the big deal. Oh, poor woman, she’s trying to save money. No, I WANT to take ETS…. So there’s so much stigma to access these resources. So you have to be really gentle and offering them resources and suggesting resources to them. I’m working with a family violence situation and I’m the home visitor for the family. The daughter is turning 16, right, so the mother doesn’t want me to come to her home because the neighbors would see a stranger is coming and then it will create a problem for the girl to get a marriage proposal in the community. So we’re in the community, she’s open to meet with me but not in the home because the neighbor can see. You know, this lady comes to meet you every week, she’s not your family, she’s not your friend, then why is she coming, what is going on. So she’s so scared for her daughter that she might not find a good match in the community if a stranger is coming because her mom is accessing resources, external resources. So I meet in the community, we go to [PLACE] we go out for lunch, we meet in the library. And then she needs help, she acknowledges that she needs help. She benefits from my meeting sessions but not in the home. [Interview, Edmonton, SP4].

In 2016 conversations with anti-violence service providers, I heard that notions and practices of cultural competency are needed to ensure psychosocial comfort, sense of acceptance, and the retention of the clients. But it is not enough to stop with these arrangements, e.g. furnishing shelter kitchens with the right spices, or making them consonant with specific food laws is beneficial, but not sufficient. It is just as, if not more, important to understand the intersecting challenges faced by clients, for example, the complex dimensions of immigration related abuse and vulnerability. It is important for service providers not to adopt a subtle condescension to immigrant help-seekers as crushed, dominated, inarticulate, confused, and largely or wholly dependent on the service agency. In other words, service should be tied to understanding the factors that create the vulnerability of those who seek help.

SP 13: What I see from women that come to our shelter is that you know we provide transportation services, we have [Inaudible 00:24:08] right. We have diverse relation of women providing the service, right. We accommodate their needs in terms of you know food or whatever but you know this is beyond just having you know different spices in the cupboard. This is not a policy that addresses cultural diversity, no. I mean that is just part of what you do because it makes women feel more comfortable and because they need it. It is no different than a woman who would come to us and say, “I have allergies and I can’t have this.”  Now what I think is important for us is that we have an understanding that women who come with languages issues or immigration issues they need to be helped more so they need more work done with them because they are more isolated. It is more difficult to get them out. There are dealing with more barriers and there is complexities in their stories including making sure that their families overseas are safe. So to us that is where the culturally aware competence is about, right. It is not just about you know making sure what they can cook. No it is about providing her and giving her the understanding that we understand that you are at a disadvantage with all these complexities and therefore you need more time to move forward. So often women who are having all those issues will have more time in terms of their ability to stay in the shelter. [Interview, Edmonton, SP13, 2016] (Mishra, 2016, p 71).

In conclusion

Cultural safety is radically different from the relatively static cultural awareness of differences between cultures, cultural sensitivity in acknowledging such differences in provision of care, and cultural competency, which focuses on the acquisition of cultural know-how about specific practices (Curtis et al., 2019; Shepherd, 2019).

Cultural safety is a dynamic process, not a fixed state of matters that can be rated using a checklist of attributes.

It is not up to the service provider to say if they have demonstrated cultural safety in their delivery of care. Rather, it is the right of the service recipients to say if they have felt respected, included, and safe, with a due consideration of their strengths, needs and challenges.

The application of the lens of cultural safety to service design and delivery can assist the creation of a space free of subtle and covert micro-aggressions. Cultural safety requires, first, the recognition that social structures and spaces have been historically constructed in a way that promotes systemic racism, whereby marginalized and disenfranchised persons have their identities questioned, appearances judged, and modes of expression silenced or invalidated (Greenwood & De Leeuw, 2012). This recognition is a prerequisite for the re-imagination and reconstruction of spaces, protocols, interactions and delivery of service[2].

Notes

[1]““It’s the first session in a therapeutic relationship. Susan, an Indigenous client, has just shared a story about her history, her experience at a residential school and what she has faced as part of a lifelong reality of colonial violence and racism. The practitioner interrupts and says, “That was in the past. You really need to move on. I will allow you to talk about it this session, but going forward, I don’t want to hear anything else about the past.” This fictional anecdote reflects a common narrative about Indigenous people—that colonization is in the past and Indigenous people need to move on. This narrative and others are prevalent in the health care system, and Indigenous people experience harm on a regular basis as a result of them. For example, the idea that Indigenous people are ‘stuck’ in the past can lead to the stereotype that Indigenous people are unwilling or unable to ‘get better.’ This stereotype can foster prejudice, such as the feeling that treating Indigenous people is a ‘waste of time,’ which can result in discriminatory treatment, such as Indigenous people receiving a reduced quality of care. Being aware of how these narratives lead to stereotypes, and then to prejudice and discrimination—and harm—is an important step in fostering a safer and more effective health care system. This awareness is part of the journey towards increased cultural safety and increased equity in health and health care” (Ward, Branch, Fridkin, 2016: 29).

[2] Oster et al. (2016) conducted an ethnographic, community-based participatory research study of the perceptions and experiences of Cree mothers in their interactions with providers of prenatal healthcare in Alberta. The study found that “Cultural understanding encompassed not just an appreciation and grasp of cultural practices, but also knowledge of the ongoing impacts of colonization, and the vulnerability and numerous challenges some patients may encounter: residential school legacy, racism, historical trauma, cultural loss, addictions, family violence, mental health issues, diabetes, crowded homes, food insecurity, poverty, poor support, limited opportunities, and lack of reliable transportation to name a few. Subsequently, HCPs were better able to understand why some First Nations women missed appointments (which was consistently cited as the most important barrier to prenatal care), as one participant described: “When you’re dealing with all those social determinants of health, then attending appointments is not a priority. And I don’t think it should be a priority either” (Oster et al., 2016: page 5 of 9).

References

Browne, A. J., Varcoe, C., Lavoie, J., Smye, V., Wong, S. T., Krause, M., … Fridkin, A. (2016). Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Services Research, 16(1), 1–17. https://doi.org/10.1186/s12913-016-1707-9

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), 1–17. https://doi.org/10.1186/s12939-019-1082-3

First Nations Health Authority. (2016). FNHA’s Policy Statement on Cultural Safety and Humility. 24. Retrieved from http://www.fnha.ca/Documents/FNHA-Policy-Statement-Cultural-Safety-and-Humility.pdf

First Nations Health Authority. (2019). #itstartswithme: Cultural Safety and Humility Key Drivers and Ideas for Change. Retrieved from https://www.fnha.ca/Documents/FNHA-Cultural-Safety-and-Humility-Key-Drivers-and-Ideas-for-Change.pdf

Greenwood, M. L., & De Leeuw, S. N. (2012). Social determinants of health and the future well-being of Aboriginal children in Canada. Paediatrics and Child Health (Canada), 17(7), 381–384. https://doi.org/10.1093/pch/17.7.381

Hart-Wasekeesikaw, F. (2015). Cultural Competence and Cultural Safety in Nursing Education A FRAMEWORK FOR FIRST NATIONS, INUIT AND MẾTIS NURSING (Vol. 3). Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/first_nations_framework_e.pdf

Mishra, A. (2016). Working in Partnership to End Violence Against Women and Girls: Honour’ based violence and related service needs, gaps and solutions in Edmonton, 2015-2016. Retrieved from https://icwaedmonton.org/wp-content/uploads/2020/03/Working-in-patnership-to-end-violence-against-women-and-girls.pdf

Oster, R. T., Bruno, G., Montour, M., Roasting, M., Lightning, R., Rain, P., … Bell, R. C. (2016). Kikiskawâwasow – prenatal healthcare provider perceptions of effective care for First Nations women: An ethnographic community-based participatory research study. BMC Pregnancy and Childbirth, 16(1). https://doi.org/10.1186/s12884-016-1013-x

Ramsden, I. M. (2002). Cultural Safety and Nursing Education in Aotearoa and Te Wai Pounamu (Victoria University of Wellington). Retrieved from http://www.nzno.org.nz/Portals/0/Files/Documents/Services/Library/2002 RAMSDEN I Cultural Safety_Full.pdf

Shepherd, S. M. (2019, January 8). Cultural awareness workshops: Limitations and practical consequences 17 Psychology and Cognitive Sciences 1701 Psychology 11 Medical and Health Sciences 1117 Public Health and Health Services. BMC Medical Education, Vol. 19. https://doi.org/10.1186/s12909-018-1450-5

Vogel, L. (2015). Is your hospital culturally safe? CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 187(1), E13. https://doi.org/10.1503/cmaj.109-4953

Ward, C., Branch, C., & Fridkin, A. (2016). What Is Indigenous Cultural Safety—and Why Should I Care About It? Visions, 11(4), 7. Retrieved from https://www.heretohelp.bc.ca/sites/default/files/visions-indigenous-people-vol11.pdf

One thought on “Cultural Safety

  1. Pingback: How healthcare providers can support women coping with violence | Working In Partnership Against Gender-based Violence

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