Cultural Safety Principles Research Articles

The emergence of cultural safety within kidney care for Indigenous Peoples in Australia.

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and community viewed as potential barriers to patient 'compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid-1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Māori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care.

“The most culturally safe training I’ve ever had”: the co-design of a culturally safe Managing hepatitis B training course with and for the Aboriginal health workforce of the Northern Territory of Australia

BackgroundThe Aboriginal health workforce provide responsive, culturally safe health care. We aimed to co-design a culturally safe course with and for the Aboriginal health workforce. We describe the factors which led to the successful co-design, delivery, and evaluation of the “Managing hepatitis B” course for the Aboriginal health workforce.MethodsA Participatory Action Research approach was used, involving ongoing consultation to iteratively co-design and then develop course content, materials, and evaluation tools. An Aboriginal and Torres Strait Islander research and teaching team received education in chronic hepatitis B and teaching methodologies. Pilot courses were held, in remote communities of the Northern Territory, using two-way learning and teach-back methods to further develop the course and assess acceptability and learnings. Data collection involved focus group discussions, in-class observations, reflective analysis, and use of co-designed and assessed evaluation tools.ResultsTwenty-six participants attended the pilot courses. Aboriginal and Torres Strait Islander facilitators delivered a high proportion of the course. Evaluations demonstrated high course acceptability, cultural safety, and learnings. Key elements contributing to success and acceptability were acknowledging, respecting, and integrating cultural differences into education, delivering messaging and key concepts through an Aboriginal and Torres Strait Islander lens, using culturally appropriate approaches to learning including storytelling and visual teaching methodologies. Evaluation of culturally safe frameworks and findings from the co-design process led to the creation of a conceptual framework, underpinned by meeting people’s basic needs, and offering a safe and comfortable environment to enable productive learning with attention to the following: sustenance, financial security, cultural obligations, and gender and kinship relationships.ConclusionsCo-designed education for the Aboriginal health workforce must embed principles of cultural safety and meaningful community consultation to enable an increase in knowledge and empowerment. The findings of this research can be used to guide the design of future health education for First Nations health professionals and to other non-dominant cultures. The course model has been successfully transferred to other health issues in the Northern Territory.

Teaching cultural safety principles: optometry student perceptions

ABSTRACT Clinical relevance Providing optometry learners with cultural safety training can improve patient safety and health outcomes among Indigenous Peoples. Background Healthcare practitioners require cultural safety training to provide safe eye care to Indigenous Peoples in Canada. Culturally safe care requires optometrists to critically reflect upon their unconscious biases and power differences that impact patient care. Informed by the cultural safety literature and working directly with learners, revisions were made to first and second-year optometry clinic experience courses in a Canadian Doctor of Optometry program. This descriptive study examined student feedback on curricular changes, focused on enhancing cultural safety. Methods An 8-item, anonymous, online survey was offered to all learners (n = 178) enrolled in clinic experience courses at in fall 2021 and winter 2022. The survey addressed student understanding of cultural safety, comfort with self-reflective activities, and course effectiveness in teaching patient-centred care. Six items used a 5-point Likert response scale. Descriptive statistics were analyzed (Wilcoxon and Wilcoxon-Pratt). Two open-ended items were analysed using content analysis for themes. Results Thirty-three surveys were completed. Overall respondents found the clinic experience courses provided effective training in cultural safety and were of professional value. Comfort engaging in self-reflective activities increased (before: mean response 4.0; after: 4.4), and students made connections with societal problems (overall mean 3.5) and with bias/power differential (overall mean 4.0). Suggested changes to support the learning objectives included increased clinic observation, scaffolding these topics in additional courses, and adding relevant literature (e.g. anti-racism) and guest speakers with Indigenous knowledge and experience. Conclusion Optometry learners were favourable about the inclusion of cultural safety concepts in their clinic experience courses. Their feedback points to areas for improvement including deepening course content, and collaborating with Indigenous Peoples in content, course design, and cross-curricular scaffolding.

Using cultural safety to enhance nursing care for children and young people.

People from minority groups frequently experience adversity in various aspects of their lives, including when accessing healthcare services. Culture has a significant role in all healthcare encounters between nurses, multidisciplinary teams, and children and young people and their families. This article defines culture and explains the importance of considering people's cultural values, beliefs and practices when providing care. It outlines the principles of cultural safety - an approach that incorporates ideas such as cultural awareness, sensitivity and competence - and describes how it can enhance the care of children and young people from a wide range of backgrounds.

Guidance relevant to the reporting of health equity in observational research: a scoping review protocol

IntroductionHealth inequities are defined as unfair and avoidable differences in health between groups within a population. Most health research is conducted through observational studies, which are able to offer real-world...

Abstract P119: Conceptualizing Cultural Safety When Implementing A Community Based Substance Use Intervention Study Among Urban Native American Youth

Background: This study was conducted in the United States of America among Urban Native American (NA) youth attending two urban NA youth programs within the State of Florida. Aim: To culturally tailor the evidence-based Lowe (2016) Keetoowah-Cherokee Talking Circle intervention for substance use prevention among Keetoowah-Cherokee youth to that of an Urban Taking Circle (UTC) intervention for use among urban NA youth. Method: The integration of a culturally relevant theory, Native-Reliance, a community-based program approach, and cultural safety principles guided the intervention study method. The study implemented a 2-condition quasi experimental design and utilized convenience and snowball sampling methods for recruiting 100 urban NA youth as study participants. Participants originated from two urban NA community programs and were randomized by program site. Statistical analysis using multivariate analysis of variance (MANOVA) provided the means for determining if there were significant differences between the scores on measures at pre-intervention (baseline) and post-intervention. Results: Data findings indicated there is a direct relationship between the urban NA youth participants’ interests in engaging in drug use, alcohol consumption, and commercial tobacco smoking. However, additional findings provide evidence that a culturally based intervention was significantly more effective for the reduction of these substance use interests and general well-being than a non-culturally based intervention for urban NA youth. Conclusion: Study findings also indicated that supporting Urban NA youths’ utilization of urban NA values and beliefs promoted healthy behavior. Culturally safe interventions that support urban NA youth as a means in reducing harm associated with high-risk behaviors, such as substance use, is strongly recommended. Impact Statement: During each phase of the study, its method established assurance of cultural safety by operationalizing Native Reliance Theory. Therefore, an in-depth examination of the study methods with cultural safety principles is presented in context and warranted.

Romani Women and Health: The Need for a Cultural-Safety Based Approach.

The Romani are the main European ethnic minority. The Romani people’s situation of social vulnerability and their difficulties accessing the health system make their health indicators worse than those of the non-Romani population. The present study will delve into health beliefs, and experiences with health services and professionals, through the perspectives of Romani women. In this qualitative study, 16 women of different ages were interviewed in a city located in the South of Spain. Four themes emerged from the analysis of the data: the construction of the identity of Romani women, difficulties in life, health and disease beliefs and barriers to accessing the health system. We conclude that every project for the improvement of the health of the Romani community must take into account the active participation of Romani women and must consider the principles of Cultural Safety, by delving into the intercultural training of health professionals and addressing the social determinants of health which affect the Romani collective.

“Teaching in Circle” with student nurses contributes to experiential understanding of cultural safety

Background: Cultural safety is mandated for Australian nursing practice and education. Cultural safety privileges the knowledge of the client, who determines whether healthcare is culturally safe. Understanding and learning cultural safety requires critical self-reflection to expose clinicians’ assumptions, unconscious biases, beliefs and actions, and their impact on clients. More research is required on best-practice strategies on how students learn about cultural safety in nursing education. Experiential pedagogical methods may be one such strategy to promote understanding of principles that underpin safe environments. Objectives: To explore the influence of “Teaching in Circle” to enhance students’ understanding of cultural safety within the classroom environment. Methods: Students in first-year undergraduate Bachelor of nursing units participated. Teachers facilitated tutorials using a respectful adaptation of “Teaching in Circle” methodology; it was underpinned by the principles of Yarning, an Aboriginal and Torres Strait Islander Peoples way of learning and communicating in groups. Students developed principles to guide the facilitation of a more culturally safe classroom, providing written feedback on the environment and their participation in the circle. Results: Student feedback was reflected in three themes: “Journey through unfamiliar territory”; “More personable way of learning and sharing” and “Relational engagement creates safety”. Student perspectives resonated strongly with the principles of cultural safety or lack of within healthcare settings. The method disrupted normative classroom/learning environments and supported experiential learning about the principles of cultural safety. Conclusions: “Teaching in circle” provided an experiential means of enhancing first-year nursing students’ understanding of the principles of cultural safety. This learning should be embedded in the nursing curriculum and on-going education to prepare nurses to provide culturally safer care to Aboriginal and Torres Strait Islander Peoples. The study supports similar research calling for innovative learner-focused, experiential methods for the development of the practice of cultural safety in Australian nursing education. Impact statement: Exploratory research project, “Teaching in Circle” with student nurses contributes to experiential understanding of cultural safety principles.

There is no health without cultural safety: why cultural safety matters

Background: Nurses and midwives predominately work in western-centric health care settings, which may not align with Indigenous perspectives of health and wellbeing. Nurses and midwives will also view care through their own cultural lens. Culturally inappropriate health care can reduce access and engagement in services and contribute to reduced health outcomes for Indigenous peoples. Australian codes of conduct for nurses and midwives now advocate for care that is holistic, free of bias and racism, challenges beliefs based on assumption, and is culturally safe for Indigenous peoples. However, there are varying understandings of cultural care, what it looks like, and how to best achieve it. Aim: To highlight the importance of cultural safety in health care and discuss the integration into nursing and midwifery practice. Design: Discussion paper. Discussion: Cultural safety has emerged in Australia as the framework to improve the access and quality of health care for Indigenous people and to improve disparities in health care outcomes. However, the application of these principles for nurses and midwives has not been widely explored. Misconceptions around the concept remain despite the inclusion in national standards and practice frameworks. Conclusion: Evaluation and research that contributes to evidence-based knowledge specifically on the integration of cultural safety in nursing and midwifery practice is required. Impact Statement: This paper provides an overview of the importance of cultural safety in nursing and midwifery practice. Although cultural safety is now embedded in professional codes and standards, there is limited evidence of how this is translated to clinical care. Research and evaluation are needed to evaluate the application of cultural safety principles by nurses and midwives.

Inequality in Pulmonary Rehabilitation - The challenges magnified by the COVID-19 pandemic.

The COVID-19 pandemic has served to expose and amplify existing inequalities in chronic respiratory disease and the social determinants of health. In this article, we summarise evidence of existing disparities associated with chronic obstructive pulmonary disease and pulmonary rehabilitation; highlighting limitations of existing data. To reduce health inequalities in pulmonary rehabilitation, there is a need to identify and target factors influencing fair access and personal agency to engage. With consideration of the influence of culture on beliefs, expectations and health behaviours, we propose a renewed approach toward progressively achieving health equity in pulmonary rehabilitation based on principles of cultural safety and adaptation. This is a key priority in improving the quality of life of people living with chronic respiratory disease. Building comprehensive pulmonary rehabilitation service delivery models based on an understanding of the holistic needs of the local population should be a priority for service providers and researchers.

Stakeholder perceptions of policy implementation for Indigenous health and cultural safety: A study of Australia's ‘Closing the Gap’ policies

AbstractIndigenous peoples in Australia and similar colonised countries are subject to racism and systemic socioeconomic disadvantages, resulting in worse health outcomes compared to non‐Indigenous counterparts. Such inequities persist despite governments’ attempts to reduce them. Since 2008, Australian governments have committed to a national ‘Closing the Gap’ (CTG) to reduce inequities in health, education, and employment outcomes between Aboriginal and Torres Strait Islander peoples and other Australians, but with limited success. We applied policy theory and a cultural safety framework developed for the research to analyse stakeholder perceptions of CTG policy implementation between 2008 and 2019. We identified policy‐shaping ideas and policy incoherence in the environment surrounding CTG policy that obstructed culturally safe policy. Top‐down, prescriptive modes of implementation were also a barrier. However, Indigenous‐led policy partnerships and community‐controlled services in the health sector have met principles of cultural safety. Identifying these strengths and weaknesses points to ways in which implementation of CTG policies can be improved to achieve cultural safety and reduce Indigenous health inequities. These results may hold lessons for similar countries such as the United States, New Zealand, and Canada.

Assessing cultural safety in Aboriginal and Torres Strait Islander Health.

The aim of this study was to explore how nurses and midwives (trained at Flinders University in Adelaide) from rural, remote and urban locations view the impact of cultural safety training on their practice and the extent to which they incorporated cultural safety principles into their practice. qualitative research study. rural, remote and urban locations across Australia. Nurses and midwives who had undertaken cultural safety training at Flinders University as part of their undergraduate degree. Participants were recruited for semi-structured interviews. Interviews were recorded and transcribed verbatim. Transcripts were coded independently by members of the research team. The use of cultural safety principles in participants' practice, and the extent to which they were applied, was determined. Barriers and enablers to enacting cultural safety in the workplace were also identified. 10 individuals participated in an interview (7 nurses and 3 midwives). The Modified Monash Model was used to classify participant location with the following observed: MM1, six; MM2, two; MM5, one; MM6, one. 3 participants were from the Northern Territory and 7 from South Australia. Participants were at varying stages in their journey of cultural safety, ranging from early stages to those able to embody the Cultural Safety Principles and negotiate barriers to provide culturally safe care. Educational strategies for participants to progress their cultural safety journey were also identified. The extent to which cultural safety principles are applied in practice is diverse amongst the nurses and midwives that participated in this study, demonstrating that cultural safety is a journey and ongoing support is needed.

A Comprehensive Quality Assurance Platform in Canada for National Point-of-Care Chronic Kidney Disease Screening: The Kidney Check Program

A Comprehensive Quality Assurance Platform in Canada for National Point-of-Care Chronic Kidney Disease Screening: The Kidney Check Program

Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care.

In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017–June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a ‘last resort’, with admission to hospital in a critical or a “near death” condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.

Paradigm-Specific Risk Conceptions, Patient Safety, and the Regulation of Traditional and Complementary Medicine Practitioners: The Case of Homeopathy in Ontario, Canada.

While the principle of risk reduction increasingly underpins health professional regulatory models across the globe, concepts of risk are neither static nor epistemically neutral. Conventional biomedicine's risk conceptions are substantially rooted in principles of scientific materialism, while many traditional and complementary medicine systems have vitalistic epistemic underpinnings that give rise to distinctive safety considerations. The statutory regulation of traditional and complementary medicine providers has been identified by the World Health Organization as a strategy for enhancing public safety. However, complex risk-related questions arise at the intersection of medical epistemologies whose concepts are at best overlapping, and at worst incommensurable. Elaborating a theoretical concept of “paradigm-specific risk conceptions,” this work employs Bacchi's poststructural mode of policy analysis (“What's the Problem Represented to Be?”) to critically analyze risk discourse in government documents pertaining to the 2015 statutory regulation of homeopathic practitioners in Ontario, Canada. The Ontario government's pre-regulatory risk assessments of the homeopathic occupation discursively emphasized cultural safety principles alongside homeopathy-specific risk conceptions. These paradigm-specific concepts, rooted in homeopathy's epistemic vitalism, extend beyond materialist constructions of adverse events and clinical omission to address potential harms from homeopathic “proving symptoms”, “aggravation,” and “disruption,” all considered implausible from a biomedical standpoint. Although the province's new homeopathy regulator subsequently articulated safety competencies addressing such vitalistic concepts, the tangible risk management strategies ultimately mandated for practitioners exclusively addressed risks consistent with the scientific materialist paradigm. This policy approach substantially echoes the implicit biomedical underpinnings evident in Ontario's broader legislative context, but leaves a significant policy gap regarding the primary safety considerations originally articulated as substantiation for homeopathy's statutory regulation. To optimally preserve patient safety and full informed consent, regulators of traditional and complementary medicine professionals should favor a pragmatic, epistemically-inclusive approach that actively negotiates paradigm-specific risk conceptions from both biomedicine and the occupation under governance.

The ‘Pedagogy of discomfort’: A qualitative exploration of non-indigenous student learning in a First Peoples health course

Abstract To improve healthcare practices and increase cultural safety when working with First Peoples, it is essential that students engage with challenging discourses that critically engage their social, political, personal, professional and historical positioning. Such engagement may provoke emotional responses in students. However, little is known about the nature of non-indigenous students’ emotional engagement when learning First Peoples health content that integrates cultural safety principles. The pedagogy of discomfort is a process of self-examination that requires students to critically engage their ideological assumptions and may be useful in examining the emotional dimension that occurs when learning this content. Eighty-two non-indigenous health students gave permission for their critical reflective essays, submitted as an assessment requirement of a First Peoples health course to be analysed. Elements of the pedagogy of discomfort informed the analytical and theoretical framework. The emotional engagement by students was captured in the following overarching themes: Acknowledging preconceived ideas; Uncomfortable emotions; Fragile identities; Spectating and Witnessing. Findings highlight how students' emotional engagement may contribute to changes in perspective and frames of reference, transpiring to a ‘call to action’ that challenges systems of differential privilege. While many students expressed discomfort when learning about key cultural safety concepts, the extent of transformative potential varied.

Cultural safety continuing professional development for midwifery academics: An integrative literature review

BackgroundAwareness of cultural safety by midwifery academics is integral to the provision of a safe learning and teaching environments, use of effective pedagogies, and academic success of Indigenous midwifery students. However, little is known about the scope and efficacy of continuing professional development activities that aim to develop awareness of cultural safety by midwifery academics. AimsTo conduct an integrative review of the literature with respect to the scope and efficacy of professional development interventions that aim to increase awareness of cultural safety by midwifery academics. MethodsAn integrative review of peer-reviewed literature from 2005 -2017 was undertaken. Documents were assessed using the Critical Appraisals Skills Program (CASP) guidelines. Concepts were mapped thematically. ResultsResults are reported and discussed using key themes identified in the analysis. Five broad themes emerged from the analysis of studies. The themes were named: Cultural Terms, Knowledge of Culture, Cultural Education, Cultural Aspirations and Culture in Curricula. ConclusionsMidwifery academics requireprofessional development to raise their awareness of cultural safety in order to adopt effective learning and teaching practices. There is currently no agreed best practice framework to support awareness of cultural safety for midwifery academics. The philosophy of midwifery practice has many synergies with the principles of cultural safety. Cultural safety needs to be embedded into professional development plans for midwifery academics.

Burn injury models of care: A review of quality and cultural safety for care of Indigenous children

Safety and quality in the systematic management of burn care is important to ensure optimal outcomes. It is not clear if or how burn injury models of care uphold these qualities, or if they provide a space for culturally safe healthcare for Indigenous peoples, especially for children. This review is a critique of publically available models of care analysing their ability to facilitate safe, high-quality burn care for Indigenous children. Models of care were identified and mapped against cultural safety principles in healthcare, and against the National Health and Medical Research Council standard for clinical practice guidelines. An initial search and appraisal of tools was conducted to assess suitability of the tools in providing a mechanism to address quality and cultural safety. From the 53 documents found, 6 were eligible for review. Aspects of cultural safety were addressed in the models, but not explicitly, and were recorded very differently across all models. There was also limited or no cultural consultation documented in the models of care reviewed. Quality in the documents against National Health and Medical Research Council guidelines was evident; however, description or application of quality measures was inconsistent and incomplete. Gaps concerning safety and quality in the documented care pathways for Indigenous peoples’ who sustain a burn injury and require burn care highlight the need for investigation and reform of current practices.

Expressions of cultural safety in public health nursing practice.

Cultural safety is an essential concept within New Zealand nursing that is formally linked to registration and competency-based practice certification. Despite its centrality to New Zealand nursing philosophies and the stated expectation of cultural safety as a practice element, there is limited evidence of its application in the literature. This research presents insight into public health nurse's (PHN) experiences, demonstrating the integration of cultural safety principles into practice. These findings emerged following secondary analysis of data from a collaborative, educative research project where PHNs explored the use of family assessment tools. In particular, the 15-minute interview tool was introduced and used by the PHNs when working with families. Critical analysis of transcribed data from PHN interviews, utilising a cultural safety lens, illuminated practical ways in which cultural safety concepts infused PHN practice with families. The themes that emerged reflected the interweaving of the principles of cultural safety with the application of the five components of the 15-minute interview. This highlights elements of PHN work with individuals and families not previously acknowledged. Examples of culturally safe nursing practice resonated throughout the PHN conversations as they grappled with the increasing complexity of working with a diverse range of families.

Perceived Discrimination of Muslims in Health Care

Discrimination is not only a human and civil rights offense, but also a detrimental influence on the health outcomes of affected populations. The Muslim population in the United States is a growing religious minority increasingly encountered by health care professionals in the clinical setting. This group has been subject to heightened discrimination since the tragic events of September 11, 2001 and often is misunderstood within the context of American society today. While research has been conducted on discrimination against Muslims in the employment and educational segments of society, more studies are needed which quantify the extent and type of discrimination faced by this group in the health care setting. This inquiry focused on the crossover of anti-Muslim discrimination from society to the health care setting. A newly developed tool to measure anti-Muslim discrimination in health care and an established perceived discrimination scale were used to create the questionnaire employed in this investigation. The items of this newly created tool addressed culturally congruent care practices based on principles of cultural safety within the nurse-patient relationship and the cultural care beliefs of the Muslim patient/family to ascertain discriminatory occurrences in the health care setting. Ray's (2010) transcultural caring dynamics in nursing and health care model served as a framework for this quantitative, univariate, descriptive, cross-sectional design. FINDINGS and implications for practice, policy, education, and recommendations for further research are discussed. Language: en