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Table 3 Key Definitions and Concepts of Cultural Safety

From: Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

TermDefinition/Concept ExamplesSources
Cultural Safetyis an outcome of nursing and midwifery education that enables safe service to be defined by those that receive the service[30]
a focus for the delivery of quality care through changes in thinking about power relationships and patients’ rights[32]
The skill for nurses and midwives does not lie in knowing the customs of ethnospecific cultures. Rather, cultural safety places an obligation on the nurse or midwife to provide care within the framework of recognizing and respecting the difference of any individual. But it is not the nurse or midwife who determines the issue of safety. It is consumers or patients who decide whether they feel safe with the care that has been given[32]
The focus of cultural safety teaching is to educate student nurses and student midwives:
- to examine their own realities and the attitudes they bring to each new person they encounter in their practice; − to be open minded and flexible in their attitudes toward people who are different from themselves, to whom they offer or delivers - not to blame the victims of historical and social processes for their current plight; − to produce a workforce of well educated, self-aware registered nurses and midwives who are culturally safe to practice
[32]
where there is no inadvertent disempowering of the recipient, indeed where recipients are involved in the decision making and become part of a team effort to maximise the effectiveness of the care. The model pursues more effective practice through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine what safety means.[65]
a nurse who could objectively evaluate his or her own culture and be familiar about the theory of power structures, is also a culturally safe nurse in all contexts[35]
places an emphasis on the health worker understanding their own culture and identity, and how this manifests in their practice. Thus, cultural safety is concerned with both systemic and individual change with the aim of examining processes of identity formation and enhancing health workers’ awareness of their own identity and its impact on the care they provide to people from indigenous cultural groups.[42]
aims to directly address the effects of colonialism within the dominant health system by focusing on the level of cultural safety felt by an individual seeking health care. The responsibility to recognize and protect a person’s cultural identity (and hence maintain their cultural safety) lies with the health service. Emphasis is placed on assisting the health worker to understand processes of identity and culture, and how power imbalances or relationships can be culturally unsafe (and thus, detrimental to a person’s health and wellbeing)[42]
a strategic and intensely practical plan to change the way healthcare is delivered to Aboriginal people. In particular, the concept is used to express an approach to healthcare that recognizes the contemporary conditions of Aboriginal people which result from their post-contact history.[63]
the movement from cultural competence to cultural safety is not merely another step on a linear continuum, but rather a more dramatic change of approach. This conceptualization of cultural safety represents a more radical, politicized understanding of cultural consideration, effectively rejecting the more limited culturally competent approach for one based not on knowledge but rather on power.[63]
best nurtured in conjunction with other embedded philosophies such as decolonization, symbolic interactionism, understanding social interaction in context, and the social justice imperative to avoid further harm from domination and oppression[47] (
a constant self-evaluation by a provider to ensure they’re focusing on the individual and are not being influenced by assumptions about that individual’s cultural background or social or economic status…also helps alter the colonial relationship and makes safe space for Indigenous peoples within the system and thereby allowing them to help reshape the system itself[62]
provides for the formal recognition of power relations within health care (and in particular nursing) interactions. By adopting cultural safety it becomes not only possible but inevitable that an exploration of the assumptions underlying practice, brought by both individuals and the profession will occur. This reflective model is effective on the individual, institutional and professional levels, and encourages identification of the assumptions and preconceptions that structure practice[66]
a powerful means of conveying the idea that cultural factors critically influence the relationship between carer and patient. Cultural safety focuses on the potential differences between health providers and patients that have an impact on care and aims to minimize any assault on the patient’s cultural identity. Specifically, the objectives of cultural safety in nursing and midwifery training are to educate students to examine their own realities and attitudes they bring to clinical care, to educate them to be open-minded towards people who are different from themselves, to educate them not to blame the victims of historical and social processes for their current plight, and to produce a workforce of well-educated and self-aware health professionals who are culturally safe to practice as defined by the people they serve.[46]
does not emphasize developing “competence” through knowledge about the cultures with which professionals are working. Instead, cultural safety emphasizes recognizing the social, historical, political and economic circumstances that create power differences and inequalities in health and the clinical encounter[46]
is underpinned by a social justice framework and requires individuals to undertake a process of personal reflection. Cultural safety is therefore a holistic and shared approach, where all individuals feel safe, can undertake learning [36] together with dignity, and demonstrate deep listening[36]
is grounded in critical theoretical perspectives and draws attention to critically oriented knowledge, such as racialization, culturalism, institutional racism and discrimination, and health and health care inequities[68]
extends beyond cultural awareness, sensitivity, and skills-based competencies and is predicated on understanding the power differentials inherent in health care service delivery to redress these inequities through educational processes, focusing on reflexive thinking[70]
is informed philosophically by “emancipatory or neocolonisation theoretical perspectives” and by an emphasis on social justice. Grounded in critical theory, cultural safety invites the nurse[71]
goes beyond describing the practices of other ethnic groups, because such a strategy can lead to a checklist mentality that essentialises group members. Furthermore, a nurse having knowledge of a client’s culture could be disempowering for a client who is disenfranchised from their own culture, and could be seen as the continuation of a colonising process that is both demeaning and disempowering or appropriating. Culturally safe nurses focus on self-understanding and the emphasis is on what attitudes and values nurses bring to their practice. A key tenet is that ‘a nurse or midwife who can understand his or her own culture and the theory of power relations can be culturally safe in any context’[60]
advocates that both professionals and institutions work to establish a safe place for patients, which is sensitive and responsive to their social, political, linguistic, economic and spiritual concerns. Cultural safety is more than an understanding of a patient’s ethnic background as it requires the ‘health professional to reflect on their own cultural identity and on their relative power as a health provider’[72]
The curriculum staircase or poutama assumes that students begin their cultural safety education at the bottom of the staircase where they bring with them their personal experiences, knowledge, and biases. Over the next 3 years of their training, the students are assessed on their ability to move to each step. This training focuses on racism awareness, the Treaty of Waitangi, ngā mea Māori (concepts important to Māori), and strategies for institutional change. Hence, the educational process involves movement from awareness to sensitivity, and ultimately to safety.[48]
we envisioned that cultural safety might assist nurses to examine how popularized notions of culture and cultural differences are taken up; to develop greater awareness of how individual and societal assumptions and stereotypes operate in practice; and to better recognize how organizational and structural inequities and wider social discourses – within health care and in our society – inevitably influence nurses’ interpretive perspectives and practices.[73]
Critical ConsciousnessIf we try to move beyond cultural competency and instead focus on the development of this critical consciousness, what is its object of knowledge? In other words, “What stuff should we learn?” The object of knowledge is not just a series of lists of cultural attributes (which can quickly degrade into dehumanizing stereotypes), nor is it a skill set of questions and demeanours we should assume when encountering a patient who is not like us. We propose that the object of knowledge of these educational efforts is the development of critical consciousness itself, that is, the knowledge and awareness to carry out the social roles and responsibilities of a physician. This way of knowing is a different type of knowledge than that required when studying the biomedical sciences— complementary, but different all the same.[58]
Cultural competency is not an abdominal exam. It is not a static requirement to be checked off some list but is something beyond the somewhat rigid categories of knowledge, skills, and attitudes: the continuous critical refinement and fostering of a type of thinking and knowing—a critical consciousness— of self, others, and the world.[58]