conceptualizing cultural safety - semantic scholar · recognized, however, that cultural competence...

Journal for Social Thought 1(1) • July 2016

Conceptualizing Cultural Safety:Definitions and Applications of Safety in Health Care for

Indigenous Mothers in Canada

Sharon Yeung

McMaster University, Hamilton, [email protected]

Abstract

The importance of delivering culturally-appropriate health care to meet the unique health needs of Indigenouspeoples in Canada has resulted in the emergence of various concepts to describe how care should be provided.However, there is lack of clarity regarding how these terms differ from one another and what they look like inpractice. An extended literature search was performed to conceptualize terminology used to describe culturally-appropriate care, emphasizing the concepts of ‘cultural safety’ and ‘cultural competence’. Maternal and childhealth programs that utilize these concepts were then surveyed to explore how they are being applied in practice.Relevant literature was identified through major databases (Ovid Medline, CIANHL, and the CHR Collection)with key terms “cultural competency”, “cultural safety”, and “Indigenous health care”, along with forwardcitation and grey literature searches. This literature review demonstrates that the theoretical definitions of culturalsafety and cultural competence are distinct, but lack strict delineations, much like the variable and dynamicnature of their application. By comparing the conceptual bases of culturally-appropriate care with their actualapplication, gaps in current provision of culturally-appropriate health care for Indigenous peoples are identifiedand recommendations generated for enhanced development of care.

KEYWORDS: Indigenous; Mothers; Health care; Cultural competence; Cultural safety

Introduction

The Indigenous-Canadian population experiencessignificant health resource disparities in compar-ison to non-Indigenous Canadians, which result

in generally inferior health outcomes. These disparitiesare perpetuated by reduced access to health care ser-vices and are rooted in inequities in the determinantsof health, which include social, economic, cultural, andpolitical factors (Baba, 2013). The severity of these in-equalities are reflected in comparative rankings on theWorld Health Organization Human Development In-dex, which is a composite measure of every country‘slife expectancy, education, and income, or standard ofliving. As a whole, Canada ranks 6th on this scale,while First Nations communities rank 68th (CanadianUNICEF Committee, 2009). Current data show that In-digenous peoples face urgent health issues, includingdisproportionate burdens of communicable diseasessuch as HIV and tuberculosis, as well as epidemic

rates of non-communicable conditions, such as obesityand diabetes (Monette, 2011; Public Health Agency ofCanada, 2007; Public Health Agency of Canada, 2000).

Many barriers reduce the access of health care byIndigenous peoples, including those related to geog-raphy and financial expenses. Additionally, negativeexperiences with the mainstream health care systemhave become prominent reasons for the delay or omis-sion of seeking timely care (McCormick, 1996; Smye &Browne, 2002). Health care institutions that do not prac-tice culturally safe care ultimately alienate Indigenouspeoples from seeking needed health services, thus per-petuating poorer health outcomes (DiLallo, 2014). Theimpact of this factor is pressing; in an urban sampleof Indigenous people, 23.9% of participants identifiedlack of trust in their health care provider as a barrier toreceiving care (Smylie et al., 2011). Furthermore, 20.9%of the sample reported that they felt the service wasnot culturally appropriate, 19.9% reported difficultyobtaining a variety of services they felt were necessary,

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and 13% indicated that they experienced unfair treat-ment because of their Indigenous identities (Smylie etal., 2011). Racialization, stereotyping, and lack of pro-fessionalism continue to compromise quality of care forIndigenous patients, and failure to recognize patients‘cultural backgrounds may lead to high health programdrop-out rates and less effective healing (Sue & Sue,1981; McCormick, 1996).

In recent years, the recognition that the health caresystem is not systemically suited to meeting the uniquehealth priorities of Indigenous clients has driven thedevelopment of cultural competence and cultural safetyas ways of providing services that acknowledge cul-tural difference. The purpose of culturally safe andcompetent services is to consider the cultural identi-ties, histories, and sociopolitical contexts of Indigenouspeople within their care, in order to maximize quality,outcome, and seeking of care (Narayan, 2002; Smye& Browne, 2002). While these concepts are still in de-velopment and have not yet been universally adopted,they are key indications of progress towards creatingmore positive relationships with Indigenous peopleswithin health care services and beyond. The aim ofthis paper is to consolidate an understanding of thetheoretical bases behind culturally safe and competentcare, and to explore examples of their implementationin the context of maternal and child health services.

Literature Review

Terminology for Culturally-Appropriate Care

Cultural competence and cultural safety are thepredominant models of care described in the litera-ture and are the broadest, most often-used terms byuniversities, organizations, and governments when dis-cussing culturally-appropriate care for Indigenous pa-tients (Baba, 2013). However, a variety of other termsexist to describe the elements that constitute culturalsafety and cultural competence, and it is still widelydebated which terms are most accurate or most suitedto the clinical context. Terms such as cultural humility,cultural awareness, cultural sensitivity, cultural knowl-edge, and cultural proficiency all partake in the discus-sion of what true culturally-appropriate care resembles.This diversity of terminology also exemplifies the com-plexity of determining whether these characteristics aresequentially or simultaneously developed. The majorconcepts of cultural competence and cultural safetyencompass and share many of these ideas and themesand are summarized in Figure 1. Whether proficiency

is more achievable than safety, or whether safety playsa role in acquiring proficiency, or whether competenceis essential for safety are all questions that demonstratethe lack of perfect clarity and distinction of these con-cepts. Regardless of semantics, their mutual goal is tomake health services more accessible and relevant forIndigenous patients for the ultimate improvement ofhealth outcomes.

Defining Cultural Competence

Cultural competence is not a term uniquely appli-cable to servicing Indigenous populations, nor is itonly applied within health care. Since its conceptionin the 1980s, it has been described as “a set of con-gruent behaviours, attitudes, and policies that cometogether in a system, agency, or amongst professionalsand enables that system, agency, or those professionalsto work effectively in a cross-cultural situation” (Cross,Bazron, Dennis, & Isaacs, 1989, p. 28). Its emphasis ison acknowledging the importance of culture and thepresence of cultural differences and culturally-uniqueneeds. Within health care, cultural competence sug-gests that these considerations must be integrated inhow patients are cared for (Betancourt, Green, Carrillo,& Ananeh-Firempong, 2003; Davis, 1997). Tangibly, thisinvolves the recognition of different health beliefs, dis-ease prevalence and incidence, and treatment outcomesfor different demographics. Cultural competence hasalso been applied beyond the cultural context to in-clude race, language, age, gender, lifestyle, ethnicity,faith, location, and socioeconomic status, thus shift-ing the focus towards reduction of ineffective healthcare through respect and acceptance for all. It must berecognized, however, that cultural competence for onepopulation does not necessarily translate into compe-tence for another (Kim, Kim, & Kelly, 2006), identifyingthe need for competence to be developed in specificintercultural contexts.

Cultural competence is most often used to describethe health care provider; it focuses on the knowledge,awareness, and skills of the practitioner that “pro-mote and advance cultural diversity and recognizesthe uniqueness of self and others in communities” (Be-tancourt et al., 2003; Walker & Sonn, 2010, p. 62). Wells(2000) describes the development of this knowledge,awareness, and skills as a continuum that begins withlearning the elements of culture and their role in shap-ing and defining health behavior (knowledge). Thisknowledge is then followed by the recognition of thecultural implications of behavior (awareness) and theintegration of cultural knowledge and awareness into



individual and institutional behavior (sensitivity). Sub-sequently, routine application of culturally appropriatehealth care interventions and practices (competence)is developed, culminating in its integration into theculture of the organization (proficiency) (Wells, 2000;Cross et al., 1989). Understanding cultural competencein this way conceptualizes it as the “process of becom-ing, not a state of being” (Campinha-Bacote, 2008, p.149), beginning with the appreciation that we are allraised and live within social cultures that shape how weperceive and interact with the world around us (Kruske,Kildea, & Barclay, 2006). It is necessary that this con-tinuum of development be present at all levels of thehealth care system, as solely shifting a practitioner‘sperspective is inadequate; the practitioner‘s knowledge,awareness, and skills need to be endorsed by the pro-fession, hiring institution, and the health care systemon municipal, provincial, and federal levels (Nguyen,2008). Recognizing the scope of cultural competencedemonstrates how vast a concept and distant a realitytrue competence is in practice today.

Over the years, certain theorists have also notedthat cultural competence should require that the prac-titioner identify and challenge his or her own culturalassumptions, values, and beliefs that extends beyondsimply being culturally aware but strives to see theworld through others‘ cultural lens (Tervalon & Murray-Garcia, 1998). Tervalon and Murray-Garcia (1998) fur-ther note that cultural competence necessitates simulta-neous knowledge acquisition (life-long learning) andself-reflection (realistic and ongoing self-appraisal) thatshifts the power balance so that the practitioner doesnot assume capability of knowing everything aboutothers‘ cultures (Brown as cited in Tervalon & Murray-Garcia, 1998). This definition emphasizes the changein attitude and behavior above knowledge acquisitionand is the characteristic that forms the focus of culturalsafety. For the most part, however, cultural competenceprizes knowledge attainable by the practitioner whichleads some to claim the impossibility of its realization,calling it a “myth that is typically American and locatedin the metaphor of American ‘know-how”’. (Dean,2001, p. 624). This argument asserts that because mod-ern culture is individually constructed and dynamicin nature, competence is not a generalizable skill set.Instead, Dean and Tervalon and Murray-Garcia sug-gest that a power shift occur, lest competency reinforcethe passive receiver role that Indigenous peoples havebeen historically subjected to (Brascoupé & Waters,2009; Dean, 2001; Tervalon & Murray-Garcia, 1998).The patient-practitioner relationship requires complete

transformation and redefinition, which is the notionemphasized in cultural safety.

Defining Cultural Safety

The concept of cultural safety emerged in the 1980sfrom the work of Maori nurse Irihapeti Ramsden inthe context of disadvantaged nursing care provided toIndigenous peoples in New Zealand (Ramsden, 2003).Since then, the concept has been extended and appliedto Indigenous peoples in other countries where ser-vice inequalities persist. This theory has been appliedto social policy areas outside of health, including ed-ucation, economic opportunity, and criminal justice,although its primary application remains within healthpolicy (Brascoupé & Waters, 2009). Because this con-cept did not originate in Canada, its definition in theCanadian Indigenous context continues to be refinedand its transportability examined, but similarities inthe way colonization has affected the Indigenous popu-lations of Canada and New Zealand make the conceptlargely applicable (Smye & Browne, 2002; Kirkham etal., 2002).

Cultural safety extends beyond cultural understand-ing and knowledge of the health care worker by em-phasizing the power imbalance inherent in the patient-practitioner relationship. This concept shifts power andauthority to the Indigenous patient receiving care, whois given the ultimate say in whether care provided wasculturally safe or not (Ramsden, 2002). As Ramsden(2002) acknowledges, this definition is more complexthan it appears. On the one hand, it may be conceptu-alized as an extension of cultural competence; however,it is simultaneously a radical and explicit departurefrom it (Ramsden, 2002). Cultural safety lies on thecontinuum of cultural competence in that it will notbe realized in practice all at once, but will likely bebuilt out of cultural competency practices, as strongerand more trusting mutual relationships develop be-tween the patient and the provider (Brascoupé & Wa-ters, 2009). While conceptualizing cultural safety in thisway makes the goal more achievable and relevant inpractice-based settings, there is danger that broadeningthe definition too much may dilute its significance andstrength because it is, by nature, a paradigm shift; it re-jects the limited cultural competency approach, whichis based on knowledge, and refocuses instead on powertransfer (Jackson as cited in Ramsden, 2002). In thissense, cultural safety is radically different; it redefinesthe patient-practitioner relationship such that respon-sibility and power lie with the patient, who is not apassive receiver, but a powerful player in the relation-



ship (Brascoupé & Waters, 2009). Its success thereforecannot be evaluated as a function of knowledge of thepractitioner, but is an outcome in and of itself that thepractitioner can only help facilitate.

Cultural safety centres upon sharing: shared re-spect, shared meaning, and shared knowledge andexperience, of learning together with dignity and atten-tion (Williams, 1999). This calls practitioners to under-stand the bicultural nature of the patient-practitionerrelationship, beginning with themselves, their own race,culture, and imprinted stereotypes, and seeking to un-derstand the social determinants of health, as they haveevolved in post-colonial times, to influence Indigenouspopulations today. Redefining the relationship, as cul-tural safety calls, questions how the practitioner is posi-tioned relative to the patient and to the system of healthcare delivery, and endorses a shared power paradigm,in which each patient is perceived as a “person of value”(J. Anderson et al., 2003, p. 208). This element of carecan only be achieved through systemic alteration ofinstitutional standards of practice (J. Anderson et al.,2003). Cultural safety therefore extends beyond clinicalpractice to become a moral discourse for informingpolicy analysis. It is necessarily coupled with appli-cation at systemic levels, including consideration ofwhether mainstream health policies put Indigenouspeoples‘ health at risk, or whether they fail to addressgaps in health in Indigenous populations, thereby alsoproducing a lack of safety (Smye & Browne, 2002).

Regardless of how we perceive the development ofcultural safety—as an extension on the cultural compe-tency continuum or as a distinct concept—its premisehighlights the issue of power, making it highly political,and therefore controversial, in nature. It is embeddedin overarching notions of Indigenous sovereignty andit challenges the hierarchies in society and the positionthat Indigenous peoples have been relegated to (Ellison-Loschmann as cited in Brascoupé & Waters, 2009). Infact, Ramsden presents cultural safety as ‘critical socialtheory’, claiming it to be “no different from teachingpeople to be aware of the sociopolitical, economic issuesin society and to recognize the impact that these issueshave on people” (Papps as cited in Ramsden, 2002, pp.132-133). Ultimately, cultural safety demands an exam-ination of Indigenous peoples‘ power in society as awhole, beyond the confines of health care. It upholdsthe political ideas of self-determination and decoloniza-tion (National Aboriginal Health Organization, 2006),while also taking into account the post-colonial theoriesthat demonstrate how colonization has brutalized and

dehumanized the colonizer as much as the colonized(Gandhi as cited in Anderson et al., 2003). This en-courages respectful consideration of both the patientand the health professional as individuals with uniqueexperiences, histories, and positions in relation to thehealth care system (Anderson, 2003). Because this is asmuch a political position as it is clinical, however, theconcept has been criticized for its integration into ed-ucation, being deemed as “force feeding culture” and“indoctrinating nursing students” with specific politicalviews (National Aboriginal Health Organization, 2006,p. 1).

While cultural competence exhibits adaptability todifferent ethno-cultural group interactions, culturalsafety was birthed with a strictly Indigenous purposeand context. Cultural safety therefore requires explicit,detailed recognition of the cultural identity of Indige-nous people and is dissimilar to universalism and mul-ticulturalism, where all cultures are assumed to pos-sess equal and undifferentiated claims on rights andresources in Canada (Brascoupé & Waters, 2009). In-stead, cultural safety asserts the primary position oforiginal people of the land, the historic legacy of powerrelations and repression (National Aboriginal HealthOrganization, 2006), and acknowledges the identityof a disadvantaged Indigenous minority to a coloniz-ing majority (Polaschek, 1998). These reflections giveway to questioning whether current health policies,research, and practice have been shaped by political,social, cultural, and economic structures that couldbe systemically recreating historical trauma (Smye &Browne, 2002).

Finally, it must also be noted that cultural safety isstill in development. Currently, little evidence of itsapplication in professional practice exists beyond aca-demic studies and government reports and critics havequestioned how readily it can truly be implemented,because it seeks to redesign social structure and drawattention to individuals‘ personal attitudes of social in-fluence (Polaschek, 1998). Nevertheless, it serves as animportant interpretive lens to view the current state ofhealth policies, research, and practice to examine howthey may be inadvertently perpetuating neocolonial ap-proaches for Indigenous people (Smye & Browne, 2002).This understanding will ultimately enable the creationof “an environment which is safe for [Indigenous] peo-ple: where there is no assault, challenge or denial oftheir identity, of who they are and what they need”(Williams, 1999, p. 213) and subsequently improvehealth outcomes.



Figure 1: A Schematic Representation of the Terminology used in Describing Culturally-Appropriate Care and Their GeneralizedRelationships to One Another

Emergent Characteristics of Applied CulturalSafety and Competence in Care

The complexity of cultural safety and competencenaturally results in complex models of application, andlike theoretical precedents, they too are still in devel-opment. Limited literature exists on the application ofculturally appropriate models of care for Indigenouspeoples and little concrete evidence proves the efficacyof one method of application over another, particularlyfor cultural safety.

Cultural competence, being rooted in the more tra-ditional view that the practitioner directs and definesculturally appropriate care, unsurprisingly involvesprofessional education centred upon developing a prac-titioner‘s knowledge, attitudes, and beliefs (Nguyen,2008). Cultural competence teaches practitioners tounderstand specific historical patterns that affect the

contemporary conditions of Indigenous people, includ-ing the impacts of colonization and social assimilationand specific phenomena such as the residential schoolssystem that has led to historical trauma and lost culture.Practitioners are taught about Indigenous spirituality,religiosity, and family dynamics, as well as culturalconstructs in communication, social etiquette, and so-cial values (Nguyen, 2008). The extent and breadth ofthis knowledge practitioners are called to know maybe dangerous, however, because it may instill a falseconfidence that seeks to fit all Indigenous patients intoone stereotypical mold and fails to consider diversitywithin the Indigenous population (Williamson & Har-rison, 2010). While elements of knowledge are usefulin establishing rapport, asking the right questions, andidentifying potentially relevant cultural variables, prac-titioners must be reminded that cultural competenceis an ongoing process, and that cultural assessment



must be done to understand the unique needs of everyindividual, family, and community (Campinha-Bacote,2008).

In contrast, cultural safety focuses less on under-standing the details of cultural traditions and valuesand instead emphasizes knowledge of colonization,residential schools, generational trauma, and its im-pact on generating the current social determinants ofhealth that breed health inequalities (Health Council ofCanada, 2011; Canadian Association of Nurses in AIDSCare, n.d.). Practitioners are encouraged to evaluatecurrent institutions and the policies that continue toimplicitly marginalize and demean Indigenous people,as well as acknowledge Indigenous peoples‘ sentimentsof being discriminated against, isolated, and judgedwhen accessing care (Health Council of Canada, 2011).Increasing the knowledge base in this way prevents thepractitioner from developing a paternalistic attitudeand instead encourages sensitivity and compassion.Practitioners are also taught about the complexity ofIndigenous information systems and their dynamic na-ture that is to each community, nation, and family, inan effort to garner deep respect for traditional healingcustoms.

Both culturally competent and safe care extends be-yond patient-practitioner relationships to acknowledgehow social and cultural influences interact at organi-zational and structural levels of the health care deliv-ery system (Betancourt et al., 2003). Organizationalstructural competence involves expanding Indigenousleadership and a workforce composition that is repre-sentative of the proportion of Indigenous patients seen,as well as developing relationships between federaland provincial authorities, and Indigenous organiza-tions (Betancourt et al., 2003; Health Council of Canada,2011). Additionally, regardless of ethnicity, providersshould be given training about Indigenous culture andlanguage (Anderson, Scrimshaw, Fullilove, Fielding,& Normand, 2003). Structural cultural competencyrequires that a system minimize barriers of access toquality health care and services, providing serviceslike interpreters and linguistically appropriate healtheducation materials, as well as proper signage (L.M.Anderson et al., 2003).

With regard to patient-practitioner relations, bothcultural competence and safety call for respect, trust-worthiness and self-awareness on the part of the careprovider (National Aboriginal Health Organization,2006). However, because cultural safety emphasizespower transfer, self-determination, and empowermentof the Indigenous patient, it promotes the collaborative

agreement on a treatment regime, using a ‘strengths-based approach’ in which practitioners focus on thepositive underlying basis of the person‘s resources andresilience, drawing upon their own community sup-ports and resources (Canadian Association of Nurses inAIDS Care, n.d.). The ultimate goal of promoting thisempowerment is to return complete control of healthcare systems and provision of health care to Indigenouscommunities. As such, cultural safety also advocatesfor the inclusion of Indigenous peoples in the healthcare and education disciplines, along with return ofownership of research and health systems planning(Williams, 1999; Smylie et al., 2011). The holistic natureof culturally safe practice that respects the physical,mental, social, spiritual, and emotional domains ofhealth, as well as the role of individuals within their re-spective families and communities, also shifts the focusof care to a more macroscopic scale. The application ofcultural safety is therefore broad, as it is concerned withultimately binding Indigenous and non-Indigenous so-ciety to live together collaboratively and respectfully,while still operating in self-determined, independentmanners, for the purpose of building complete well-ness in both health care systems and society-at-largefor both Indigenous and non-Indigenous people alike(Polaschek, 1998).

Case Studies: Indigenous

Maternal and Child Health

The largest growing demographic in Canada is thatof the Indigenous population, having reached 1.17 mil-lion in 2006 and being significantly younger than thenon-Indigenous population, as well as possessing sig-nificantly higher birth rates (Statistics Canada, 2008).Despite the fact that Indigenous peoples will continueto comprise a significant proportion of future genera-tions, there exists a deficiency of Indigenous maternaland child health data (Smylie, Fell, Ohlsson, Joint Work-ing Group on First Nations Indian Inuit, & CanadianPerinatal Surveillance System, 2010). The few reliablestatistics indicate a grim reality that infant mortalityrates for Status First Nations remains twice as highas Canadian rates, and the health of Indigenous chil-dren is significantly poorer, with higher risk of injury,extreme birth weights, and skyrocketing rates of obe-sity (Boyd, 2007; Health Canada, 2011). These healthinequities are exacerbated by poor access to and qual-ity of Indigenous maternal care; Indigenous womenoften have little or no prenatal or antenatal care, andthe birthing experience is frequently negative, which



resonates intimately with the intergenerational traumaand historic destruction of experiences surroundingpregnancy and parenting (David Thompson HealthRegion as cited in DiLallo, 2014).

Increasing the self-directed seeking of health careby Indigenous mothers depends on creating positiveand supportive maternal health service experiences.The Royal Commission on Aboriginal Peoples (1996)noted that Indigenous women who are pregnant “needculture-based prenatal outreach and support programs,designed to address their particular situation and vul-nerabilities” (p. 122). The concepts of cultural safetyand competence are therefore highly relevant in thefield of Indigenous maternal and child health. There isno definite, objective standard with which we measurehow ‘culturally safe’ a program is, resulting in a largespectrum of programs that vary in how and to whatextent they integrate cultural values. The followingcase studies provide several instances of cultural safetyin practice and are selected for their diverse but cleardemonstrations of the principle‘s core values. A moredetailed comparison of case study elements is providedin Figure 2.

Case Study 1: Aboriginal Prenatal WellnessProgram (APWP)

Culturally-safe practice is characterized by holis-tic, continuous care, and empowerment of familiesand communities to become key actors in health pro-gramming. The Aboriginal Prenatal Wellness Program(APWP), which operates from Wetaskiwin Family Med-ical Practice, based in Wetaskiwin, Alberta, exemplifiesthese qualities by recognizing the pivotal role of ma-ternal health in the wellness of children and families(DiLallo, 2014).

APWP is based on a holistic care model that alignswith Medicine Wheel teachings, encompassing mental,emotional, spiritual, and physical wellness (NationalAboriginal Health Organization, 2006). Every clientis cared for in all domains; the first evaluation withinthe program, for instance, includes assessments in eacharea of health (DiLallo, 2014). Services provided alsoinvolve community agencies, health professionals, so-cial workers, life support counselors, and Indigenouscommunity elders, acknowledging the multifaceted de-terminants of health (DiLallo, 2014). The respect forholistic care and health experiences is also applied inAPWP‘s commitment to walking every client throughpregnancy, from prenatal care to delivery, to postnatalcare (DiLallo, 2014).

Cultural safety also requires that the value of In-digenous knowledge be accepted as an equal partnerin health. APWP possesses a traditional healing com-ponent led by Elders and community members that isnot additional or superficial, but a core element withinthe program. For instance, when a client confirmsa pregnancy, she is offered an appointment with anElder for personalized discussion and education thatexplains the prenatal care to be received (DiLallo, 2014).Experiences are placed in the context of teachings ofthe Creator‘s role in conception and blessings and cer-emonies are performed (DiLallo, 2014). The presenceof Elders and community member workers servingalongside nurses, physicians, laboratory specialists,counsellors and doulas establishes a power balancethat prizes Indigenous health values and practices asequals to biomedical care (DiLallo, 2014). The culturallysafe mandate of equality and collaborative communitypartnership is also evident in program governance, asprogram representatives meet regularly with commu-nity members, health unit and clinic representatives, aswell as practitioners (DiLallo, 2014). Beyond equalizingpower, the tenets of cultural safety also resonate in howthe role of the biomedical practitioner is defined: theyare not expected to be ‘experts’ in Indigenous culturewhatsoever. Instead, the traditional Healers and Eldersassume authority over the traditions and ceremonies,leaving the non-Indigenous practitioners to focus onprovision of biomedical care that assumes no authorityover traditional healing.

Case Study 2: Inuulitsivik Health CentreMidwifery Initiative

Cultural safety is ultimately concerned with restor-ing power, autonomy, self-government, and revival ofIndigenous peoples‘ culture in all domains of society.The reclamation of authority over health services is ex-emplified in the establishment of the midwifery wardat the Hudson Hospital (Inuulitsivik), located withinthe village of Puvirnituq in Nunavik, Québec. Thisinitiative is a result of efforts between the InuulitsivikHealth Centre and local activists who advocated forreturn of birth to Inuit communities as a part of reviv-ing Inuit culture and self-governance (Centre de santéInuulitsivik, n.d.). Being a community-led initiative, itsvery creation thus represents the empowering outcomecultural safety is designed to promote (Epoo, Stonier,Van Wagner, & Harney, 2012). The mission of the centreis to reintegrate traditional knowledge about birth intothe modern approaches to care, and its inception hasencouraged the opening of local birth programs within



the network of Inuulitsivik Health Centres in Inukjuakand Salluit (Van Wagner, Epoo, Nastapoka & Harney,2007). These centres were opened in response to thelack of local birthing services in many Inuit commu-nities in Northern Canada, which made it necessaryfor pregnant mothers to fly into urban centres weeksbefore their due date to give birth (Chamberlain & Bar-clay, 2000). Over time, evacuation of women from theircommunities has led to a loss of birth as a celebratedcomponent of the community culture, thereby weaken-ing the health, strength, and spirit of the communities(Lalonde, Butt, & Bucio, 2009; Crosbie as cited in VanWagner et al., 2007). The removal of birth from thecommunity has been seen as an “act of disrespect, ne-glect, and a colonialist approach to health care andto indigenous communities” (Van Wagner et al., 2007,p. 387), and the placement of women in foreign andlonely biomedical institutional environments producespsychological fright and perpetuates the dread of seek-ing of medical care, which is particularly unhealthyduring birth (Smith, 2002).

Cultural safety, which requires an equal valuingof Indigenous knowledge, is epitomized and even ex-panded by the Inuulitsivik centres in that all care pro-vided is midwifery-led, in accordance with the tradi-tional ways of birth (Van Wagner et al., 2007). Powerover the birthing services is therefore not simply equal-ized, but completely owned by the Inuit peoples andtheir unique expertise and ways of knowing. The mid-wives are the lead caregivers and are supplemented bya multidisciplinary team of nurses, physicians, socialworkers, and Southern midwives, who act primarily asback-up support and trainers (Benoit, Carroll, & Eni,2006; Stout & Harp, 2009). The Inuit midwives providecare in Inuktitut, the Inuit language, and encouragepractice of cultural tradition such as that of having mul-tiple friends and family attend and witness the birth(Epoo et al., 2012). The power redistribution in thismodel also extends into the government of the hospi-tal in Puvirnituq by an interdisciplinary council thatreceives feedback from the Perinatal Committee, whichis led by a team of midwives (Van Wagner et al., 2007).

As a value of cultural safety, the ownership andtransfer of responsibility and power over health to thecommunity is also embedded within the Inuulitsivik‘seducation model that ensures its sustainability and con-tinuation as being locally-led in the future. Within theprogram, Inuit women are provided with academicand clinical education in their own communities, witha curriculum framework that is consistent with clinicalcontent of southern Canadian programs, but adapted

for northern realities and inclusive of Inuit culture (VanWagner et al., 2007). Transferring education of healthcare to the communities is in itself a statement of re-covery and healing from the effects of colonization onhealth system. The training program focuses on obser-vational learning from midwives who act as ‘mentors’,through storytelling, and other oral methods of teach-ing of Inuit pedagogy (Epoo et al., 2012). In this way,the traditional methods of knowledge transfer are pre-served, while also meeting the standards for midwiferypractice in Québec. The program also has a heavyemphasis on experiential learning; mentors guide andteach new students along with Elders, who pass ontraditional knowledge of how to benefit from healthydiets of natural foods, and Inuit approaches to labor,birth, and baby care (Van Wagner et al., 2007). Southernmidwives are involved to teach skills on emergency sit-uation care, but the practices of using pharmaceuticalsand acute interventions are always coupled with tradi-tional beliefs, such as avoiding knots during pregnancyor folding a finger to control post-partum hemorrhage(Van Wagner et al., 2007). Ultimately, each student is as-sessed on the development of key competencies in Inuitmidwifery that have been established; these competen-cies also cover the requirements for standard midwiferyeducation in Quebec. This provides a systematic wayto utilize traditional learning methods while blendingInuit and non-Inuit knowledge and approaches (VanWagner et al., 2007).

The Inuulitsivik Midwifery Education Program andits return of birth to Nunavik has become an exam-ple of a “community-led initiative capable of workingcreatively within the sphere of local conditions andresources to restore quality midwifery and perinatalservices” (Epoo et al., 2012, p. 291). It exemplifies thereliance on the Inuit cultural perspective to not onlyinform, but completely guide services and educationprograms, representing the return of birth to remotecommunities for healing and capacity building. Thisphenomenon is not universal for all Indigenous peo-ples; however, there are great deficiencies in informa-tion on First Nations and Métis birthing practices, sig-nifying the importance of moving towards applicationof these cultural safety principles in birth universally(National Aboriginal Health Organization, 2008).

Case Study 3: Strengthening FamiliesMaternal and Child Health Program

Beyond power transfer in clinical settings, culturalsafety prioritizes and ultimately endeavours to restorecomplete community wellness. The Strengthening Fam-



ilies Maternal and Child Health Program exemplifiesthis tenet of safety by providing family-focused, in-home visiting programs by nurses and trained homevisitors for pregnant women, fathers, and families ofinfants and young children aged 0 to 6 years, reachingdirectly into the daily lives of mothers and childrenand caring for them within the context of the rest of thefamily (Eni, 2010; Eni & Rowe, 2011). The program em-phasis of restoring family structure and relationshipsrecognizes the intergenerational effects on Indigenousfamilies that persist from historic assimilationist andcolonialist endeavors, like the residential schools policy.The program is based in 14 First Nations communitiesin Manitoba, and fosters strong attachments betweenparents and children, improves parental capacities inparenting and child development, and increases accessin supports and health services to decrease isolation

(Eni & Rowe, 2011). This is particularly important forthe coordination of services for children with complexneeds.

Cultural safety includes the element of a strengths-based approach that acknowledges the diversity in cul-ture between Indigenous communities. The Strengthen-ing Families program is operated in part by the Assem-bly of Manitoba Chiefs, which provides regional sup-port to tailor a standardized program model to individ-ual community cultures, thus mitigating assumptionsregarding communities‘ needs and priorities (HealthCouncil of Canada, 2011). Existing services (takinginto account characteristics like opportunities for em-ployment, education, extra-curricular activity, socialservices, etc.) are used in each context to increase theprogram‘s sustainability and relevance (Eni, 2010; Eni& Rowe, 2011).

Figure 2: Summary Chart of Case Studies and Their Unique Applications of Cultural Safety



Discussion and Recommendations

The preceding case studies demonstrate thatpromising practices integrate cultural safety withina consistent set of domains (governance, biomedicalcare, traditional care, program development, and com-munity integration). However, these domains are notuniversally or officially recognized as elements neces-sary for a culturally safe practice, and as a result, theapplication of cultural safety is not universally stan-dardized. This allows adaptation of services to theunique priorities of every Indigenous community, de-parting from a ‘one size fits all’ model. Simultaneously,the lack of official guideline for implementation ofcultural safety also results in a large spectrum of ini-tiatives being put forth as ‘culturally safe’ —some ofwhich may, in actuality, simply consist of layering asemblance of traditional knowledge over mainstreamWestern biomedicine. True cultural safety in healthservices requires that respect for Indigenous knowl-edge and systems of healing underlies the foundationof all programming and the philosophy of the entireorganization itself, with particular regard for Indige-nous concepts of holistic health, relationship-buildingbetween patient and practitioner, and reciprocity andpower balance within those relationships for mutualteaching and learning. The presence of a guiding base-line application framework for cultural safety wouldtherefore be beneficial as a starting point for health caresystems seeking to serve Indigenous populations. Simi-lar to the necessity of a baseline application framework,cultural competency and safety training for health pro-fessionals should also have some degree of standard-ized curricula, for the creation of a recognized, mutualunderstanding of concepts and their importance.

While many different conceptualizations of culturalsafety have appeared in health care practice, establishedefficacy evaluation of these strategies is particularlylacking in Canada, where cultural competency andsafety standards are not embedded in federal and statepolicy and reporting requirements, like they are in theUnited States, or within national legislation or policy,as in New Zealand and Australia (O‘Brien, Boddy, &Hardy as cited in Clifford, McCalman, Bainbridge, &Tsey, 2015; Office of Minority Health, 2001). Evaluationschemes and indicators are necessary to compare andcontrast programs and objectively determine whichapplications of cultural safety are meeting their goals,and which are not. These evaluation criteria must beproduced in a manner that, in itself, is culturally safe,through consultative processes that heavily depend on

the Indigenous world view, systems of knowing, andvoices of the Indigenous peoples being serviced. Pro-ducing a set of standardized evaluation criteria mustnot, however, prevent these tools from being dynamicenough to accurately reflect the potentially unantici-pated effects of the program, nor must they neglect toconsider a community‘s specific strengths and weak-nesses.

The centralization of information on culturally safepractices exists as a gap in the literature. While it is ev-ident that many different health services have soughtto apply principles of cultural safety and introducecollaborative biomedical and traditional Indigenouspractices in their own way, little work has been doneto compile the impacts and lessons learned from theseefforts into a single, widely-distributed document. TheHealth Council of Canada‘s report entitled Empathy,dignity, and respect: Creating cultural safety for Indigenouspeople in urban health care (2011) summarizes, to an ex-tent, the scope of programs available by province, buta full compendium dissecting all programs would bebeneficial. This type of review would enable more di-rected, systems-level intervention. While it is beneficialthat many different programs providing culturally safeprimary health care are appearing in pockets across thecountry, work must be done to channel efforts into acohesive revolution of care, so that programs do notoverlap and so that specific gaps are identified andfilled. This lack of information sharing consequentlyprevents cohesive advocacy for regional, provincial,and national level policy changes to support univer-salized implementation of culturally safe practice forIndigenous peoples in Canada, which is necessary forsustainable impacts to be made in the most direct, effi-cient, and effective way possible.

Conclusion

Developing culturally appropriate care has gainedattention in recent years and a multitude of conceptsto describe the elements of this care have subsequentlyappeared. These concepts are particularly importantwith regards to health care for Indigenous peoples ofCanada, who are often underserviced and do not re-ceive adequate medical attention. The two most notableand applied of these concepts are those of cultural com-petence and cultural safety. While cultural competenceemphasizes the more traditional perspective of gather-ing information of Indigenous culture, cultural safetyis an outcome, defined and experienced by patients re-ceiving health care service. Cultural safety is based on



respectful engagement with patients and on the under-standing of the power differentials inherent in healthservice delivery, encouraging a return of power to thepatient and a questioning of institutional and systemicdiscrimination by providers. Finally, cultural safetyenforces the need for providers to acknowledge thatthey too are bearers of culture, prompting need for self-reflection. While these concepts have been developed intheory over time, little research has focused specificallyon the experiences of Indigenous mothers accessingdifferent forms of culturally appropriate care and theirpriorities regarding how and what type of health careis delivered. It is therefore important from an academicperspective that research efforts be made towards rec-ognizing the unique needs of Indigenous mothers andchildren, which should in turn form the foundationof any program development, in order to circumventpaternalistic impositions of what is assumed to be ap-propriate. From an applied perspective, there is stilla need to define how the concepts of cultural safetyand competency may translate into practice and policy,prompting the following recommendations:

1. Guidelines for the application of cultural safetyacross health care services need to be developedbased on key themes that have been consistentlyidentified as important by Indigenous patients, dis-seminated, and universalized as a framework forapplication.

2. By extension, a framework detailing how culturalcompetency and safety training can be adapted andtaught within professional health education is nec-essary. While many cultural safety curricula exist,an official guideline is lacking, creating a lack of uni-versal understanding of the concepts and of theirimportance.

3. There is a need for a key evaluation frameworkthat can be adapted to determine the efficacy of“culturally-safe” interventions in order to determinethe best practice for care. This framework mustalign with Indigenous values and ways of knowing.

4. Centralization of information detailing the ways inwhich different health care programs are conceptu-alizing and applying cultural safety in their prac-tices will be useful for understanding how muchprogress has been made and the gaps that have yetto be filled in the grand scheme.

5. Initiatives designed to produce systems-levelchanges must be put forth in order to bridge theefforts of all organizations that have interpreted pro-vision of culturally-safe care. In order for change to

be directed and sustainable, efforts must be madeto channel individual organization and program ef-forts into one movement towards a safer overarchinglandscape.

In summary, the development of cultural safety as aconcept represents progress towards more respectfuland appropriate engagement with Indigenous patientsin health care contexts, but its application continuesto remain a challenge. Future work must therefore fo-cus on developing culturally safe care in practice, in away that prioritizes Indigenous leadership and patientfeedback throughout.

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Acknowledgments

I wish to thank my project advisor, Dr. Chelsea Gabel,for her patience and guidance throughout the researchand writing process. Additionally, I wish to acknowl-edge the Bachelor of Health Sciences Program at Mc-Master University, whose flexible curriculum enabledme to design and pursue the completion of this project.


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