Research consistently shows that ethnic minorities are less likely than their White counterparts to receive health care services in various settings.1 These differences were unrelated to the patient's attitudes or preference for treatment but based on interactions between the provider and the patient and bias on the part of the provider.1 As mentioned in Curtis et al,2 Indigenous and minority ethnic groups experience inequalities in their exposure to the determinants of health, access to care, and receipt of high-quality care. The role of providers and health systems in creating and maintaining these inequities is increasingly being evaluated. As providers and advocates for patients, we have an obligation to address social determinants of health inequities, ensuring the delivery of appropriate and equitable care. This is accomplished by delivering culturally safe care, which has gained growing recognition in the fight for achieving equitable health care. This is my personal reflection on the concept of cultural safety as it relates to Indigenous and minority people.

DESCRIPTION

Cultural safety allows one to feel secure physically, spiritually, socially, and emotionally. It means one's identity and past experiences are considered and involves behaviors that recognize, respect, and foster the unique cultural identity of a person and safely meet his or her needs. Understanding cultural safety requires identifying the key elements.

According to Day and Tenney,3 there are 3 core tenets to cultural safety. The first core tenet is understanding the history and context of Indigenous and minority people and being honest with the fact that colonization was the original cause of inequities. The second core tenet involves health care providers having self-awareness toward patients, positionality, and power imbalances. The third core tenet establishes that the patient decides whether the care he or she receives is culturally safe. This allows the patient to make an autonomous decision on his or her cultural safety. Emphasis on cultural safety focuses on various features of society that impact health outcomes including the social, economic, and political aspects along with historical events.4 Cultural safety is on a continuum of care that involves the related concepts of cultural humility and cultural competence.5 It is imperative that cultural safety, cultural humility, and cultural competency are implemented in every stage of the continuum of care including preventive care, medical intervention, rehabilitation, and maintenance.

Cultural humility is a lifelong process of self-reflection and self-critique whereby the individual not only learns about another's culture but also one starts with an examination of his or her own beliefs and cultural identities.6 To truly have cultural humility, one must first become aware and acknowledge historic realities such as violence and oppression against certain groups. In comparison, cultural competence is a set of values, attitudes, behaviors, and practices within a system or organization that come together and allow one to interact with people from cultures or belief systems different from one's own. Cultural competency is a more comprehensive skills-based concept involving both the system and the patient whereby the professional works and communicates effectively and appropriately with people from diverse cultures and backgrounds.2

ANALYZE

Before reviewing the concept of cultural safety, I knew little about the historical experiences of Native Americans and Aboriginal people. Unfortunately, the historical traumas continue to haunt them today, impacting their experience with health care.3 I can relate as an African American with the history of views on the impact of health care received. Looking through the lens of cultural safety, I understand how my own biases and stereotypical behavior impacted patients and my part in inflicting some of these same health inequities that African Americans endured on others.

In 2008, I worked as a public health nurse; our patient population was mostly Hispanic. I observed patients showing up for appointments late if they came at all and when they did, their young children would be in tow. We would have these patients rescheduled if late. In hindsight, we were not understanding the fact these women were stay-at-home mothers who survived with one income, which impacted childcare and transportation. We contributed to a culturally unsafe environment and were the cause of health inequities as some patients never returned for follow-up appointments. This is a prime example of how positionality causes a power imbalance, which cripples the patient-provider relationship and leads to poor health outcomes.

APPLY

Post-reflection, I have developed empathy, enabling me to become a better advocate contributing to better health outcomes. Our focus should have been on ways to reduce inequities, which may have included offering additional night and weekend option clinics. We could have considered resources that would have allowed for on-site childcare. Building relationships with our patients and thinking creatively to meet our patients right where they are should have been the goal. In this case, we were the problem and created barriers to care.

To understand and care for anyone, we must first understand how their histories and past experiences shape who they are. This allows us to care for our patients holistically and from their point of view versus our own. I still have much to learn and digest regarding these concepts. My biggest obstacle is remembering that I am not the expert. Providers are taught to diagnose and treat. However, culture plays a big part in how patients view certain therapies, and one shoe does not fit all. I must take a step back and allow the patient to become the expert and together with shared decision-making define the course of treatment, in a culturally safe environment.

CONCLUSION

The purpose of cultural safety is to educate health professionals on how to self-reflect on their own personal bias, and it involves a deliberate and practical plan to change the way health care is delivered. Without internal reflection, the risk for personal biases and assumptions lead to culturally unsafe practices and negative patient outcomes. We must remember, feelings of safety can only be defined by patients themselves.3 I am reminded of a quote by Maya Angelou, “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.” If we are to build trusting relationships with our patients, we must first ensure our patients feel safe with us as providers. We do this by creating a culturally safe environment and continually self-reflecting on our own biases and ways to eliminate them.

—Corey S. Roman, MSN, RN, CHPN
Frontier Nursing University
Versailles, Kentucky
[email protected]

REFERENCES 1. Mkandawire-Valhmu L. Cultural Safety, Healthcare and Vulnerable Populations: A Critical Theoretical Perspective. New York, NY: Routledge; 2018. 2. Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health. 2019;18(1):174. doi:10.1186/s12939-019-1082-3. 3. Day D, Tenney E. Module 2: caring in a complex world; in introduction to cultural safety. https://ceu.catalog.instructure.com/courses/introduction2culturalsafety. Published 2021. Accessed 2021. 4. Richardson A, Yarwood J, Richardson S. Expressions of cultural safety in public health nursing practice. Nurs Inq. 2017;24(1):e12171. doi:10.1111/nin.12171. 5. Yeung S. Conceptualizing cultural safety: definitions and applications of safety in health care for Indigenous mothers in Canada. J Soc Thought. 2016;1(1):1–13. 6. Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–125. doi:10.1353/hpu.2010.0233.